Skip to main content
SpringerLink
Log in

Mode of anesthesia, mortality and outcome in geriatric patients

Anästhesieverfahren, Mortalität und Verlauf bei geriatrischen Patienten

  • Beiträge zum Themenschwerpunkt
  • Published:
Zeitschrift für Gerontologie und Geriatrie Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Aitkenhead AR (2005) Injuries associated with anaesthesia. A global perspective. Br J Anaesth 95:95–106

    Article  CAS  PubMed  Google Scholar 

  2. Amato B, Markabaoui AK, Piscitelli V et al (2005) Carotid endarterectomy under local anesthesia in elderly: is it worthwhile? Acta Biomed 76(Suppl 1):64–68

    PubMed  Google Scholar 

  3. Amato B, Compagna R, Della Corte GA et al (2012) Feasibility of inguinal hernioplasty under local anaesthesia in elderly patients. BMC Surg 12(Suppl 1):S2

    Article  PubMed Central  PubMed  Google Scholar 

  4. Arbous MS, Grobbee DE, Kleef JW van et al (2001) Mortality associated with anaesthesia: a qualitative analysis to identify risk factors. Anaesthesia 56:1141–1153

    Article  CAS  PubMed  Google Scholar 

  5. Ballotta E, Da Giau G, Ermani M et al (2009) Early and long-term outcomes of carotid endarterectomy in the very elderly: an 18-year single-center study. J Vasc Surg 50:518–525

    Article  PubMed  Google Scholar 

  6. Blommers E, Klimek M, Hartholt KA et al (2011) Perioperative care of the older patient. Z Gerontol Geriatr 44:187–191

    Article  CAS  PubMed  Google Scholar 

  7. Bryson GL, Wyand A (2006) Evidence-based clinical update: general anesthesia and the risk of delirium and postoperative cognitive dysfunction. [Mise à jour clinique fondée sur des données probantes: l’anesthésie générale et le risque de délire et de dysfonctionnement cognitif postopératoire]. Can J Anaesth 53:669–677

    Article  PubMed  Google Scholar 

  8. Compagna R, Vigliotti G, Coretti G et al (2012) Comparative study between Levobupivacaine and Bupivacaine for hernia surgery in the elderly. BMC Surg 12(Suppl 1):S12

    Article  PubMed Central  PubMed  Google Scholar 

  9. Covert CR, Fox GS (1989) Anaesthesia for hip surgery in the elderly. Can J Anaesth 36:311–319

    Article  CAS  PubMed  Google Scholar 

  10. Devgan A, Sangwan SS (2002) External fixator in the management of trochanteric fractures in high risk geriatric patients—a friend to the elderly. Indian J Med Sci 56:385–390

    CAS  PubMed  Google Scholar 

  11. DeVries JG, Berlet GC (2010) Understanding levels of evidence for scientific communication. Foot Ankle Spec 3(4):205–209

    Article  PubMed  Google Scholar 

  12. Dobie I, Bennett D, Spence DJ et al (2012) Periarticular local anesthesia does not improve pain or mobility after THA. Clin Orthop Relat Res 470:1958–1965

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  13. Dzankic S, Pastor D, Gonzalez C, Leung JM (2001) The prevalence and predictive value of abnormal preoperative laboratory tests in elderly surgical patients. Anesth Analg 93:301–308

    CAS  PubMed  Google Scholar 

  14. Fetherston CM, Ward S (2011) Relationships between post-operative pain management and short term functional mobility in total knee arthroplasty patients with a femoral nerve catheter: a preliminary study. J Orthop Surg Res 6:7

    Article  PubMed Central  PubMed  Google Scholar 

  15. Fleischman RJ, Adams AL, Hedges JR et al (2010) The optimum follow-up period for assessing mortality outcomes in injured older adults. J Am Geriatr Soc 58:1843–1849

    Article  PubMed Central  PubMed  Google Scholar 

  16. Foss NB, Kristensen MT, Kehlet H (2008) Anaemia impedes functional mobility after hip fracture surgery. Age Ageing 37:173–178

    Article  PubMed  Google Scholar 

  17. Foss NB, Kristensen MT, Jensen PS et al (2009) The effects of liberal versus restrictive transfusion thresholds on ambulation after hip fracture surgery. Transfusion 49:227–234

    Article  PubMed  Google Scholar 

  18. Foss NB, Kristensen MT, Palm H, Kehlet H (2009) Postoperative pain after hip fracture is procedure specific. Br J Anaesth 102:111–116

    Article  CAS  PubMed  Google Scholar 

  19. Lewis SC, Warlow CP, Bodenham AR et al (2008) General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet 372:2132–2142

    Article  PubMed  Google Scholar 

  20. Gaudio RM, Feltracco P, Barbieri S et al (2010) Traumatic dental injuries during anaesthesia: part I: clinical evaluation. Dent Traumatol 26:459–465

    Article  PubMed  Google Scholar 

  21. Gurlit S, Möllmann M (2008) How to prevent perioperative delirium in the elderly? Z Gerontol Geriatr 41:447–452

    Article  PubMed  Google Scholar 

  22. Handoll HH, Parker MJ (2008) Conservative versus operative treatment for hip fractures in adults. Cochrane Database Syst Rev 3:CD000337

    PubMed  Google Scholar 

  23. Hershkovitz A, Kalandariov Z, Hermush V et al (2007) Factors affecting short-term rehabilitation outcomes of disabled elderly patients with proximal hip fracture. Arch Phys Med Rehabil 88:916–921

    Article  PubMed  Google Scholar 

  24. Higuera CA, Elsharkawy K, Klika AK et al (2011) 2010 Mid-America Orthopaedic Association Physician in Training Award: predictors of early adverse outcomes after knee and hip arthroplasty in geriatric patients. Clin Orthop Relat Res 469:1391–1400

    Article  PubMed Central  PubMed  Google Scholar 

  25. Irvin GL 3rd, Carneiro DM (2001) “Limited” parathyroidectomy in geriatric patients. Ann Surg 233:612–616

    Article  PubMed Central  PubMed  Google Scholar 

  26. Jadad AR, Moore RA, Carroll D et al (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17:1–12

    Article  CAS  PubMed  Google Scholar 

  27. Kammerlander C, Gosch M, Blauth M et al (2011a) The Tyrolean Geriatric Fracture Center: an orthogeriatric co-management model. Z Gerontol Geriatr 44:363–367

    Article  CAS  PubMed  Google Scholar 

  28. Kammerlander C, Gosch M, Kammerlander-Knauer U et al (2011b) Long-term functional outcome in geriatric hip fracture patients. Arch Orthop Trauma Surg 131:1435–1444

    Article  PubMed  Google Scholar 

  29. Keating HJ 3rd (1992) Major surgery in nursing home patients: procedures, morbidity, and mortality in the frailest of the frail elderly. J Am Geriatr Soc 40:8–11

    PubMed  Google Scholar 

  30. Kim KI, Park KH, Koo KH et al (2013) Comprehensive geriatric assessment can predict postoperative morbidity and mortality in elderly patients undergoing elective surgery. Arch Gerontol Geriatr 56:507–512

    Article  PubMed  Google Scholar 

  31. Kohn LT, Corrigan JM, Donaldson MS (Hrsg) (2000) To Err is human: building a safer health system. National Academic Press, Washington, DC

  32. Koivusalo AM, Pere P, Valjus M, Scheinin T (2008) Laparoscopic cholecystectomy with carbon dioxide pneumoperitoneum is safe even for high-risk patients. Surg Endosc 22:61–67

    Article  PubMed  Google Scholar 

  33. Kopp L, Edelmann K, Obruba P et al (2009) Mortality risk factors in the elderly with proximal femoral fracture treated surgically. Acta Chir Orthop Traumatol Cech 76:41–46

    CAS  PubMed  Google Scholar 

  34. Krämer S, Wenk M, Fischer G et al (2011) Continuous spinal anesthesia versus continuous femoral nerve block for elective total knee replacement. Minerva Anestesiol 77:394–400

    PubMed  Google Scholar 

  35. Kristensen MT, Foss NB, Ekdahl C, Kehlet H (2010) Prefracture functional level evaluated by the New Mobility Score predicts in-hospital outcome after hip fracture surgery. Acta Orthop 81:296–302

    Article  PubMed Central  PubMed  Google Scholar 

  36. Lagasse RS (2002) Anesthesia safety: model or myth? Anesthesiology 97:1609–1617

    Article  PubMed  Google Scholar 

  37. Lee AR, Choi DH, Ko SJ et al (2011) Effect of combined single-injection femoral nerve block and patient-controlled epidural analgesia in patients undergoing total knee replacement. Yonsei Med J 52:145–150

    Article  PubMed Central  PubMed  Google Scholar 

  38. Leung JM, Dzankic S (2001) Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients. J Am Geriatr Soc 49:1080–1085

    Article  CAS  PubMed  Google Scholar 

  39. Le-Wendling L, Bihorac A, Baslanti TO et al (2012) Regional anesthesia as compared with general anesthesia for surgery in geriatric patients with hip fracture: does it decrease morbidity, mortality, and health care costs? Results of a single-centered study. Pain Med 13:948–956

    Article  PubMed Central  PubMed  Google Scholar 

  40. Liu LL, Leung JM (2000) Predicting adverse postoperative outcomes in patients aged 80 years or older. J Am Geriatr Soc 48:405–412

    CAS  PubMed  Google Scholar 

  41. Louis DJ, Hsu A, Brand MI, Saclarides TJ (2009) Morbidity and mortality in octogenarians and older undergoing major intestinal surgery. Dis Colon Rectum 52:59–63

    Article  PubMed  Google Scholar 

  42. Luger TJ, Kammerlander C, Gosch M et al (2010) Neuroaxial versus general anaesthesia in geriatric patients for hip fracture surgery: does it matter? Osteoporos Int 21(Suppl 4):S555–S572

    Article  CAS  PubMed  Google Scholar 

  43. Luger TJ, Kammerlander C, Benz M et al (2012) Peridural anesthesia or ultrasound-guided continuous 3-in-1 block: which is indicated for analgesia in very elderly patients with hip fracture in the emergency department? Geriatr Orthop Surg Rehabil 3:121–128

    Article  PubMed Central  PubMed  Google Scholar 

  44. MacRae MG (2007) Closed claims studies in anesthesia: a literature review and implications for practice. AANA J 75:267–274

    PubMed  Google Scholar 

  45. Manku K, Bacchetti P, Leung JM (2003a) Prognostic significance of postoperative in-hospital complications in elderly patients. I. Long-term survival. Anesth Analg 96:583–589

    PubMed  Google Scholar 

  46. Manku K, Leung JM (2003b) Prognostic significance of postoperative in-hospital complications in elderly patients. II. Long-term quality of life. Anesth Analg 96:590–594

    PubMed  Google Scholar 

  47. Marciani RD (1999) Critical systemic and psychosocial considerations in management of trauma in the elderly. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 87:272–280

    Article  CAS  PubMed  Google Scholar 

  48. McFarlane AJR, Prasad GA, Chan VWS, Brull R (2009) Does regional anaesthesia improve outcome after total hip arthroplasty? A systematic review. Br J Anaesth 103:335–345

    Article  Google Scholar 

  49. Michalska-Krzanowska G (2012) Anaphylactic reactions during anaesthesia and the perioperative period. Anaesthesiol Intensive Ther 44:104–111

    PubMed  Google Scholar 

  50. Neufeld KJ, Leoutsakos JM, Sieber FE et al (2013) Outcomes of early delirium diagnosis after general anesthesia in the elderly. Anesth Analg 117:471–478

    Article  CAS  PubMed  Google Scholar 

  51. Newman S, Stygall J, Hirani S et al (2007) Postoperative cognitive dysfunction after noncardiac surgery: a systematic review. Anesthesiology 106:572–590

    Article  PubMed  Google Scholar 

  52. Norton R, Campbell AJ, Reid IR et al (1999) Residential status and risk of hip fracture. Age Ageing 28:135–139

    Article  CAS  PubMed  Google Scholar 

  53. Parikh SS, Chung F (1995) Postoperative delirium in the elderly. Anesth Analg 80:1223–1232

    CAS  PubMed  Google Scholar 

  54. Parker MJ, Griffiths R, Appadu BN (2002) Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures. Cochrane Database Syst Rev 1:CD001159

    PubMed  Google Scholar 

  55. Parker MJ, Handoll HHG, Griffiths R (2004) Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev 4:CD000521

    PubMed  Google Scholar 

  56. Paul JE, Arya A, Hurlburt L et al (2010) Femoral Nerve Block Improves Analgesia Outcomes after Total Knee Arthroplasty. A Meta-analysis of Randomized Controlled Trials. Anesthesiology 113:1144–1162

    Article  PubMed  Google Scholar 

  57. Radcliff TA, Henderson WG, Stoner TJ et al (2008) Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. J Bone Joint Surg Am 90:34–42

    Article  PubMed  Google Scholar 

  58. Rerkasem K, Rothwell PM (2008) Local versus general anaesthesia for carotid endarterectomy. Cochrane Database Syst Rev 4:CD000126

    PubMed  Google Scholar 

  59. Rodgers A, Walker N, Schug S et al (2000) Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 321:1493

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  60. Schulz CM, Endsley MR, Kochs EF et al (2013) Situation awareness in anesthesia: concept and research. Anesthesiology 118(3):729–742

    Article  PubMed  Google Scholar 

  61. Semple T, Toh G (2007) Anaesthesia and hip fracture: a review of the current literature. In: Riley R (Hrsg) Australasian Anaesthesia 2007. Australian and New Zealand College of Anaesthetists, McKellar Renown Press Pty Ltd, Melbourne, S 1–8

  62. Siddiqi N, Stockdale R, Britton AM, Holmes J (2007) Interventions for preventing delirium in hospitalised patients. Cochrane Database Syst Rev 18:CD005563

    Google Scholar 

  63. Slor CJ, Jonghe JF de, Vreeswijk R et al (2011) Anesthesia and postoperative delirium in older adults undergoing hip surgery. J Am Geriatr Soc 59:1313–1319

    Article  PubMed  Google Scholar 

  64. Subasi M, Kesemenli C, Kapukaya A, Necmioglu S (2001) Treatment of intertrochanteric fractures by external fixation. Acta Orthop Belg 67:468–474

    CAS  PubMed  Google Scholar 

  65. Tamdee D, Charuluxananan S, Punjasawadwong Y et al (2009) Factors related to 24-hour perioperative cardiac arrest in geriatric patients in a Thai university hospital. J Med Assoc Thai 92:198–207

    PubMed  Google Scholar 

  66. Toglia MR, Nolan TE (2003) Morbidity and mortality rates of elective gynecologic surgery in the elderly woman. Am J Obstet Gynecol 189:1584–1587

    Article  PubMed  Google Scholar 

  67. Turillazzi E, Bello S, Bonsignore A et al (2012) Retrospective analysis of anaesthesia-related deaths during a 12-year period: looking at the data from a forensic point of view. Med Sci Law 52:112–115

    Article  CAS  PubMed  Google Scholar 

  68. Urwin SC, Parker MJ, Griffiths R (2000) General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials. Br J Anaesth 84:450–455

    Article  CAS  PubMed  Google Scholar 

  69. Vaccaro AR, Kepler CK, Kopjar B et al (2013) Functional and quality-of-life outcomes in geriatric patients with type-II dens fracture. J Bone Joint Surg Am 95:729–735

    Article  PubMed  Google Scholar 

  70. Yip AG, Brayne C, Matthews FE, MRC Cognitive Function and Ageing Study (2006) Risk factors for incident dementia in England and Wales: the Medical Research Council Cognitive Function and Ageing Study. A population-based nested case-control study. Age Ageing 35:154–160

    Article  PubMed  Google Scholar 

  71. Zieren J, Zieren HU, Wenger F, Müller JM (2000) Leistenhernienreparation beim alten Menschen. Ergebnisse der Plug-und-Patch-Reparation unter besonderer Berücksichtigung der Lebensqualität. [Repair of inguinal hernia in the elderly. Results of the plug-and-patch repair with special reference to quality of life]. Chirurg 71:564–567

    Article  CAS  PubMed  Google Scholar 

  72. Zuckerman JD (1996) Hip fracture. N Engl J Med 334:1519–1525

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

The authors thank Mary Heaney Margreiter, native speaker and professional editor, Innsbruck, Austria, for her critical review of the manuscript.

Compliance with ethical guidelines

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.

Author information

Authors and Affiliations

  1. Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstr. 25, 6020, Innsbruck, Austria

    T.J. Luger, M.F. Luger & U. Kammerlander-Knauer

  2. Department of Traumatology and Sports Medicine, Innsbruck Medical University, Innsbruck, Austria

    C. Kammerlander

  3. Department of Internal Medicine and Acute Geriatry, Hochzirl State Hospital, Zirl, Austria

    M. Gosch

Authors
  1. T.J. Luger
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. C. Kammerlander
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M.F. Luger
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. U. Kammerlander-Knauer
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. M. Gosch
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to T.J. Luger.

Rights and permissions

Reprints and permissions

About this article

Cite this article

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

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00391-014-0611-3

Keywords

Schlüsselwörter

Search

Navigation