Delirium and postoperative neurocognitive disorder are the commonest perioperative complications in patients more than 65 yr of age. However, data suggest that we often fail to screen patients for ...preoperative cognitive impairment, to warn patients and families of risk, and to take preventive measures to reduce the incidence of perioperative neurocognitive disorders. As part of the American Society of Anesthesiologists (ASA) Perioperative Brain Health Initiative, an international group of experts was invited to review published best practice statements and guidelines. The expert group aimed to achieve consensus on a small number of practical recommendations that could be implemented by anaesthetists and their partners to reduce the incidence of perioperative neurocognitive disorders. Six statements were selected based not only on the strength of the evidence, but also on the potential for impact and the feasibility of widespread implementation. The actions focus on education, cognitive and delirium screening, non-pharmacologic interventions, pain control, and avoidance of antipsychotics. Strategies for effective implementation are discussed. Anaesthetists should be key members of multidisciplinary perioperative care teams to implement these recommendations.
Hip fracture is a common, morbid, and costly event among older adults. Data are inconclusive as to whether epidural or spinal (regional) anesthesia improves outcomes after hip fracture surgery.
The ...authors examined a retrospective cohort of patients undergoing surgery for hip fracture in 126 hospitals in New York in 2007 and 2008. They tested the association of a record indicating receipt of regional versus general anesthesia with a primary outcome of inpatient mortality and with secondary outcomes of pulmonary and cardiovascular complications using hospital fixed-effects logistic regressions. Subgroup analyses tested the association of anesthesia type and outcomes according to fracture anatomy.
Of 18,158 patients, 5,254 (29%) received regional anesthesia. In-hospital mortality occurred in 435 (2.4%). Unadjusted rates of mortality and cardiovascular complications did not differ by anesthesia type. Patients receiving regional anesthesia experienced fewer pulmonary complications (359 6.8% vs. 1,040 8.1%, P < 0.005). Regional anesthesia was associated with a lower adjusted odds of mortality (odds ratio: 0.710, 95% CI 0.541, 0.932, P = 0.014) and pulmonary complications (odds ratio: 0.752, 95% CI 0.637, 0.887, P < 0.0001) relative to general anesthesia. In subgroup analyses, regional anesthesia was associated with improved survival and fewer pulmonary complications among patients with intertrochanteric fractures but not among patients with femoral neck fractures.
Regional anesthesia is associated with a lower odds of inpatient mortality and pulmonary complications among all hip fracture patients compared with general anesthesia; this finding may be driven by a trend toward improved outcomes with regional anesthesia among patients with intertrochanteric fractures.
Since the pandemic began, U.S. health care safety has declined severely, suggesting that our system lacks a sufficiently resilient safety culture and infrastructure. We need to build a more resilient ...delivery system, capable of maintaining high safety levels in crises.
Postoperative delirium is a geriatric syndrome that manifests as changes in cognition, attention, and levels of consciousness after surgery. It occurs in up to 50% of patients after major surgery and ...is associated with adverse outcomes, including increased hospital length of stay, higher cost of care, higher rates of institutionalization after discharge, and higher rates of readmission. Furthermore, it is associated with functional decline and cognitive impairments after surgery. As the age and medical complexity of our surgical population increases, practitioners need the skills to identify and prevent delirium in this high-risk population. Because delirium is a common and consequential postoperative complication, there has been an abundance of recent research focused on delirium, conducted by clinicians from a variety of specialties. There have also been several reviews and recommendation statements; however, these have not been based on robust evidence. The Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together a team of multidisciplinary experts to formally survey and evaluate the literature on postoperative delirium prevention and provide evidence-based recommendations using an iterative Delphi process and Grading of Recommendations Assessment, Development and Evaluation (GRADE) Criteria for evaluating biomedical literature.
Quality has been defined by six domainseffective, equitable, timely, efficient, safe, and patient centered. Quality of anesthesia care can be improved through measurement, either through local ...measures in quality improvement or through national measures in value-based purchasing programs. Death directly related to anesthesia care has been reduced, but must be measured beyond simple mortality. To improve perioperative care for our patients, we must take shared accountability for all surgical outcomes including complications, which has traditionally been viewed as being surgically related. Anesthesiologists can also impact public health by being engaged in improving cognitive recovery after surgery and addressing the opiate crisis. Going forward, we must focus on what patients want and deserveimproved patient-oriented outcomes and satisfaction with our care. By listening to our patients and being engaged in the entire perioperative process, we can make the greatest impact on perioperative care.
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