Regional anesthesia techniques

Sooner or later, someone will make a sufficiently close examination of the anatomy involved, so that exact techniques will be developed. Alon P. Winnie, 1994 (before the introduction of ultrasound-guided blocks) Introduction Although no substantial differences have been found over the years in perioperative morbidity and mortality after general anesthesia (GA) or regional anesthesia (RA), there is a diffuse perception among professionals that elderly patients would better benefit from RA, which usually offers optimal surgical conditions, contributes to reduce surgical stress (badly tolerated in these patients) and can moreover be performed in association with GA to obtain postoperative pain control. Nevertheless, a number of factors may influence the outcome in elderly patients undergoing RA either alone or associated with GA, such as the type and duration of surgery, coexisting medical and cognitive conditions, age-related changes modifying local anesthetic pharmacodynamics and kinetics, degenerative phenomena affecting spine bones and joints, and perioperative care. Last but not least, the skill and expertise of both the surgeon and the anesthetist may act as critical factors. Many studies have tried to demonstrate the superiority of one of these two techniques without reaching definitive conclusions. Some studies showed a significant benefit of spinal anesthesia with lower mortality and incidence of pneumonia (Neuman et al. 2012); however, these studies included a small number of patients or had a retrospective approach. A recent meta-analysis reported no evidence for the benefit of central neural blockade versus GA regarding 1 month mortality, risk of pneumonia, myocardial infarction, cerebrovascular accident and acute confusion state. As always, what makes the difference is the ability of professionals to apply a case-by-case, individualized approach; a concept that is even more pivotal when referring to the elderly patient. Benefits Expected from RA Whether RA provides a better and safer option in elderly patients compared with GA is an ongoing debate; indeed, the literature lacks consistency for all ages, but especially for elderly patients. The main reason is probably the multiple factors influencing outcome. However, benefits of RA in elderly patients have been identified, for example Halaszynski (2009) has proposed an exhaustive list.