Anesthesia Technique, Mortality, and Length of Stay After Hip Fracture Surgery

Mark D. Neuman, MD, MSc; Paul R. Rosenbaum, PhD; Justin M. Ludwig, MA; Jose R. Zubizarreta, PhD; Jeffrey H. Silber, MD, PhD

JAMA. 2014;311(24):2508-2517

The investigators conducted a matched retrospective cohort study involving patients 50 years or older who were undergoing surgery for hip fracture at general acute care hospitals Of 56 729 patients, 15 904 (28%) received regional anesthesia and 40 825 (72%) received general anesthesia. Overall, 3032 patients (5.3%) died in New York State between July 1, 2004, and December 31, 2011.

To go beyond prior observational studies, they used 2 statistical techniques intended to address selection bias, multivariable matching, and instrumental variable analysis. They hypothesized that regional anesthesia would be associated with improved outcomes compared with general anesthesia.

The near-far matched analysis showed no significant difference in 30-day mortality by anesthesia type among the 21 514 patients included in this match

Regional anesthesia was associated with a 0.6-day shorter length of stay than general anesthesia

Increased risk of acute kidney injury associated with higher infusion rate of mannitol in patients with intracranial hemorrhage

Clinical article

Min Young Kim ,MD et al

Journal of Neurosurgery

Jun 2014 / Vol. 120 / No. 6 / Pages 1340-1348 

 The objectives of this study were to assess the impact of mannitol on the incidence and severity of acute kidney injury (AKI) and to identify risk factors and outcome for AKI in patients with intracranial hemorrhage (ICH).

 The authors retrospectively evaluated 153 adult patients who received mannitol infusion after ICH between January 2005 and December 2009 in the neurosurgical intensive care unit.

 The overall incidence of AKI among study participants was 10.5% 

(n = 16). 

Acute kidney injury occurred more frequently in patients who received mannitol infusion at a rate ≥ 1.34 g/kg/day than it did in patients who received mannitol infusion at a rate < 1.34 g/kg/day.

 A higher mannitol infusion rate was associated with more severe AKI. Independent risk factors for AKI were mannitol infusion rate ≥ 1.34 g/kg/day, age ≥ 70 years, diastolic blood pressure (DBP) ≥ 110 mm Hg, and glomerular filtration rate < 60 ml/min/1.73 m²

Intraoperative Maintenance of Normoglycemia with Insulin and Glucose Preserves Verbal Learning after Cardiac Surgery.

 Schricker T, Sato H, Beaudry T, Codere T, Hatzakorzian R, Pruessner JC.

 PLoS One. 2014 Jun 18;9(6)

 

Patients were randomly assigned to receive combined administration of insulin and glucose, titrated to preserve normoglycemia (3.5-6.1 mmol L-1; experimental group), or standard metabolic care (blood glucose 3.5-10 mmol L-1; control group), during open heart surgery. The patients' cognitive function was assessed during three home visits, approximately two weeks before the operation, and two months and seven months after surgery.  Questionnaires measuring specific traits known to affect cognitive performance, such as self-esteem, depression, chronic stress and social support, were also administered. The primary outcome was to assess the effect of hyperinsulinemic-normoglycemic clamp therapy versus standard therapy on specific cognitive parameters in patients receiving normoglycemic clamp, or standard metabolic care.

Twenty-six patients completed the study with 14 patients in the normoglycemia and 12 patients in the control group. Multiple analysis of covariance (MANCOVA) for the RAVLT showed a significant effect for the interaction of group by visit (F = 4.07, p = 0.035), and group by visit by recall (F = 2.21, p = 0.04). The differences occurred at the second and third visit. MANCOVA for the digit span task, trail making and word pair association test showed no significant effect.

CONCLUSIONS:

Preserving intraoperative normoglycemia by intravenous insulin and glucose may prevent the impairment of memory function, both short and long-term, after cardiac surgery.

Effect of General Anesthesia in Infancy on Long-Term Recognition Memory in Humans and Rats.

Stratmann G et al

Neuropsychopharmacology. 2014 Jun 9.

The authors compared twenty eight children ages 6-11 who had undergone a procedure requiring general anesthesia before age 1 to twenty eight age- and gender-matched children who had not undergone anesthesia.

 Recollection and familiarity were assessed in an object recognition memory test using receiver operator characteristic analysis. In addition, IQ and Child Behavior Checklist scores were assessed.

 In parallel, thirty three 7-day old rats were randomized to receive anesthesia or sham anesthesia. Over ten months, recollection and familiarity were assessed using an odor recognition test.

They found that anesthetized children had significantly lower recollection scores and were impaired at recollecting associative information compared to controls. Familiarity, IQ, and Child Behavior Checklist scores were not different between groups.

In rats, anesthetized subjects had significantly lower recollection scores than controls while familiarity was unaffected. Rats that had undergone tissue injury during anesthesia had similar recollection indices as rats that had been anesthetized without tissue injury.

These findings suggest that general anesthesia in infancy impairs recollection later in life in humans and rats. In rats, this effect is independent of underlying disease or tissue injury.

Reversal of a rocuronium-induced grade IV anaphylaxis via early injection of a large dose of sugammadex

Conte B, Zoric L, Bonada G, Debaene B, Ripart J.

Can J Anaesth.  2014 Jun;61(6):558-562

A 22-yr-old female without relevant medical history developed an anaphylactic reaction within three minutes of rocuronium injection at induction of anesthesia for a routine cholecystectomy. During the first six minutes, she was unresponsive to usual treatment and her condition evolved to a grade IV anaphylaxis reaction despite a cumulated dose of epinephrine 0.7 mg. Sugammadex 14 mg·kg^-1, injected six minutes after rocuronium, resulted in total resolution of all manifestations of anaphylaxis within three minutes. The patient was discharged from hospital the next day. Allergy investigations confirmed rocuronium as the cause of anaphylaxis.