Regional Anesthesia
2025 ASA Practice Advisory for the Perioperative Care of Older Adults Undergoing Inpatient Surgery
23 Dec, 2024 | 20:27h | UTCIntroduction: This summary outlines the American Society of Anesthesiologists (ASA) 2025 advisory on optimizing perioperative care for older adults (age 65 years or older) undergoing inpatient surgery. It focuses on preoperative, intraoperative, and postoperative measures to mitigate cognitive complications, especially delirium and longer-term cognitive decline, in a population that is highly vulnerable to functional deterioration and loss of independence. The recommendations are based on systematic reviews and meta-analyses, supplemented by expert consensus where evidence is limited. Although not intended as strict standards of care, these advisory statements provide practical guidance that can be adapted to local contexts and patient-specific needs.
Key Recommendations:
- Expanded Preoperative Evaluation:
- Incorporate frailty assessment, cognitive screening, and psychosocial or nutritional evaluations into routine preoperative workups for older patients.
- Patients identified with frailty or cognitive deficits should receive targeted interventions, such as geriatric co-management, deprescribing when indicated, and early family education about delirium risks.
- Evidence suggests a modest decrease in postoperative delirium when such evaluations are included.
- Choice of Primary Anesthetic (Neuraxial vs. General):
- Current studies do not demonstrate a clear advantage of neuraxial over general anesthesia in reducing postoperative delirium risk.
- Both approaches are acceptable; individualize decisions based on patient factors, surgical requirements, and preference-sensitive discussions.
- Maintenance of General Anesthesia (Total Intravenous vs. Inhaled Agents):
- Data are inconclusive regarding delirium prevention, with no significant difference between total intravenous anesthesia (TIVA) and inhaled volatile agents.
- Some low-level evidence indicates TIVA might reduce short-term cognitive decline, but this effect is inconsistent over longer follow-up.
- Dexmedetomidine for Delirium Prophylaxis:
- Moderate-level evidence supports dexmedetomidine for reducing delirium incidence in older patients, yet its use may increase bradycardia and hypotension.
- Optimal dosing and timing remain uncertain, and baseline patient vulnerability should inform decisions.
- Medications with Potential Central Nervous System Effects:
- Drugs such as benzodiazepines, antipsychotics, anticholinergics, ketamine, and gabapentinoids warrant careful risk-benefit analysis.
- Current findings are inconclusive, suggesting neither a firm endorsement nor outright disapproval; preexisting conditions and polypharmacy should guide individualized treatment plans.
Conclusion: Preserving cognitive function and independence in older adults undergoing inpatient surgery is a growing priority. These recommendations highlight the importance of comprehensive preoperative screenings (frailty, cognition, and psychosocial domains), shared decision-making when choosing anesthetic techniques, and thoughtful use of pharmacologic agents. While dexmedetomidine shows promise in mitigating delirium, vigilance regarding hypotension and bradycardia is essential. Ultimately, these strategies aim to reduce anesthesia-related complications in older patients by addressing the multifaceted determinants of postoperative cognitive outcomes.
Updated Guidelines on Perioperative Management of Anticoagulant and Antiplatelet Therapy for Interventional Techniques – Pain Physician
18 Aug, 2024 | 14:52h | UTCIntroduction: The American Society of Interventional Pain Physicians (ASIPP) has published updated guidelines for the perioperative management of patients undergoing interventional techniques while receiving antiplatelet and anticoagulant therapy. These guidelines are essential for clinicians to balance the risk of thromboembolism against the risk of bleeding during interventional procedures.
Key Points:
1 – Risk of Thromboembolic Events:
– Thromboembolic events have a higher risk of morbidity and mortality compared to the risk of epidural hematoma. Thus, interruption of antithrombotic therapy should be carefully considered.
2 – Risk Stratification of Procedures:
– Interventional techniques are classified into three categories based on risk: low, moderate, or high. For high-risk procedures, cessation of anticoagulant or antiplatelet therapy is recommended, whereas for low to moderate-risk procedures, therapy may continue under certain conditions.
3 – Management of Direct Oral Anticoagulants (DOACs):
– DOACs such as dabigatran, apixaban, rivaroxaban, and edoxaban should generally be discontinued for 2 days before high-risk procedures and one day for moderate-risk procedures. Adjustments are needed based on renal function, specially for dabigatran.
4 – Discontinuation of Aspirin:
– For high-risk interventional procedures, discontinuation of aspirin (81 or 325 mg) is recommended 6 days before the procedure. However, for low to moderate-risk procedures, aspirin therapy may be continued or stopped for 3 days depending on individual risk factors and clinical judgment.
5 – Discontinuation of Other Antiplatelet Agents:
– Clopidogrel (Plavix) and Prasugrel (Effient): These agents should be discontinued 6 days before high-risk procedures. For low-risk procedures, these medications can be continued.
– Ticagrelor (Brilinta): Discontinue for 5 days before high-risk procedures, with consideration of patient-specific risk factors.
6 – Timing for Restarting Therapy:
– Antithrombotic therapy should typically be resumed within 12-24 hours after low to moderate-risk procedures and within 24-48 hours after high-risk procedures, depending on bleeding risk and patient status.
7 – Shared Decision-Making:
– Decisions on whether to continue or discontinue antithrombotic therapy should involve shared decision-making between the patient, the interventional pain specialist, and other treating physicians, considering all associated risks.
Conclusion: These guidelines provide a comprehensive framework for managing the delicate balance between thromboembolic and bleeding risks in patients on anticoagulant or antiplatelet therapy undergoing interventional procedures. They emphasize the importance of personalized care and multidisciplinary collaboration.
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8 Aug, 2023 | 13:17h | UTC
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Review | Regional analgesia for acute pain relief after open thoracotomy and video-assisted thoracoscopic surgery
31 Jul, 2023 | 14:03h | UTC
Pro-Con Debate | Peripheral nerve blockade should be provided routinely in extremity trauma
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M-A | Postoperative analgesic effects of serratus anterior plane block for thoracic and breast surgery
18 Apr, 2023 | 13:01h | UTC
Review | The failed peripheral nerve block
31 Mar, 2023 | 13:28h | UTCThe failed peripheral nerve block – BJA Education
Review | Regional anesthesia as part of enhanced recovery strategies in pediatric cardiac surgery
21 Mar, 2023 | 13:09h | UTCRegional anesthesia as part of enhanced recovery strategies in pediatric cardiac surgery – Current Opinion in Anesthesiology (free for a limited period)
M-A | Analgesic effect of erector spinae plane block in adults undergoing laparoscopic cholecystectomy
21 Mar, 2023 | 13:06h | UTC
RCT | Addition of preoperative transversus abdominis plane block to multimodal analgesia in open gynecological surgery
2 Mar, 2023 | 12:43h | UTC
Regional anesthesia for thoracic surgery: a narrative review of indications and clinical considerations
23 Feb, 2023 | 13:11h | UTC
M-A | Effects of ultrasound-guided regional anesthesia in cardiac surgery
20 Jan, 2023 | 14:35h | UTC
RCT | Bilateral ultrasound-guided erector spinae plane block vs. wound infiltration for postoperative analgesia in lumbar spinal fusion surgery
20 Jan, 2023 | 14:18h | UTC
RCT | Anterior quadratus lumborum block at lateral supra-arcuate ligament vs. thoracic epidural analgesia after open liver surgery
13 Jan, 2023 | 13:03h | UTCUltrasound-Guided Anterior Quadratus Lumborum Block at Lateral Supra-Arcuate Ligament vs Thoracic Epidural Analgesia after Open Liver Surgery: A Randomized, Controlled, Noninferiority Trial – Journal of the American College of Surgeons (link to abstract – $ for full-text)
Commentary on Twitter
https://twitter.com/acsJACS/status/1594420458413527040
RCT | Comparing bupivacaine alone to liposomal bupivacaine plus bupivacaine in interscalene blocks for total shoulder arthroplasty.
15 Dec, 2022 | 13:36h | UTC
RCT | US-guided pudendal nerve block vs. US-guided penile nerve block for analgesia during pediatric circumcision.
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RCT | Ropivacaine perineal infiltration after episiotomy did not reduce postpartum pain.
13 Dec, 2022 | 14:16h | UTCRopivacaine perineal infiltration for postpartum pain management in episiotomy repair: a double-blind, randomised, placebo-controlled trial – BJOG (link to abstract – $ for full-text)
RCT | Efficacy of single wound infiltration with bupivacaine and adrenaline during cesarean delivery for reduction of postoperative pain.
12 Dec, 2022 | 12:25h | UTC
Commentary on Twitter
https://twitter.com/JAMANetworkOpen/status/1592563091325190147
RCT | Effect of local anesthetic infiltration on postoperative pain after laparoscopic cholecystectomy.
10 Nov, 2022 | 13:56h | UTC
Commentary on Twitter
Does it matter where you put local #anasthetic after #lapchole?
This #RCT 🇹🇭 shows that getting the local into the sheath, not just skin, reduces pain.#some4surgery #surgicalresearchhttps://t.co/ByRt7zuLfR@asgbi @SEIQuirurgica @villesallinen @Gio_Marchegiani pic.twitter.com/Cszf9H2wO2
— BJS Open (@BjsOpen) June 3, 2022
RCT | Preoperative ultrasound-guided percutaneous cryoneurolysis for the treatment of pain after mastectomy.
10 Nov, 2022 | 13:41h | UTCInfographic: Tip of the Iceberg: The History of Cryoneurolysis – Anesthesiology
M-A | Postoperative analgesia efficacy of erector spinae plane block in adult abdominal surgery.
3 Nov, 2022 | 13:59h | UTC
RCT | Liposomal bupivacaine transversus abdominis plane block did not reduce postoperative pain after abdominal wall reconstruction.
31 Oct, 2022 | 13:30h | UTCThe Efficacy of Liposomal Bupivacaine on Postoperative Pain Following Abdominal Wall Reconstruction: A Randomized, Double-blind, Placebo-controlled Trial – Annals of Surgery (link to abstract – $ for full-text)
Review | Regional anesthesia for shoulder surgery.
7 Oct, 2022 | 14:05h | UTCRegional anesthesia for shoulder surgery – Minerva Anestesiologica
Review | Regional anesthesia and acute perioperative pain management in thoracic surgery.
30 Sep, 2022 | 12:32h | UTC