Abstract
Background
In older non-cardiac surgery patients, the influence of the mode of anesthesia on late-term outcome (rehabilitation, mobility, independence) is a controversial issue in the medical literature. In light of an aging society, this review assessed the association between regional (RA), local (LA) and general anesthesia (GA) and mortality and morbidity.
Methods
A literature search within the PubMed and Cochrane databases yielded 47 clinical trials and 35 reviews/meta-analyses published between 1965 and 2013. Potential outcome-influencing factors such as mortality, risk factors, early complications (e.g. postoperative confusion, aspiration, vomiting), adverse events (e.g. deep vein thrombosis, pulmonary embolism), discharge, rehabilitation and mobilization were evaluated in relation to the mode of anesthesia (RA, LA or GA).
Results
The current literature contains 82 references covering 74,476 non-cardiac surgery patients. Analysis shows that the particular mode of anesthesia influences mortality and morbidity. RA is associated with reduced early mortality and morbidity, e.g. fewer incidents of deep vein thrombosis and less acute postoperative confusion, as well as a tendency toward fewer myocardial infarctions and fatal pulmonary embolisms. GA has the advantages of a lower incidence of hypotension and reduced surgery time.
Conclusion
Strictly speaking, true anesthesia-related complications appear to be rare and many adverse outcomes may be multifactorial. Postoperative complications are largely related to the perioperative procedure and not to the anesthesia itself. GA and RA are both useful for older non-cardiac patients, but for some procedures, e.g. hip fracture surgery, RA seems to be the technique of choice. The mode of anesthesia may only play a secondary role in mobility, rehabilitation and discharge destination. In general, due to the many different possible outcomes—which are often very difficult or impossible to compare—no other specific recommendations can be made with regard to the type of anesthesia to be preferred for older non-cardiac patients.
Zusammenfassung
Hintergrund
Bei älteren chirurgischen Patienten (außer Herzchirurgie) ist der Einfluss des Anästhesieverfahrens auf den Langzeitverlauf (Rehabilitation, Mobilität, Eigenständigkeit) in der Fachliteratur umstritten. Angesichts einer alternden Gesellschaft wurde in dieser Übersicht der Zusammenhang zwischen Regionalanästhesie (RA), Lokalanästhesie (LA) sowie Vollnarkose einerseits und Mortalität sowie Morbidität andererseits untersucht.
Methoden
Die Literatursuche in den Datenbanken PubMed und Cochrane ergab 47 klinische Studien und 35 Übersichten/Metaanalysen, die zwischen 1965 und 2013 publiziert worden waren. Potenzielle Einflussfaktoren auf den Verlauf wie Mortalität, Risikofaktoren, Frühkomplikationen (z. B. postoperative Verwirrtheit, Aspiration, Erbrechen), unerwünschte Ereignisse (z. B. tiefe Beinvenenthrombose, Lungenembolie), Entlassung, Rehabilitation und Mobilisation wurden in Hinblick auf das Anästhesieverfahren untersucht (RA, LA oder Vollnarkose)
Ergebnisse
Die aktuelle Literatur umfasst 82 Quellen zu 74.476 chirurgischen Patienten (außer Herzchirurgie). Wie die Auswertung ergab, beeinflusst die Wahl des Anästhesieverfahrens Mortalität und Morbidität. Dabei geht die RA mit einer verminderten Frühmortalität und -morbidität einher, z. B. mit weniger Fällen tiefer Beinvenenthrombose und akuter postoperativer Verwirrtheit, sowie mit einer Tendenz zu weniger Herzinfarkten und tödlichen Lungenembolien. Dagegen weist die Vollnarkose den Vorteil einer geringeren Hypotonie-Inzidenz und kürzeren Operationsdauer auf.
Schlussfolgerung
Genau genommen scheinen wirklich narkosebedingte Komplikationen selten zu sein und viele ungünstige Verläufe möglicherweise multifaktoriell bedingt. Postoperative Komplikationen hängen weitgehend mit dem perioperativen Vorgehen und nicht mit der Anästhesie an sich zusammen. Sowohl die Vollnarkose als auch die RA sind sinnvoll für ältere Patienten, aber für einige Eingriffe, z. B. eine Operation wegen einer Hüftfraktur, scheint die RA das Verfahren der Wahl zu sein. Das Anästhesieverfahren spielt möglicherweise bezüglich Mobilität, Rehabilitation und Entlassungsziel nur eine sekundäre Rolle. Im Allgemeinen können aufgrund der vielen verschiedenen möglichen Verläufe, die oft sehr schwer oder unmöglich zu vergleichen sind, keine weiteren speziellen Empfehlungen in Hinblick auf das bevorzugte Anästhesieverfahren für ältere Patienten gegeben werden.
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Acknowledgments
The authors thank Mary Heaney Margreiter, native speaker and professional editor, Innsbruck, Austria, for her critical review of the manuscript.
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Conflict of interest. T.J. Luger, C. Kammerlander, M.F. Luger, U. Kammerlander-Knauer and M. Gosch state that there are no conflicts of interests. This article does not contain any studies with human or animal subjects.
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Luger, T., Kammerlander, C., Luger, M. et al. Mode of anesthesia, mortality and outcome in geriatric patients. Z Gerontol Geriat 47, 110–124 (2014). https://doi.org/10.1007/s00391-014-0611-3
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DOI: https://doi.org/10.1007/s00391-014-0611-3