Perioperative myocardial ischaemia in patients undergoing surgery for fractured hip randomized to incremental spinal, single-dose spinal or general anaesthesia. [The effect of anesthesiologic technique on the mental state of elderly patients submitted for orthopedic surgery of the lower limbs]. Anaesthesia for surgical correction of fractured femoral neck. A comparison of three techniques. [Comparative repercussions of general and spinal anesthesia on the psychological functions of the aged subject]. [Postoperative course and endocrine stress reaction of geriatric patients with para-articular hip fractures. Prospective randomized study comparing spinal anesthesia and halothane intubation narcosis]. Mental function and morbidity after acute hip surgery during spinal and general anaesthesia. Prospective, multi-centre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly. Postoperative confusion after anesthesia in elderly patients with femoral neck fractures. Combined lumbar and sacral plexus block compared with plain bupivacaine spinal anesthesia for hip fractures in the elderly. Changes in body heat during hip fracture surgery: a comparison of spinal analgesia and general anaesthesia. [Comparative results of general and peridural anesthesia for hip surgery in the very old patient]. [Comparative study of general and spinal anesthesia in elderly women in hip surgery]. The effect of anaesthesia on changes in blood pressure and plasma cortisol levels induced by cementation with methylmethacrylate. Randomized comparison between sevoflurane anaesthesia and unilateral spinal anaesthesia in elderly patients undergoing orthopaedic surgery. Preoperative and postoperative oxygen saturation in the elderly following spinal or general anaesthesia--an audit of current practice. Anaesthetic techniques for surgical correction of fractured neck of femur. A comparative study of ketamine and relaxant anaesthesia in elderly women. Anaesthetic techniques for surgical correction of fractured neck of femur. A comparative study of spinal and general anaesthesia in the elderly. Spinal or general anaesthesia for surgery of the fractured hip? A prospective study of mortality in 578 patients. [Postoperative delirium after general anesthesia vs. spinal anesthesia in geriatric patients]. Spinal anaesthesia or general anaesthesia for emergency hip surgery in elderly patients. Long-term outcome after repair of fractured neck of femur. Comparison of subarachnoid and general anaesthesia.
Quantitative assessment of myocardial ischaemia during incremental spinal, single-dose spinal and general anaesthesia may provide guidelines for the choice of anaesthetic technique for osteosynthesis of hip fractures in the elderly atherosclerotic individual. Forty-three patients with coronary artery disease were allocated to receive either incremental spinal anaesthesia (bupivacaine 0.5% plain) (A), single-dose spinal anaesthesia (2.5 mL of bupivacaine 0.5% plain) (B) or general anaesthesia (fentanyl, thiopentone, atracurium, enflurane, N2O/O2) (C) for hip surgery. ST segment monitoring was performed from the induction of anaesthesia and for the following 48 h, and perioperative hypotension, blood loss and fluid therapy were recorded. ST depression developed in two out of 14 (A), seven out of 15 (B) and six out of 14 (C) patients (P = 0.14). In (A), a total of seven ST depressions occurred in the observation period as opposed to 125 in (B) and 16 in (C) (P < 0.05). Intra-operative ST depression only occurred in (B). Three (A), 33 (B) and 40 (C) hypotensive events were recorded (P < 0.002). Altogether, 56% of hypotensive patients developed ST depression compared with 10% of normotensive patients (P < 0.003). In (A), 1.6 mL of 0.5% bupivacaine were used as opposed to the fixed 2.5 mL dose in (B) (P < 0.001). In the first post-operative week, mortality was higher in (B) (P < 0.05) but, after 1 month, there was no significant difference in mortality between the three groups. The incidence of hypotension and myocardial ischaemia was lowest in the group receiving incremental spinal anaesthesia. Influence of anesthetic technique on mental status in elderly patients submitted 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 implications.
                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.
                Controlled, comparative study.
                Sixty patients aged > or = 70, ASA I-II, submitted to femoral neck repair.
                Anesthesia Dept. and Orthopedic Dept. of a District Hospital in Italy.
                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 randomly 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.
                No statistically significant differences were found between pre- and postoperative OBS scores in both GA and SA group, whether "oriented" or "confuse".
                Mental status of elderly patients submitted to femoral neck repair doesn't seem to be influenced by the anesthetic technique chosen, independent of preoperative psychic conditions. Sixty patients with fractured neck of femur and scheduled for surgical correction were randomly allocated to receive one of three anaesthetic techniques: general anaesthesia; spinal analgesia; psoas compartment block. The patients in the local anaesthetic groups also received a light general anaesthetic. There was little difference in the pre-, intra- and postoperative events, and no difference in postoperative mortality. Although worsening cerebral function in the elderly is often said to be due to anaesthesia, it still remains to be proved that anesthesia acts on an elderly patient's psychological make-up. This study aimed to compare the psychological effects of general or spinal anaesthesia on 35 patients more than 70-yr old under repair of a subcapital femoral fracture, after having excluded 63 patients. They were randomly divided into two groups, the first receiving a spinal anaesthetic with 1.5 mg.kg-1 prilocaine (RA; n = 19), and the others a general anaesthetic with 5 mg.kg-1 thiopentone, dextromoramide, nitrous oxide and enflurane (GA; n = 16). None of the patients wer given a premedication. They underwent a battery of six psychological tests before and 36 h after surgery, all carried out by the same physician. Six patients in GA group and three in RA group developed a transient fall in mean blood pressure just after anaesthetic induction (not significant). There were no significant differences between the two groups in age, sex distribution, ASA class and performance in the tests, both before and after surgery. Individual psychological scores did not differ either. In the RA group, the postoperative tests were even better carried out than before surgery (p less than 0.05). It could therefore be concluded that anaesthesia alone has little impact on the psychological status of elderly patients. During a period of one year, all patients above the age of 60 with surgical repair of fractured neck of femur were investigated in a prospectively randomized design. A follow-up study included a total number of 56 patients, 32 were allocated to halothane anaesthesia with intubation, 24 received spinal anaesthesia. In addition, 15 patients of the halothane group and 17 patients with spinal anaesthesia were investigated with regard to endocrine stress response. Total mortality was 12.5%, and different anaesthetic management had no influence on the postoperative course. During the operation, adrenaline and ADH increased in both groups. This increase was attenuated by spinal anaesthesia. Noradrenaline was markedly increased even before the operation, and concentrations increased in the halothane group in the course of the operation. There was a linear correlation to time between accident and the beginning of the operation. With regard to endocrine parameters, prompt surgical treatment is beneficial. Forty elderly patients (mean age 78.9 years) undergoing acute surgery for hip fracture were given at random either spinal analgesia with bupivacaine 0.75% or general anaesthesia with diazepam, fentanly and N2O/O2. Mental function was studied pre-operatively with an abbreviated mental test and 1 week and 3 months postoperatively in both groups. Mortality and number of complications was similar in the two groups, but a shorter time of ambulation was seen in the spinal group compared to the general anaesthetic group. No persistent impairment in mental function was found after acute hip surgery under spinal or general anaesthesia and the only advantage of regional technique was a shorter time of ambulation. In a prospective randomized multi-centre study, the mortality following internal fixation surgery for fracture of the upper femur was investigated in 538 elderly patients allocated to receive subarachnoid blockade or general (narcotic-relaxant) anaesthesia. The 28-day mortality was 6.6% with subarachnoid, and 5.9% with general, anaesthesia. The difference was not significant (95% confidence limits: -3.5 to +4.8). At 1 year following surgery, the mortality was 20.4%. Increasing age, ischaemic heart disease, cardiac failure, preoperative arrhythmias and poor ASA status were all associated with increases in early and long term mortality. A delay to surgery of more than 24 h from admission was also associated with an increased 28-day mortality. Senile dementia and admission other than from the patient's own home, were factors associated with a poorer long term outcome. From the point of view of mortality, subarachnoid anaesthesia did not appear to confer any advantages over general anaesthesia in non-prosthetic surgery for hip fracture in the elderly. Fifty-seven patients, all over the age of 64, with femoral neck fracture were randomized to receive epidural or halothane anesthesia to see if the anesthetic technique influenced the incidence of postoperative confusion. All patients were lucid on admission. Using the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) as criteria for confusion, we found that 44% of the patients developed confusion that correlated closely to a history of mental depression (P less than 0.01) and to the use of drugs with anticholinergic effect (P less than 0.005). There was no difference in the incidence of confusion between the two anesthetic groups. In patients given halothane, however, early postoperative hypoxemia was associated with confusion (P less than 0.05). Patients with confusion had significantly more postoperative complications and almost four times longer hospitalization times. It is concluded that anticholinergic medication and a history of mental depression are predominant risk factors for development of postoperative confusion and in this respect are more important than the anesthetic technique. This prospective randomized study was designed to determine the hemodynamic effects and quality of combined lumbar and sacral plexus block compared with plain bupivacaine spinal anesthesia in the elderly for repair of proximal femoral fractures.
                Twenty-nine elderly patients ranging in age from 68 to 97 years were randomly assigned to 2 groups: a spinal anesthesia group with single-shot 3 mL 0.5% plain bupivacaine, and a combined block group with 30 mL lidocaine 1.33% with epinephrine for the posterior lumbar plexus block and 10 mL same mixture for the parasacral block and an iliac crest block with 5 mL lidocaine 1%.
                No need for general anesthesia was encountered in either group. Anesthesia was judged unsatisfactory in 1 of 15 patients in the combined block group. The initial decrease of mean arterial pressure was 38% in the spinal group and 27% in the block group and was not significantly different. A more prolonged hemodynamic effect was found in the spinal group, indicated by the more frequent use of ephedrine to stabilize blood pressure (P<.05). Patients over 85 years had a significantly larger decrease in blood pressure than younger patients (P<.01).
                Plain bupivacaine spinal anesthesia and combined lumbar/sacral plexus block provided adequate anesthesia for repair of hip fracture in the elderly. Hypotension was induced by both the combined peripheral nerve block and plain bupivacaine spinal anesthesia in aged patients; hypotension was found to be longer lasting after spinal anesthesia and of a larger magnitude in patients over 85 years of age. Postoperative hypothermia initiates an increased oxygen demand in the postoperative period and may endanger patients with restricted cardiopulmonary reserves. In order to compare net heat losses and gains, we studied 28 women undergoing hip fracture surgery, using either general anaesthesia or spinal analgesia. The superficial and central temperatures were followed in the per- and postoperative period. Total body heat was calculated from temperature measurements. Temperature changes were unrelated to the type of anaesthesia. Large net heat losses occurred on transfer to the recovery room. nan The choice between regional versus general anaesthesia for elderly patients undergoing hip surgery is debated. It is vitally important to see if the type of anaesthetic administered affects per- and postoperative morbidity and mortality. Seventy women more than 75 yr old suitable for spinal anaesthesia were included in this study. They were randomly divided into two groups: in one (n = 35), general anaesthesia was given with sodium thiopentone, fentanyl, enflurane and vecuronium; in the other (n = 35), spinal anaesthesia was performed with 3 ml 0.5% bupivacaine in isobaric solution. During the anaesthetic period, there were no statistically significant differences between both groups in systolic arterial pressure falls or in increases in the heart rate X systolic arterial pressure product. No serious cardiovascular collapse was encountered. Seven patients (20%) receiving general anaesthesia had mental changes against four only (14.2%) in the spinal group. In patients having general anaesthesia, 22.9% developed bronchopneumonia as opposed to 8.6% in the spinal anaesthesia group (p less than 0.05). The mortality rate at three months was rather similar in the two groups. It was concluded that, in order to reduce the incidence of postoperative central dysfunction and bronchopneumonia, spinal anaesthesia should be preferred in geriatric patients for lower limb surgery. The effects of cementation on arterial blood pressure, arterial oxygen tension and plasma levels of cortisol were studied in 30 patients with femoral neck fracture treated with the Thompson prosthesis in spinal (n = 15) or general (n = 15) anaesthesia. In spinal anaesthesia hypotension of clinical importance was observed coincidentally with the use of methylmethacrylate, while the levels of plasma cortisol remained unchanged. A significant rise was noted in arterial blood pressure and plasma levels of cortisol after cementation in general anaesthesia. Arterial oxygen tension fell in both groups. These findings indicate that the hypotension frequently reported in connection with cementation is triggered by a complex mechanism which can be modified by the anaesthetic technique. This prospective, randomized study was conducted to compare unilateral spinal block using small doses of hyperbaric bupivacaine and single-agent anaesthesia with sevoflurane in elderly patients undergoing hip surgery.
                Thirty patients (> 65 yr) undergoing hip fracture repair were randomly allocated to receive unilateral spinal anaesthesia with hyperbaric bupivacaine 7.5 mg 0.5% (Group Spinal, n = 15) or volatile induction and maintenance anaesthesia with sevoflurane (Group SEVO, n = 15). General anaesthesia was induced by increasing the inspired concentration to 5%. A laryngeal mask airway was placed without muscle relaxants, and the end-tidal concentrations of sevoflurane were adjusted to maintain cardiovascular stability. Hypotension (decrease in systolic arterial pressure > 20% from baseline), hypertension or bradycardia (heart rate < 50 beats min(-1)) requiring treatment, and the length of stay in the postanaesthesia care unit was recorded. Cognitive functions were evaluated the previous day, and 1 and 7 days after surgery with the Mini Mental State Examination test.
                Hypotension occurred in seven patients of Group Spinal (46%) and in 12 patients of Group SEVO (80%) (P = 0.05). Phenylephrine was required to control hypotension in three spinal patients (21%) and four SEVO patients (26%) (n.s.). SEVO patients had lower heart rates than spinal patients from 15 to 60 min after anaesthesia induction (P = 0.01). Bradycardia was observed in three SEVO patients (22%). Discharge from the postanaesthesia care unit required 15 (range 5-30) min in Group Spinal and 55 (15-80) min in Group SEVO (P = 0.0005). Eight patients in Group Spinal (53%) and nine patients in Group SEVO (60%) showed cognitive decline (Mini Mental State Examination test decreased > or = 2 points from baseline) 24 h after surgery (n.s.). Seven days after surgery, confusion was still present in one patient of Group Spinal (6%) and in three patients of Group SEVO (20%) (n.s.).
                In elderly patients undergoing hemiarthroplasty of the hip, induction and maintenance with sevoflurane provide a rapid emergence from anaesthesia without more depression of postoperative cognitive function compared with unilateral spinal anaesthesia. This technique represents an attractive option when patient refusal, lack of adequate co-operation or concomitant anticoagulant therapy contraindicate the use of spinal anaesthesia. We have compared the incidence of preoperative and postoperative oxygen desaturation in 20 elderly patients undergoing dynamic hip screw insertion for fractured neck of femur, allocated randomly to two groups to receive subarachnoid anaesthesia (SA, n = 10) or a general anaesthetic (GA, n = 10). Oximetry data were recorded during the preoperative night and the first 48 hours after surgery using Satmaster. Data associated with zero amplitude signal were automatically invalidated by the software and decreases in SpO2 which were preceded by contemporaneous changes in signal amplitude which conformed to a previously described template were assumed to be artefactual and were discarded from final data analysis. Data demonstrated a wide interpatient variability. However, those patients who desaturated preoperatively continued to do so in the postoperative period. The differences between the preoperative and postoperative oximetry profiles were examined for each patient and demonstrated a significantly longer time spent with SpO2 < 90% in the GA group compared with the SA group, in all the recorded time periods, except on the day of surgery. The SA group showed an improvement in oxygen saturation postoperatively when compared to the preoperative night, spending less time with an SpO2 < 85%. We conclude that the subarachnoid anaesthetic technique was associated with a lower incidence of postoperative oximetry desaturation when compared with general anaesthetic for these elderly patients undergoing repair of fractured neck of femur. Ketamine has been compared with 'relaxant' anaesthesia in operations for fractured neck of femur in elderly women. Ketamine was found to reduce early mortality principally by a reduction in thromboembolic complications, but at the expense of more unsatisfactory surgical results. It is suggested that the mortality after relaxant anaesthesia for these operations is unacceptable. Fifty-five patients presenting with fractured neck of femur were randomly allocated to either a standard general anaesthetic or spinal block in the lateral position combined with light sedation. The comparability of the two groups was established. There was little difference in the intra-operative course of postoperative morbidity in the two groups. There was a statistically significant difference in post-operative mortality between two groups, the general anaesthetic group showing a much higher mortality than the spinal group. The mortality following surgical correction of upper femoral fractures was investigated in 578 patients, over the age of 50 yr, randomly allocated to receive spinal (bupivacaine) or general (enflurane or neurolept) anaesthesia. Thirty days after surgery the mortality was 6% after spinal and 8% after general anaesthesia (ns). Six months to 2 years after surgery the mortality was identical in the two groups. There were no differences with respect to ambulation and discharge. The estimated blood loss was smaller (P less than 0.05) in patients receiving spinal anaesthesia. Regardless of the anaesthetic technique, a high short-term mortality was related to age, male sex, and trochanteric fracture, whereas excess long-term mortality was related to male sex and high ASA scores. Influence of the type of anesthesia on postoperative delirium was examined in geriatric patients with femoral neck fracture.
                Forty patients aged 70 or more were randomly allocated to receive either general anesthesia (sevoflurane, nitrous oxide in oxygen, G group, n = 21) or spinal anesthesia (0.5% bupivacaine, S group, n = 19). G group received the oxygen therapy during the 12-hour postoperative period. Postoperative assessments included the rate of postoperative delirium during the 4-day postoperative period, oxygen saturation during the 18-hour postoperative period, the value of hemoglobin at 1 postoperative day and the number of analgesics requirements during the 4-day postoperative period.
                The rate of postoperative delirium was similar between the two groups during the 4-day postoperative period. However, that of S group tended to be higher during the 1-day postoperative period. Postoperative analgesic effect and the value of hemoglobin at 1 postoperative day were similar between the two groups. Oxygen saturation was similar between the two groups except 6 hours after the operation.
                The type of anesthesia, general or spinal, does not affect the postoperative delirium in geriatric patients with femoral neck fracture. One hundred and thirty-two elderly patients undergoing emergency hip surgery were randomly allocated to receive subarachnoid block (SAB) or general anaesthesia (GA). Using the 125.I fibrinogen uptake test, deep vein thrombosis was found to occur in 17 of 37 patients in the SAB group and 30 of 39 patients in the GA group (P 0.05). Blood loss was 513 ml (+/- SEM 44) in the SAB group and 714 ml (+/- SEM 67) in the GA group (P less than 0.01). Hypoxaemia was present preoperatively (mean PaO2 9.2 kPa). Immediately following general anaesthesia, the mean fall in PaO2 was 0.86 kPa compared with preoperative values but only 0.16 kPa following subarachnoid block (P less than 0.01). At 24 hours postoperatively the fall in PaO2 was similar in both groups and recovered only slowly during the first week. Twelve patients died, three in the SAB group and nine in the GA group. This difference in mortality was not statistically significant. One hundred and forty-eight patients undergoing "pin-and-plate" repair of fractured neck of femur received either subarachnoid blockade or general anaesthesia. The patients were followed up for 1 year after surgery. At the end of the year, 34% had died and 50% had returned home. Twelve per cent were either in hospital or in institutional care; 4% were lost to follow up. The mean duration of acute plus convalescent hospital bed occupancy was 84.4 days. There was a significantly lower mortality in the subarachnoid anaesthetic group by 14 days after surgery. The majority of the deaths in the general anaesthetic group were clustered between 6 and 16 days. However, at the end of 2 months the mortality rates were similar in both groups. It is conceivable that the difference in the distribution of deaths between the groups was a result of thrombo-embolism.
Overall, there was insufficient evidence available from trials comparing regional versus general anaesthesia to rule out clinically important differences. Regional anaesthesia may reduce acute postoperative confusion but no conclusions can be drawn for mortality or other outcomes.