NYSORA News

Recent clinical trials have sparked a shift in anesthesia practices for hip fracture surgery, prompting debate over whether neuraxial anesthesia still holds value in the era of advanced general anesthesia. A compelling discourse by Dr. Alexander B. Stone and colleagues argues strongly that neuraxial anesthesia (NA) remains a critical tool, despite findings from high-profile studies like REGAIN and RAGA. Background: The REGAIN and RAGA trials Two major trials brought neuraxial anesthesia under scrutiny: 1. REGAIN trial (NEJM, 2021) Compared spinal vs. general anesthesia in 1,600 patients ≥ 50 years. Primary outcome: death or inability to walk 10 feet at 60 days. Result: No significant difference between groups. 2. RAGA trial (JAMA, 2022) Included 950 patients ≥65 years. Focused on postoperative delirium within 7 days. Again, no superiority was shown for neuraxial over general anesthesia. Key concerns with trial interpretation Stone et al. raise several concerns: 1. Composite endpoints Outcomes like “death or inability to walk” are not directly linked to anesthesia type. These endpoints may dilute the effect of anesthesia on perioperative morbidity. 2. Sample size & power issues Both trials were underpowered due to lower-than-expected event rates. REGAIN: Expected 34.2%, observed 18–18.5%. RAGA: Expected 11.1–23.3%, observed 5.1–6.2%. 3. Generalizability 15% of neuraxial cases in REGAIN were converted to general anesthesia, questioning standardization across sites. Documented benefits of neuraxial anesthesia Despite newer data, several clinically relevant benefits of neuraxial anesthesia remain: Pulmonary benefits Reduced incidence of pneumonia and pulmonary complications. Avoids airway manipulation and preserves pulmonary dynamics. Cardiovascular and hemodynamic stability Promotes stable blood pressure through sympathetic blockade. Decreased systemic inflammatory response. Reduced blood loss Associated with less intraoperative blood loss and fewer transfusions. Lower risk of Venous Thromboembolism (VTE) NA-induced vasodilation may reduce VTE risks. Lower incidence of nausea and delirium Reduced opioid use contributes to less postoperative nausea. […]

NYSORA News

Intrathecal morphine (ITM) is a widely used analgesic technique for postoperative and obstetric pain management. Despite its effectiveness, concerns persist regarding its potential complications. A recent systematic review and meta-analysis by Renard et al. (2024) explores non-pulmonary complications associated with ITM administration, analyzing data from 168 trials involving 9,917 patients. Key findings of the study The primary objective of the study was to determine whether a threshold dose exists for non-pulmonary complications and to assess the relationship between ITM dose and adverse effects. Increased rates of non-pulmonary complications ITM significantly increased the rates of: Postoperative nausea and vomiting (PONV)  Pruritus (itching)  Urinary retention  No dose-response relationship found Meta-regression analysis failed to establish an association between ITM dose and the rates of non-pulmonary complications, suggesting that these side effects occur independently of the administered dose. Impact across surgical specialties The study found no significant subgroup differences in the incidence of complications based on: Type of surgery (orthopedic, abdominal, gynecological, cardiothoracic, or obstetric procedures) Anesthetic technique (general anesthesia vs. spinal anesthesia) Quality of evidence Using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system, the quality of evidence was determined to be low, indicating that future research is needed to refine these findings. Implications for clinical practice Increased risk of PONV, pruritus, and urinary retention The findings highlight the need for prophylactic strategies to manage these side effects in patients receiving ITM. Possible interventions include: PONV: Routine administration of antiemetics, such as 5-HT3 receptor antagonists (ondansetron) or dexamethasone. Pruritus: Use of antihistamines or opioid antagonists (nalbuphine, naloxone). Urinary Retention: Monitoring and, if necessary, early catheterization in high-risk patients. No clear dose-dependent effect The absence of a dose-dependent relationship suggests that even lower doses of ITM do not necessarily mitigate the risk of these complications. This challenges prior assumptions that reducing the […]