Delirium in Older Patients after Combined Epidural–General Anesthesia or General Anesthesia for Major Surgery: A Randomized Trial

Background Delirium is a common and serious postoperative complication, especially in the elderly. Epidural anesthesia may reduce delirium by improving analgesia, reducing opioid consumption, and blunting stress response to surgery. This trial therefore tested the hypothesis that combined epidural–general anesthesia reduces the incidence of postoperative delirium in elderly patients recovering from major noncardiac surgery. Methods Patients aged 60 to 90 yr scheduled for major noncardiac thoracic or abdominal surgeries expected to last 2 h or more were enrolled. Participants were randomized 1:1 to either combined epidural–general anesthesia with postoperative epidural analgesia or general anesthesia with postoperative intravenous analgesia. The primary outcome was the incidence of delirium, which was assessed with the Confusion Assessment Method for the Intensive Care Unit twice daily during the initial 7 postoperative days. Results Between November 2011 and May 2015, 1,802 patients were randomized to combined epidural–general anesthesia (n = 901) or general anesthesia alone (n = 901). Among these, 1,720 patients (mean age, 70 yr; 35% women) completed the study and were included in the intention-to-treat analysis. Delirium was significantly less common in the combined epidural–general anesthesia group (15 [1.8%] of 857 patients) than in the general anesthesia group (43 [5.0%] of 863 patients; relative risk, 0.351; 95% CI, 0.197 to 0.627; P < 0.001; number needed to treat 31). Intraoperative hypotension (systolic blood pressure less than 80 mmHg) was more common in patients assigned to epidural anesthesia (421 [49%] vs. 288 [33%]; relative risk, 1.47, 95% CI, 1.31 to 1.65; P < 0.001), and more epidural patients were given vasopressors (495 [58%] vs. 387 [45%]; relative risk, 1.29; 95% CI, 1.17 to 1.41; P < 0.001). Conclusions Older patients randomized to combined epidural–general anesthesia for major thoracic and abdominal surgeries had one third as much delirium but 50% more hypotension. Clinicians should consider combining epidural and general anesthesia in patients at risk of postoperative delirium, and avoiding the combination in patients at risk of hypotension. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Epidural and general anesthesia versus general anesthesia in radical prostatectomy

Medicina ◽

10.3390/medicina45100100 ◽

2009 ◽

Vol 45 (10) ◽

pp. 772 ◽

Cited By ~ 5

Author(s):

Renatas Tikuišis ◽

Povilas Miliauskas ◽

Narimantas Samalavičius ◽

Aleksas Žurauskas ◽

Algimantas Sruogis

Keyword(s):

Radical Prostatectomy ◽

Blood Loss ◽

General Anesthesia ◽

Epidural Anesthesia ◽

Allogeneic Blood ◽

Blood Transfusions ◽

Intraoperative Blood Loss ◽

Induced Hypotension ◽

General Anesthesia Group ◽

Anesthesia Group

Induced hypotension with epidural anesthesia influences the intraoperative blood loss in prostate cancer patients undergoing radical prostatectomy. The aim of this study was to evaluate intraoperative blood loss and need of blood transfusions in patients who underwent radical prostatectomy under epidural/general anesthesia and general anesthesia. Two groups were selected: epidural/general anesthesia group (study group, 27 patients) received epidural anesthesia in association with general anesthesia, and general anesthesia group (control group, 27 patients) received general anesthesia alone. Epidural/general anesthesia was performed using 0.5% solution of bupivacaine and maintained by volatile anesthetic sevoflurane. General anesthesia was performed with endotracheal ventilation using sevoflurane and intravenous fentanyl. The present study showed that the mean blood loss in epidural/general anesthesia group was significantly lower in comparison with that of general anesthesia group (740±210 mL versus 1150±290 mL, P<0.001). In addition, less allogeneic blood was transfused in epidural/general anesthesia group: 0.19 blood units transfused versus 0.52 blood units in general anesthesia group (P=0.007). Our study proved that induced hypotension with epidural/general anesthesia reduced intraoperative blood loss and need of allogeneic blood transfusions in cancer patient undergoing open radical prostatectomy.

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Dexmedetomidine Induces Low Patient State Indices While Preventing the Development of Postoperative Delirium in Older Patients Undergoing General Anesthesia - A Secondary Analysis of a Randomized Controlled Trial (NEUPRODEX)

10.21203/rs.3.rs-858293/v1 ◽

2021 ◽

Author(s):

Juliane Thomas ◽

Susanne Koch ◽

Claudia D Spies ◽

Leonie Liederwald ◽

Anne Pohrt ◽

...

Keyword(s):

Placebo Group ◽

General Anesthesia ◽

Older Patients ◽

Postoperative Delirium ◽

Mixed Model ◽

Controlled Trial ◽

Secondary Analysis ◽

Control Group ◽

Patient State ◽

Patients At Risk

Abstract Background: Dexmedetomidine may have a delirium preventive effect in high-risk surgical patients. Accurate frontal EEG-guided anesthesia can decrease the incidence of postoperative delirium by avoiding too deep anesthesia. Aim of our study is to evaluate the incidence of postoperative delirium under intraoperative frontal EEG neuromonitoring during general anesthesia with dexmedetomidine.Methods: A secondary analysis of a single-center, randomized, double-blinded, placebo-controlled trial. Patients > 60 years were included with either abdominal or cardiac surgery, receiving intraoperative dexmedetomidine or placebo. Delirium incidence was measured up to the fifth postoperative day. Anesthetic depth was measured as Patient State Index (PSi™) every 15 minutes during surgery using EEG-based neuromonitoring.Results: Of the 60 patients included, the incidence of postoperative delirium was significantly reduced in the dexmedetomidine group (n=28) vs. the control group (n=32) (p=0.031). A PSi less than 25 at least once was seen in 85.2% of the verum group and 58.1% of the placebo group (p=0.024). The mean (SD) PSi value in the dexmedetomidine group was 28.17 (10.35) and 33.55 (11.31) in the placebo group using mixed-model ANOVA.Conclusions: Intraoperative Dexmedetomidine reduces the incidence of postoperative delirium in older patients at risk, although presenting with lower intraoperative PSi levels.

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Evaluation Of Anxiety During Nasal Pack Removal In Patients Operated Under Local Versus General Anesthesia

Journal of Bahria University Medical and Dental College ◽

10.51985/jbumdc2018070 ◽

2018 ◽

Vol 08 (04) ◽

pp. 226-230

Author(s):

Amer Sabih Hydri ◽

Muhammad Junaid Alam ◽

Iqbal Hussain Udaipurwala ◽

Furqan Mirza

Keyword(s):

General Anesthesia ◽

Local Anesthesia ◽

Rating Scale ◽

Military Hospital ◽

General Anesthesia Group ◽

Nasal Pack ◽

Assessment Scores ◽

Anesthesia Group ◽

Group B ◽

Hamilton Anxiety

Objective: To evaluate the anxiety experienced before, during and after conventional paraffin gauze nasal pack removal in patients operated under local versus general anesthesia. Study design: Comparative study. Place and duration of study: Department of ENT, Combined Military Hospital Sialkot and PAF Hospital Shorkot from July 2017 to June 2018. Material and methods: A total of 120 patients planned for Septoplasty were enrolled and divided into two groups. Sixty patients were to be operated under local anesthesia (Group A) while the other 60 were undergoing the same procedure under general anesthesia (Group B). Conventional paraffin gauze nasal packing was done for 24 hours in all 120 patients. Hamilton Anxiety Rating Scale (HAM-A) was used to determine the patients’ anxiety in both groups, 1 hour pre-operatively, immediately before and 1 hour after nasal pack removal. Results: The mean Hamilton Anxiety Scale assessment scores in both groups were of ‘mild’ category. The highest scores in both groups were observed immediately before nasal pack removal, with a range of 15-18, while the lowest scores in both groups were documented one hour after pack removal with a range of 13-16. Anxiety level in patients operated under general anesthesia was slightly lower than patients administered local anesthesia mean score of 16.40 ± 0.763 vs 17.21 ± 0.666 (p<0.001). Conclusion: Anxiety during nasal pack removal is mainly associated with prior pain experienced during nasal pack insertion. It is recommended that proper analgesia, adequate topical anesthesia, gentle insertion would make this process less distressing and will subsequently result in less anxiety at its removal.

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The Effect of Sevoflurane Anesthesia for Dental Procedure on Neurodevelopment in Children: A Prospective, Equivalence, Controlled Trial

10.21203/rs.3.rs-78114/v1 ◽

2020 ◽

Author(s):

Pinping Zhou ◽

Chao Zhang ◽

Guijin Huang ◽

Yuan Hu ◽

Wenzhu Ma ◽

...

Keyword(s):

General Anesthesia ◽

Local Anesthesia ◽

Primary Outcome ◽

Controlled Trial ◽

Age Groups ◽

Outcome Data ◽

Clinical Trial Registry ◽

General Anesthesia Group ◽

Anesthesia Group ◽

Significant Difference

Abstract Background: Dental procedures under general anesthesia (DGA) was found to improve the oral health-related quality of children's life. However, some parents and pediatricians expressed concern about the neurotoxicity of general anesthesia. The purpose of this trial was to investigate whether DGA in children has an adverse effect on neurodevelopment.Methods: In this prospective, assessor-masked, controlled, equivalence trial, we recruited 340 children younger than 7 years who were undergoing caries treatment between Feb 1, 2019, and Aug 31, 2019, without factors affecting neurodevelopment. They received either sevoflurane-based general anesthesia or awake-local anesthesia. The Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition was used to evaluate the neurodevelopment of children at six months after surgery, and the Full-Scale IQ (FSIQ) was selected as the primary outcome. Predefine the 95% CI of a difference in means within five (1/3 SD) as the equivalence margin.Results: The outcome data were obtained from 129 children in the general anesthesia group and 144 in the local anesthesia group. The median length of general anesthesia was 130 min (IQR 110 – 160). There was equivalence in means of FSIQ score between the general anesthesia group and the local anesthesia group (local minus general anesthesia 0.46, 95% CI -2.35 to 1.61). There was no significant difference in FSIQ scores between different age groups and different anesthesia durations. Only the mother's education could affect the primary outcome.Conclusions: In this trial, prolonged DGA with a sevoflurane-only anesthetic in preschool children, does not adversely affect neurodevelopment at six months after surgery compared with awake-local anesthesia. Trial registration: Chinese Clinical Trial Registry, ChiCTR1800015216. Registered Mar 15 2018, http://www.chictr.org.cn/showproj.aspx?proj=24830.

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Spinal block and delirium in oncologic patients after laparoscopic surgery in the Trendelenburg position: A randomized controlled trial

PLoS ONE ◽

10.1371/journal.pone.0249808 ◽

2021 ◽

Vol 16 (5) ◽

pp. e0249808

Author(s):

Jorge Kiyoshi Mitsunaga ◽

Vinicius Fernando Calsavara ◽

Elton Shinji Onari ◽

Vinicius Monteiro Arantes ◽

Carolina Paiva Akamine ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Laparoscopic Surgery ◽

General Anesthesia ◽

Controlled Trial ◽

Spinal Block ◽

Trendelenburg Position ◽

General Anesthesia Group ◽

Randomized Controlled ◽

Anesthesia Group ◽

Oncologic Patients

Delirium is the most common postsurgical neurological complication and has a variable incidence rate. Laparoscopic surgery, when associated with the Trendelenburg position, can cause innumerable physiological changes and increase the risk of neurocognitive changes. The association of general anesthesia with a spinal block allows the use of lower doses of anesthetic agents for anesthesia maintenance and facilitates better control over postoperative pain. Our primary outcome was to assess whether a spinal block influences the incidence of delirium in oncologic patients following laparoscopic surgery in the Trendelenburg position. Our secondary outcome was to analyze whether there were other associated factors. A total of 150 oncologic patients who underwent elective laparoscopic surgeries in the Trendelenburg position were included in this randomized controlled trial. The patients were randomized into 2 groups: the general anesthesia group and the general anesthesia plus spinal block group. Patients were immediately evaluated during the postoperative period and monitored until they were discharged, to rule out the presence of delirium. Delirium occurred in 29 patients in total (22.3%) (general anesthesia group: 30.8%; general anesthesia plus spinal block: 13.8% p = 0.035). Patients who received general anesthesia had a higher risk of delirium than patients who received general anesthesia associated with a spinal block (odds ratio = 3.4; 95% confidence interval: 1.2–9.6; p = 0.020). Spinal block was associated with reduced delirium incidence in oncologic patients who underwent elective laparoscopic surgeries in the Trendelenburg position.

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Could spinal anesthesia be a choice for retrograde intrarenal surgery

Urologia Journal ◽

10.1177/0391560318758936 ◽

2018 ◽

Vol 85 (4) ◽

pp. 169-173 ◽

Cited By ~ 5

Author(s):

Ibrahim Karabulut ◽

Erdem Koc ◽

Ali Haydar Yilmaz ◽

Elif Oral Ahiskali ◽

Ercument Keskin ◽

...

Keyword(s):

Visual Analogue Scale ◽

General Anesthesia ◽

Spinal Anesthesia ◽

Analogue Scale ◽

Complication Rates ◽

Retrograde Intrarenal Surgery ◽

General Anesthesia Group ◽

Group I ◽

Anesthesia Group ◽

Spinal Anesthesia Group

Objective: In this study, we aimed to compare cases of retrograde intrarenal surgery performed under spinal or general anesthesia through investigating relevant parameters for the first time in the literature. Material and method: In total, 86 patients with diagnosis of kidney stone who were treated by retrograde intrarenal surgery were included in this randomized controlled prospective study. In total, 43 of these operations were performed under spinal anesthesia (group I) and 43 were performed under general anesthesia (group II). The groups were compared in terms of demographic features, American Society of Anesthesiologists score, duration of operation, complication rates, postoperative visual analogue scale, postoperative hospitalization period, stone-free rates, and cost value ratios. Results: There were no significant differences between the two groups in terms of demographic findings, preoperative stone loads, postoperative stone-free rates, complication rates and postoperative hospitalization periods (p > 0.05). Postoperative visual analogue scale scores and cost value ratios were found statistically significantly lower in the spinal anesthesia group (group I) when compared with the general anesthesia group (group II; p < 0.001). Conclusion: Performing retrograde intrarenal surgery in the presence of spinal anesthesia is equally effective with general anesthesia. Spinal anesthesia also appears to be a more advantageous method due to statistically significantly lower mean postoperative pain scores and treatment cost value ratios.

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Abstract 15714: Prediction of Sudden Cardiac Death With Automated High-Throughput Analysis of T-Wave Heterogeneity in Standard 12-Lead Electrocardiogram

Circulation ◽

10.1161/circ.130.suppl_2.15714 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Tuomas Kenttä ◽

Bruce D Nearing ◽

Kimmo Porthan ◽

Jani T Tikkanen ◽

Matti Viitasalo ◽

...

Keyword(s):

At Risk ◽

Relative Risk ◽

Sudden Cardiac Death ◽

General Population ◽

Cardiac Death ◽

Left Ventricular ◽

Adjusted Relative Risk ◽

T Wave ◽

Increased Risk ◽

Patients At Risk

Introduction: Noninvasive identification of patients at risk for sudden cardiac death (SCD) remains a major clinical challenge. Abnormal ventricular repolarization is associated with increased risk of lethal ventricular arrhythmias and SCD. Hypothesis: We investigated the hypothesis that spatial repolarization heterogeneity can identify patients at risk for SCD in general population. Methods: Spatial R-, J- and T-wave heterogeneities (RWH, JWH and TWH, respectively) were automatically analyzed with second central moment technique from standard digital 12-lead ECGs in 5618 adults (46% men; age 50.9±12.5 yrs.) who took part in Health 2000 Study, an epidemiological survey representative of the entire Finnish adult population. During average follow-up of 7.7±1.4 years, a total of 72 SCDs occurred. Thresholds of RWH, JWH and TWH were based on optimal cutoff points from ROC curves. Results: Increased RWH, JWH and TWH (Fig.1) in left precordial leads (V4-V6) were univariately associated with SCD (P<0.001, each). When adjusted with clinical risk markers (age, gender, BMI, systolic blood pressure, cholesterol, heart rate, left ventricular hypertrophy, QRS duration, arterial hypertension, diabetes, coronary heart disease and previous myocardial infarction) JWH and TWH remained as independent predictors of SCD. Increased TWH (≥102μV) was associated with a 1.9-fold adjusted relative risk (95% confidence interval [CI]: 1.2 - 3.1; P=0.011) and increased JWH (≥123μV) with a 2.0-fold adjusted relative risk for SCD (95% CI: 1.2 - 3.3; P=0.004). When both TWH and JWH were above threshold, the adjusted relative risk for SCD was 3.2-fold (95% CI: 1.7 - 6.2; P<0.001). When all heterogeneity measures (RWH, JWH and TWH) were above threshold, the risk for SCD was 3.7-fold (95% CI: 1.6 - 8.6; P=0.003). Conclusions: Automated measurement of spatial J- and T-wave heterogeneity enables analysis of high patient volumes and is able to stratify SCD risk in general population.

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Real-time utilisation of administrative data in the ED to identify older patients at risk: development and validation of the Dynamic Silver Code

BMJ Open ◽

10.1136/bmjopen-2019-033374 ◽

2019 ◽

Vol 9 (12) ◽

pp. e033374 ◽

Cited By ~ 2

Author(s):

Daniela Balzi ◽

Giulia Carreras ◽

Francesco Tonarelli ◽

Luca Degli Esposti ◽

Paola Michelozzi ◽

...

Keyword(s):

At Risk ◽

Cohort Study ◽

Real Time ◽

Administrative Data ◽

Older Patients ◽

Clinical Decision Making ◽

External Validation ◽

Clinical Decision ◽

Patients At Risk ◽

Ed Visits

ObjectiveIdentification of older patients at risk, among those accessing the emergency department (ED), may support clinical decision-making. To this purpose, we developed and validated the Dynamic Silver Code (DSC), a score based on real-time linkage of administrative data.Design and settingThe ‘Silver Code National Project (SCNP)’, a non-concurrent cohort study, was used for retrospective development and internal validation of the DSC. External validation was obtained in the ‘Anziani in DEA (AIDEA)’ concurrent cohort study, where the DSC was generated by the software routinely used in the ED.ParticipantsThe SCNP contained 281 321 records of 180 079 residents aged 75+ years from Tuscany and Lazio, Italy, admitted via the ED to Internal Medicine or Geriatrics units. The AIDEA study enrolled 4425 subjects aged 75+ years (5217 records) accessing two EDs in the area of Florence, Italy.InterventionsNone.Outcome measuresPrimary outcome: 1-year mortality. Secondary outcomes: 7 and 30-day mortality and 1-year recurrent ED visits.ResultsAdvancing age, male gender, previous hospital admission, discharge diagnosis, time from discharge and polypharmacy predicted 1-year mortality and contributed to the DSC in the development subsample of the SCNP cohort. Based on score quartiles, participants were classified into low, medium, high and very high-risk classes. In the SCNP validation sample, mortality increased progressively from 144 to 367 per 1000 person-years, across DSC classes, with HR (95% CI) of 1.92 (1.85 to 1.99), 2.71 (2.61 to 2.81) and 5.40 (5.21 to 5.59) in class II, III and IV, respectively versus class I (p<0.001). Findings were similar in AIDEA, where the DSC predicted also recurrent ED visits in 1 year. In both databases, the DSC predicted 7 and 30-day mortality.ConclusionsThe DSC, based on administrative data available in real time, predicts prognosis of older patients and might improve their management in the ED.

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