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 The Effect of Neuraxial Versus General Anesthesia Techniques on Postoperative Quality of Recovery and Analgesia After Abdominal Hysterectomy: A Prospective, Randomized, Controlled Trial A randomized study of maternal serum cytokine levels following cesarean section under general or neuraxial anesthesia. 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 Effects of two different anesthesia-analgesia methods on incidence of postoperative delirium in elderly patients undergoing major thoracic and abdominal surgery: study rationale and protocol for a multicenter randomized controlled trial Laryngeal mask airway versus endotracheal tube for outpatient surgery: analysis of anesthesia-controlled time. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition) Spinal Versus General Anesthesia for Orthopedic Surgery: Anesthesia Drug and Supply Costs Ultrasound Imaging Facilitates Spinal Anesthesia in Adults with Difficult Surface Anatomic Landmarks Can postoperative nausea and vomiting be predicted? The Effect of Epidural Versus General Anesthesia on Postoperative Pain and Analgesic Requirements in Patients Undergoing Radical Prostatectomy [The effect of anesthesiologic technique on the mental state of elderly patients submitted for orthopedic surgery of the lower limbs]. Anesthesia with ketamine, propofol, and fentanyl decreases the frequency of postoperative psychosis emergence and confusion in schizophrenic patients. Effect of preoperative feeding on gallbladder size and peristaltic of the small bowel following spinal anesthesia for the hip surgery. The Anticatabolic Effect of Neuraxial Blockade After Hip Surgery Goal-Directed Fluid Therapy Based on Stroke Volume Variations Improves Fluid Management and Gastrointestinal Perfusion in Patients Undergoing Major Orthopedic Surgery Active warming, not passive heat retention, maintains normothermia during combined epidural-general anesthesia for hip and knee arthroplasty. Cognitive effects after epidural vs general anesthesia in older adults. A randomized trial. Postoperative Pain in Ambulatory Surgery Comparison of Domperidone, Droperidol, and Metoclopramide in the Prevention and Treatment of Nausea and Vomiting after Balanced General Anesthesia Simplified use of mixed propofol and alfentanil for anesthesia in remote locations. Intraoperative Modulation of Alveolar Macrophage Function during Isoflurane and Propofol Anesthesia The improved quality of postoperative analgesia after intrathecal morphine does not result in improved recovery and quality of life in the first 6 months after orthopedic surgery: a randomized controlled pilot study
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 : Patients undergoing abdominal hysterectomy often have significant postoperative pain despite the use of concurrent multimodal pain strategies . Neuraxial anesthesia has opioid-sparing effects and may provide better postoperative recovery to patients when compared with general anesthesia . Our main objective in this study was to compare the effects of neuraxial and general anesthesia on postoperative quality of recovery after abdominal hysterectomy . METHODS : The study was a prospect i ve , r and omized , controlled clinical trial . Seventy healthy females were recruited and r and omized to a general anesthesia or neuraxial technique  as their primary anesthetic regimen . The primary outcome was the global quality of recovery—40 question naire ( QoR–40 ) at 24 hours after the surgical procedure . Other data collected included postoperative pain scores and opioid consumption . Data were analyzed using the Mann – Whitney U test , Fisher 's exact test , and linear regression . A P value < 0.05 was considered statistically significant . RESULTS : The median difference ( 95 % confidence interval [ CI ] ) in the global QoR–40 score at 24 hours between the neuraxial and general anesthesia groups was 17 ( 11 to 21.5 ) ( P < 0.001 ) . Patients in the neuraxial anesthesia group had better quality of recovery scores in all the QoR–40 subcomponents than did the general anesthesia group ( all P < 0.005 ) . The median difference in global QoR–40 scores at 48 hours between the neuraxial anesthesia and the general anesthesia groups was 8 ( 6–10 ) ( P < 0.001 ) . Postoperative opioid consumption and pain scores were higher in the general anesthesia group than in the neuraxial anesthesia group . There was an inverse linear relationship between opioid consumption and postoperative quality of recovery at 24 hours , r 2 = 0.67 ( P < 0.0001 , 95 % CI of 0.77 to 0.51 ) , and at 48 hours , r 2 = 0.58 ( P < 0.0001 , 95 % CI of 0.72 to 0.42 ) . CONCLUSION : Neuraxial anesthesia provides better quality of recovery than does general anesthesia for patients undergoing abdominal hysterectomy . The opioid-sparing effects of neuraxial anesthesia were associated with a better quality of recovery in patients after the surgical procedure . In the absence of contraindications , neuraxial anesthesia seems to be a better anesthetic plan for those patients BACKGROUND Cytokines are significant mediators of the immune response to surgery and also play a role in parturition . The aim of the study was to investigate the impact of the anesthetic technique for cesarean section on plasma levels of cytokines IL-6 and TNF-alpha . METHODS Thirty-five parturients scheduled for elective cesarean section were r and omly assigned to  general ( n=18 ) or neuraxial ( n=17 ) anesthesia . The general anesthesia group received thiopental 4 mg/kg , succinylcholine 1 - 1.5 mg/kg and 1 % end-tidal concentration of sevoflurane in nitrous oxide and 50 % oxygen . The neuraxial anesthesia group received intrathecal 0.5 % levobupivacaine 1.8 - 2.2 mL and epidural fentanyl 1 microg/kg . Blood sample s were taken for IL-6 and TNF-alpha immediately after positioning the parturient on the operating table , after uterine incision and before the umbilical cord clamping and 24h after surgery ( T(1 ) , T(2 ) and T(3 ) respectively ) . RESULTS The two groups did not differ in IL-6 ( P=0.15 ) or TNF-alpha ( P=0.73 ) serum concentrations at any time point . In the general and neuraxial anesthesia groups , IL-6 serum concentrations were significantly higher in the third blood sample , T(3 ) ( 12.2+/-5.0 and 15.2+/-4.3 pg/mL ) , than in T(1 ) ( 0.41+/-0.38 and 0.29+/-0.10 pg/mL ) and T(2 ) ( 0.37+/-0.47 and 0.24+/-0.05 ) respectively ( P<0.001 ) . Within each group , serum TNF-alpha concentrations did not differ significantly over time ( P=0.44 ) . CONCLUSIONS Under the present study design anesthetic technique did not affect IL-6 or TNF-alpha concentrations in parturients undergoing elective cesarean section . Serum IL-6 levels increased 24 h postoperatively independently of anesthetic technique 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 Background Delirium is a common complication in elderly patients after surgery and associated with increased morbidity and mortality . Studies suggest that deep anesthesia and intense pain are important precipitating factors of postoperative delirium . Neuraxial block is frequently used in combination with general anesthesia for patients undergoing major thoracic and abdominal surgery . Compared with general anesthesia alone and postoperative intravenous analgesia , combined epidural-general anesthesia and postoperative epidural analgesia decreases the requirement of general anesthetics during surgery and provided better pain relief after surgery . However , whether combined epidural-general anesthesia plus epidural analgesia is superior to general anesthesia plus intravenous analgesia in decreasing the incidence of postoperative delirium remains unknown . Methods / design This is a multicenter , open-label , r and omized , parallel-controlled clinical trial . One thous and eight hundred elderly patients ( age range 60–90 years ) who are scheduled to undergo major thoracic or abdominal surgery are r and omized to receive either general anesthesia plus postoperative intravenous analgesia or combined epidural-general anesthesia plus postoperative epidural analgesia . The primary outcome is the 7-day incidence of postoperative delirium . Secondary outcomes include the duration of postoperative delirium , the intensity of pain during the first three days after surgery , the 30-day incidences of postoperative non-delirium complications , the length of stay in hospital after surgery and 30-day all-cause mortality . Discussion Results of the present study will provide information to guide clinical practice in choosing appropriate anesthesia-analgesia method for elderly patients undergoing major thoracic and abdominal surgery . Trial registration The study is registered on Clinical Trials.gov NCT01661907 and Chinese Clinical Trial Registry ChiCTR-TRC-12002371 STUDY OBJECTIVE To show that efficiency of operating room times can be improved significantly using rapid changes between operative procedures . DESIGN R and omized , prospect i ve clinical study . SETTING Tertiary care university hospital , elective peripheral trauma-related orthopedic surgery . PATIENTS 72 adult , ASA physical status I , II , and III patients scheduled for elective peripheral trauma-related orthopedic surgery requiring general anesthesia . INTERVENTIONS Patient airways were managed using either a Laryngeal Mask Airway ( LMA ) or an endotracheal tube ( ETT ) in the h and s of anesthesiologists experienced in both . They were not informed as to the primary intention of the study . All perioperative data , including the preoperative and postoperative outpatient stay at the outpatient surgical ward , were recorded with an anesthesia information management system . MEASUREMENTS The primary outcome measures were : time needed for anesthesia induction and emergence from anesthesia . All manual recording into the anesthesia information management system during anesthesia was accomplished by nurses who were uninformed as to the aim of the study . MAIN RESULTS Anesthesia induction was significantly ( p < 0.01 ) shorter using LMAs ( means + /- SD , medians , [ interquartile ranges ] ) ( LMA : 5.8 + /- 1.5 , 5 , [ 5;7 ] vs. ETT : 7.4 + /- 1.8 , 7 , [ 7;8 ] min ) , whereas emergence from anesthesia was not different ( LMA : 11.8 + /- 3.3 , 11 , [ 9;14 ] vs. ETT : 13.2 + /- 4.8 ; 12 , [ 10;16 ] min ) . CONCLUSION The clinical relevance of reduced anesthesia induction time using LMA is question able . The lack of difference in emergence time could be a result of the use of total intravenous anesthesia 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 Total hip or knee replacement surgeries are common orthopedic interventions that can be performed with spinal anesthesia ( SA ) or general anesthesia ( GA ) . No study has investigated the economic aspects associated with the two anesthetic techniques for this common surgery . We r and omized 40 patients to receive either SA or GA  and analyzed the drug and supply costs for anesthesia und recovery . Anesthesia-related times , hemodynamic variables , and pain scores were also recorded . Total costs per case without personnel costs were almost half in the SA group compared with the GA group ; this was a result of less cost for anesthesia ( P < 0.01 ) and for recovery ( P < 0.05 ) . This finding was supported by a sensitivity analysis . There were no relevant differences regarding anesthesia-related times . Patients in the GA group were admitted to the postanesthesia care unit with a higher pain score and needed more analgesics than patients in the SA group ( both P < 0.01 ) . We conclude that SA is a more cost-effective alternative to GA in patients undergoing hip or knee replacement , as it is associated with lower fixed and variable costs . Moreover , SA seems to be more effective , as patients in the SA group showed lower postoperative pain scores during their stay in the postanesthesia care unit Background : Poor surface anatomic l and marks are highly predictive of technical difficulty in neuraxial blockade . The authors examined the use of ultrasound imaging to reduce this difficulty . Methods : The authors recruited 120 orthopedic patients with one of the following : body mass index more than 35 kg/m2 and poorly palpable spinous processes ; moderate to severe lumbar scoliosis ; or previous lumbar spine surgery . Patients were r and omized to receive spinal anesthetic by the conventional surface l and mark-guided technique ( group LM ) or by an ultrasound-guided technique ( group US ) . Patients in group US had a preprocedural ultrasound scan to locate and mark a suitable needle insertion point . The primary outcome was the rate of successful dural puncture on the first needle insertion attempt . Normally distributed data were summarized as mean ± SD and nonnormally distributed data were summarized as median [ interquartile range ] . Results : The first-attempt success rate was twice as high in group US than in group LM ( 65 % vs. 32 % ; P < 0.001 ) . There was a twofold difference between groups in the number of needle insertion attempts ( group US , 1 [ 1–2 ] vs. group LM , 2 [ 1–4 ] ; P < 0.001 ) and number of needle passes ( group US , 6 [ 1–10 ] vs. group LM , 13 [ 5–21 ] ; P = 0.003 ) . More time was required to establish l and marks in group US ( 6.7 ± 3.1 ; group LM , 0.6 ± 0.5 min ; P < 0.001 ) , but this was partially offset by a shorter spinal anesthesia performance time ( group US , 5.0 ± 4.9 vs. group LM , 7.3 ± 7.6 min ; P = 0.038 ) . Similar results were seen in subgroup analyses of patients with body mass index more than 35 kg/m2 and patients with poorly palpable l and marks . Conclusion : Preprocedural ultrasound imaging facilitates the performance of spinal anesthesia in the nonobstetric patient population with difficult anatomic l and marks BACKGROUND Iletrospective studies fail to identify predictors of postoperative nausea and vomiting ( PONV ) . The authors prospect ively studied 17,638 consecutive out patients who had surgery to identify predictors . METHODS Data on medical conditions , anesthesia , surgery , and PONV were collected in the post-anesthesia care unit , in the ambulatory surgical unit , and in telephone interviews conducted 24 h after surgery . Multiple logistic regression with backward stepwise elimination was used to develop a predictive model An independent set of patients was used to vali date the model RESULTS Age ( younger or older ) , sex ( female or male ) , smoking status ( nonsmokers or smokers ) , previous PONV , type of anesthesia ( general or other ) , duration of anesthesia ( longer or shorter ) , and type of surgery ( plastic , orthopedic shoulder , or other ) were independent predictors of PONV . A 10-yr increase in age decreased the likelihood of PONV by 13 % . The risk for men was one third that for women . A 30-min increase in the duration of anesthesia increased the likelihood of PONV by 59 % . General anesthesia increased the likelihood of PONV 11 times compared with other types of anesthesia . Patients with plastic and orthopedic shoulder surgery had a sixfold increase in the risk for PONV . The model predicted PONV accurately and yielded an area under the receiver operating characteristic curve of 0.785+/-0.011 using an independent validation set . CONCLUSIONS A vali date d mathematical model is provided to calculate the risk of PONV in out patients having surgery . Knowing the factors that predict PONV will help anesthesiologists determine which patients will need antiemetic therapy Background Although preemptive analgesia has been shown to decrease postinjury pain in animals , studies in humans have provided controversial results . The authors studied whether surgical epidural anesthesia with local anesthetics could affect postoperative pain and analgesic dem and s , when compared with general anesthesia . Methods Male patients scheduled for radical retropubic prostatectomy were r and omly assigned to receive  epidural anesthesia only ( EA , n = 34 ) , combined epidural and general anesthesia ( EG , n = 32 ) , or general anesthesia only ( GA , n = 30 ) . A lumbar epidural catheter was inserted and tested in all patients . In the EA group , an induction dose of 0.25 ml/kg epidural bupivacaine ( 0.5 % ) was followed during surgery by a continuous infusion of 0.1 ml.kg–1.h–10.125 % bupivacaine . In the EG group , 0.2 ml/kg epidural bupivacaine ( 0.5 % ) was injected after induction of general anesthesia but before surgery , followed by epidural infusion of 0.1 ml.kg–1.h–10.125 % bupivacaine . In the GA group , anesthesia was maintained with morphine , isoflurane , and N2O . Epidural patient-controlled analgesia ( PCA ) was provided with bupivacaine and fentanyl for all patients in the postoperative period . Postoperative pain scores and analgesic requirements were examined and compared between groups every 4–8 h for 3–5 postoperative days . Results Intraoperatively , EA patients received significantly more epidural bupivacaine than EG patients ( 129 ± 6 mg vs. 98 ± 6 mg , respectively . Recovery room median residual sensory level in EA patients ( T6 ± 2 ) was significantly higher than in EG patients ( T10 ± 2 ) . PCA dem and was greater in the GA and EG groups when compared with the EA group in postoperative days 2 ( 126 ± 9 ml , 112 ± 9 ml , 90 ± 6 ml , respectively ; P = 0.01 ) and 3 ( 89 ± 10 ml , 83 ± 9 ml , 48 ± 5 respectively ; P = 0.005 ) . There was no difference in PCA dem and between the GA and EG groups in the postoperative period . No significant clinical differences in postoperative mean pain scores were recorded in the first 5 days after surgery in the three anesthetic groups ( range 0–2/10 ) . Conclusions In patients undergoing lower abdominal surgery , the neuraxial blockade and surgical anesthesia achieved by epidural local anesthetics was associated with decreased postoperative analgesic dem and s. Lower postoperative analgesic requirements in the EA group , when compared with both the EG and GA groups , indicate that : ( 1 ) EA patients had less postoperative pain , and ( 2 ) an efficient intraoperative blockade of noxious afferent signals to the central nervous system is fundamental in reducing postoperative pain UNLABELLED Influence of anesthetic technique on mental status in elderly patients su bmi tted to major orthopedic procedures of lower limbs . Mental impairment is a common occurrence in elderly patients after major orthopedic surgery . Few studies have been published so far on this topic in spite of its relevant clinical and economic implication s. OBJECTIVE 1 ) To verify whether anesthesia has a causative role in postoperative mental confusion in elderly patients ; 2 ) to compare the effects of General Anesthesia ( GA ) and Spinal Anesthesia ( SA ) on mental status . DESIGN Controlled , comparative study . PATIENTS Sixty patients aged > or = 70 , ASA I-II , su bmi tted to femoral neck repair . SETTING Anesthesia Dept . and Orthopedic Dept . of a District Hospital in Italy . METHOD The day before surgery the mental status of elected patients was evaluated employing a modified Organic Brain Syndrome ( OBS ) scale ( Gustafsson ) . The better the mental status , the lesser the OBS score . It was possible therefore to distinguish " oriented " from " confuse " patients ( 38 vs 22 ) if they scored < or = 6 or > 6 respectively . Patients from each group were than r and omly assigned to receive either GA or selective SA . Neither group was premedicated . GA was induced with propofol 1 mg/kg and maintained with O2/N2O 40/60 % and isoflurane ; atracurium was employed to facilitate mioresolution . Spinal anesthesia was performed with hyperbaric 1 % bupivacaine . All patients were monitored in the Recovery Room ( RR ) for at least one hour . Occurrence of hypotension and /or hypoxia in the Operating Room ( OR ) or the RR was immediately treated . Mental status was reassessed on the 1st and 2nd postoperative day and results were compared with the corresponding preoperative OBS scores both in GA patients and in SA patients . RESULTS No statistically significant differences were found between pre- and postoperative OBS scores in both GA and SA group , whether " oriented " or " confuse " . CONCLUSIONS Mental status of elderly patients su bmi tted to femoral neck repair does n't seem to be influenced by the anesthetic technique chosen , independent of preoperative psychic conditions STUDY OBJECTIVE To investigate whether total IV anesthesia with ketamine , propofol , and fentanyl affects the frequency of postoperative psychosis emergence or confusion in schizophrenic patients . DESIGN Prospect i ve , controlled study . SETTING Hirosaki National Hospital and Hako date Watanabe Hospital . PATIENTS 76 ASA physical status I and II schizophrenic patients taking chronic antipsychotic drugs and schedule for orthopedic surgery of extremities . INTERVENTIONS In Group A ( n = 38 ) patients , anesthesia was maintained with sevoflurane , nitrous oxide , and fentanyl . In Group B ( n = 38 ) patients , anesthesia was maintained with ketamine , propofol , and fentanyl . MEASUREMENTS AND MAIN RESULTS The frequency of psychosis emergence or confusion ( 54 % ) in Group A during the first 48 hours after surgery was significantly higher than the 30 % figure in Group B. CONCLUSION Ketamine , when combined with propofol and fentanyl , is an appropriate anesthetic drug for schizophrenic patients The main aim of our study was to determine the influence of preoperative feeding with clear carbohydrate rich drink ( PreOp 200 mL ) on peristaltic of the small intestine and gallbladder size early after the orthopedic surgery in spinal anesthesia . Clinical study includes 120 patients with fracture of femoral neck or pertrochanteric fracture . All patients were r and omized in two groups , sixty patients , PreOp group  , consumed carbohydrate drink two hours before surgery . Other 60 patients , Control group , represent patients who fasted overnight .  After surgery , patients were su bmi tted to ultrasound examination for measurement of the small bowel motions and gallbladder size . Four quadrants ( up-right , up-left , down-right and down-left ) of the abdomen were examined , each one in duration of 30 seconds . The results show that the length of the gallbladder is considerably different across the two groups ; 5.866 cm in the PreOp group and 7.178 cm in the Control group ( p = 0.00 ) . The width , however , differed somewhat less ( PreOp group 2.437 cm , Control group 2.735 cm ) and the statistically significant difference can be observed at 7 % level ( p = 0.073 ) . We found no statistically significant relationship between PreOp and Control group variables of each abdominal quadrant ( lowest p > 0.087 ) . Accordingly , the means of the variables were found statistically significantly different between groups ( p > 0.05 ) . In conclusion our study showed that the preoperative feeding of the patients undergoing orthopedic surgery in spinal anesthesia shortens the length but not the width of the gallbladder when compared with overnight fasting patients and also clearly enhance motility of the small bowel in all four quadrant of the abdomen 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 Objective : To evaluate the influence of stroke volume variation (SVV)-based goal -directed therapy ( GDT ) on splanchnic organ functions and postoperative complications in orthopedic patients . Subjects and Methods : Eighty patients scheduled for major orthopedic surgery under general anesthesia were r and omly allocated to one of two equal groups to receive either intraoperative volume therapy guided by SVV ( GDT ) or st and ard fluid management ( control ) . In the SVV group , patients received colloid boluses of 4 ml/kg to maintain an SVV < 10 % when in the supine position or an SVV < 14 % if prone . In the control group , fluids were given to maintain a mean arterial pressure > 65 mm Hg , a heart rate < 100 bpm , a central venous pressure of 8 - 14 mm Hg , and a urine output > 0.5 ml/kg/h . Intraoperative organ perfusion , hemodynamic data , hospitalization , postoperative complications , and mortality were recorded . Results : The heart rate at the end of surgery was significantly lower ( p < 0.05 ) , there were fewer hypotensive episodes ( p < 0.05 ) , the arterial and gastric intramucosal pH were higher ( p < 0.05 for both ) , the gastric intramucosal PCO2 was lower ( p < 0.05 ) , the intraoperative infused colloids and the total infused volume were lower ( p < 0.05 for both ) , and the postoperative time to flatus was shorter ( p < 0.05 ) in the GDT group than in the control group . No differences in the length of hospital stay , complications , or mortality were found between the groups . Conclusion : SVV-based GDT during major orthopedic surgery reduced the volume of the required intraoperative infused fluids , maintained intraoperative hemodynamic stability , and improved the perioperative gastrointestinal function STUDY OBJECTIVE to compare passive heat retention by low-flow anesthesia , alone and with additional thermal insulation by reflective blankets , with forced-air warming preventing intraoperative hypothermia during combined epidural-general anesthesia . DESIGN R and omized , controlled study . SETTING Inpatient anesthesia at a university department of orthopedic surgery . PATIENTS 30 ASA physical status I and II patients , who were scheduled for elective hip or knee arthroplasty and were free from systemic disease . INTERVENTIONS Patients received epidural block up to T10 by alkalinized lidocaine 2 % , and then were administered st and ard general anesthesia by means of low-flow rebreathing system ( fresh gas flow = 1 L/min ) . All procedures started between 8 and 10 AM , and operating room ( OR ) temperature was maintained between 21 degrees and 23 degrees C , with relative humidity ranging between 40 % and 45 % . For heat retention or warming therapy , patients received either low-flow anesthesia only ( control , n = 10 ) , low-flow anesthesia with additional reflective blankets ( blanket , n = 10 ) , or low-flow anesthesia with active forced-air warming ( forced-air , n = 10 ) . Tympanic temperature was measured at OR arrival ( baseline ) ; immediately following general anesthesia induction ; 30 , 60 , 90 , and 120 minutes from general anesthesia induction ; and at the end of surgery . MEASUREMENTS AND MAIN RESULTS Duration of anesthesia , invasiveness of surgery , and baseline core temperature were similar in the three groups . Core temperature decreased in all the three groups 30 minutes after general anesthesia induction compared with baseline ( p < 0.01 ) ; afterwards , it progressively decreased in the control and blankets groups ( p = 0.004 ) , with a reduction from baseline values measured at the end of surgery of 2.0 degrees C and 1.6 degrees C , respectively . In the forced-air group , after the initial significant decrease ( p = 0.01 vs. baseline ) , core temperature progressively increased to 35.8 + /- 0.6 degrees C , which was similar to preoperative values and significantly higher than either the control or blankets groups ( p = 0.004 ) . CONCLUSIONS During combined epidural-general anesthesia for elective hip and knee arthroplasty , passive heat retention by means of low-flow anesthesia alone and in combination with reflective blankets is ineffective in maintaining intraoperative normothermia and definitely inferior to active forced-air warning OBJECTIVE To compare the effect of epidural vs general anesthesia on the incidence of long-term cognitive dysfunction after total knee replacement surgery in older adults . DESIGN R and omized controlled clinical trial . SETTING Orthopedic specialty academic hospital . PATIENTS A total of 262 patients undergoing elective primary total knee replacement with a median age of 69 years ; 70 % women . INTERVENTION R and om assignment to either epidural or general anesthesia . MAIN OUTCOME MEASURES A thorough neuropsychological assessment was performed preoperatively and repeated at 1 week and 6 months postoperatively . Cognitive outcome was assessed by within-patient change on 10 tests of memory , psychomotor , and language skills . Prospect i ve st and ardized surveillance for cardiovascular complications was performed to allow simultaneous assessment of anesthetic effects on cognitive and cardiovascular outcomes . RESULTS The two groups were similar at baseline in terms of age , sex , comorbidity , and cognitive function . There were no significant differences between the epidural and general anesthesia groups in within-subject change from baseline on any of the 10 cognitive test results at either 1 week or 6 months . Overall , 5 % of patients showed a long-term clinical ly significant deterioration in cognitive function . There was no difference between the anesthesia groups in the incidence of major cardiovascular complications ( 3 % overall ) . CONCLUSIONS The type of anesthesia , general or epidural , does not affect the magnitude or pattern of postoperative cognitive dysfunction or the incidence of major cardiovascular complications in older adults undergoing elective total knee replacement . This is the largest trial of the effects of general vs regional anesthesia on cerebral function reported to date , with more than 99 % power to detect a clinical ly significant difference on any of the neuropsychological tests Postoperative pain is a common reason for the delayed discharge and unanticipated hospital admission of out patients .In this study , we examined the pattern of  pain in ambulatory surgical patients and determined those factors that predict postoperative pain .  Ten thous and eight consecutive ambulatory surgical patients were prospect ively studied .  Preoperative patient characteristics , intraoperative variables , and pain in the postanesthesia care unit ( PACU ) and the ambulatory surgical unit ( ASU ) and 24 h postoperatively were documented . The incidence of severe pain was 5.3 % in the PACU , 1.7 % in the ASU , and 5.3 % 24 h postoperatively . In the PACU , younger male adults ( 36 + /- 13 vs 47 + /- 22 yr ) , ASA physical status I patients , and patients with a higher body mass index ( 26 + /- 5 vs 25 + /- 5 kg ) had a higher incidence of severe pain . In the group with severe pain , the duration of anesthesia , the duration of stay in the PACU and the ASU , and the time to discharge was longer than in the group without severe pain . In the PACU , orthopedic patients had the highest incidence of pain ( 16.1 % ) , followed by urologic ( 13.4 % ) , general surgery ( 11.5 % ) , and plastic surgery ( 10.0 % ) patients . In patients who had general anesthesia , the intraoperative dose of fentanyl  was significantly smaller in the group with severe pain than in the group without severe pain when body mass index and duration of anesthesia were taken into consideration . Body mass index , duration of anesthesia , and certain types of surgery were significant predictors of severe pain in the PACU . This knowledge will allow us to identify those patients at risk of severe postoperative pain and manage them prophylactically . Implication s : The  pattern of pain  was examined in 10,008 consecutive ambulatory surgical patients . The incidence of severe pain was 5.3 % in the postanesthesia care unit , 1.7 % in the ambulatory surgical unit , and 5.3 % 24 h postoperatively . Body mass , duration of anesthesia , and certain types of surgery were significant predictors of pain in the postanesthesia care unit . These data will allow us to better predict those patients who need intense prophylactic analgesic therapy . ( Anesth Analg 1997;85:808 - 16 Women ( 185 ) undergoing elective orthopedic surgery under balanced general anesthesia were given 5 or 10 mg of domperidone , 1.25 mg of droperidol , 10 mg of metoclopramide , or a saline placebo intravenously in a double-blind r and om fashion 5 minutes before the end of anesthesia to prevent postoperative vomiting . Administration of the same antiemetic was repeated intramuscularly during the first 24 hours postoperatively if the patient complained of nausea or retched or vomited . Significantly ( p < 0.05 to p < 0.001 ) , fewer of the patients given droperidol were nauseated ( 25 % ) or vomited ( 17 % ) in comparison with patients given saline ( incidence of nausea was 55 % and vomiting 40 % ) . Incidences of nausea and vomiting were similar in patients given domperidone , metoclopramide , or saline . Furthermore , 39 to 45 % of the patients given domperidone , metoclopramide , or saline needed additional doses of the same drug , whereas only 22 % of the patient given droperidol required a second dose . It is concluded that droperidol is effective in the prevention and treatment of postoperative nausea and vomiting after balanced general anesthesia but that domperidone or metoclopramide are not Total intravenous anesthesia ( TIVA ) is a useful technique in precarious situations in which anesthesia ventilators and medical gas can be difficult to obtain . The aim of the study is to compare TIVA technique using a simplified infusion scheme for propofol and alfentanil mixed together ( 45 ml of propofol 1 % and 2,500 micrograms of alfentanil in a 50-ml syringe ) with an inhalational anesthetic technique ( isoflurane/N2O , sufentanil ) .  Thirty-two American Society of Anesthesiologists physical status I patients undergoing orthopedic surgery were studied .  Intubation conditions and hemodynamic responses to intubation were comparable in the two groups . Only patients receiving TIVA had responses to surgery . In the TIVA group , time to extubation was shorter ( 16 + /- 5 vs. 25 + /- 7 minutes ) and postoperative requirement for morphine was lower ( 6.2 % vs. 25 % ) than in the inhalation group ( p < 0.05 ) . TIVA using a mixture of propofol and alfentanil is a reliable technique of anesthesia in patients without multiple injuries Background Alveolar macrophages are a critical part of the defense against pulmonary infection . Thus the authors determined time‐dependent changes in alveolar macrophage functions in patients having surgery who were anesthetized with isoflurane or propofol .  Methods Patients anesthetized with propofol ( n = 30 ) or isoflurane ( n = 30 ) during orthopedic surgery were studied . Alveolar macrophages were harvested by bronchoalveolar lavage immediately , and 2 , 4 , and 6 h after induction anesthesia and at the end of surgery . The fraction of aggregated and nonviable macrophages was determined . Then phagocytosis was measured by ingestion of opsonized and unopsonized particles . Finally , microbicidal activity was determined as the ability of the macrophages to kill Listeria monocytogenes directly . Results Demographic and morphometric characteristics of the patients given propofol and isoflurane were similar , as were their levels of pulmonary function and hemodynamic responses . The fraction of alveolar macrophages ingesting opsonized and unopsonized particles , and the number of particles ingested , decreased significantly over time , with the decrease slightly but significantly greater during isoflurane anesthesia . Microbicidal function decreased progressively during anesthesia and surgery , with the decrease almost twice as great during isoflurane compared with propofol anesthesia . The fraction of aggregated macrophages and recovered neutrophils increased over time in the patients given each anesthetic . Conclusions Pulmonary immunologic function changed progressively during anesthesia and surgery . The data from this study suggest that pulmonary defenses are modulated by the type of anesthesia and by the duration of anesthesia and surgery Objective In orthopedic surgery , it is well known that the use of intrathecal morphine ( ITM ) leads to an improved quality of postoperative analgesia . Little is known how this improved analgesia affects the long-term course after surgery . Study design A r and omized , double-blind trial . Setting Academic medical center . Subjects Forty-nine patients undergoing total hip or knee replacement surgery in spinal anesthesia . Methods Patients were r and omly assigned to receive either 0.1 mg ( n=16 ) or 0.2 mg ( n=16 ) morphine sulfate intrathecally or physiological saline ( n=17 ) added to 3 mL 0.5 % isobaric bupivacaine for spinal anesthesia . As a function of the quality of the short-term postoperative analgesia , the effect on recovery and quality of life was evaluated at various time points up to 26 weeks after surgery . Results In both ITM groups , the additionally required postoperative systemic morphine dose was significantly reduced compared with the placebo group ( P=0.004 ) . One week after operation , patients with ITM reported significantly less pain at rest ( P=0.01 ) compared to the placebo group . At discharge , in comparison with the 0.1 mg ITM and placebo group , the 0.2 mg ITM group showed a higher degree of impairment regarding pain , stiffness , and physical function of the respective joint ( P=0.02 ) . Over the further follow-up period of 6 months after surgery , recovery and the quality of life did not differ significantly between the three study groups ( P>0.2 ) . Conclusion Morphine ( 0.1 mg ) as adjunct to 0.5 % bupivacaine for spinal anesthesia is effective to produce a pronounced postoperative analgesia with a beneficial analgesic effect up to 1 week after surgery . With this study design , the different quality of postoperative analgesia had no effect on quality of life and recovery in patients over the 6-month follow-up period . In the medium term , ITM may induce hyperalgesic effects
So far , the evidence available from the studies included is insufficient to prove that neuraxial anesthesia is more effective and safer than general anesthesia for orthopedic surgery .
However , this systematic review does not rule out clinical ly important differences with regard to mortality , stroke , myocardial infa rct ion , length of hospitalization , postoperative cognitive dysfunction or pneumonia
CONTEXT AND OBJECTIVE Taking the outcome of mortality into consideration , there is controversy about the beneficial effects of neuraxial anesthesia for orthopedic surgery .
The aim of this study was to compare the effectiveness and safety of neuraxial anesthesia versus general anesthesia for  orthopedic surgery .