title: Early postoperative cognitive dysfunction and postoperative delirium after anaesthesia with various hypnotics: study protocol for a randomised controlled trial - The PINOCCHIO trial Intraoperative blood loss during radical retropubic prostatectomy: epidural versus general anesthesia. Anaesthesia for transurethral prostatectomy Effect of epidural versus general anaesthesia on peroperative blood loss during retropubic prostatectomy Induced hypotension with epidural/general anesthesia reduces transfusion in radical prostate surgery General versus spinal anesthesia in patients undergoing radical retropubic prostatectomy: results of a prospective, randomized study. The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. General Anesthesia versus Epidural and General Anesthesia in Radical Cystectomy Combined general and epidural anesthesia with ropivacaine for renal transplantation. Intrathecal Anesthesia and Recovery from Radical Prostatectomy: A Prospective, Randomized, Controlled Trial Spinal-epidural anesthesia versus general anesthesia in the management of percutaneous nephrolithotripsy. Relation between Quality of Recovery in Hospital and Quality of Life at 3 Months after Cardiac Surgery External validity of randomised controlled trials: “To whom do the results of this trial apply?” The Effect of Epidural Versus General Anesthesia on Postoperative Pain and Analgesic Requirements in Patients Undergoing Radical Prostatectomy
abstract: Background Postoperative delirium can result in increased postoperative morbidity and mortality , major dem and for postoperative care and higher hospital costs . Hypnotics serve to induce and maintain anaesthesia and to abolish patients ' consciousness . Their persisting clinical action can delay postoperative cognitive recovery and favour postoperative delirium . Some evidence suggests that these unwanted effects vary according to each hypnotic 's specific pharmacodynamic and pharmacokinetic characteristics and its interaction with the individual patient . We design ed this study to evaluate postoperative delirium rate after general anaesthesia with various hypnotics in patients undergoing surgical procedures other than cardiac or brain surgery . We also aim ed to test whether delayed postoperative cognitive recovery increases the risk of postoperative delirium . Methods / Design After local ethics committee approval , enrolled patients will be r and omly assigned to one of three treatment groups . In all patients anaesthesia will be induced with propofol and fentanyl , and maintained with the anaesthetics desflurane , or sevoflurane , or propofol and the analgesic opioid fentanyl . The onset of postoperative delirium will be monitored with the Nursing Delirium Scale every three hours up to 72 hours post anaesthesia . Cognitive function will be evaluated with two cognitive test batteries ( the Short Memory Orientation Memory Concentration Test and the Rancho Los Amigos Scale ) preoperatively , at baseline , and postoperatively at 20 , 40 and 60 min after extubation . Statistical analysis will investigate differences in the hypnotics used to maintain anaesthesia and the odds ratios for postoperative delirium , the relation of early postoperative cognitive recovery and postoperative delirium rate . A subgroup analysis will be used to categorize patients according to demographic variables relevant to the risk of postoperative delirium ( age , sex , body weight ) and to the preoperative score index for delirium . Discussion The results of this comparative anaesthesiological trial should whether each the three hypnotics tested is related to a significantly different postoperative delirium rate . This information could ultimately allow us to select the most appropriate hypnotic to maintain anaesthesia for specific subgroups of patients and especially for those at high risk of postoperative delirium . Registered at Trial.gov Number Clinical Trials.gov : OBJECTIVES There are conflicting reports on the influence of different anesthetic techniques , such as regional versus general anesthesia , on intraoperative blood loss . The purpose of this study was to eluci date the effects of anesthetic technique on intraoperative blood loss in men undergoing radical retropubic prostatectomy ( RRP ) . METHODS One hundred patients undergoing RRP for prostate cancer were r and omly assigned to receive either epidural anesthesia ( EA ) , combined epidural and general anesthesia ( EG ) , or general anesthesia alone ( GA ) .  Intraoperative blood loss was calculated by using a formula that accounted for the volume and hematocrit of the fluid suctioned from the surgical field , blood absorbed on surgical pads , and the patient 's hematocrit . RESULTS Mean blood loss in the EA group ( 1490 + /- 90 mL ; mean + /- SEM ) was significantly less than mean blood loss in both the EG group ( 1810 + /- 100 mL ) and the GA group ( 1940 + /- 130 mL ) ( P = 0.01 ) . Blood loss was not different between the EG and the GA groups ( P = 0.7 ) . Significantly less blood was transfused during surgery in the EA group ( 730 + /- 50 mL ) compared with the EG ( 960 + /- 60 mL ) and GA ( 950 + /- 70 mL ) groups ( P = 0.02 ) . CONCLUSIONS Similar blood loss in patients receiving general anesthesia , either alone or when combined with epidural anesthesia , implies that epidural anesthesia did not reduce bleeding , but , rather , that general anesthesia increased blood loss One hundred and fifty patients who presented for transurethral prostatectomy were r and omly allocated to one of three groups for the purpose of anaesthesia . Group A received spinal intradural analgesia , Group B general anaesthesia with spontaneous ventilation and Group C general anaesthesia with controlled ventilation . The comparability of the three groups was established Peroperative blood loss , arterial blood pressure and central venous pressure were studied in patients subjected to retropubic prostatectomy . The patients were r and omly allocated to two groups , continuous lumbar epidural analgesia for up to 24 hours and a thiopentone-oxyg n-nitrous oxide-alcuronium-pethidine sequence with intermittent positive pressure ventilation .  The mean peroperative blood loss during operations under epidural analgesia was significantly less than that under general anaesthesia ( 370±34 ml vs. 590∓35 ml , mean ∓SE ) . Only one patient out of 17 cases of epidural analgesia needed a peroperative blood transfusion , in contrast to 5 out of 21 general anaesthesias . Both the arterial systolic and diastolic pressures , and central venous pressure were significantly lower under epidural analgesia than general anaesthesia . It was concluded that decreased arterial and venous pressure were responsible for the reduced blood loss under epidural analgesia Purpose Radical prostatectomy is associated with substantial blood loss frequently requiring allogeneic blood transfusion . We investigated the efficacy of deliberate hypotension using combined epidural/general anesthesia in reducing allogeneic transfusion requirements in patients undergoing radical prostatectomy . Methods In a prospect i ve , r and omized , single-blind trial , 102 patients undergoing radical prostatectomy were allocated to either an epidural group ( n = 51 ) or a control group ( n = 51 ) . In the epidural group , deliberate hypotension was achieved with a target mean arterial pressure of 55–60 mmHg . The trigger for allogeneic blood transfusion in both groups was a hematocrit value < 0.25 . Results Operative blood loss in the epidural group was significantly less than that in the control group ( 955 ± 517 mL vs 1477 ± 823 mL respectively , P < 0.001 ) . The percentage of patients who reached the threshold trigger for allogenic transfusion was significantly less in the epidural group ( 8 % vs 26 % , respectively , P = 0.019 ) and the number of patients who were actually transfused during hospitalization was also significantly less ( P = 0.028 ) . There were no serious adverse events in either group during the study . Conclusion Controlled hypotension using a combined epidural/general anesthetic technique is associated with significantly less blood loss , and a reduction in the use of allogeneic blood in patients undergoing radical prostatectomy compared to general anesthesia alone . RésuméObjectifLa prostatectomie radicale est associée à une perte sanguine importante qui nécessite des transfusions allogéniques . Nous avons vérifié l’efficacité d’une hypotension contrôlée pendant l’anesthésie péridurale et générale combinée pour réduire la nécessité de transfusion allogénique chez les patients qui subissent une prostatectomie radicale . MéthodeDans une étude prospect i ve , r and omisée et à simple insu , 102 patients devant subir une prostatectomie radicale ont été dirigés vers le groupe de péridurale ( n = 51 ) ou le groupe témoin ( n = 51 ) . Avec la péridurale , une hypotension contrôlée a été réalisée avec une tension artérielle moyenne cible de 55–60 mmHg . Un hématocrite < 0,25 était le seuil pour l’administration d’une transfusion sanguine allogénique . RésultatsLa perte sanguine opératoire a été significativement moindre dans le groupe de péridurale que dans le groupe témoin ( 955 ±517mLvs 1477 ± 823 mL , P < 0,001 ) . Le pourcentage de patients chez qui l’hématocrite seuil a déclenché la transfusion a été significativement moindre avec la péridurale ( 8 % vs 26 % , respectivement , P = 0,019 ) et le nombre de patients transfusés pendant l’hospitalisation a aussi été significativement moindre ( P = 0,028 ) . Aucun événement indésirable grave n’a été relevé pendant l’étude . Conclusion L’hypotension contrôlée pendant une anesthésie péridurale et générale combinée , comparée à l’anesthésie générale seule , est associée à une perte sanguine significativement plus faible et à une réduction de transfusion allogénique chez des patients qui subissent une prostatectomie radicale OBJECTIVES To evaluate the impact of general anesthesia ( GA ) versus spinal anesthesia ( SpA ) on intraoperative and postoperative outcome in patients undergoing radical retropubic prostatectomy . METHODS Seventy-two consecutive patients with clinical ly localized prostate cancer were r and omized into group 1  ( GA : 34 patients ) or group 2  ( L2-L3 or L3-L4 SpA : 38 patients ) and underwent radical retropubic prostatectomy .  The intraoperative and postoperative anesthetic and surgical variables were evaluated . RESULTS The mean + /- SEM operative time was not significantly different between the two groups ( P = 0.43 ) . The overall blood loss was less in group 2 ( P = 0.04 ) . The mean + /- SEM postoperative time in the postoperative holding area was significantly shorter after SpA than after GA ( P < 0.0001 ) . The perioperative pain outcome in the postoperative holding area was significantly better for group 2 than for group 1 ( P = 0.0017 ) , but postoperative pain on day 1 was not significantly different between the two groups . The postoperative sedation score was significantly less in group 2 than in group 1 ( P < 0.0001 ) . On day 1 , first flatus passed in a significantly larger number of patients in group 2 ( P < 0.0001 ) , and the overall gait was greater for group 2 patients ( P = 0.02 ) . CONCLUSIONS These results suggest that SpA allows good muscle relaxation and a successful surgical outcome in patients undergoing radical retropubic prostatectomy with pelvic lymphadenectomy for clinical ly localized prostate cancer . Moreover , SpA results in less intraoperative blood loss , less postoperative pain , and a faster postoperative recovery than GA Most systematic review s rely substantially on the assessment of the method ological quality of the individual trials . The aim of this study was to obtain consensus among experts about a set of generic core items for quality assessment of r and omized clinical trials ( RCTs ) . The invited participants were experts in the field of quality assessment of RCTs . The initial item pool contained all items from existing criteria lists . Subsequently , we reduced the number of items by using the Delphi consensus technique . Each Delphi round comprised a question naire , an analysis , and a feedback report . The feedback report included staff team decisions made on the basis of the analysis and their justification . A total of 33 international experts agreed to participate , of whom 21 completed all question naires . The initial item pool of 206 items was reduced to 9 items in three Delphi rounds . The final criteria list ( the Delphi list ) was satisfactory to all participants . It is a starting point on the way to a minimum reference st and ard for RCTs on many different research topics . This list is not intended to replace , but rather to be used alongside , existing criteria lists Introduction : The aim of this study is to compare two different anesthetic techniques in radical cystectomy with regard to blood loss , transfusional requirements , intraoperative complications and the quality of analgesia . Material s and Methods : 50 patients scheduled for radical cystectomy were r and omized to two groups : group GA – general anesthesia , n = 25 and group CEGA – combined epidural and general anesthesia . The patients were monitored and hemodynamic changes , intraoperative bleeding , transfusional requirements , quality of analgesia and postoperative complications were evaluated . Results : There were no significant differences between the demographic characteristics of the two groups . Intraoperative bleeding which was 874.8 ± 190.7 ml in the CEGA group and 1,248.3 ± 343.4 ml in the GA group was statistically different ( p < 0.05 ) . Significantly more intraoperative blood transfusions in terms of units were required in the GA group . Analgesia was better in the CEGA group , with VAS values at 0 , 1 , 2 , 4 , 6 , 12 and 24 h significantly ( p < 0.05 ) lower than those observed in the GA group . No significant differences in intraoperative hemodynamic parameters or postoperative complications were noted between the two groups . Conclusions : Statistically significant differences in intraoperative bleeding were observed between the two groups : CEGA provides lower intraoperative bleeding and a better postoperative analgesia . Major operations such as radical cystectomy , which also is associated with considerable blood loss , a combination of general and epidural anesthesia may allow for less blood loss , with a better postoperative analgesia and without any increase in complications AIM To evaluate the effectiveness and safety of epidural ropivacaine anesthesia in association with light general anesthesia during renal transplantation and compare epidural and endovenous analgesia techniques for postoperative pain control . METHODS EXPERIMENTAL DESIGN prospect i ve r and omized study . SETTING Organ Transplantation Center , Department of Surgery , " Tor Vergata " University of Rome , St. Eugenio Hospital , Rome . PATIENTS 25 patients affected by chronic renal failure were enrolled in this study . Thirteen constituted the  combined epidural-general anesthesia group ( EPI-GEN ) , mean age 40.15+/-9.81 years ; while the others constituted the general anesthesia group ( GEN ) , mean age 46.75+/-7.45 years . Operation : cadaveric renal transplantation . Group EPI-GEN : epidural anesthesia performed with 12 - 15 ml of a ropivacaine 0.75 % and fentanyl 5 microg/ml solution followed by light intravenous or inhalatory general anesthesia and postoperative epidural analgesia with ropivacaine 0.2 % and fentanyl 2 mg/ml . Group GEN : inhalatory or intravenous general anesthesia and intravenous tramadol postoperative analgesia . MEASUREMENTS hemo-dynamics , renal function , arterial blood gases analysis , acid-base balance and postoperative pain data was collected and examined . RESULTS Postoperative epidural analgesia result ed significantly more effective than intravenous tramadol . PaO(2)/FiO(2 ) ratio was significantly higher in group EPI-GEN patients both on awakening and throughout postoperative observation . Hemodynamics and renal function did not appear to differ significantly . CONCLUSION Combined epidural-general anesthesia is as valid a technique as any for renal transplantation ; however postoperative epidural ropivacaine analgesia result ed more effective than intravenous tramadol . Respiratory function appeared less affected , facilitating a fast and uncomplicated postoperative recovery Background Previous studies suggest that intraoperative anesthetic care may influence  postoperative pain and recovery from surgery . The authors tested the hypothesis that the addition of intrathecal analgesia to general anesthesia would improve long-term functional status and decrease pain in patients undergoing radical retropubic prostatectomy . Methods One hundred patients received either general anesthesia supplemented with intravenous fentanyl or general anesthesia preceded by intrathecal administration of bupivacaine ( 15 mg ) , clonidine ( 75 & mgr;g ) , and morphine ( 0.2 mg ) . Patients and providers were masked to treatment assignment . All patients received multimodal pain management postoperatively . Primary outcomes included pain and functional status over the first 12 postoperative weeks . Results Patients receiving intrathecal analgesia  required more intravenous fluids and vasopressors intraoperatively . Pain was well controlled throughout the study ( mean numerical pain scores < 3 in both groups at all times studied ) . Intrathecal analgesia decreased pain and supplemental intravenous morphine use over the first postoperative day but increased the frequency of pruritus . Pain and functional status after discharge from the hospital did not differ between groups . Intrathecal analgesia significantly decreased the duration of hospital stay ( from 2.8 ± 2.0 to 2.1 ± 0.5 days ; P < 0.01 ) as a result of five patients in the control group who stayed in the hospital more than 3 days . Conclusions The benefits of improved immediate analgesia and decreased morphine requirements result ing from intrathecal analgesia must be weighed against factors such as pruritus , increased intraoperative requirement for fluids and vasopressors , and re sources needed to implement this modality . Further studies are needed to determine the significance of the decrease in duration of hospital stay OBJECTIVE To compare the efficacy between combined spinal-epidural block and general anesthesia in patients undergoing percutaneous nephrolithotripsy ( PNL ) . METHODS A total of 180 patients undergoing PNL were r and omly allocated to receive spinal-epidural anesthesia plus intravenous patient-controlled anesthesia with tramadol or general anesthesia ( propofol induction , maintenance with sevoflurane ) plus intravenous patient-controlled anesthesia with tramadol ( G group ) . Hemodynamic changes , postanesthesia care unit ( PACU ) discharge times , times to home readiness , side effects , patient and endoscopist satisfaction , postoperative pain ( scored from 0 to 10 on a visual analog scale ) , and analgesic medication were recorded . RESULTS Rates of hypotension ( p = 0.06 ) and bradycardia ( p = 0.14 ) did not differ between the groups . Compared with the G group , duration of PACU and the time to home readiness ( p = 0.001 for each ) were shorter in the spinal-epidural group . The incidence of nausea was higher in the G group ( p = 0.001 ) ; vomiting and pruritus rates were similar between groups . No patient had respiratory depression . The spinal-epidural group had better patient satisfaction ( p = 0.001 ) and lower pain scores ( p = 0.001 ) . The G group required more diclofenac during the first 48 h ( p = 0.001 ) . CONCLUSIONS In patients undergoing PNL , spinal-epidural anesthesia and analgesia gave greater patient satisfaction , shorter times for PACU and home readiness , and less postoperative pain .  Spinal-epidural anesthesia is an attractive alternative to general anesthesia in these patients Background Improved quality of life ( QoL ) is a desirable outcome of cardiac surgery . The aim of the current study was to measure the association between quality of recovery 3 days after surgery and QoL measured 3 months later . Methods After obtaining ethics committee approval and consent , 120 adult cardiac surgical patients were studied . A 40-item quality of recovery score ( QoR-40 ) was used to measure postoperative health status on days 1–3 and 1 month after surgery . QoL was measured using the  short-form health survey ( SF-36 ) at 1 and 3 months after surgery . The effect size ( & Dgr;mean/SD ) was used to define responsiveness , a clinical ly important difference in health . Associations were measured using correlation and reliability coefficients . Results There was a significant change in the mean QoR-40 for up to 1 month after surgery ( P < 0.0005 ) . QoL was improved at 3 months ( P < 0.0005 ) but not 1 month ( P = 0.29 ) after surgery . There was a moderate correlation between day-3 QoR-40 and 3-month SF-36 ( r = 0.39;P < 0.0005 ) . A poor- quality recovery in hospital predicted a poor QoL at 3 months ( adjusted odds ratio , 4.20 ; 95 % confidence interval , 1.41–12.5;P = 0.01 ) . Conclusions The QoR-40 is a valid measure of quality of recovery after surgery and anesthesia . When compared with the SF-36 , it is a better measure of early postoperative recovery . A poor- quality recovery on the days after surgery can predict a poor QoL at 3 months after surgery . This may allow earlier and more effective support strategies while patients are still in the hospital ( counseling , home assistance , local doctor notification , cardiac rehabilitation ) In making treatment decisions , doctors and patients must take into account relevant r and omised controlled trials ( RCTs ) and systematic review s. Relevance depends on external validity ( or generalisability)--ie , whether the results can be reasonably applied to a definable group of patients in a particular clinical setting in routine practice . There is concern among clinicians that external validity is often poor , particularly for some pharmaceutical industry trials , a perception that has led to underuse of treatments that are effective . Yet research ers , funding agencies , ethics committees , the pharmaceutical industry , medical journals , and governmental regulators alike all neglect external validity , leaving clinicians to make judgments . However , reporting of the determinants of external validity in trial publications and systematic review s is usually inadequate . This review discusses those determinants , presents a checklist for clinicians , and makes recommendations for greater consideration of external validity in the design and reporting of RCTs Background Although preemptive analgesia has been shown to decrease postinjury pain in animals , studies in humans have provided controversial results . The authors studied whether surgical epidural anesthesia with local anesthetics could affect postoperative pain and analgesic dem and s , when compared with general anesthesia . Methods Male patients scheduled for radical retropubic prostatectomy were r and omly assigned to receive  epidural anesthesia only ( EA , n = 34 ) , combined epidural and general anesthesia ( EG , n = 32 ) , or general anesthesia only ( GA , n = 30 ) . A lumbar epidural catheter was inserted and tested in all patients . In the EA group , an induction dose of 0.25 ml/kg epidural bupivacaine ( 0.5 % ) was followed during surgery by a continuous infusion of 0.1 ml.kg–1.h–10.125 % bupivacaine . In the EG group , 0.2 ml/kg epidural bupivacaine ( 0.5 % ) was injected after induction of general anesthesia but before surgery , followed by epidural infusion of 0.1 ml.kg–1.h–10.125 % bupivacaine . In the GA group , anesthesia was maintained with morphine , isoflurane , and N2O . Epidural patient-controlled analgesia ( PCA ) was provided with bupivacaine and fentanyl for all patients in the postoperative period . Postoperative pain scores and analgesic requirements were examined and compared between groups every 4–8 h for 3–5 postoperative days . Results Intraoperatively , EA patients received significantly more epidural bupivacaine than EG patients ( 129 ± 6 mg vs. 98 ± 6 mg , respectively . Recovery room median residual sensory level in EA patients ( T6 ± 2 ) was significantly higher than in EG patients ( T10 ± 2 ) . PCA dem and was greater in the GA and EG groups when compared with the EA group in postoperative days 2 ( 126 ± 9 ml , 112 ± 9 ml , 90 ± 6 ml , respectively ; P = 0.01 ) and 3 ( 89 ± 10 ml , 83 ± 9 ml , 48 ± 5 respectively ; P = 0.005 ) . There was no difference in PCA dem and between the GA and EG groups in the postoperative period . No significant clinical differences in postoperative mean pain scores were recorded in the first 5 days after surgery in the three anesthetic groups ( range 0–2/10 ) . Conclusions In patients undergoing lower abdominal surgery , the neuraxial blockade and surgical anesthesia achieved by epidural local anesthetics was associated with decreased postoperative analgesic dem and s. Lower postoperative analgesic requirements in the EA group , when compared with both the EG and GA groups , indicate that : ( 1 ) EA patients had less postoperative pain , and ( 2 ) an efficient intraoperative blockade of noxious afferent signals to the central nervous system is fundamental in reducing postoperative pain
target: At the moment , the evidence available can not prove that neuraxial anesthesia is more effective and safer than general anesthesia for urological surgery .
  There were insufficient data to pool the results relating to mortality , stroke , myocardial infa rct ion , length of hospitalization , quality of life , degree of satisfaction , postoperative cognitive dysfunction and blood transfusion requirements
background: CONTEXT AND OBJECTIVE Choosing the best anesthetic technique for urological surgery with the aim of mortality reduction remains controversial .
  The objective here was to compare the effectiveness and safety of neuraxial anesthesia versus general anesthesia for urological surgery .