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AbstractObjectiveTo examine the associations between neuraxial anaesthesia or general anaesthesia and clinical outcomes, length of hospital stay, and readmission in adults undergoing lower limb revascularisation surgery.DesignComparative effectiveness study using linked, validated, population based databases.SettingOntario, Canada, 1 April 2002 to 31 March 2015.Participants20 988 patients Ontario residents aged 18 years or older who underwent their first lower limb revascularisation surgery in hospitals performing 50 or more of these surgeries annually.Main outcome measuresPrimary outcome was 30 day all cause mortality. Secondary outcomes were in-hospital cardiopulmonary and renal complications, length of hospital stay, and 30 day readmissions. Multivariable, mixed effects regression models, adjusting for patient, procedural, and hospital characteristics, were used to estimate associations between anaesthetic technique and outcomes. Robustness of analyses were evaluated by conducting instrumental variable, propensity score matched, and survival sensitivity analyses.ResultsOf 20 988 patients who underwent lower limb revascularisation surgery, 6453 (30.7%) received neuraxial anaesthesia and 14 535 (69.3%) received general anaesthesia. The percentage of neuraxial anaesthesia use ranged from 0.6% to 90.6% across included hospitals. Furthermore, use of neuraxial anaesthesia declined by 17% over the study period. Death within 30 days occurred in 204 (3.2%) patients who received neuraxial anaesthesia and 646 (4.4%) patients who received general anaesthesia. After multivariable, multilevel adjustment, use of neuraxial anaesthesia compared with use of general anaesthesia was associated with decreased 30 day mortality (absolute risk reduction 0.72%, 95% confidence interval 0.65% to 0.79%; odds ratio 0.68, 95% confidence interval 0.57 to 0.83; number needed to treat to prevent one death=139). A similar direction and magnitude of association was found in instrumental variable, propensity score matched, and survival analyses. Use of neuraxial anaesthesia compared with use of general anaesthesia was also associated with decreased in-hospital cardiopulmonary and renal complications (odds ratio 0.73, 0.63 to 0.85) and a reduced length of hospital stay (−0.5 days, −0.3 to−0.6 days).ConclusionsUse of neuraxial anaesthesia compared with general anaesthesia for lower limb revascularisation surgery was associated with decreased 30 day mortality and hospital length of stay. These findings might have been related to reduced cardiopulmonary and renal complications after neuraxial anaesthesia and support the increased use of neuraxial anaesthesia in patients undergoing these surgeries until the results of a large, confirmatory randomised trial become available.

AbstractThe American Society of Regional Anesthesia and Pain Medicine's Third Practice Advisory on local anesthetic systemic toxicity is an interim update from its 2010 advisory. The advisory focuses on new information regarding the mechanisms of lipid resuscitation, updated frequency estimates, the preventative role of ultrasound guidance, changes to case presentation patterns, and limited information related to local infiltration anesthesia and liposomal bupivacaine. In addition to emerging information, the advisory updates recommendations pertaining to prevention, recognition, and treatment of local anesthetic systemic toxicity.What’s New in This Update?This interim update summarizes recent scientific findings that have enhanced our understanding of the mechanisms that lead to lipid emulsion reversal of LAST, including rapid partitioning, direct inotropy, and post-conditioning. Since the previous practice advisory, epidemiological data have emerged that suggest a lower frequency of LAST as reported by single institutions and some registries, nevertheless a considerable number of events still occur within the general community. Contemporary case reports suggest a trend toward delayed presentation, which may mirror the increased use of ultrasound guidance (fewer intravascular injections), local infiltration techniques (slower systemic uptake), and continuous local anesthetic infusions. Small patient size and sarcopenia are additional factors that increase potential risk for LAST. An increasing number of reported events occur outside of the traditional hospital setting and involve non-anesthesiologists.

IntroductionWe aimed to determine whether regional anesthesia (RA) has any advantages over general anesthesia (GA) in total joint arthroplasty (TJA) in terms of mortality and postoperative complications.MethodsThis population-based retrospective cohort study included data of adults who underwent total knee or hip arthroplasty under RA or GA between 2016 and 2021 from the National Health Insurance Service of South Korea. RA included spinal or epidural anesthesia or a combination of both. Endpoints were 30-day mortality, 90-day mortality, and postoperative complications. Propensity score (PS) matching was used for statistical analysis.ResultsWe included 517 960 patients (RA, n=380 698; GA, n=137 262) who underwent TJA. After PS matching, 186 590 patients (93 295 in each group) were included in the final analysis. In the logistic regression analyses using the PS-matched cohort, the RA group compared with the GA group showed 31% (OR: 0.69; 95% CI, 0.60 to 0.80; p<0.001) and 22% (OR: 0.78; 95% CI, 0.72 to 0.85; p<0.001) lower 30-day and 90-day mortality rates, respectively. However, the total postoperative complication rate did not differ significantly between the two groups (p=0.105).ConclusionRA compared with GA was associated with improved 30-day and 90-day survival outcomes in patients who underwent TJA. However, the postoperative complication rate did not differ significantly. Therefore, our results should be interpreted with caution, and more well-designed future studies are needed to clarify the most appropriate type of anesthesia for TJA.

ABSTRACTThe experimental use of lipid emulsion for local anesthetic toxicity was originally identified in 1998. It was then translated to clinical practice in 2006 and expanded to drugs other than local anesthetics in 2008. Our understanding of lipid resuscitation therapy has progressed considerably since the previous update from the American Society of Regional Anesthesia and Pain Medicine, and the scientific evidence has coalesced around specific discrete mechanisms. Intravenous lipid emulsion therapy provides a multimodal resuscitation benefit that includes both scavenging (eg, the lipid shuttle) and nonscavenging components. The intravascular lipid compartment scavenges drug from organs susceptible to toxicity and accelerates redistribution to organs where drug (eg, bupivacaine) is stored, detoxified, and later excreted. In addition, lipid exerts nonscavenging effects that include postconditioning (via activation of prosurvival kinases) along with cardiotonic and vasoconstrictive benefits. These effects protect tissue from ischemic damage and increase tissue perfusion during recovery from toxicity. Other mechanisms have diminished in favor based on lack of evidence; these include direct effects on channel currents (eg, calcium) and mass-effect overpowering a block in mitochondrial metabolism. In this narrative review, we discuss these proposed mechanisms and address questions left to answer in the field. Further work is needed, but the field has made considerable strides towards understanding the mechanisms.

ABSTRACTThe American Society of Regional Anesthesia and Pain Medicine (ASRA) periodically revises and updates its checklist for the management of local anesthetic systemic toxicity. The 2017 update replaces the 2012 version and reflects new information contained in the third ASRA Practice Advisory on Local Anesthetic Systemic Toxicity. Electronic copies of the ASRA checklist can be downloaded from the ASRA Web site (www.asra.com) for inclusion in local anesthetic toxicity rescue kits or perioperative checklist repositories.

Background and ObjectivesPotentially, perioperative regional anesthesia and analgesia (RA) could influence the outcomes of patients with cancer. The aim of this systematic review and meta-analysis was to evaluate the effects of perioperative RA on survival and cancer recurrence after oncologic surgery.MethodsThe authors searched computerized databases (from inception to December 2014) and reference lists and considered all studies comparing the effects of RA on cancer recurrence or overall survival with that of general anesthesia (GA). Risk estimates were pooled to determine the effects of RA on risks of cancer recurrence and mortality. Twenty eligible studies were included.ResultsPerioperative RA use was associated with improved overall survival (Hazard ratio [HR] = 0.84, 95% CI, 0.75 − 0.94; I2 =41%), but not with reduced cancer recurrence (HR=0.91, 95% CI, 0.70 − 1.18; I2=83%).ConclusionsOur meta-analysis suggests that RA may improve overall survival but not reduce cancer recurrence after oncologic surgery.

BACKGROUND AND OBJECTIVESAmputations of the lower extremity remain a common procedure in a high-risk population. Perioperative morbidity and mortality reach as high as 14.1% in below-knee amputations. We aimed to determine whether regional, or neuraxial, anesthesia, when compared with general anesthesia (GA), would be associated with reduced perioperative morbidity and mortality. METHODSWe queried the American College of Surgeons National Surgical Quality Improvement Program data set. The study population was divided into 2 groupspatients undergoing regional anesthesia (RA) and those undergoing GA. The primary end point for our study was 30-day mortality. The secondary end points were return to the operating room, surgical site infections, pulmonary complications, acute kidney injury, urinary tract infection, cardiac arrest, myocardial infarction, perioperative transfusions, thromboembolisms, sepsis, composite measure of postoperative complications, and days from operation to discharge. RESULTSTwelve thousand seven hundred twenty-three patients were identified. Older patients, white patients, patients with a higher body mass index, patients without dyspnea, patients with independent functional status, smokers, patients with sepsis, and patients with bleeding disorders were associated with receiving GA. Hispanic patients, patients with chronic obstructive pulmonary disease, and patients with congestive heart failure were associated with receiving RA. Our study did not reveal a 30-day mortality difference between RA and GA. Regional anesthesia was associated with a significantly decreased need for perioperative blood transfusions (11.8% vs 16.5%, P < 0.001) and a decrease in the composite measure of postoperative complications (25.7% vs 29.1%, P < 0.04). CONCLUSIONSRegional anesthesia does not offer a mortality advantage over GA, but RA may reduce the need for perioperative blood transfusions.

Objective To examine whether regional anaesthesia (RA) versus general anaesthesia (GA) is associated with the one-year postoperative mortality among the older surgical patients. Methods We conducted a single-center retrospective cohort study from 2012 to 2016. Patients aged 70 years or older who underwent surgery were included, and those who underwent transplantation, burn surgery, or minor procedures were excluded. The primary exposure was anaesthesia type (RA vs. GA); the main outcome was one-year all-cause mortality, which was verified through hospital records and a national registry. Demographic, clinical, and laboratory variables were included as covariates. Multivariable-adjusted logistic regression models were used to evaluate the independent effect of anaesthesia methods on one-year mortality. Kaplan-Meier curves assessed survival rates by anaesthesia method, with log-rank tests comparing the curves. Main results Among 16,599 older adults, 29.7% received RA. The one-year mortality rate was lower in the RA group (6.44%) than in the GA group (9.52%), yielding an adjusted odds ratio of 0.72 (95% CI, 0.63–0.82). K‒M analyses revealed improved survival in the RA group (log-rank P  < 0.05). Propensity score matching and inverse probability weighting analyses corroborated these findings. The E-value of 2.12 demonstrates the robustness of the results against unmeasured confounding. Conclusions Regional anaesthesia may be linked to better one-year survival in older patients. Although other confounding factors cannot be excluded, these findings underscore the need for multicenter, prospective investigations to inform perioperative decisions in geriatric populations.

Background and ObjectivesRecent preclinical basic science studies suggest that patient tumor immunity is altered by general anesthesia (GA), potentially worsening cancer outcomes. A single retrospective review concluded that breast cancer patients receiving paravertebral block and GA had better cancer outcomes compared with patients receiving GA alone. This study has not been validated. We hypothesized that local or regional anesthesia (LRA) would be associated with better cancer outcomes compared with GA.MethodsWe retrospectively reviewed a prospectively collected database to identify all stage 0-III breast cancer patients undergoing surgery in a single center during a 9-year period ending January 1, 2010. Patients were divided into 2 groups: those who received only LRA and those who received GA. Overall survival (OS), disease-free survival (DFS), and local regional recurrence (LRR) were calculated using the Kaplan-Meier method with log-rank comparison before and after propensity score matching.ResultsMedian age of the 1107 patients who met study criteria was 64 years (range, 24–97 years). Median and longest follow-up were 5.5 and 12.5 years, respectively. General anesthesia was used for 461 patients (42%), and 646 (58%) received LRA. The point estimates of cumulative OS, DFS, and LRR “free” rates at 5 years for the GA and LRA groups were 85.5% and 87.1%, 94.2% and 96.1%, and 96.3% and 95.8%, respectively. Cox regression showed no significant differences between the 2 groups (GA and LRA) for the 3 outcomes: OS (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.59–1.10; P = 0.17), DFS (HR, 0.91; 95% CI, 0.55–1.76; P = 0.87), and LRR (HR, 1.73; 95% CI, 0.83–3.63; P = 0.15).ConclusionsBreast cancer OS, DFS, and LRR were not affected by type of anesthesia in our institution. This result differs from that of the only prior published clinical report on this topic and does not provide clinical corroboration of the basic science studies that suggest oncologic benefits to LRA.

Background The perioperative period of major oncologic surgery is characterized by immunosuppression, angiogenesis, and an increased load of circulating malignant cells. It is a window period in which cancer cells may seed, invade, and proliferate. Thus, it has been hypothesized that the use of regional anesthesia with the goal of reducing surgical stress and opioid and volatile anesthetic consumption would avoid perioperative immune suppression and angiogenesis and ultimately cancer recurrence. Questions/purposes We performed a systematic review of the literature on the use of regional anesthesia and postoperative analgesia to improve cancer-related survival after oncologic surgery. Our primary topic of interest is survival after orthopaedic oncologic surgery, but because that literature is limited, we also have systematically reviewed the question of survival after breast, gastrointestinal, and genitourologic cancers. Methods We searched the PubMed and Embase databases with the search terms: “anesthesia and analgesia”, “local neoplasm recurrence”, “cancer recurrence”, “loco-regional neoplasm recurrence”, “disease-free survival”, and “cumulative survival rates”. Our initial search of the two databases provided 836 studies of which 693 were rejected. Of the remaining 143 studies, only 13 articles qualified for inclusion in this systematic review, based on defined inclusion criteria. All these studies had retrospective design. Due to the high heterogeneity among the identified studies and the complete absence of randomized controlled trials from the literature on this topic, the results of a meta-analysis would be heavily confounded; hence, we instead performed a systematic review of the literature. Results No eligible studies addressed the question of whether regional anesthesia and analgesia have an impact on survival after musculoskeletal cancer surgery. Only one relevant clinical study was identified on regional breast cancer survival; it suggested a benefit. The literature on gastrointestinal and genitourinary surgery was larger but mixed, although some preliminary studies do suggest a benefit of regional anesthesia on survival after oncologic surgery in those patient populations. Conclusions Although basic science studies suggest a potential benefit of regional anesthesia and stress response reduction in cancer formation, we found little clinical evidence to support the theory that regional anesthesia and analgesia improve overall patient survival after oncologic surgery.