Abstract
Purpose
The purpose of this structured, evidence-based, clinical update was to identify the best evidence comparing general and regional anesthesia and their influence on delirium or cognitive dysfunction (POCD) in the postoperative period.
Source
In June 2005 a structured search of MEDLINE from 1966 to present using OVID software was undertaken. Medical subject headings and textwords describing both delirium and POCD were employed. OVID’s Therapy (sensitivity) algorithm was used to maximize the detection of randomized trials. The bibliographies of eligible publications were hand-searched to identify trials not identified in the electronic search. Publications enrolling children were excluded. Levels of evidence and grades of recommendations were scored using Centre for Evidence Based Medicine criteria.
Principal findings
A total of 18 unique randomized controlled trials were identified: two evaluating delirium; ten evaluating POCD; and six evaluating both. Outcomes for delirium were abstracted from eight trials that enrolled 765 patients (387 regional anesthesia; 378 general anesthesia). Outcomes for POCD were identified from 16 trials that enrolled 2,708 patients (1,313 regional anesthesia; 1,395 general anesthesia). Both delirium (11-43%) and POCD (15-25%) were relatively common in trials actively seeking these outcomes. Consistent Level 2b evidence suggests no significant increase in delirium in patients receiving general anesthesia compared with those receiving regional anesthesia. Similarly, consistent Level 1 evidence indicates that exposure to general anesthesia is not significantly associated with POCD.
Conclusion
Available randomized controlled trials suggest that there is no significant difference in the incidence of delirium or POCD when general anesthesia and regional anesthesia are compared.
Résumé
Objectif
Identifier, par une mise à jour clinique structurée et fondée sur des données probantes, la meilleure preuve en comparant l’anesthésie générale et régionale et leur influence sur le délire ou le dysfonctionnement cognitif postopératoires (DCPO).
Source
En juin 2005, une recherche structurée a été entreprise dans MEDLINE, de 1966 à nos jours, en utilisant le logiciel OVID. Les vedettes-matières et les textes décrivant le délire et le DCPO ont été utilisés. Un algorithme thérapeutique (sensibilité) tiré de OVID a servi à optimaliser la détection d’études randomisées. Les bibliographies des études admissibles ont été fouillées manuellement pour découvrir les études non repérées dans la recherche électronique. Les recherches portant sur des enfants ont été exclues. Les niveaux d’évidence et les degrés de recommandations ont été évalués selon les critères du Centre for Evidence Based Medicine.
Constatations principales
Nous avons trouvé 18 études randomisées et contrôlées originales : deux évaluaient le délire, dix le DCPO et six évaluaient les deux. Les données sur le délire ont été extraites de huit études regroupant 765 patients (387 pour l’anesthésie régionale et 378 pour l’anesthésie générale). Les données sur le DCPO ont été tirées de 16 études sur 2 708 patients (1 313 pour l’anesthésie régionale et 1 395 pour l’anesthésie générale). Le délire (11 - 43 %) et le DCPO (15 - 25 %) étaient relativement fréquents dans les études qui recherchaient activement ces résultats. l’évidence d’un niveau 2b persistant montre qu’il n’y a pas d’augmentation significative du délire chez les patients sous anesthésie générale comparée à l’anesthésie régionale. De même, l’évidence d’un niveau 1 persistant indique que l’exposition à l’anesthésie générale n’est pas significativement associée au DCPO.
Conclusion
Les études randomisées et contrôlées accessibles montrent que l’incidence de délire ou de DCPO n’est pas significativement différente avec l’anesthésie générale ou régionale.
Article PDF
Similar content being viewed by others
References
Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996; 17: 1–12.
Phillips B,Ball C,Sackett D,et al. Levels of evidence and grades of recommendation. Available from URL; http://www.cebm.net/levels_of_evidence.asp, 2003.
Berggren D, Gustafson Y, Eriksson B, et al. Postoperative confusion after anesthesia in elderly patients with femoral neck fractures. Anesth Analg 1987; 66: 497–504.
Campbell DN, Lim M, Muir MK, et al. A prospective randomised study of local versus general anaesthesia for cataract surgery. Anaesthesia 1993; 48: 422–8.
Chung F, Meier R, Lautenschlager E, Carmichael FJ, Chung A. General or spinal anesthesia: which is better in the elderly? Anesthesiology 1987; 67: 422–7.
Forster A, Altenburger H, Gamulin Z. Effects of anesthesia on higher brain functions in the elderly (French). Presse Med 1990; 19: 1577–81.
Kamitani K, Higuchi A, Asahi T, Yoshida H. Postoperative delirium after general anesthesia vs. spinal anesthesia in geriatric patients (Japanese). Masui 2003; 52: 972–5.
Nielson WR, Gelb AW, Casey JE, Penny FJ, Merchant RN, Manninen PH. Long-term cognitive and social sequelae of general versus regional anesthesia during arthroplasty in the elderly. Anesthesiology 1990; 73: 1103–9.
Rasmussen LS, Johnson T, Kuipers HM, et al. Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients [see comment]. Acta Anaesthesiol Scand 2003; 47: 260–6.
Somprakit P, Lertakyamanee J, Sattararatanamai C, et al. Mental state change after general and regional anesthesia in adults and elderly patients, a randomized clinical trial. J Med Assoc Thai 2002; 85(Suppl 3): S875–83.
Williams-Russo P, Sharrock NE, Mattis S, Szatrowski TP, Charlson ME. Cognitive effects after epidural vs general anesthesia in older adults. A randomized trial. JAMA 1995; 274: 44–50.
Wu CL, Hsu W, Richman JM, Raja SN. Postoperative cognitive function as an outcome of regional anesthesia and analgesia. Reg Anesth Pain Med 2004; 29: 257–68.
Asbjorn J, Jakobsen BW, Pilegaard HK, Blom L, Ostergaard A, Brandt MR. Mental function in elderly men after surgery during epidural analgesia. Acta Anaesthesiol Scand 1989; 33: 369–73.
Bigler D, Adelhoj B, Petring OU, Pederson NO, Busch P, Kalhke P. Mental function and morbidity after acute hip surgery during spinal and general anaesthesia. Anaesthesia 1985; 40: 672–6.
Chung FF, Chung A, Meier RH, Lautenschlaeger E, Seyone C. Comparison of perioperative mental function after general anaesthesia and spinal anaesthesia with intravenous sedation. Can J Anaesth 1989; 36: 382–7.
Cook PT, Davies MJ, Cronin KD, Moran P. A prospective randomised trial comparing spinal anaesthesia using hyperbaric cinchocaine with general anaesthesia for lower limb vascular surgery. Anaesth Intensive Care 1986; 14: 373–80.
Crul BJ, Hulstijn W, Burger IC. Influence of the type of anaesthesia on post-operative subjective physical well-being and mental function in elderly patients. Acta Anaesthesiol Scand 1992; 36: 615–20.
Edwards H, Rose EA, Schorow M, King TC. Postoperative deterioration in psychomotor function. JAMA 1981; 245: 1342–3.
Fredman B, Zohar E, Philipov A, Olsfanger D, Shalev M, Jedeikin R. The induction, maintenance, and recovery characteristics of spinal versus general anesthesia in elderly patients. J Clin Anesth 1998; 10: 623–30.
Ghoneim MM, Hinrichs JV, O‘Hara MW, et al. Comparison of psychologic and cognitive functions after general or regional anesthesia. Anesthesiology 1988; 69: 507–15.
Haan J, van Kleef JW, Bloem BR, et al. Cognitive function after spinal or general anesthesia for transurethral prostatectomy in elderly men. J Am Geriatr Soc 1991; 39: 596–600.
Hole A, Terjesen T, Breivik H. Epidural versus general anaesthesia for total hip arthroplasty in elderly patients. Acta Anaesthesiol Scand 1980; 24: 279–87.
Hughes D, Bowes JB, Brown MW. Changes in memory following general or spinal anaesthesia for hip arthroplasty. Anaesthesia 1988; 43: 114–7.
Jhaveri RM. The effects of hypocapnic ventilation on mental function in elderly patients undergoing cataract surgery. Anaesthesia 1989; 44: 635–40.
Jones MJ, Piggott SE, Vaughan RS, et al. Cognitive and functional competence after anaesthesia in patients aged over 60: controlled trial of general and regional anaesthesia for elective hip or knee replacement. BMJ 1990; 300: 1683–7.
Karhunen U, Jonn G. A comparison of memory function following local and general anaesthesia for extraction of senile cataract. Acta Anaesthesiol Scand 1982; 26: 291–6.
O’Hara DA, Duff A, Berlin JA, et al. The effect of anesthetic technique on postoperative outcomes in hip fracture repair. Anesthesiology 2000; 92: 947–57.
Riis J, Lomholt B, Haxholdt O, et al. Immediate and long-term mental recovery from general versus epidural anesthesia in elderly patients. Acta Anaesthesiol Scand 1983; 27: 44–9.
Ryhanen P, Helkala EL, Ihalainen O, et al. Effects of anaesthesia on the psychological function of patients. Ann Clin Res 1978; 10: 318–22.
Diagnostic and Statistical Manual - Text Revision (DSM-IV-TRTM, 2000). First MB (Ed.). STAT! Ref Online Electronic Medical Library. 2000. American Psychiatric Association; 2004: 9–17.
Dyer CB, Ashton CM, Teasdale TA. Postoperative delirium. A review of 80 primary data-collection studies. Arch Intern Med 1995; 155: 461–5.
McCusker J, Cole MG, Dendukuri N, Belzile E. Does delirium increase hospital stay? J Am Geriatr Soc 2003; 51: 1539–46.
Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med 1998; 13: 234–42.
McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium predicts 12-month mortality. Arch Intern Med 2002; 162: 457–63.
Moller JT, Cluitmans P, Rasmussen LS, et al. Longterm postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lance 1998; 351: 857–61.
Newman MF, Grocott HP, Mathew JP, et al.;Neurologic Outcome Research Group and the Cardiothoracic Anesthesia Research Endeavors (CARE) Investigators of the Duke Heart Center. Report of the substudy assessing the impact of neurocognitive function on quality of life 5 years after cardiac surgery. Stroke 2001; 32: 2874–81.
Abildstrom H, Rasmussen LS, Rentowl P, et al. Cognitive dysfunction 1-2 years after non-cardiac surgery in the elderly. ISPOCD group. International Study of Post-Operative Cognitive Dysfunction. Acta Anaesthesiol Scand 2000; 44: 1246–51.
Marcantonio ER, Goldman L, Orav EJ, Cook EF, Lee TH. The association of intraoperative factors with the development of postoperative delirium. Am J Med 1998; 105: 380–4.
Canet J, Raeder J, Rasmussen LS, et al.;ISPOCD2 Investigators. Cognitive dysfunction after minor surgery in the elderly. Acta Anaesthesiol Scand 2003; 47: 1204–10.
Trzepacz PT. Is there a final common neural pathway in delirium? Focus on acetylcholine and dopamine. Semin Clin Neuropsychiatry 2000; 5: 132–48.
Agostini JV, Leo-Summers LS, Inouye SK. Cognitive and other adverse effects of diphenhydramine use in hospitalized older patients. Arch Intern Med 2001; 161: 2091–7.
Grantham C,Geerts H. The rationale behind cholinergic drug treatment for dementia related to cerebrovascular disease. J Neurol Sci 2002; 203–4: 131–6.
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113: 941–8.
Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001; 29: 1370–9.
Rasmussen LS, Larsen K, Houx P, Skovgaard LT, Hanning CD, Moller JT;ISPOCD Group;The International Study of Postoperative Cognitive Dysfunction. The assessment of postoperative cognitive function. Acta Anaesthesiol Scand 2001; 45: 275–89.
Murkin JM, Newman SP, Stump DA, Blumenthal JA. Statement of consensus on assessment of neurobehavioral outcomes after cardiac surgery. Ann Thorac Surg 1995; 59: 1289–95.
Murkin JM, Stump DA, Blumenthal JA, McKhann G. Defining dysfunction: group means versus incidence analysis--a statement of consensus. Ann Thorac Surg 1997; 64: 904–5.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Bryson, G.L., Wyand, A. Evidence-based clinical update: General anesthesia and the risk of delirium and postoperative cognitive dysfunction. Can J Anesth 53, 669–677 (2006). https://doi.org/10.1007/BF03021625
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF03021625