Chronic Subdural Hematoma Drainage Under Local Anesthesia with Sedation versus General Anesthesia and Its Outcome.

BACKGROUND: Burr hole drainage is the criterion standard treatment for chronic subdural hematoma (CSDH), a common neurosurgical condition. However, apart from the surgical technique, the method of anesthesia also has a significant impact on postoperative patient outcome. Currently, there are limited studies comparing the use of local anesthesia with sedation (LA sedation) versus general anesthesia (GA) in the drainage of CSDH. The objective of this study was to compare the morbidity and mortality outcomes of using LA sedation versus GA in CSDH burr hole drainage. METHODS: This retrospective study presents a total of 257 operations in 243 patients from 2 hospitals. A total of 130 cases were operated under LA sedation in hospital 1 and 127 cases under GA in hospital 2. Patient demographics and presenting features were similar at baseline. RESULTS: Values are shown as LA sedation versus GA. Postoperatively, most patients recovered well in both groups with Glasgow Outcome Scale scores of 4-5 (96.2% vs. 88.2%, respectively). The postoperative morbidity was significantly increased by an odds ratio of 5.44 in the GA group compared with the LA sedation group (P = 0.005). The mortality was also significantly higher in the GA group (n = 5, 3.9%) than the LA sedation group (n = 0, 0.0%; P = 0.028). The CSDH recurrence rate was 4.6% in the LA sedation group versus 6.3% in the GA group. No intraoperative conversion from LA sedation to GA was reported. CONCLUSIONS: This study demonstrates that CSDH drainage under LA sedation is safe and efficacious, with a significantly lower risk of postoperative mortality and morbidity when compared with GA.

Comparison of preoxygenation with a high-flow nasal cannula and a simple mask before intubation during induction of general anesthesia in patients undergoing head and neck surgery: Study protocol clinical trial (SPIRIT Compliant).

BACKGROUND: To assess the arterial oxygen partial pressure (PaO2) at defined time points during preoxygenation and to compare high-flow heated humidified nasal oxygenation with standard preoxygenation using oxygen insufflation via a facemask for at least 5 minutes, before intubation during induction of general anesthesia. METHODS: This randomized, single-blinded, prospective study will be conducted in patients undergoing head and neck surgery. After standard monitoring, the artery catheter at the radial artery or dorsalis pedis artery will be placed and arterial blood gas analysis (ABGA) for baseline values will be performed simultaneously. Each group will be subjected to 1 of 2 preoxygenation methods (high-flow nasal cannula or simple facemask) for 5 minutes, and ABGA will be performed twice. After confirming intubation, we will start mechanical ventilation and check the vital signs and perform the final ABGA. DISCUSSION: This trial aims to examine the trajectory of PaO2 levels during the whole preoxygenation procedure and after intubation. We hypothesize that preoxygenation with the high-flow nasal cannula will be superior to that with the face mask. STUDY REGISTRATION: This trial was registered with the Clinical Trial Registry (NCT03896906; ClinicalTrials.gov).

A 10% blood pressure drop from baseline during mechanical thrombectomy for stroke is strongly associated with worse neurological outcomes.

BACKGROUND: Mechanical thrombectomy (MT) for acute ischemic stroke can be performed under local anesthesia, with or without conscious sedation (CS), or under general anesthesia (GA). The hemodynamic consequence of anesthetic drugs may explain why GA may be associated with worse outcomes. We evaluated the association between hypotension duration during MT and the 90 day functional outcome under both anesthetic regimens. METHODS: Patients were included in this retrospective study if they had an ischemic stroke treated by MT under GA or CS. The main exposure variable was the time below 90% of the reference value of arterial pressure measured before MT. The primary outcome was poor functional outcome defined as a 90 day modified Rankin Score ≥3. RESULTS: 371 patients were included in the study. GA was performed in 42%. A linear association between the duration of arterial hypotension and outcome was observed. The odds ratio for poor functional outcome of 10 min under 90% of the baseline mean arterial pressure was 1.13 (95% CI 1.06 to 1.21) without adjustment and 1.11 (95% CI 1.02 to 1.21) after adjustment for confounding factors. The functional outcome was poorer for patients treated under GA compared with CS, but the association with the depth of hypotension remained similar under both conditions. CONCLUSION: In this study, we observed a linear association between the duration of hypotension during MT and the functional outcome at 90 days. An aggressive and personalized strategy for the treatment of hypotension should be considered. Further trials should be conducted to address this question.

[Initial Experience of a TAVI Program: Analysis of the Anesthetic Decision and its Evolution]. / Experiência Inicial de um Programa de TAVI: Análise da Decisão Anestésica e sua Evolução.

INTRODUCTION: Transcatheter aortic valve implantation is a less invasive option for aortic valve replacement. The number of transcatheter aortic valve implantations under local anesthesia with sedation has been increasing as the team's experience increases and less invasive accesses are used. The aim of this study is to describe the evolution of the anesthetic technique in patients undergoing transcatheter aortic valve implantation at our center over the years, as which was compared. MATERIAL AND METHODS: Retrospective study in 149 consecutive patients undergoing transcatheter aortic valve implantation in Hospital Santa Marta (January 2010 to December 2016). Data was collected from the periprocedural records of patients. Patients were stratified according to anesthetic technique. RESULTS: From our patients' sample, 57.0% were female, with median age 82 [58 - 95] years. Most patients underwent general anesthesia (68.5%). In the local anesthesia with sedation group there was a shorter duration of the procedure (120; [60 - 285] vs 155 [30 - 360]) and a lower number of patients requiring administration of vasopressors (61.8% vs 28.3%) - p < 0.05. There were no differences regarding length of hospital stay (9 [4 - 59] vs 10 [3 - 87]), periprocedural complications (66.0% vs 72.5%), readmission rate (4.3% vs 3.9%) or 30-days (2.1% vs 4.9%) and 1-year mortality (6.4% vs 7.8%) - p < 0.05. There was an increasing number of transcatheter aortic valve implantations performed under local anesthesia with sedation over the years. DISCUSSION: The choice of anesthetic technique depends on the patient's characteristics, experience and preference of the team. CONCLUSION: Local anesthesia with sedation seems to be associated with similar results as general anesthesia. The increase in the number of transcatheter aortic valve implantations under local anesthesia with sedation seems to follow the trend of lower invasiveness of the procedure.

Introdução: A implantação percutânea de válvula aórtica constitui uma opção menos invasiva de substituição valvular. O número de procedimentos sob anestesia local com sedação tem vindo a crescer com o aumento da experiência da equipa e os acessos cada vez menos invasivos. O trabalho tem como objetivo a descrição da evolução da técnica anestésica utilizada nos doentes submetidos a implantação percutânea de válvula aórtica no nosso centro ao longo dos anos, e sua comparação. Material e Métodos: Estudo retrospetivo em 149 doentes consecutivos submetidos a implantação percutânea de válvula aórtica no Hospital de Santa Marta (janeiro de 2010 a dezembro de 2016). Os dados foram colhidos a partir dos registos peri-procedimento e estratificados de acordo com a técnica anestésica. Resultados: Da amostra recolhida, 57,0% dos doentes eram do sexo feminino, com mediana idade 82 [58 - 95] anos. A maioria dos doentes foi submetida a anestesia geral (68,5%). Verificou-se menor duração do procedimento (120 [60 - 285] vs 155 [30 - 360]) e menor número de doentes com necessidade de administração de vasopressores na implantação percutânea de válvula aórtica (61,8% vs 28,3%) ­ p < 0,05. Não se registaram diferenças referentes à duração do internamento (9 [4 - 59] vs 10 [3 - 87]), complicações periprocedimento (66,0% vs 72,5%), reinternamento (4,3% vs 3,9%), mortalidade aos 30 dias (2,1% vs 4,9%) e 1 ano (6,4% vs 7,8%) ­ p > 0,05. O número de implantações percutâneas de válvula aórtica realizados sob anestesia local com sedação aumentou ao longo dos anos. Discussão: A escolha da técnica anestésica tende a variar consoante as características do doente, a experiência e preferência da equipa. Conclusão: Os resultados da anestesia local com sedação são similares aos da anestesia geral, tendo o aumento do número de procedimentos de implantação percutânea de válvula aórtica sob anestesia local com sedação acompanhado a tendência de menor invasibilidade do procedimento.

Effect of local infiltration analgesia, peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in unicompartmental knee arthroplasty.

BACKGROUND: The aim of the study was to analyze the effect of local infiltration analgesia (LIA), peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in primary unicompartmental knee arthroplasty (UKA). METHODS: Between January 2016 until August 2016, 134 patients underwent primary UKA and were subdivided into four groups according to their concomitant pain and anesthetic procedure with catheter-based techniques of femoral and sciatic nerve block (group GA&FNB, n = 38) or epidural catheter (group SP&EPI, n = 20) in combination with general anesthesia or spinal anesthesia, respectively, and LIA combined with general anesthesia (group GA&LIA, n = 46) or spinal anesthesia (group SP&LIA, n = 30). Outcome parameters focused on the evaluation of pain (NRS scores), mobilization, muscle strength and range of motion up to 7 days postoperatively. The cumulative consumption of (rescue) pain medication was analyzed. RESULTS: The LIA groups revealed significantly lower (about 50%) mean NRS scores (at rest) compared to the catheter-based groups at the day of surgery. In the early postoperative period, the dose of hydromorphone as rescue pain medication was significantly lower (up to 68%) in patients with SP&EPI compared to all other groups. No significant differences could be detected with regard to grade of mobilization, muscle strength and range of motion. However, there seemed to be a trend towards improved mobilization and muscle strength with general anesthesia and LIA, whereof general anesthesia generally tended to ameliorate mobilization. CONCLUSIONS: Except for a significant lower NRS score at rest in the LIA groups at day of surgery, pain relief was comparable in all groups without clinically relevant differences, while the use of opioids was significantly lower in patients with SP&EPI. A clear clinically relevant benefit for LIA in UKA cannot be stated. However, LIA offers a safe and effective treatment option comparable to the well-established conventional procedures.

Effect of local infiltration analgesia, peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in total knee arthroplasty.

BACKGROUND: Postoperative pain control and enhanced mobilization, muscle strength and range of motion following total knee arthroplasty (TKA) are pivotal requisites to optimize rehabilitation and early recovery. The aim of the study was to analyze the effect of local infiltration analgesia (LIA), peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in primary total knee arthroplasty. METHODS: Between January 2016 until August 2016, 280 patients underwent primary TKA and were subdivided into four groups according to their concomitant pain and anesthetic procedure with catheter-based techniques of femoral and sciatic nerve block (group GA&FNB, n = 81) or epidural catheter (group SP&EPI, n = 51) in combination with general anesthesia or spinal anesthesia, respectively, and LIA combined with general anesthesia (group GA&LIA, n = 86) or spinal anesthesia (group SP&LIA, n = 61). Outcome parameters focused on the evaluation of pain (NRS scores), mobilization, muscle strength and range of motion up to 7 days postoperatively. The cumulative consumption of (rescue) pain medication was analyzed. RESULTS: Pain relief was similar in all groups, while the use of opioid medication was significantly lower (up to 58%) in combination with spinal anesthesia, especially in SP&EPI. The LIA groups, in contrast, revealed significant higher mobilization (up to 26%) and muscle strength (up to 20%) in the early postoperative period. No analgesic technique-related or surgery-related complications occurred within the first 7 days. Due to insufficient pain relief, 8.4% of the patients in the catheter-based groups and 12.2% in the LIA groups resulted in a change of the anesthetics pain management. CONCLUSIONS: The LIA technique offers a safe and effective treatment option concerning early functional recovery and pain control in TKA. Significant advantages were shown for mobilization and muscle strength in the early postoperative period while pain relief was comparable within the groups.

Anesthesia-Related Outcomes for Endovascular Stroke Revascularization: A Systematic Review and Meta-Analysis.

BACKGROUND AND PURPOSE: There is currently controversy on the ideal anesthesia strategy during mechanical thrombectomy for acute ischemic stroke. We performed a systematic review and meta-analysis of studies comparing clinical and angiographic outcomes of patients undergoing general anesthesia (GA group) and those receiving either local anesthesia or conscious sedation (non-GA group). METHODS: A literature search on anesthesia and endovascular treatment of acute ischemic stroke was performed. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome at 90 days (modified Rankin Score≤2), symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, and time to groin puncture. RESULTS: Twenty-two studies (3 randomized controlled trials and 19 observational studies), including 4716 patients (1819 GA and 2897 non-GA) were included. In the nonadjusted analysis, patients in the GA group had higher odds of death (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.66-2.45) and respiratory complications (OR, 1.70; 95% CI, 1.22-2.37) and lower odds of good functional outcome (OR, 0.58; 95% CI, 0.48-0.64) compared with the non-GA group. There was no difference in procedure time between the 2 primary comparison groups. When adjusting for baseline National Institutes of Health Stroke Scale, GA was still associated with lower odds of good functional outcome (OR, 0.59; 95% CI, 0.29-0.94). When considering studies performed in the stent-retriever/aspiration era, there was no significant difference in good neurological outcome rates (OR, 0.84; 95% CI, 0.67-1.06). CONCLUSIONS: Acute ischemic stroke patients undergoing intra-arterial therapy may have worse outcomes when treated with GA as compared with conscious sedation/local anesthesia. However, major limitations of current evidence (ie, retrospective studies and selection bias) indicate a need for adequately powered, multicenter randomized controlled trials to answer this question.

The Royal College of Ophthalmologists' National Ophthalmology Database Study of vitreoretinal surgery: report 5, anaesthetic techniques.

AIMS: To explore trends over time and variation in the use of anaesthetic techniques for vitreoretinal (VR) surgery in the UK. METHODS: Prospectively collected data from 13 centres contributing >50 VR operations, including either pars plana vitrectomy (PPV) or scleral buckle (SB), between May 2000 and November 2010 were retrospectively analysed. Anaesthesia was categorised as general anaesthesia (GA) or local anaesthesia (LA) and results were reported by year, centre, grade of surgeon and type of operation. RESULTS: 160 surgeons performed 12 124 operations on 10 405 eyes (9935 patients); 6054 (49.9%) under GA and 6070 (50.1%) under LA. The percentage performed under GA decreased from 95.3% in 2001 to 40.9% in 2010. Within LA techniques, peribulbar or retrobulbar injection was used in 2783 (45.8%) operations and sub-Tenon's cannula in 3287 (54.2%). The proportions of operations performed under GA or LA were similar for consultants and trainees. Primary SB, primary combined PPV and SB for retinal detachment (RD), repeat RD surgery and complex vitrectomy surgery were more commonly performed under GA (85.8%, 67.0%, 63.5% and 69.4%, respectively), while primary PPV for RD, simple vitrectomy surgery and macular surgery were more commonly performed under LA (58.1%, 53.7% and 58.2%, respectively). Marked intercentre variation existed with the extremes being one centre with 100% of operations performed under GA and one centre with 98.3% under LA. CONCLUSIONS: LA for VR surgery has steadily increased over the last decade in the UK but marked intercentre variation exists.

Variability in anesthetic considerations for arteriovenous fistula creation.

INTRODUCTION: Anesthetic options for arteriovenous fistula (AVF) creation include regional anesthesia (RA), general anesthesia (GA) and local anesthetic for select cases. In addition to the benefits of avoiding GA in high-risk patients, recent studies suggest that RA may increase perioperative venous dilation and improve maturation. Our objective was to assess perioperative outcomes of AVF creation with respect to anesthetic modality and identify patient-level factors associated with variation in contemporary anesthetic selection. METHODS: National Surgical Quality Improvement Project (NSQIP) data (2007-2010) were accessed to identify patients undergoing AVF creation. Univariate analysis and multivariate logistic regression were performed to assess the relationships among patient characteristics, anesthesia modality and outcome. RESULTS: Of 1,540 patients undergoing new upper extremity AVF creation, 52% were male and 81% were younger than 75 years. Anesthesia distribution was GA in 85.2%, local/monitored anesthetic care (MAC) in 2.9% and RA in 11.9% of cases. By multivariate analysis, independent predictors of RA were dyspnea at rest (hazard ratio [HR] 2.3, 95% confidence interval [CI] 1.1-4.9), age >75 (HR 1.6, 95% CI 1.1-2.3) and teaching hospital status as indicated by housestaff involvement (HR 3.7, 95% CI 2.5-5.5). RA was associated with higher total operative time, duration of anesthesia, length of time in operating room and duration of anesthesia start until surgery start (p<0.01). There were no differences between perioperative complications or mortality among anesthetic modalities, although all deaths occurred in the GA group. DISCUSSIONS: Despite recent reports highlighting potential benefits of RA for AVF creation, GA was surprisingly used in the vast majority of cases in the United States. The only comorbidities associated with preferential RA use were advanced age and dyspnea at rest. Practice environment may influence anesthetic selection for these cases, as a nonteaching environment was associated with GA use. The trend seen here toward higher mortality in GA and the potential perioperative benefits of RA for the access should encourage more widespread use of RA in practice for this high-risk patient population.

Anestesia subaracnoidea selectiva: Soluciones diluidas a bajas dosis / No disponible

No disponible

[Descriptive analysis of work and trends in anaesthesiology from 2005 to 2006: quantitative and qualitative aspects of effects and evaluation of anaesthesia].

INTRODUCTION: In anaesthesiology, economic aspects have been insufficiently studied. OBJECTIVE: The aim of this paper was the assessment of rational choice of the anaesthesiological services based on the analysis of the scope, distribution, trend and cost. METHODS: The costs of anaesthesiological services were counted based on "unit" prices from the Republic Health Insurance Fund. Data were analysed by methods of descriptive statistics and statistical significance was tested by Student's t-test and chi2-test. RESULTS: The number of general anaesthesia was higher and average time of general anaesthesia was shorter, without statistical significance (t-test, p = 0.436) during 2006 compared to the previous year. Local anaesthesia was significantly higher (chi2-test, p = 0.001) in relation to planned operation in emergency surgery. The analysis of total anaesthesiological procedures revealed that a number of procedures significantly increased in ENT and MFH surgery, and ophthalmology, while some reduction was observed in general surgery, orthopaedics and trauma surgery and cardiovascular surgery (chi2-test, p = 0.000). The number of analgesia was higher than other procedures (chi2-test, p = 0.000). The structure of the cost was 24% in neurosurgery, 16% in digestive (general) surgery,14% in gynaecology and obstetrics, 13% in cardiovascular surgery and 9% in emergency room. Anaesthesiological services costs were the highest in neurosurgery, due to the length anaesthesia, and digestive surgery due to the total number of general anaesthesia performed. CONCLUSION: It is important to implement pharmacoeconomic studies in all departments, and to separate the anaesthesia services for emergency and planned operations. Disproportions between the number of anaesthesia, surgery interventions and the number of patients in surgical departments gives reason to design relation database.

Pain control in voluntary surgical contraception.

The reduction of anxiety and control of pain in 1,546 clients undergoing voluntary surgical contraception (VSC) is presented. Psychological support through adequate counselling and abdominal breathing exercises are vital. General anaesthesia was used in 254 (16.4%) of the clients; sedation plus local anaesthetic agents in 296 (19.2%) while local anaesthetic alone was used in 996 (64.4%) of clients. There was progressive shift from the use of general anaesthesia (GA) to local anaesthesia (LA), particularly for the minilaparotomy procedure following the introduction of Association for Voluntary Surgical Contraception (AVSC) programme in our department since this type of anaesthesia was cheap, safe, affordable and readily available. Recommendations for successful VSC techniques include gentle tissue handling, proper use of the correct instruments to reduce painful stimuli, while low dose intravenous sedation should be used only when necessary. Minilaparotomy under local anaesthesia (ML/LA) has been successfully established in Jos University Teaching Hospital, Jos, Nigeria.

PIP: This study aimed to review the methods of anesthesia and/or analgesia used in voluntary surgical contraception procedures at Jos University Teaching Hospital, Plateau State, Nigeria. The study included 1546 clients who voluntarily opted for surgical contraception after proper counseling and signing a consent form. Of a total of 1546 clients, 254 (16.4%) received general anesthesia, 296 (19.2%) were sedated and received local anesthesia, and 996 (64.4%) received only local anesthesia. It was found that there was a progressive shift from the use of general anesthesia to local anesthesia, particularly for the minilaparotomy procedure following the introduction of the Association for Voluntary Surgical Contraception program. The use of local anesthesia for pain control considerably reduces the risk of vomiting, drowsiness and, in extreme cases, anesthetic death. Furthermore, the cost, availability, and safety of local anesthesia render it appropriate for pain control in Nigeria.

Planning future general anaesthetic services in paediatric dentistry on the basis of evidence: an analysis of children treated in the Day Stay Centre at the Royal Hospitals NHS Trust, London, between 1985-95.

This study aimed to provide evidence for future planning of general anaesthetic services in Paediatric Dentistry. An audit was carried out on children (< or = 17 years) with special needs who were treated under general anaesthesia in the Day Stay Centre at The Royal Hospitals NHS Trust, London, between 1985-95. During these years, 586 child patients were treated, of which 350 had medical complications and/or mental disabilities. Although the number of peri-operative admissions were low (11 planned and 9 emergency), it highlighted the necessity for these patients to be treated in a hospital. Comprehensive dental treatments were carried out which included 1630 deciduous and 596 permanent tooth restorations, and 1382 deciduous and 261 permanent tooth extractions. These patients had follow-up preventive support in the Dental Institute and the readmission rate for further dental treatment under general anaesthesia was low (14 per cent). Comparing the results between 1985-87, 1988-91 and 1992-95 periods, there was a trend for more patients, travelling longer distances, to be treated in the latter periods. It is suggested that more centres with appropriate equipment and trained staff need to be established to meet the increased demand.

Economic aspects of general anaesthesia.

Proper economic evaluation involves comparative analysis of alternative courses of action in terms of both costs and outcome. This is difficult for general anaesthesia as there are few alternatives and measurement of outcome is difficult to define. All that is generally available is a cost description of different anaesthetic techniques. This article outlines the choice of drugs, breathing systems and ventilatory pattern available to the anaesthetist, and compares regional with general anaesthesia. For each technique the cost and advantages/disadvantages are outlined. There is a discussion of some wider issues involved together with their implications: the abandonment of cyclopropane and nitrous oxide; equipment costs and recommendations by the Association of Anaesthetists of Great Britain and Ireland; staffing levels; legal aspects and the increase in day surgery. The limitation of cost-effectiveness analysis of general anaesthesia is outlined.