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Questions and Answers

What was the primary outcome measured in the trial comparing combined epidural-general anesthesia and general anesthesia?

Duration of surgery

Incidence of intraoperative hypotension

Incidence of postoperative delirium (correct)

Amount of opioid consumption

What complication was more frequent in patients assigned to epidural anesthesia compared to those receiving general anesthesia?

Intraoperative hypotension (correct)

Delayed recovery from anesthesia

Postoperative infection

Increased pain levels

What percentage of patients in the general anesthesia group developed postoperative delirium?

5.0% (correct)

7.5%

3.2%

1.8%

What age range were the patients enrolled in the trial?

60 to 90 years Signup and view all the answers

What anesthesia method was used for patients with a failed epidural block?

Postoperative patient-controlled intravenous analgesia Signup and view all the answers

Which drug was NOT permitted as a premedication in either group?

Sufentanil Signup and view all the answers

What was the lockout interval for patient-controlled intravenous analgesia?

6 to 10 minutes Signup and view all the answers

How were participants randomized in the study?

Central randomization with computer-generated codes Signup and view all the answers

Which statement describes the monitoring of the study?

The Peking University Clinical Research Institute managed the study monitoring. Signup and view all the answers

What type of surgeries were included in this trial?

Major noncardiac thoracic or abdominal surgeries Signup and view all the answers

What concentration of ropivacaine was maintained during the surgery for combined epidural and general anesthesia?

0.375 to 0.5% Signup and view all the answers

Which organization provided ethical approval for the trial?

Peking University Institutional Review Board Signup and view all the answers

What was the background infusion rate for patient-controlled epidural analgesia?

4 ml/h Signup and view all the answers

What are the routine management strategies employed for intraoperative hypotension?

Fluid infusion, administering vasopressors, reducing anesthetic depth Signup and view all the answers

Which of the following assessments measures cognitive function?

Mini-Mental State Examination Signup and view all the answers

What is the primary outcome of the study involving delirium?

Incidence of delirium Signup and view all the answers

Which of the following statements about the Richmond Agitation Sedation Scale is true?

A score of 0 indicates alert and calmness Signup and view all the answers

What monitoring was included for patients admitted to the ICU after surgery?

Electrocardiogram, intraarterial pressure, and pulse oxygen saturation Signup and view all the answers

What score indicates more severe symptoms for both anxiety and depression according to the Hospital Anxiety and Depression Scale?

7 Signup and view all the answers

Which types of delirium are classified according to the Richmond Agitation Sedation Scale?

Hyperactive, hypoactive, and mixed Signup and view all the answers

Which measure is evaluated using the Barthel Index?

Activities of daily living Signup and view all the answers

How often was delirium assessed after surgery during the postoperative period?

Twice daily for the first 7 days Signup and view all the answers

What is one of the roles of the research staff in managing patient assessments?

Hiding patient-controlled analgesia apparatus from investigators Signup and view all the answers

What was the primary outcome measured in older patients receiving combined epidural-general anesthesia compared to general anesthesia alone?

Incidence of postoperative delirium Signup and view all the answers

What did the combination of epidural and general anesthesia result in regarding hypotension?

Increased incidence of hypotension Signup and view all the answers

What is a proposed mechanism by which epidural anesthesia might help prevent postoperative delirium?

Reduction of opioid dosage Signup and view all the answers

According to the analyzed studies, which surgeries have a reported incidence of postoperative delirium?

Major surgeries, varying by type Signup and view all the answers

What is a significant challenge in interpreting results from studies on regional anesthesia and delirium?

Sedatives given to patients may promote delirium Signup and view all the answers

Which of the following represents a long-term outcome associated with postoperative delirium in older patients?

Increased hospital readmissions Signup and view all the answers

What advantage does epidural analgesia offer in the postoperative setting?

Enhanced pain control Signup and view all the answers

What is true about the causes of postoperative delirium following major surgery in older adults?

Surgery-related stress and inflammation may contribute Signup and view all the answers

What is the suggested anesthetic approach for older patients at risk of delirium during major surgeries?

Combined epidural-general anesthesia Signup and view all the answers

Which statement regarding postoperative delirium is correct?

It can decrease quality of life and functional status Signup and view all the answers

What was the primary reason for determining whether the trial should be suspended?

High incidence of violations or evidence of harm Signup and view all the answers

What was the estimated sample size required to achieve 80% power in the study?

1,664 participants Signup and view all the answers

How many patients were ultimately included in the per-protocol analysis?

1,602 patients Signup and view all the answers

What was the incidence of postoperative delirium among older patients given general anesthesia for major abdominal surgery?

13.1% Signup and view all the answers

During the screening phase, how many patients were screened for inclusion in the trial?

3,049 patients Signup and view all the answers

What was the dropout expectation percentage set during the planning of the trial?

7.5% Signup and view all the answers

What were the two anesthesia techniques compared in the trial?

General anesthesia alone and combined epidural-general anesthesia Signup and view all the answers

What was the total number of patients who dropped out of the study after randomization?

25 patients Signup and view all the answers

What was the primary finding regarding the effectiveness of liposomal bupivacaine in abdominal fascial plane blocks compared to plain local anesthetics?

There was no difference in pain severity between the two agents. Signup and view all the answers

What secondary outcomes showed no clinically important differences between liposomal bupivacaine and plain local anesthetics?

Duration of hospital stay and opioid-related side effects. Signup and view all the answers

How many randomized trials were included in the analysis of liposomal bupivacaine vs. plain local anesthetics?

13 randomized trials Signup and view all the answers

What time frame was used to compare pain severity scores in the study's primary outcome?

24 to 72 hours postoperatively Signup and view all the answers

Which of the following statements is true regarding the use of liposomal bupivacaine?

There is no evidence-based preference for liposomal bupivacaine over plain local anesthetics. Signup and view all the answers

What was a significant observation regarding opioid consumption in the groups studied?

Both groups showed equal opioid consumption patterns. Signup and view all the answers

What was the main finding regarding the comparison between liposomal bupivacaine and plain local anesthetics in terms of area under the curve pain scores?

No significant difference was observed between the two groups. Signup and view all the answers

What eclectic mixture was observed in the studies regarding the administration of liposomal bupivacaine?

Liposomal bupivacaine was mixed with plain bupivacaine in several studies. Signup and view all the answers

What was the sample size of patients enrolled in the trials examining liposomal bupivacaine?

1,287 patients Signup and view all the answers

What secondary outcomes were evaluated in the comparison of liposomal bupivacaine and plain local anesthetics?

Rest pain at various time points and analgesic consumption Signup and view all the answers

Which statistical method was employed to pool the data from the trials?

Hartung-Knapp-Sidik-Jonkman random effects method Signup and view all the answers

What was the standardized mean difference observed for area under the curve pain scores between the two groups?

-0.21 cm.h Signup and view all the answers

What can be concluded about the analgesic effectiveness of liposomal bupivacaine compared to plain local anesthetics based on this meta-analysis?

Both have similar analgesic effectiveness when used for abdominal fascial plane blocks. Signup and view all the answers

Were there any differences noted for secondary outcomes on day 2 or day 3 between the two analgesic groups?

No, there were no differences observed. Signup and view all the answers

Study Notes

Delirium in Postoperative Patients

Delirium is a significant and common postoperative complication, particularly in elderly patients following major surgery.
Incidence rates of delirium vary by surgery type: 6-46% after cardiac surgery, 5-39% after vascular, 8-54% after gastrointestinal, and 5-14% after total joint arthroplasty.
Associated outcomes of postoperative delirium include longer hospital stays, complications, increased healthcare costs, and impaired long-term cognitive and functional abilities.

Anesthesia Methods and Study Overview

The trial aimed to test whether combined epidural-general anesthesia reduces postoperative delirium compared to general anesthesia alone.
Patients aged 60 to 90 scheduled for major thoracic or abdominal surgeries lasting 2 or more hours were involved.
Participants were randomized to either combined epidural-general anesthesia with postoperative epidural analgesia or standard general anesthesia with postoperative intravenous analgesia.

Study Results

Between November 2011 and May 2015, 1,802 patients were randomized, with 1,720 completing the study (mean age 70; 35% females).
Delirium was significantly less common in the combined epidural group (1.8%) compared to the general anesthesia group (5.0%), with a relative risk of 0.351.
Intraoperative hypotension (systolic BP < 80 mmHg) was more prevalent in the epidural group (49% vs. 33%; relative risk of 1.47).
More patients in the epidural group required vasopressors (58% vs. 45%; relative risk of 1.29).

Implications for Clinical Practice

The combined epidural-general anesthesia approach could be beneficial for older patients at risk of postoperative delirium, while cautioning against its use in patients predisposed to hypotension.
Adequate pain management and reduced opioid usage through epidural analgesia may contribute to lower delirium rates.

Key Definitions

Delirium: Acute syndrome characterized by fluctuations in concentration, consciousness, and cognitive function.
Epidural Anesthesia: Involves administering anesthetics into the epidural space to provide effective pain relief during and after surgery.

Study Design and Methodology

This multicenter, randomized trial was conducted across five tertiary hospitals in Beijing, China, with institutional review board approval.
Randomization was achieved using a computer-generated method, ensuring concealed allocation until shortly before the procedure.
Primary outcome measured was the incidence of delirium, assessed using the Confusion Assessment Method for the ICU twice daily for up to 7 postoperative days.

Adverse Events and Monitoring

Strict monitoring of intraoperative and postoperative parameters was implemented to manage hypotension and other potential complications.
Secondary outcomes included time to onset of delirium, hospitalization duration, ICU admission rates, and all-cause mortality within 30 days.

Statistical Analysis

Analyses of primary outcomes utilized chi-squared tests, with a significance threshold set at P < 0.05.
Missing data were appropriately handled for robust results, considering last observation carried forward.

Conclusion

The trial supports the use of combined epidural-general anesthesia in older patients to reduce postoperative delirium, while highlighting the increased risk of hypotension associated with this technique.

Background

Liposomal bupivacaine is thought to extend analgesia duration for abdominal fascial plane blocks versus plain local anesthetics.
Mixed evidence exists from randomized trials regarding its effectiveness.

Study Aim

Meta-analysis designed to compare the analgesic effectiveness of liposomal bupivacaine with plain local anesthetics in adults undergoing abdominal fascial plane blocks.

Methods

Inclusion of randomized trials comparing liposomal bupivacaine to plain local anesthetics in abdominal fascial plane blocks.
Primary outcome measured: area under the curve (AUC) for rest pain between 24 to 72 hours postoperatively.
Secondary outcomes examined included:
- Rest pain at various time points (1, 6, 12, 24, 48, 72 hours).
- Analgesic consumption over several intervals (0-24, 25-48, 49-72 hours).
- Time until the first analgesic request.
- Duration of hospital stay.
- Opioid-related side effects.
Pooled data using Hartung-Knapp-Sidik-Jonkman random effects method.

Results

Analysis included 16 trials with a total of 1,287 patients (667 in liposomal bupivacaine group; 620 in plain local anesthetics group).
Common combinations used liposomal bupivacaine mixed with plain bupivacaine (10 studies), solely liposomal bupivacaine (5 studies), or both in a three-armed study.
No significant difference in AUC pain scores between the groups, with a standardized mean difference of -0.21 cm.h (95% CI: -0.43 to 0.01; P = 0.058).
Results consistent even after subgroup analysis regarding potential conflicts of interest and mixing of anesthetics.
No notable differences in secondary outcomes on days 2 and 3, including rest pain scores or opioid consumption.

Conclusions

Systematic review and meta-analysis indicate similar analgesic effectiveness of liposomal bupivacaine and plain local anesthetics in abdominal fascial plane blocks.
Findings do not support a preference for liposomal bupivacaine over plain local anesthetics based on current evidence.

Editor's Perspective

Prior knowledge: Liposomal bupivacaine reported to potentially prolong analgesia duration compared to traditional local anesthetics.
New insights: This systematic review and meta-analysis provides evidence of no difference in analgesic effectiveness between liposomal bupivacaine and plain local anesthetics for abdominal fascial plane blocks.
Included: Analysis of 874 patients across 13 randomized trials focusing on pain severity scores at rest between 24 and 72 hours postoperatively.
No clinically important differences found in secondary outcomes, including rest pain scores, opioid consumption, timing for analgesic requests, hospital discharge, and opioid-related side effects.

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Description

This quiz covers the impact of combined epidural-general anesthesia on postoperative delirium in elderly patients. It explores the rationale behind using epidural anesthesia to enhance recovery and minimize complications after major noncardiac surgeries. Test your knowledge on this critical area of anesthesia research.