Randomized trial of hypotensive
epidural anesthesia in older adults.
Williams-Russo P, Sharrock NE, Mattis S, Liguori GA, Mancuso
C, Peterson MG, Hollenberg J, Ranawat C, Salvati E, Sculco T.
Department of Medicine, Cornell Medical College, New York, New
York, USA. pgwruss@mail.med.cornell.edu
BACKGROUND: Data are sparse on the incidence of postoperative
cognitive, cardiac, and renal complications after deliberate hypotensive
anesthesia in elderly patients. METHODS: This randomized, controlled
clinical trial included 235 older adults with comorbid medical
illnesses undergoing elective primary total hip replacement with
epidural anesthesia. The patients were randomly assigned to one
of two levels of intraoperative mean arterial blood pressure management:
either to a markedly hypotensive mean arterial blood pressure
range of 45-55 mmHg or to a less hypotensive range of 55-70 mmHg.
Cognitive outcome was assessed by within-patient change on 10
neuropsychologic tests assessing memory, psychomotor, and language
skills from before surgery to 1 week and 4 months after surgery.
Prospective standardized surveillance was performed for cardiovascular
and renal outcomes, delirium, thromboembolism, and blood loss
and replacement. RESULTS: The two groups were similar at baseline
in terms of age (mean, 72 yr), sex (50% women), comorbid conditions,
and cognitive function. After operation, no significant differences
in the incidence of early or long-term cognitive dysfunction were
observed between the two blood pressure management groups. There
were no significant differences in the rates of other adverse
consequences, including cardiac, renal, and thromboembolic complications.
In addition, no differences occurred in the duration of surgery,
intraoperative estimated blood loss, or transfusion rates. CONCLUSIONS:
Elderly patients can safely receive controlled hypotensive epidural
anesthesia with this protocol. There was no evidence of greater
risks, or early benefits, with the use of the more markedly hypotensive
range.
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