Neuraxial block, death and serious cardiovascular morbidity in the POISE trial. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition) Nitrous Oxide and Serious Morbidity and Mortality in the POISE Trial A prospective observational study on the effectiveness and safety of bemiparin, first dose administered 6 h after knee or hip replacement surgery The impact of peripheral nerve blocks on perioperative outcome in hip and knee arthroplasty—a population-based study The Safety and Efficacy of Extended Thromboprophylaxis With Fondaparinux After Major Orthopedic Surgery of the Lower Limb With or Without a Neuraxial or Deep Peripheral Nerve Catheter: The EXPERT Study Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane Systematic Review. Ultrasonographic guidance for sciatic and femoral nerve blocks in children. Effect of perioperative β blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. Dietetic guidelines: diet in secondary prevention of cardiovascular disease. The effects of timing of prophylaxis, type of anesthesia, and use of mechanical methods on outcome in major orthopedic surgery – subgroup analyses from 17,701 patients in the XAMOS study Epidural infusion or combined femoral and sciatic nerve blocks as perioperative analgesia for knee arthroplasty. Effect of informational internet web pages on patients’ decision‐making: randomised controlled trial regarding choice of spinal or general anaesthesia for orthopaedic surgery Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial. Incidence of neuraxial haematoma after total hip or knee surgery: RECORD programme (rivaroxaban vs. enoxaparin) Ultrasound-guided spinal anaesthesia in obstetrics: is there an advantage over the landmark technique in patients with easily palpable spines? A randomised controlled trial comparing needle movements during combined spinal‐epidural anaesthesia with and without ultrasound assistance Cardiac Outcome after Peripheral Vascular Surgery: Comparison of General and Regional Anesthesia Intraperitoneal Local Anesthetic Improves Recovery After Colon Resection: A Double-Blinded Randomized Controlled Trial The Anticatabolic Effect of Neuraxial Blockade After Hip Surgery The safety of addition of nitrous oxide to general anaesthesia in at-risk patients having major non-cardiac surgery (ENIGMA-II): a randomised, single-blind trial Comparison of Forced-air Warming and Radiant Heating during Transurethral Prostatic Resection under Spinal Anaesthesia
BACKGROUND This post hoc analysis aim ed to determine whether neuraxial block was associated with a composite of cardiovascular death , non-fatal myocardial infa rct ion ( MI ) and non-fatal cardiac arrest within 30 days of r and omization in POISE trial patients . METHODS A total of 8351 non-cardiac surgical patients at high risk of cardiovascular complications were r and omized  to β-blocker or placebo . Neuraxial block was defined as spinal , lumbar or thoracic epidural anaesthesia . Logistic regression , with weighting using estimated propensity scores , was used to determine the association between neuraxial block and primary and secondary outcomes . RESULTS Neuraxial block was associated with an increased risk of the primary outcome [ 287 ( 7.3 % ) vs 229 ( 5.7 % ) ; odds ratio ( OR ) , 1.24 ; 95 % confidence interval ( CI ) , 1.02 - 1.49 ; P=0.03 ] and MI [ 230 ( 5.9 % ) vs 177 ( 4.4 % ) ; OR , 1.32 ; 95 % CI , 1.07 - 1.64 ; P=0.009 ] but not stroke [ 23 ( 0.6 % ) vs 32 ( 0.8 % ) ; OR , 0.76 ; 95 % CI , 0.44 - 1.33 ; P=0.34 ] , death [ 96 ( 2.5 % ) vs 111 ( 2.8 % ) ; OR , 0.87 ; 95 % CI , 0.65 - 1.17 ; P=0.37 ] or clinical ly significant hypotension [ 522 ( 13.4 % ) vs 484 ( 12.1 % ) ; OR , 1.13 ; 95 % CI , 0.99 - 1.30 ; P=0.08 ] . Thoracic epidural with general anaesthesia was associated with a worse primary outcome than general anaesthesia alone [ 86 ( 12.1 % ) vs 119 ( 5.4 % ) ; OR , 2.95 ; 95 % CI , 2.00 - 4.35 ; P<0.001 ] . CONCLUSIONS In patients at high risk of cardiovascular morbidity , neuraxial block was associated with an increased risk of adverse cardiovascular outcomes , which could be causal or because of residual confounding The actual incidence of neurologic dysfunction result ing from hemorrhagic complications associated with neuraxial blockade is unknown . Although the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics , recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient population s. Overall , the risk of clinical ly significant bleeding increase with age , associated abnormalities of the spinal cord or vertebral column , the presence of an underlying coagulopathy , difficulty during needle placement , and an indwelling neuraxial catheter during sustained anticoagulation ( particularly with st and ard heparin or low-molecular weight heparin ) . The need for prompt diagnosis and intervention to optimize is also consistently reported . In response to these patient safety issues , the American Society of Regional Anesthesia and Pain Medicine ( ASRA ) convened its Third Consensus Conference on Regional Anesthesia and Anticoagulation . Practice guidelines or recommendations summarize evidence -based review s. However , the rarity of spinal hematoma defies a prospect i ve r and omized study , and there is no current laboratory model . As a result , the ASRA consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation . These are based on case reports , clinical series , pharmacology , hematology , and risk factors for surgical bleeding . An underst and ing of the complexity of this issue is essential to patient management BACKGROUND : In this post hoc sub analysis of the Perioperative Ischemic Evaluation ( POISE ) trial , we sought to determine whether nitrous oxide was associated with the primary composite outcome of cardiovascular death , nonfatal myocardial infa rct ion ( MI ) , and nonfatal cardiac arrest within 30 days of r and omization . METHODS : The POISE trial of perioperative & bgr;-blockade was undertaken in 8351 patients .  Nitrous oxide anesthesia was defined as the coadministration of nitrous oxide in patients receiving general anesthesia  , with or without additional neuraxial blockade or peripheral nerve blockade . Logistic regression , with inverse probability weighting using estimated propensity scores , was used to determine the association of nitrous oxide with the primary outcome , MI , stroke , death , and clinical ly significant hypotension . RESULTS :  Nitrous oxide was administered to 1489 ( 29 % ) of the 5133 patients included in this analysis . Nitrous oxide had no significant effect on the risk of the primary outcome ( 112 [ 7.5 % ] vs 248 [ 6.9 % ] ; odds ratio [ OR ] , 1.08 ; 95 % confidence interval [ CI ] , 0.82–1.44 ; 99 % CI , 0.75–1.57 ; P = 0.58 ) , MI ( 89 [ 6.0 ] vs 204 [ 5.6 ] ; OR , 0.99 ; 95 % CI , 0.75–1.31 ; 99 % CI , 0.69–1.42 ; P = 0.94 ) , stroke ( 6 [ 0.4 % ] vs 28 [ 0.8 % ] ; OR , 0.85 ; 95 % CI , 0.26–2.82 ; 99 % CI , 0.17–4.11 ; P = 0.79 ) , death ( 40 [ 2.7 % ] vs 100 [ 2.8 % ] ; OR , 1.04 ; 95 % CI , 0.6–1.81 ; 99 % CI , 0.51–2.15 ; P = 0.88 ) or clinical ly significant hypotension ( 219 [ 14.7 % ] vs 544 [ 15.0 % ] ; OR , 0.92 ; 95 % CI , 0.74–1.15 ; 99 % CI , 0.70–1.23 ; P = 0.48 ) . CONCLUSIONS : In this post hoc sub analysis , nitrous oxide was not associated with an increased risk of adverse outcomes in the POISE trial patients . This analysis was limited by the observational nature of the data and the lack of information on the concentration and duration of nitrous oxide administration . Further r and omized controlled trial evidence is required Introduction Bemiparin has shown to be effective and safe in clinical trials in total knee or hip replacement . Material s and methods We conducted a prospect i ve , open , multicentre , uncontrolled study to audit the utilisation patterns of bemiparin 3,500 IU/day , first dose administered 6 h after surgery , in 1,009 patients undergoing total hip or knee replacement surgery in st and ard clinical practice . We analysed rates of documented symptomatic venous thromboembolism ( VTE ) [ deep-vein thrombosis ( DVT ) and pulmonary embolism ( PE ) ] confirmed by objective methods , major bleeding , death , thrombocytopaenia and other adverse events up to 6 weeks . Results Rate of documented symptomatic DVT was 0.3 % ( 95 % CI , 0.1–0.9 % ) . No cases of documented PE were reported . There were 14 ( 1.4 % ) major bleedings ( 95 % CI , 0.8–2.3 % ) . Neuraxial anaesthesia was used in 937 ( 92.9 % ) patients . There were no cases of spinal haematoma , fatal bleeding or bleeding in critical organs . There were 6 ( 0.6 % ) cases of mild thrombocytopaenia , which did not require treatment discontinuation . No cases of severe type II heparin-induced thrombocytopaenia were observed . There were no deaths during bemiparin prophylaxis . The median length of hospitalisation was 9 days and 92.5 % of patients continued prophylaxis post-hospitalisation for a total median time of 38 days . There were no thromboembolic or bleeding complications during post-hospitalisation prophylaxis . Postoperative start of prophylaxis with bemiparin permitted that 29.3 % of patients could be admitted to hospital the same day of the intervention . Conclusion Bemiparin prophylaxis , started 6 h after surgery and given for 5–6 weeks after total hip or knee replacement , was associated with low rates of VTE , major bleeding and other adverse events in normal clinical practice . Bemiparin thromboprophylaxis started 6 h after surgery makes neuraxial anaesthesia/analgesia procedures easier , without compromising efficacy Abstract The role of anesthesia techniques on perioperative outcomes on a population level has recently gained widespread interest . Although mainly neuraxial vs general anesthesia has been addressed , population -level data on the impact of peripheral nerve blocks ( PNBs ) are still lacking . Therefore , we investigated the association between PNB use and outcomes using retrospective data on 1,062,152 recipients of hip and knee arthroplasties ( total hip arthroplasty [THA]/total knee arthroplasty [ TKA ] ) from the national Premier Perspective data base ( 2006 - 2013 ) . Multilevel multivariable logistic regression models measured associations between PNB use and outcomes . Complications included cardiac , pulmonary , gastrointestinal and renal complications , cerebrovascular events , infections , wound complications , thromboembolic complications , inpatient falls , and mortality . Re source utilization variables included blood transfusions , intensive care unit admissions , opioid consumption , cost , and length of stay . Overall , 12.5 % of patients received a PNB , with an increase over time particularly among TKAs . Peripheral nerve block use was associated with lower odds for most adverse outcomes mainly among patients with THA . Notable beneficial effects were seen for wound complications ( odds ratio 0.60 [ 95 % confidence interval , 0.49 - 0.74 ] ) among THA recipients and pulmonary complications ( odds ratio 0.83 [ 95 % confidence interval , 0.72 - 0.94 ] ) in patients with TKA . Peripheral nerve block use was significantly ( P < 0.0001 ) associated with a −16.2 % and −12.7 % reduction in opioid consumption for patients with THA and TKA , respectively . In conclusion , our results indicate that PNBs might be associated with superior perioperative population -level outcomes . In light of the inability to establish a causal relationship and the presence of residual confounding , we strongly advocate for further prospect i ve investigation , ideally in multicenter , r and omized trials , to establish the potential impact of PNBs on outcomes on a population level BACKGROUND : The benefit-risk ratio of extended fondaparinux therapy has not been assessed in patients undergoing major lower limb joint arthroplasty . Few data on the concomitant use of fondaparinux and continuous neuraxial or deep peripheral nerve blockade are available . We performed a prospect i ve intervention study in patients undergoing major orthopedic surgery primarily design ed to assess the efficacy of fondaparinux when drug administration was withheld for 48 h to permit removal of a neuraxial or deep peripheral nerve catheter . The safety and efficacy of extended fondaparinux therapy for the prevention of venous thromboembolism were also evaluated . METHODS : Patients received a daily subcutaneous injection of 2.5 mg fondaparinux for 3 to 5 wk postoperatively . In patients with a neuraxial or deep peripheral nerve catheter , the catheter was removed 36 h after the last fondaparinux dose . The next fondaparinux dose was administered 12 h after catheter removal . The primary end points were symptomatic venous thromboembolism and major bleeding up to 4–6 wk after surgery . RESULTS : We recruited 5704 patients . A neuraxial or deep peripheral nerve catheter was inserted in 1553 ( 27 % ) patients and 78 ( 1.4 % ) patients , respectively . The rate of venous thromboembolism was 1.0 % ( 54 of 5387 ) . There was no difference between patients without ( 1.1 % ) or with ( 0.8 % ) a catheter ( the upper limit of the 95 % confidence interval of the odds ratio , 1.49 , being below the predetermined noninferiority margin of 1.75 ) . The incidence of major bleeding was 0.8 % ( 42 of 5382 ) . No neuraxial or perineural hematoma was reported . CONCLUSIONS : Once-daily subcutaneous injection of 2.5 mg fondaparinux given for 3 to 5 wk was effective and safe for prevention of venous thromboembolism after major orthopedic surgery . Temporary discontinuation of fondaparinux for 48 h permitted safe removal of a neuraxial or deep peripheral nerve catheter without decreasing thromboprophylatic efficacy This systematic review and meta- analysis summarizes the clinical effects of increasing perioperative blood flow using fluids with or without inotropes/vasoactive drugs to explicit defined goals in adults . We included r and omized controlled trials of adult patients ( aged 16 years or older ) undergoing surgery . We included 31 studies of 5292 participants . There was no difference in mortality at the longest follow-up : 282/2615 ( 10.8 % ) died in the control group and 238/2677 ( 8.9 % ) in the treatment group , RR of 0.89 ( 95 % CI : 0.76 - 1.05 ; P=0.18 ) . However , the results were sensitive to analytical methods and withdrawal of studies with method ological limitations . The intervention reduced the rate of three morbidities ( renal failure , respiratory failure , and wound infections ) but not the rates of arrhythmia , myocardial infa rct ion , congestive cardiac failure , venous thrombosis , and other types of infections . The number of patients with complications was also reduced by the intervention . Hospital length of stay was reduced in the treatment group by 1.16 days . There was no difference in critical care length of stay . The primary analysis of this review showed no difference between groups but this result was sensitive to the method of analysis , withdrawal of studies with method ological limitations , and was dominated by a single large study . Patients receiving this intervention stayed in hospital 1 day less with fewer complications . It is unlikely that the intervention causes harm . The balance of current evidence does not support widespread implementation of this approach to reduce mortality but does suggest that complications and duration of hospital stay are reduced BACKGROUND Recent studies have shown that ultrasound guidance for paediatric regional anaesthesia can improve the quality of upper extremity and neuraxial blocks . We therefore investigated whether ultrasound guidance for sciatic and femoral nerve blocks prolongs sensory blockade in comparison with nerve stimulator guidance in children . METHODS Forty-six children scheduled for surgery of one lower extremity were r and omized to receive a sciatic and femoral nerve block under either ultrasound or nerve stimulator guidance . After induction of general anaesthesia , the blocks were performed using an ultrasound-guided multiple injection technique until the nerves were surrounded by levobupivacaine , or by nerve stimulator guidance using a predefined dose of 0.3 ml kg(-1 ) of levobupivacaine . An increase in heart rate of more than 15 % of baseline during surgery defined a failed block . The duration of the block was determined from the injection of local anaesthetic to the time when the patient received the first postoperative analgesic . RESULTS Two blocks in the nerve stimulator group failed . There were no failures in the ultrasound group . The duration of analgesia was longer in the ultrasound group mean ( sd ) 508 ( 178 ) vs 335 ( 169 ) min ( P < 0.05 ) . The volume of local anaesthetic in sciatic and femoral nerve blocks was reduced with ultrasound compared with nerve stimulator guidance [ 0.2 ( 0.06 ) vs 0.3 ml kg(-1 ) ( P < 0.001 ) and 0.15 ( 0.04 ) vs 0.3 ml kg(-1 ) ( P < 0.001 ) , respectively ] . CONCLUSIONS Ultrasound guidance for sciatic and femoral nerve blocks in children increased the duration of sensory blockade in comparison with nerve stimulator guidance . Prolonged sensory blockade was achieved with smaller volumes of local anaesthetic when using ultrasound guidance Abstract Objectives To evaluate the long term effects of perioperative β blockade on mortality and cardiac morbidity in patients with diabetes undergoing major non-cardiac surgery . Design R and omised placebo controlled and blinded multicentre trial . Analyses were by intention to treat . Setting University anaesthesia and surgical centres and one coordinating centre . Participants 921 patients aged > 39 scheduled for major non-cardiac surgery . Interventions 100 mg metoprolol controlled and extended release or placebo administered from the day before surgery to a maximum of eight perioperative days . Main outcome measures The composite primary outcome measure was time to all cause mortality , acute myocardial infa rct ion , unstable angina , or congestive heart failure . Secondary outcome measures were time to all cause mortality , cardiac mortality , and non-fatal cardiac morbidity . Results Mean duration of intervention was 4.6 days in the metoprolol group and 4.9 days in the placebo group . Metoprolol significantly reduced the mean heart rate by 11 % ( 95 % confidence interval 9 % to 13 % ) and mean blood pressure by 3 % ( 1 % to 5 % ) . The primary outcome occurred in 99 of 462 patients in the metoprolol group ( 21 % ) and 93 of 459 patients in the placebo group ( 20 % ) ( hazard ratio 1.06 , 0.80 to 1.41 ) during a median follow-up of 18 months ( range 6 - 30 ) . All cause mortality was 16 % ( 74/462 ) in the metoprolol group and 16 % ( 72/459 ) in the placebo group ( 1.03 , 0.74 to 1.42 ) . The difference in risk for the proportion of patients with serious adverse events was 2.4 % ( − 0.8 % to 5.6 % ) . Conclusions Perioperative metoprolol did not significantly affect mortality and cardiac morbidity in these patients with diabetes . Confidence intervals , however , were wide , and the issue needs re assessment . Trial registration Current Controlled Trials IS RCT N58485613 [ controlled-trials.com BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery . METHODS We performed a r and omized , multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infa rct ion within 30 days after major vascular surgery in patients at high risk for these events . High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography . Eligible patients were r and omly assigned to receive st and ard perioperative care or st and ard care plus perioperative beta-blockade with bisoprolol . RESULTS A total of 1351 patients were screened , and 846 were found to have one or more cardiac risk factors . Of these 846 patients , 173 had positive results on dobutamine echocardiography . Fifty-nine patients were r and omly assigned to receive bisoprolol , and 53 to receive st and ard care .  Fifty-three patients were excluded from r and omization because they were already taking a beta-blocker , and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing . Two patients in the bisoprolol group died of cardiac causes ( 3.4 percent ) , as compared with nine patients in the st and ard-care group ( 17 percent , P=0.02 ) . Nonfatal myocardial infa rct ion occurred in nine patients given st and ard care only ( 17 percent ) and in none of those given st and ard care plus bisoprolol ( P<0.001 ) . Thus , the primary study end point of death from cardiac causes or nonfatal myocardial infa rct ion occurred in 2 patients in the bisoprolol group ( 3.4 percent ) and 18 patients in the st and ard-care group ( 34 percent , P<0.001 ) . CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infa rct ion in high-risk patients who are undergoing major vascular surgery AIM To produce dietetic guidelines summarizing the systematic review evidence on dietary advice for secondary prevention of cardiovascular disease . METHODS The Cochrane Library , MEDLINE and EMBASE were comprehensively search ed for systematic review s on aspects of diet and heart health . Review s were included if they search ed systematic ally for r and omised controlled trials relating to diet and secondary prevention of cardiovascular disease . Two members of the UK Heart Health and Thoracic Dietitians Group critically appraised each review . The quality and results of each review were discussed and summarized in a whole group meeting . The guidelines were trialled in seven dietetic departments and modified where necessary . RESULTS Providing evidence -based dietary information ( including increasing omega-3 fat plus fruit and vegetable intake ) to all people after myocardial infa rct ion will save more lives than concentrating dietary advice on those in need of weight loss or lipid lowering . The practice of prioritizing dietetic time to those with raised lipids is out of date since the advent of statin therapy . CONCLUSION There is good systematic review evidence that dietary advice to those with cardiovascular disease can reduce mortality and morbidity as well as modify risk factors .  Dietary advice that does this most effectively should be prioritized Purpose Real-world data on the use of rivaroxaban in the perioperative period in patients undergoing major orthopedic surgery are limited . Subsets of data from the Phase IV , non-interventional XAMOS study were analyzed to explore the potential influence of timing of the first thrombo prophylactic dose , type of anesthesia , and concomitant mechanical prophylaxis on clinical outcomes in patients undergoing major orthopedic surgery in routine clinical practice . Patients and methods In XAMOS , 8,778 patients received rivaroxaban ( 10 mg once daily ) and 8,635 received st and ard-of-care ( SOC ) pharmacological prophylaxis  ( safety population ) . Crude incidences of symptomatic thromboembolic and treatment-emergent bleeding events were analyzed according to timing of the first postoperative thromboprophylactic dose , use of general or neuraxial anesthesia , and use of mechanical prophylaxis with pharmacological thromboprophylaxis . Results In the rivaroxaban group , the incidences of symptomatic thromboembolic events were 0.7 % , 1.0 % , and 0.7 % in patients receiving the first thromboprophylactic dose at ≤6 hours , > 6 hours to ≤10 hours , and > 10 hours to ≤24 hours after surgery , respectively . In the SOC group , the incidence of symptomatic thromboembolic events was slightly higher when the postoperative dose was given at > 10 hours to ≤24 hours ( 1.8 % vs 1.1 % at ≤6 hours and 1.3 % at > 6 hours to ≤10 hours ) . The antithrombotic effect of rivaroxaban was maintained in comparison to the SOC group . The incidence of major bleeding ( RECORD trial definition ) was low and similar between the two treatment groups and was not influenced by timing of the first thromboprophylactic dose . Neuraxial anesthesia was used more than any other form of anesthesia for both hip and knee surgery ; the effectiveness of rivaroxaban was not influenced by the type of anesthesia used . No spinal hematomas were reported in patients receiving neuraxial anesthesia in either treatment group . Use of mechanical thromboprophylaxis in addition to rivaroxaban or SOC pharmacological prophylaxis did not reduce the risk of thromboembolic events further . Conclusion The effectiveness and safety of rivaroxaban in patients undergoing major orthopedic surgery in routine clinical practice were maintained irrespective of timing of the first postoperative dose within 24 hours after surgery , the type of anesthesia , and the additional use of mechanical thromboprophylaxis BACKGROUND Peripheral neural blockade appears to provide effective analgesia with potentially less morbidity than central neuraxial techniques . We compared the relative benefits of combined femoral ( 3-in-1 ) and sciatic nerve block with epidural blockade for postoperative knee arthroplasty analgesia . METHODS Sixty patients , ASA I-III , undergoing unilateral knee replacement were prospect ively r and omized to receive either a lumbar epidural infusion or combined single-shot femoral ( 3-in-1 ) and sciatic blocks ( combined blocks ) . All patients received st and ard general anaesthesia .  Visual analogue pain scores and rescue opioid requirements were recorded at four time points postoperatively . Patient satisfaction , morbidity , block insertion time , perioperative blood loss and rehabilitation indices were also assessed . RESULTS In both groups , pain on movement was well controlled at discharge from recovery and 6 h postoperatively but increased at 24 and 48 h. Median ( 95 % CI ) analogue scale scores were 0 ( 0 - 0 ) , 15 ( 0 - 30 ) , 55 ( 38 - 75 ) and 54 ( 30 - 67 ) mm for epidural block and 0.5 ( 0 - 22 ) , 21.5 ( 10 - 28 ) , 40 ( 20 - 50 ) and 34.5 ( 21 - 55 ) mm for combined block . VAS pain scores with the combined blocks were significantly lower at 24 h ( P=0.004 ) . Total morphine usage was low in both groups : median epidural group 17 mg ( 8 - 32 ) versus combined blocks 13 mg ( 7.8 - 27.5 ) . Patient satisfaction was high in both groups with median ( 95 % CI ) scores of 100 ( 85 - 100 ) , 83 ( 70 - 100 ) and 82 ( 57 - 90 ) mm for epidural and 90 ( 73 - 100 ) , 100 ( 77 - 100 ) and 97 ( 80 - 100 ) mm for combined blocks ( not significant ) . Perioperative blood loss and rehabilitation indices were also similar . CONCLUSIONS Combined femoral ( 3-in-1 ) and sciatic blocks offer a practical alternative to epidural analgesia for unilateral knee replacements This study explored whether patients ’ preference for particular types of anaesthesia  could be influenced pre‐operatively by giving them the addresses of various relevant websites . Patients at an orthopaedic pre‐ assessment education clinic completed a question naire , which included a short multiple‐choice general knowledge quiz about anaesthesia , and also question ed them as to their choice of anaesthesia ( general or neuraxial ) . Patients were r and omly assigned to intervention or control groups . Intervention group members were given the addresses of three relevant anaesthesia and health related websites to access at home . All patients were asked to complete the question naires on a second occasion , before surgery . Initially , most patients stated a preference for general anaesthesia . Subsequently , the intervention group altered their preference towards neuraxial anaesthesia compared to the control group ( p ≤ 0.0001 ) . The increase in median ( IQR [ range ] ) anaesthesia knowledge test score was greater in the intervention group ( from 10.0 ( 9.0–12.0 [ 5.0–14.0 ] ) to 13.0 ( 11.0–14.0 [ 6.0–14.0 ] ) ) than in the control group ( from 10.0 ( 9.0–11.5 [ 3.0–13.0 ] ) to 11.0 ( 9.0–12.0 [ 4.0–14.0 ] ) ; p = 0.0068 ) OBJECTIVE To assess whether a pragmatic policy of perioperative beta-blockade , with metoprolol , reduced the 30-day cardiovascular morbidity and mortality and reduced the length of hospital stay in average patients undergoing infrarenal vascular surgery . METHODS This was a double-blind r and omized placebo-controlled trial that occurred in vascular surgical units in four UK hospitals . Participants were 103 patients without previous myocardial infa rct ion who had infrarenal vascular surgery between July 2001 and March 2004 . Interventions were oral metoprolol ( 50 mg twice daily , supplemented by intravenous doses when necessary ) or placebo from admission until 7 days after surgery . Holter monitors were kept in place for 72 hours after surgery . RESULTS Eighty men and 23 women ( median age , 73 years ) were r and omized , 55 to  metoprolol  and 48 to placebo , and 97 ( 94 % ) underwent surgery during the trial . The most common operations were aortic aneurysm repair ( 38 % ) and distal bypass ( 29 % ) . Intraoperative inotropic support was required in 64 % and 92 % of patients in the placebo and metoprolol groups , respectively . Within 30 days , cardiovascular events occurred in 32 patients , including myocardial infa rct ion ( 8 % ) , unstable angina ( 9 % ) , ventricular tachycardia ( 19 % ) , and stroke ( 1 % ) . Four ( 4 % ) deaths were reported . Cardiovascular events occurred in 15 ( 34 % ) and 17 ( 32 % ) patients in the placebo and metoprolol groups , respectively ( unadjusted relative risk , 0.94 ; 95 % confidence interval , 0.53 - 1.66 ; adjusted [ for age , sex , statin use , and aortic cross-clamping ] relative risk , 0.87 ; 95 % confidence interval , 0.48 - 1.55 ) . Time from operation to discharge was reduced from a median of 12 days ( 95 % confidence interval , 9 - 19 days ) in the placebo group to 10 days ( 95 % confidence interval , 8 - 12 days ) in the metoprolol group ( adjusted hazard ratio , 1.71 ; 95 % confidence interval , 1.09 - 2.66 ; P < .02 ) . CONCLUSIONS Myocardial ischemia was evident in a high proportion ( one third ) of the patients after surgery . A pragmatic regimen of perioperative beta-blockade with metoprolol did not seem to reduce 30-day cardiovascular events , but it did decrease the time from surgery to discharge Patients receiving anticoagulants could be at higher risk of compressive haematoma with neuraxial anaesthesia use . The phase III RECORD programme compared rivaroxaban with enoxaparin for prevention of venous thromboembolism after total hip or knee replacement surgery in more than 12,500 patients . This observational analysis evaluated the risk of neuraxial haematoma after neuraxial anaesthesia in patients receiving rivaroxaban or enoxaparin  using pooled RECORD1–4 data BACKGROUND Data are scarce on the advantage of ultrasound-guided spinal anaesthesia in patients with easily identifiable bony l and marks . In this study , we compared the use of ultrasound to the l and mark method in patients with no anticipated technical difficulty , presenting for caesarean delivery under spinal anaesthesia . METHODS A total of 150 pregnant women were recruited in this r and omized , controlled study . Ultrasound examination and spinal anaesthesia were performed by three anaesthetists with experience in ultrasound-guided neuraxial block . Patients were r and omized to either the Ultrasound Group ( n=75 ) or the L and mark Group ( n=75 ) . In both groups the level of L3 - 4 or L4 - 5 was identified by ultrasound ( transverse and longitudinal approach ) or palpation . The primary outcome was the procedure time , measured from the time of skin puncture by the introducer to the time of viewing cerebrospinal fluid at the hub of the spinal needle . Secondary outcomes were the number of skin punctures , number of passes , and incidence of successful spinal blockade . RESULTS The average procedure time , number of skin punctures and needle passes , were similar in both groups . The number of patients with successful spinal anaesthesia after one puncture was not statistically different between the groups . CONCLUSION The present results indicate that when performed by anaesthetists experienced in both ultrasound and l and mark techniques , the use of ultrasound does not appear to increase the success rate of spinal anaesthesia , or reduce the procedure time or number of attempts in obstetric patients with easily palpable spines Ultrasound assistance for neuraxial techniques may improve technical performance ; however , it is unclear which population s benefit most . Our study aim ed to investigate the efficacy of neuraxial ultrasound in women having caesarean section with combined spinal‐epidural anaesthesia , and to identify factors associated with improved technical performance . Two‐hundred and eighteen women were r and omly allocated to ultrasound‐assisted or control groups . All the women had a pre‐procedure ultrasound , but only women in the  ultrasound group had this information conveyed to the anaesthetist . Primary outcomes were first‐pass success ( a single needle insertion with no redirections ) and procedure difficulty . Secondary outcomes were block quality , patient experience and complications . Exploratory sub‐group analysis and regression analysis were used to identify factors associated with success . Data from 215 women were analysed .  First‐pass success was achieved in 67 ( 63.8 % ) and 42 ( 38.2 % ) women in the ultrasound and control groups , respectively ( adjusted p = 0.001 ) . Combined spinal‐epidural anaesthesia was ‘ difficult ’ in 19 ( 18.1 % ) and 33 ( 30.0 % ) women in the ultrasound and control groups , respectively ( adjusted p = 0.09 ) . Secondary outcomes did not differ significantly . Anaesthetists misidentified the intervertebral level by two or more spaces in 23 ( 10.7 % ) women . Sub‐group analysis demonstrated a benefit for ultrasound in women with easily palpable spinous processes ( adjusted p = 0.027 ) . Regression analysis identified use of ultrasound and easily palpable spinous processes to be associated with first‐pass success Background Despite evidence that regional anesthesia may be associated with fewer perioperative complications than general anesthesia , most studies that have compared cardiac outcome after general or regional anesthesia alone have not shown major differences . This study examines the impact of anesthetic choice on cardiac outcome in patients undergoing peripheral vascular surgery who have a high likelihood of associated coronary artery disease . Methods Four hundred twenty‐three patients , between 1988 and 1991 , were r and omly assigned to receive general ( n = 138 ) , epidural ( n = 149 ) , or spinal anesthesia ( n = 136 ) for femoral to distal artery bypass surgery . All patients were monitored with radial artery and pulmonary artery catheters . Postoperatively , patients were in a monitored setting for 48–72 h and had daily electrocardiograms for 4–5 days and creatine phosphokinase/isoenzymes every 8 h x 3 , then daily for 4 days . Cardiac outcomes recorded were myocardial infa rct ion , angina , and congestive heart failure . Results Baseline clinical characteristics were not different between anesthetic groups . Overall , the patient population included 86 % who were diabetic , 69 % with hypertension , 36 % with a history of a prior myocardial infa rct ion , and 41 % with a history of smoking . Cardiovascular morbidity and overall mortality were not significantly different between groups when analyzed by either intention to treat or type of anesthesia received . In the intention to treat analysis , incidences of cardiac event or death for general , spinal , and epidural groups were 16.7 % , 21.3 % , and 15.4 % , respectively . The absolute risk difference observed between general and all regional anesthesia groups for cardiac event or death was ‐1.6 % ( 95 % confidence interval ‐9.2 % , 6.1 % ) This reflected a nonsignificant trend for lower risk of postoperative events with general anesthesia . Conclusions The choice of anesthesia , when delivered as described , does not significantly influence cardiac morbidity and overall mortality in patients undergoing peripheral vascular surgery Background : Two wounds are created after abdominal surgery . The surgical insult to the peritoneal cavity and viscera has not been emphasized as a target for interventions . In animal models vagotomy blunts the intraperitoneal response to induced inflammation . This is not feasible in humans . However a transient chemical afferentectomy after colectomy by using neuraxial blockade ( epidural ) and intraperitoneal blockade may be possible . We investigated the effects of intraoperative instillation and postoperative infusion of intraperitoneal local anesthetic ( IPLA ) on recovery parameters after colectomy , in the setting of an established enhanced recovery after surgery ( ERAS ) program . Methods : Double blinded , r and omized , placebo controlled design . The study group ( IPLA ) received instillation of intraperitoneal ropivacaine ( 75 mg ) before dissection and postoperative infusion of 0.2 % solution at 4 mL/hour for 3 days continuously . The placebo group ( NS ) was treated as above with 0.9 % saline solution . All patients were cared for under ERAS st and ardized perioperative care . Epidural infusion was stopped on day 2 . Patients were discharged from day 3 onwards once criteria met . Perioperative data , surgical recovery score ( SRS ) , complications , and length of stay were recorded . Systemic cytokines response , neuroendocrine parameters , pain measures and opioid use data were collected . Patients were followed up for 60 days . Results : Sixty patients were recruited . Patients were equivalently matched at baseline . There were no local anesthetic related adverse events . The complication rate , including anastomotic leak rate , was equivalent between groups . IPLA group had better SRS scores for the duration of intraperitoneal infusion . Pain and opioid use was reduced in the IPLA group . Systemic cytokine and cortisol response was diminished in the IPLA group . IPLA group had consistently higher systemic ropivacaine levels than placebo group . Conclusion : Instillation and infusion of intraperitoneal ropivacaine after colectomy improves early surgical recovery . This was associated with a blunting of postsurgical systemic cytokines and cortisol . Patients also had significantly reduced pain and opioid use over and above the effect of an epidural infusion . Therefore a transient chemical afferentectomy with clinical benefit is possible with this method . A longer IPLA infusion duration needs to be studied . This study is registered at clinical trials.gov and carries the ID number NCT00722709 Although the protein-sparing effect of neuraxial blockade after abdominal surgery is well established , its metabolic effect after operations on the lower extremities remains unclear . In this study , we tested the hypothesis that combined spinal and epidural blockade ( CSE ) inhibits amino acid oxidation after hip surgery . Sixteen patients undergoing hip replacement surgery received either general anesthesia followed by IV patient-controlled analgesia with piritramide ( control ; n = 8) or CSE using bupivacaine 0.5 % for spinal anesthesia and ropivacaine 0.2 % with 0.5 & mgr;g/mL of sufentanil for postoperative epidural analgesia ( CSE ; n = 8) . Glucose and protein kinetics were assessed by stable isotope tracer technique ( [6,6 - 2H2]glucose , L-[1 - 13C]leucine ) on the day before and one day after surgery . Plasma concentrations of glucose , lactate , free fatty acids , cortisol , glucagon , and insulin were also determined . CSE prevented the increase in plasma glucose concentration during and immediately after the operation ( 60 min after skin incision : CSE 4.9 ± 0.7 versus control 6.2 ± 0.7 mmol/L ; P < 0.05 ; postanesthesia care unit : CSE 5.0 ± 0.9 versus control 7.3 ± 1.1 mmol/L ; P < 0.05 ) . Intraoperative cortisol plasma concentrations were smaller in the CSE group than in the control group . One day after the operation , however , glucose plasma concentration , glucose production , and glucose clearance were comparable in both groups . CSE inhibited the postoperative increase in leucine oxidation rate ( CSE 30 ± 12 versus control 43 ± 8 & mgr;mol·kg−1·h−1 ; P < 0.05 ) . There were no differences between the groups in protein breakdown , whole body protein synthesis , and plasma concentrations of lactate , free fatty acids , insulin , and glucagon . In conclusion , CSE prevents hyperglycemia during hip surgery and inhibits protein catabolism thereafter BACKGROUND Nitrous oxide is commonly used in general anaesthesia but concerns exist that it might increase perioperative cardiovascular risk . We aim ed to gather evidence to establish whether nitrous oxide affects perioperative cardiovascular risk . METHODS We did an international , r and omised , assessor-blinded trial in patients aged at least 45 years with known or suspected coronary artery disease having major non-cardiac surgery . Patients were r and omly assigned via automated telephone service , stratified by site , to receive a general anaesthetic with or without nitrous oxide . Attending anaesthetists were aware of patients ' group assignments , but patients and assessors were not . The primary outcome measure was a composite of death and cardiovascular complications ( non-fatal myocardial infa rct ion , stroke , pulmonary embolism , or cardiac arrest ) within 30 days of surgery . Our modified intention-to-treat population included all patients r and omly assigned to groups and undergoing induction of general anaesthesia for surgery . This trial is registered at Clinical Trials.gov , number NCT00430989 . FINDINGS Of 10,102 eligible patients , we enrolled 7112 patients between May 30 , 2008 , and Sept 28 , 2013 . 3543 were assigned to receive nitrous oxide and 3569 were assigned not to receive nitrous oxide . 3483 patients receiving nitrous oxide and 3509 not receiving nitrous oxide were assessed for the primary outcome . The primary outcome occurred in 283 ( 8 % ) patients receiving nitrous oxide and in 296 ( 8 % ) patients not receiving nitrous oxide ( relative risk 0·96 , 95 % CI 0·83–1·12 ; p=0·64 ) . Surgical site infection occurred in 321 ( 9 % ) patients assigned to nitrous oxide , and in 311 ( 9 % ) patients in the no-nitrous oxide group ( p=0·61 ) , and severe nausea and vomiting occurred in 506 patients ( 15 % ) assigned to nitrous oxide and 378 patients ( 11 % ) not assigned to nitrous oxide ( p<0·0001 ) . INTERPRETATION Our findings support the safety profile of nitrous oxide use in major non-cardiac surgery . Nitrous oxide did not increase the risk of death and cardiovascular complications or surgical-site infection , the emetogenic effect of nitrous oxide can be controlled with antiemetic prophylaxis , and a desired effect of reduced volatile agent use was shown . FUNDING Australian National Health and Medical Research Council ; Australian and New Zeal and College of Anaesthetists ; Heart and Stroke Foundation of Quebec , Heart and Stroke Foundation of Ontario , Canada ; General Research Fund of the Research Grant Council , Hong Kong Special Administrative Region , China Forced-air warming is commonly used to warm patients intraoperatively , but may not achieve normothermia during a short procedure . Comparative trials of a new radiant warming device in general anaesthesia ( Suntouch ™ , Fisher and Paykel , Auckl and , New Zeal and ) have had conflicting results . We conducted a r and omized controlled trial to compare the efficacy and thermal comfort of the Suntouch ™ radiant warmer and forced-air warming in patients at high risk of hypothermia during neuraxial blockade . With ethics committee approval , 60 patients having transurethral resection of the prostate under spinal were r and omized to either radiant warming or forced-air warming . All intravenous and irrigation fluids were warmed but pre-warming was not used . The final intraoperative rectal temperatures for the radiant warming and forced-air warming groups were 36.1 ° C and 36.4 ° C respectively ( P=0.03 ) . A large proportion of patients in both groups ( 46 % and 33 % respectively , P=0.3 ) were hypothermic ( < 36 ° C ) on arrival in the post-anaesthesia care unit . No other patient variables were significantly different . Neither warming device reliably prevented hypothermia , although forced-air warming was slightly superior
Compared with general anaesthesia , a central neuraxial block may reduce the zero to 30-day mortality for patients undergoing surgery with intermediate to high cardiac risk ( level of evidence , moderate ) .
BACKGROUND Various beneficial effects derived from neuraxial blocks have been reported .
However , it is unclear whether these effects have an influence on perioperative mortality and major pulmonary/cardiovascular complications .
OBJECTIVES Our primary objective was to summarize Cochrane systematic review s that assess the effects of neuraxial blockade on perioperative rates of death , chest infection and myocardial infa rct ion by integrating the evidence from all such review s that have compared neuraxial blockade with or without general anaesthesia versus general anaesthesia alone for different types of surgery in various population s. Our secondary objective was to summarize the evidence on adverse effects ( an adverse event for which a causal relation between the intervention and the event is at least a reasonable possibility ) of neuraxial blockade .