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Questions and Answers
What was the primary outcome measured in the trial comparing combined epidural-general anesthesia and general anesthesia?
What was the primary outcome measured in the trial comparing combined epidural-general anesthesia and general anesthesia?
What complication was more frequent in patients assigned to epidural anesthesia compared to those receiving general anesthesia?
What complication was more frequent in patients assigned to epidural anesthesia compared to those receiving general anesthesia?
What percentage of patients in the general anesthesia group developed postoperative delirium?
What percentage of patients in the general anesthesia group developed postoperative delirium?
What age range were the patients enrolled in the trial?
What age range were the patients enrolled in the trial?
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What anesthesia method was used for patients with a failed epidural block?
What anesthesia method was used for patients with a failed epidural block?
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Which drug was NOT permitted as a premedication in either group?
Which drug was NOT permitted as a premedication in either group?
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What was the lockout interval for patient-controlled intravenous analgesia?
What was the lockout interval for patient-controlled intravenous analgesia?
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How were participants randomized in the study?
How were participants randomized in the study?
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Which statement describes the monitoring of the study?
Which statement describes the monitoring of the study?
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What type of surgeries were included in this trial?
What type of surgeries were included in this trial?
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What concentration of ropivacaine was maintained during the surgery for combined epidural and general anesthesia?
What concentration of ropivacaine was maintained during the surgery for combined epidural and general anesthesia?
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Which organization provided ethical approval for the trial?
Which organization provided ethical approval for the trial?
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What was the background infusion rate for patient-controlled epidural analgesia?
What was the background infusion rate for patient-controlled epidural analgesia?
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What are the routine management strategies employed for intraoperative hypotension?
What are the routine management strategies employed for intraoperative hypotension?
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Which of the following assessments measures cognitive function?
Which of the following assessments measures cognitive function?
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What is the primary outcome of the study involving delirium?
What is the primary outcome of the study involving delirium?
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Which of the following statements about the Richmond Agitation Sedation Scale is true?
Which of the following statements about the Richmond Agitation Sedation Scale is true?
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What monitoring was included for patients admitted to the ICU after surgery?
What monitoring was included for patients admitted to the ICU after surgery?
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What score indicates more severe symptoms for both anxiety and depression according to the Hospital Anxiety and Depression Scale?
What score indicates more severe symptoms for both anxiety and depression according to the Hospital Anxiety and Depression Scale?
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Which types of delirium are classified according to the Richmond Agitation Sedation Scale?
Which types of delirium are classified according to the Richmond Agitation Sedation Scale?
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Which measure is evaluated using the Barthel Index?
Which measure is evaluated using the Barthel Index?
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How often was delirium assessed after surgery during the postoperative period?
How often was delirium assessed after surgery during the postoperative period?
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What is one of the roles of the research staff in managing patient assessments?
What is one of the roles of the research staff in managing patient assessments?
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What was the primary outcome measured in older patients receiving combined epidural-general anesthesia compared to general anesthesia alone?
What was the primary outcome measured in older patients receiving combined epidural-general anesthesia compared to general anesthesia alone?
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What did the combination of epidural and general anesthesia result in regarding hypotension?
What did the combination of epidural and general anesthesia result in regarding hypotension?
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What is a proposed mechanism by which epidural anesthesia might help prevent postoperative delirium?
What is a proposed mechanism by which epidural anesthesia might help prevent postoperative delirium?
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According to the analyzed studies, which surgeries have a reported incidence of postoperative delirium?
According to the analyzed studies, which surgeries have a reported incidence of postoperative delirium?
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What is a significant challenge in interpreting results from studies on regional anesthesia and delirium?
What is a significant challenge in interpreting results from studies on regional anesthesia and delirium?
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Which of the following represents a long-term outcome associated with postoperative delirium in older patients?
Which of the following represents a long-term outcome associated with postoperative delirium in older patients?
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What advantage does epidural analgesia offer in the postoperative setting?
What advantage does epidural analgesia offer in the postoperative setting?
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What is true about the causes of postoperative delirium following major surgery in older adults?
What is true about the causes of postoperative delirium following major surgery in older adults?
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What is the suggested anesthetic approach for older patients at risk of delirium during major surgeries?
What is the suggested anesthetic approach for older patients at risk of delirium during major surgeries?
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Which statement regarding postoperative delirium is correct?
Which statement regarding postoperative delirium is correct?
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What was the primary reason for determining whether the trial should be suspended?
What was the primary reason for determining whether the trial should be suspended?
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What was the estimated sample size required to achieve 80% power in the study?
What was the estimated sample size required to achieve 80% power in the study?
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How many patients were ultimately included in the per-protocol analysis?
How many patients were ultimately included in the per-protocol analysis?
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What was the incidence of postoperative delirium among older patients given general anesthesia for major abdominal surgery?
What was the incidence of postoperative delirium among older patients given general anesthesia for major abdominal surgery?
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During the screening phase, how many patients were screened for inclusion in the trial?
During the screening phase, how many patients were screened for inclusion in the trial?
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What was the dropout expectation percentage set during the planning of the trial?
What was the dropout expectation percentage set during the planning of the trial?
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What were the two anesthesia techniques compared in the trial?
What were the two anesthesia techniques compared in the trial?
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What was the total number of patients who dropped out of the study after randomization?
What was the total number of patients who dropped out of the study after randomization?
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What was the primary finding regarding the effectiveness of liposomal bupivacaine in abdominal fascial plane blocks compared to plain local anesthetics?
What was the primary finding regarding the effectiveness of liposomal bupivacaine in abdominal fascial plane blocks compared to plain local anesthetics?
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What secondary outcomes showed no clinically important differences between liposomal bupivacaine and plain local anesthetics?
What secondary outcomes showed no clinically important differences between liposomal bupivacaine and plain local anesthetics?
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How many randomized trials were included in the analysis of liposomal bupivacaine vs. plain local anesthetics?
How many randomized trials were included in the analysis of liposomal bupivacaine vs. plain local anesthetics?
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What time frame was used to compare pain severity scores in the study's primary outcome?
What time frame was used to compare pain severity scores in the study's primary outcome?
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Which of the following statements is true regarding the use of liposomal bupivacaine?
Which of the following statements is true regarding the use of liposomal bupivacaine?
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What was a significant observation regarding opioid consumption in the groups studied?
What was a significant observation regarding opioid consumption in the groups studied?
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What was the main finding regarding the comparison between liposomal bupivacaine and plain local anesthetics in terms of area under the curve pain scores?
What was the main finding regarding the comparison between liposomal bupivacaine and plain local anesthetics in terms of area under the curve pain scores?
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What eclectic mixture was observed in the studies regarding the administration of liposomal bupivacaine?
What eclectic mixture was observed in the studies regarding the administration of liposomal bupivacaine?
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What was the sample size of patients enrolled in the trials examining liposomal bupivacaine?
What was the sample size of patients enrolled in the trials examining liposomal bupivacaine?
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What secondary outcomes were evaluated in the comparison of liposomal bupivacaine and plain local anesthetics?
What secondary outcomes were evaluated in the comparison of liposomal bupivacaine and plain local anesthetics?
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Which statistical method was employed to pool the data from the trials?
Which statistical method was employed to pool the data from the trials?
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What was the standardized mean difference observed for area under the curve pain scores between the two groups?
What was the standardized mean difference observed for area under the curve pain scores between the two groups?
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What can be concluded about the analgesic effectiveness of liposomal bupivacaine compared to plain local anesthetics based on this meta-analysis?
What can be concluded about the analgesic effectiveness of liposomal bupivacaine compared to plain local anesthetics based on this meta-analysis?
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Were there any differences noted for secondary outcomes on day 2 or day 3 between the two analgesic groups?
Were there any differences noted for secondary outcomes on day 2 or day 3 between the two analgesic groups?
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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.