REGIONAL ANESTHESIA IN GERIATRIC

PATIENTS
09-01-2016

Wahyudi
 ITRODUCTION

• THERE HAS BEEN INCREASE IN THE ELDERLY THROUGHOUT

THE PAST CENTURY
• BY 2030 UP TO 20 % OF WESTERN POPULATION WILL BE
MORE THAN 65 YEARS OF AGE
• THIS SITUATION HAS LEAD TO AN INCREASE IN THE NUMBER
OF SURGICAL INTERVENTION
• IT HAS BEEN ESTIMATED THAT MORE THAN HALF OF THE
OLDER THAN 65 YEARS WILL REQUIRE SURGICAL
INTERVENTION AT LEAST ONCE DURING THE REMANIDER OF
THEIR LIVES
• REGIONAL ANESTHESIA IS FREQUENTLY USED IN ELDERLY
PATIENTS
• KNOWLEDGE OF THE AGE-RELATED EFFECTS IS IMPORTANT
TO THE DESIGN OF REGIONAL ANESTHETIC REGIMEN
 AGE-RELATED CHANGES TO REGIONAL
ANESTHESIA
• A DECLINING NUMBER OF NEURONS
• DETERIORATION IN MYELIN SHEATHS IN THE VENTRAL AND
DORSAL ROOTS
• CHANGES IN THE ANATOMY OF THE SPINE AND
INTREVERTEBRAL FORAMINA
• THE NUMBER OF AXONS IN PERIPHERAL NERVES DECREASES
• THE CONDUCTION VELOCITY DIMINISHES PARTICULARY IN
MOTOR NERVES
• CHANGES IN THE CONNECTIVE TISSUE SUBTANCES MAY
RESULT IN CHANGES IN LOCAL DISTRIBUTION TO THE SITE
ACTION
• THE DURA BECOMES MORE PERMEABLE TO LOCAL
ANESTHETICS BECAUSE OF ENLARGED ARACHNOID VILLI
• AGING IS POSSIBLY ASSOCIATED WITH A REDUCTION OF THE
TOTAL CSF AND WITH INCREASE OF THE SPECIFIC GRAVITY
• ANATOMIC AND PHYSIOLOGIC CHANGES, MAY AFFECT THE
NERVE BLOCK CHARACTERISTICS AND PHARMACOKINETICS
AFTER ADMINISTRATION OF LOCAL ANESTHETICS
 EPIDURAL ANESTHESIA

• THE SPREAD OF ANALGESIA INCREASES WITH ADVANCING

AGE AFTER EPIDURAL ADMINISTRATION
• ELDERLY, HAVE A FASTER ONSET OF ANALGESIA IN THE
CAUDAD SEGMENTS AND THE RATE OF REGRESSION IS
PROLONGED
• WITH EPIDURAL AN ENHANCED INTENSITY OF MOTOR
BLOCKADE IS SHOWN WITH ADVANCING AGE
• IN OLDER PATIENTS, THE ENHANCED SPREADING OF THE
LOCAL ANESTHETIC IN THE EPIDURAL SPACE IS PROMOTED BY
:
1. SCLEROSIS AND CALCIFICATION OF THE INTERVERTEBRAL
FORAMINA
2. A REDUCED FATTY TISSUE OF THE EPIDURAL SPACE
3. LESS RESISTANT OF EPIDURAL SPACE
• EPINEPHRINE IS USED FREQUENTLY IN THE EPIDURAL TEST
DOSE, BUT WILL NOT BE RELIABLE IN OLDER PATIENTS,
BECAUSE OF DECREASED BETA-ADRENERGIC RESPONSIVENESS
• THE ALDERLY PATIENTS EXHIBIT AN INCREASED SENSITIVITY
TO OPIOIDS, SO EPIDURAL – PCA HAS BEEN SHOWN TO BE
EFFECTIVE IN THE MANAGEMENT OF PAIN
• AND IT HAS BEEN SUGGESTED TO REDUCE THE BOLUS DOSE
AND INFUSION RATE OF OPIOID UP TO 50 % WHEN
ADMINISTERED TO THE ELDERLY
 SPINAL ANESTHESIA

• THE EFFECT OF AGE ON THE CLINICAL PROFILE OF SPINAL

ANESTHESIA DEPEND ON THE BARICITY OF THE INJECTED
SOLUTION
• WITH 2 % MEPIVACAINE A SLIGHTLY HIGHER LEVEL OF
SENSORY ANALGESIA
• WITH 0,5 % BUPIVACAINE WHICH AS A SLIGHTLY HYPOBARIC,
THE SPREAD OF ANALGESIA UNALTERED WITH AGE
• WITH HYPERBARIC SOLUTION, THE LEVEL OF ANALGESIA
INCREASES EXTENDING SOME 3 – 4 SEGMENTS HIGHER IN
ELDERLY AS COMPARED TO YOUNG ADULT PATIENTS
• A QUICKER ONSET TIME OF MOTOR BLOCK HAS BEEN FOUND
IN OLDER PATIENTS
• WITH BOTH HYPERBARIC AND GLUCOSE-FREE BUPIVACAINE,
THE DURATION OF ANALGESIA IS PROLONGED
 PERIPHERAL NERVE BLOCKADE

• THE MAJOR PHYSIOLOGIC CHANGES ARE IN THE RESPONSE OF

THE NERVES TO LOCAL ANESTHETICS
• BY THE AGE OF 90 YEARS, ONE-THIRD OF THE MYELINATED
FIBERS HAVE DISAPPEARED FROM PERIPHERAL NERVES
• IN ADDITION, CONDUCTION VELOCITY DECREASES WITH AGE
• THE DURATION OF SENSORY BLOCK AND MOTOR BLOCK IS
GREATER THAN IN YOUNGER PATIENTS
• ONSET TIME OF COMPLETE MOTOTR BLOCK IS SHORTER IN
ELDERLY
 PHARMACOLOGY

• REGIONAL ANESTHETIC BLOCK ARE PERFORMED BY INJECTING

LOCAL ANESTHETIC AGENTS TO NERVE TRUNKS
• TWO QUITE SEPARATE PROCESSES SIMULTANEOUSLY OCCUR
AFTER INJECTION, WHILE THERE IS VASCULAR UPTAKE OF THE
DRUG INTO TO THE SYSTEMIC CIRCULATION AND DIFFUSES
DIRECTLY TO NEURAL STRUCTURE
• THE UPTAKE INTO THE SYSTEMIC CIRCULATION MAY LEAD TO
SIDE EFFECTS
PHARMACOKINETICS OF LOCAL ANESTHETICS

• CHANGES IN BODY COMPOSITION AND CHARACTERISTICS OF

TISSUES AND ORGAN ,MAY HAVE AN IMPACT ON THE RATE
AND EXTENT OF ABSORPTION, DISTRIBUTION AND
ELIMINATION OF LOCAL ANESTHETICS
• WITH INCREASING AGE, COULD ALTER THE CLINICAL PROFILE
OF LOCAL ANESTHETICS AFTER REGIONAL PROCEDURE
SYSTEMIC ABSORPTION

• KNOWLEDGE OF THE PHARMACOKINETICS IS OF IMPORTANCE

IN RELATION WITH THE DURATION OF ACTION, SYSTEMIC SIDE
EFFECTS AND TOXICITY
• LOCAL ANESTHETICS EXHIBIT A BIPHASIC ABSORPTION
PATTERN, A FAST INITIAL ABSORPTION AND FOLLOWED BY A
SLOWER ABSORPTION PHASE AFTER EPIDURAL AND
SUBARACHNOID ADMINISTRATION
• THE INITIAL FAST ABSORPTION IS A REFLECTION OF THE HIGH
INITIAL CONCENTRATION AND LARGE VASCULARITY OF THE
EPIDURAL SPACE
• WITH SPINAL ANESTHESIA, THE INITIAL ABSORPTION IS MUCH
SLOWER, BECAUSE THE SUBARACHNOID SPACE HAS A POOR
PERFUSION
• THE SLOWER SECOND ABSORPTION PHASE IS BELIEVED TO
OCCUR FROM SLOW UPTAKE OF LOCAL ANESTHETICS
SYSTEMIC DISPOSITION ( DISTRIBUTION AND
ELIMINATION) :
• AGE-RELATED CHANGES IN DRUG DISTRIBUTION MAY RESULT
FROM :
1. BODY COMPOSITION :
AS FATTY TISSUE INCREASES, THE DISTRIBUTION OF
LIPOPHILIC LOCAL ANESTHETICS WOULD BE EXPECTED TO
INCREASE
2. PLASMA BINDING :
THE PLASMA PROTEIN BINDING OF LODOCAINE TO
INCREASE SLIGHTLY WITH AGE BUT DOES NOT FOR
BUPIVACAINE
3. TISSUE PERFUSION :
THE LARGE VASCULARITY IS REFLECTION A GOOD PERFUSION
AND RESULT FOR INCREASE VOLUME DISTRIBUTION
• ELIMINATION :

• LOCAL ANESTHETICS ARE ELIMINATED BY METABOLISM AND

EXCRETION
• METABOLISM AND EXCRETION ARE RELATED TO CHANGES IN
HEPATIC FUNCTION
• DECREASES IN HEPATC MASS, HEPATIC BLOOD FLOW AND
HEPATIC ENZYME ACTIVITY WITH ADVANCING AGE, MAY
RESULT IN IMPAIRMENT OF METABOLISM
• TOTAL PLASMA CLEARENCE OF LOCAL ANESTHETICS HAS
BEEN FOUND TO DECREASE WITH INCREASING AGE AFTER
EPIDURAL AND SUBARACHNOID ADMINISTRATION
• THE AGE-RELATED DECREASED CLEARENCE OF LOCAL
ANESTHETICS, ADMINISTRATION OF MULTIPLE INTERMITTENT
INJECTIONS OR CONTINUOUS EPIDURAL INFUSION MAY LEAD
TO INCREASED ACCUMULATION OF THESE AGENTS,
CONSEQUENTLY THE POTENTIAL OF DEVELOPING SIDE
EFFECTS AND TOXICITY
• LONGTERM EPIDURAL INFUSION OF LOCAL ANESTHETICS HAS
BEEN SHOWN TO RESULT IN PROGRESIVELY INCREASING
PLASMA CONCENTRATIONS
 PROBLEMS

• PERFORMING EPIDURAL AND SPINAL ANESTHESIA MAY BE

MORE DIFFICULT IN ELDERLY
• IT IS OFTEN NOT EASY TO POSITION A APPROPRIATELY
BECAUSE OF ANATOMIC DISTORTION, PARTICULARY
CURVATURE OR ROTATION OF THE SPINE
• AGING IS FREQUENTLY ACCOMPANIED BY AN INCREASE IN
THE DEGREE OF LUMBAR LORDOSIS CAUSE BY OSTEOPOROSIS
• CALCIFICATION OF THE INTERSPINOUS AND FLAVUM
LIGAMENTS, TO BECOME GRADUAL STENOSING OF THE
INTERVERTEBRAL FORAMINA, MAKE NEDLE PLACEMENT AND
ADVANCEMENT MORE COMPLICATED
• THE INCIDENCE OF POSTSPINAL HEADACHE IS DECREASED
WITH AGE, BECAUSE LESS CSF LEAKS AWAY FROM THE
SUBARACHNOID SPACE
 HYPOTENSION

• HYPOTENSION IS THE MOST COMMON CARDIOVASCULAR

DISTURBANCE PARTICULARY ASSOCIATED WITH CENTRAL
NEURAL BLOCKADE IN ELDERLY
• IT OCCURS CAUSE BY SYMPATHETIC BLOCK WITH
VASODILATATION AND REDISTRIBUTION OF BLOOD TO LOWER
EXTREMITIES AND SPLACHNIC BAD
• THE INCIDENCE OF HYPOTENSION ABOUT 15 – 33 %
• A GREATER SPREAD OF ANALGESIA IN ELDERLY IS
ACCOMPANIED WITH A HIGHER INCIDENCE OF HYPOTENSION
AND BRADYCARDIA
• THIS PROBLEM IS IMPORTANT IN ELDRLY WITH
CARDIOVASCULAR DISEASE, BECAUSE THE RISK FOR
ISCHEMIA SECONDARY TO HYPOTENSION
• MARKED HYPOTENSION IS ESPECIALLY HARMFUL TO
ELDERLY WITH LIMITED CARDIAC RESERVE
• STRUCTURAL CHANGES IN THE ARTERIOLES AND IN THE
AUTONOMIC NERVOUS SYSTEM MAY CONTRIBUTE TO
HYPOTENSION
• IN ADDITION AGE-RELATED BAROREFLEX DYSFUNCTION MAY
COMPROMISE ARTERIAL PRESSURE HOMEOSTASIS
• HEMODYNAMIC INSTABILITY TO BE EXAGGERATED ON
ELDERLY BECAUSE OF LARGER DECREASES IN SVR
• SYSTOLIC BLOOD PRESSURE DECREASED BY 25 % AS EARLY
AS 6 – 9 MINUTES AFTER THE BLOCK, SO SHOULD BE
MONITORED IMMEDIATELY AFTER SAB
TREATMENT OF HYPOTENSION :

• COMMON STRATEGIES TI PREVENT OR REDUCE

HYPOTENSION INCLUDE IV FLUID BOLUS AND THE USE OF
VASOPRESSORS
• IT IS COMMON PRACTICE TO GIVE IV FLUIDS BEFORE AND
DURING SPINAL ANESTHESIA
• IN ELDERLY PATIENTS, FLUID PRE-LOADING IS NOT ALWAYS
EFFECTIVE
• ADDITIONALLY, A LIMITED PHYSIOLOGIC RESERVE IN ELDERLY
TO MAKE THEM LESS ABLE TO INCREASE CARDIAC OUTPUT IN
RESPONSE TO VOLUME LOADING
• ADMINISTRATION OF A COLLOID PRELOAD ABOUT 7 ML/KG.
HAS BEEN RECOMMENDED TO COMPENSATE FOR ANY
DECREASE CVP
• HOWEVER THAT RAPID VOLUME PRELOADING A POTENTIAL
RISK IN PATIENTS WITH LIMITED CARDIAC RESERVE
• AT THE SAME TIME , AN ALPHA AGONIST SHOULD BE USED TO
REVERSE ANY DECREASE IN VASCULAR RESISTANCE
• THE DEGREE OF HYPOTENSION CORRELATES WITH THE
LEVEL OF SYMPATHETIC BLOCK, WHICH IS GENERALLY TWO
TO FOUR SEGMENTS HIGHER THAN THE LEVEL OF ANALGESIA
• THE RATIONALE FOR COMBINING LOCAL ANESTHETICS WITH
ADJUVANT DRUGS IS TO USE LOWER DOSES OF EACH AGENT
AND TO PRESERVE ANALGESIA WITH FEWER SIDE EFFECTS
• A “ MINIDOSE “ OF 4 MG OF BUPIVACAINE IN COMBINATION
WITH 20 µG OF FENTANYL PROVIDE SPINAL ANESTHESIA FOR
SURGICAL REPAIR OF HIP FRACTURE IN THE ELDERLY
• HOWEVER, UNILATERAL SEGMENTAL SPINAL ANESTHESIA
MAY RESULT IN MORE RESTRICTED ANESTHETIC SPREAD
WITH LESS HEMODYNAMIC VARIABILITY
• CONTINUOUS SPINAL ANESTHESIA ( CSA ) IS A TECHNIQUE
THAT ALLOWS TO TITRATE LOCAL ANESTHETIC SOLUTIONS
AND THUS REDUCE THE DOSAGE OF LOCAL ANESTHETICS,
PROVIDING A MORE ADEQUATE ANALGESIA WITH A LOWER
LEVEL OF SYMPATHETIC BLOCKADE AND MINIMIZING
HYPOTENSION AND BRADYCARDIA
• ALSO, COMBINED SPINAL EPIDURAL ( CSE ) TECHNIQUE
ENABLES SMALLER INTRATHECAL DOSES TO BE USED WITH
THE OPTION OF TOPPING UP DOSE THROUGH THE EPIDURAL
CATETHER IF THE BLOCK IS INADEQUATE
• WHEN HEMODYNAMIS STABLITY IS CRITICAL, CSE OR CSA
MAY THE TECHNIQUES OF THE CHOICE FOR LOWER LIMB
SURGERY IN THE ELDERLY PATIENTS
 HYPOTHERMIA

• AS WITH GENERAL ANESTHESIA, ADVANCED AGE IS

ASSOCIATED WITH HYPOTHERMIA DURING EPIDURAL AND
SPINAL ANESTHESIA
• THIS SHOULD BE ATTRIBUTED TO A VARIETY OF FACTOR
SUCH AS A PHYSIOLOGIC DECREASE IN BASAL METABOLISM,
CHANGE SIN THE THERMOREGULATORY CENTER AND
DIMINISHED MUSCULAR MASS
• THE SHIVERING THRESHOLD IS DECREASED IN PROPORTION
WITH THE LEVEL OF SPINAL BLOCKADE BECAUSE THE
VASOMOTOR TONE IS INHIBITED BELOW THE LEVEL OF
SPINAL BLOCK
• SHIVERING AND INCREASE IN OXYGEN DEMAND FURTHER
COMPROMISE PATIENTS ESPECIALLY WITH CARDIOVASCULAR
DISEASE
 SEDATION

• PROMPT AND COMPLETE POSTOPERATIVE RECOVERY OF

MENTAL FUNCTION IS PARTICULARY IMPORTANT IN ELDERLY
PATIENTS
• ELDERLY PEOPLE ARE EASY CONFUSION AND ARE OFTEN
SENSITIVE TO LOW DOSES OF SEDATIVE DRUGS
• GERIATRIC PATIENTS SHOW AN INCREASED
RESPONSIVENESS FOR BENZODIAZEPINE COMPOUNDS,
THEREFOR SMALLER DOSES AND INCREMENTS MUST BE
USED
• OLDER PATIENTS REQUIRE LOWER DOSES, IN MANY CASES
AS LITTLE AS 30 % OF THE EXPECTED STANDARD DOSE
• ELDERLY PATIENTS MAY REQUIRE MORE PROLONGED
OBSERVASION PERIOD AFTER SEDATION
 POSTOPERATIVE COGNITIVE FUNCTION

• A MOSTLY ELDERLY PATIENTS DEVELOP EARLY

POSTOPERATIVE COGNITIVE DYSFUNCTION, CONFUSION AND
DELIRIUM
• THIS POSTOPERAIVE MENTAL CONDITION MAY PERSIST FOR
SEVERAL DAYS TO SEVERAL WEEKS AND CAN RESULT IN
INCREASED MORBIDITY, DELAYED RECOVERY AND
PPROLONGED HOSPITAL STAY
• IN MOST CASES, RECOVERY OF COGNITIVE FUNCTION IS
PROMPT AND COMPLTE WITHIN 1 WEEK
• THE MANAGEMENT OF POSTOPERATIVE PAIN SEEM TO BE AN
IMPORTANT DETERMINANT OF POSTOPERATIVE CONFUSION
IN ELDERLY PATIENTS
• THE FACTORS THAT EXPLAIN THE DEVELOPMENT OF
POSTOPERATIVE BRAIN DYSFUNCTION ARE : AGE,
HOSPITALIZATION AND EXTENSION OR DURATION OF
SURGERY
BENEFICAL ASPECTS OF REGIONAL ANESTHESIA

• THE USE REGIONAL ANALGESIA TECHNIQUES PRVIDES

PHYSIOLOGIC BENEFITS AND MAY ATTENUATE THE
PATHOPHYSIOLOGY THAT OCCURS AFTER SURGERY
• LOCAL ANESTHETIC AGENTS HAE BE THE CAPABILITY TO
BLOCK AFFERENT AND EFFERENT SIGNAL TO AND FROM THE
SPINAL CORD, THUS SUPPRESSING THE SURGICAL STRESS
RESPONSE
• EPIDURAL OR SPINAL ANALGESIA AND ANESTHESIA
ATTENUATES THE HYPERCOAGULABLE PERIOPERATIVE
STATE BY INCREASING FIBRINOLYSIS AND DECREASING
COAGULABILITY
• REGIONAL ANESTHESIA TECHNIQUES PROVIDE EXCELLENT
PAIN MANAGEMENT AND FACILITATING EARLY
POSTOPERATIVE MOBILIZATION FOR A FASTER
CONVALESCENCE
• WHEN COMPARED WITH GENERAL ANESTHESIA,
INTRAOPERATIVE BLOOD LOSS IS REDUCED BY SPINAL OR
EPIDURAL ANESTHESIA AND ARE NOT ASSOCIATED WITH
CHANGES IN ARTERIAL BLOOD GASES
CARDIOVASCULAR SYSTEM

• THORACIC EPIDURAL ANESTHESIA ( TEA ) AN PRODUCE A

SELECTIVE SEGMENTAL BLOCKADE OF CARDIAC
SYMPATHETIC NERVES ( T1 – T5 ) WITH LOSS OF
CHRONOTROPIC AND INOTROPIC DRIVE TO THE HEART
• TEA RESULTED IN REDISTRIBUTION OF FLOW TO THE
EPICARDIUM AWAY FROM THE ENDOCARDIUM, AFFECTING
BENEFICIALLY COLLATERAL BLOOD FLOW DURING
MYOCARDIAL ISCHEMIA
• HIGH TEA IN HUMAN IMPROVED AN ISCHEMIA-INDUCED LEFT
VENTRICULAR DYSFUNCTION AND PROVIDED RELIEF OF
ISCHEMIC CHEST PAIN
PULMONARY SYSTEM

• THORACIC AND LUMBAR EPIDURAL ANESTHESIA ARE OFTEN

COMBINED WITH GENERAL ANESTHESIA
• EPIDURAL ANESTHESIA HAS LITTLE EFFECT ON RESPIRATION
IN PATIENTS WITH PREEXISTING LUNG DISEASE
• THE MOST PROFOUND EFFECT OF MAJOR ABDOMINAL AND
THORACIC SURGERY ON PULMONARY FUNCTION IS A
REDUCTION IN THE FUNCTIONAL RESIDUAL CAPACITY AS A
RESULT OF DIAPHRAGMATIC DYSFUNCTION
• THIS IS CAUSED BY REFLEX INHIBITION OF THE PHRENIC
NERVE AFTER MAJOR SURGERY , A DECREASED CHEST WALL
COMPLIANCE AND PAIN-LIMITED INSPIRATION
• DIAPHRAGMATIC ACTIVITY INCREASES AFTER TEA,
POSSIBILITY BECAUSE OF THE INTERUPTION OF AN
INHIBITORY REFLEX OF PHRENIC NERVE MOTOR DRIVE,
EITHER RELATED TO DIRECT DEAFFERENTATION OF
VESCERAL SENSORY PATHWAY AND BY INCREASED
ABDOMINAL COMPLIANCE
GASTROINTESTINAL SYSTEM

• A TEA OVER T-12 ASSOCIATED WITH SYMPHATETIC NERVOUS

BLOCKADE WHICH RESULTS IN REDUCED INHIBITORY GI-
TONE, INCREASE INTESTINAL BLOOD FLOW AND ALSO
RESULT IN A CONTRACTED BOWEL BECAUSE OF VAGAL
PREDOMINANCE
• IN ADDITION, TEA IMPROVES MICROVASCULAR PERFUSION OF
THE SMALL INTESTINE
 CONCLUSION

• OLDER PATIENTS EXPERIENCE SLIGHTLY HIGHER LEVELS OF

SENSORY AND MOTOR BLOCKADE AFTER EPIDURAL AND
SPINAL ANESTHESIA AND ARE ALSO GREATER RISK FOR
ARTERIAL HYPOTENSION, BECAUSE OF THE SYMPATICOLYTIC
CONSEQUENSES OF ACUTE PERIPHERAL AUTONOMIC
BLOCKADE
• BOLUS DOSES OF LOCAL ANESTHETIC SHOULD BE REDUCED
IN ELDERLY PATIENTS TO LIMIT THE SIDE EFFECTS
• REGIONAL ANESTHESIA OFFERS SEVERAL BENEFICIAL ASPECTS TO
ELDERLY PATIENTS INCLUDING : REDUCE BLOOD LOSS, BETTER
PERIPHERAL VASCULAR CIRCULATION, SUPPRESSION OF THE SURGICAL
STRESS RESPONSE AND BETTER POSTOPERATIVE PAIN CONTROL
• THE CARDIAC BENEFITS OF REGIONAL ANESTHESIA HAVE BEEN
ESPECIALLY ATTRIBUTED TO TEA, PARTICULARY IN PATIENTS WITH
ISCHEMIC HEART DISEASE AND POSSIBLY POSTOPERATIVE TEA REDUCES
CARDIAC MORBIDITY IN HIGH RISK CARDIAC PATIENTS
• POSTOPERATIVE EPIDURAL ANALGESIA CAN IMPROVE
OUTCOME AFTER SURGERY BY REDUCING PUMONARY
COMPLICATIONS
• PERSISTENT COGNITIVE DYSFUNCTION SEEMS NOT TO BE
RELATED TO THE HYSTORY OF AN OPERATION UNDER
GENERAL OR REGIONAL ANESTHESIA, SUGGESTING THE
EXISTENCE OF OTHER INTERACTING ETIOLOGIC FACTOR
• REGIONAL ANESTHESIA MAY REDUCE MORTALITY ESPECIALLY
IN ELDERLY PATIENTS BY DECREASE IN THROMBOEMBOLISM
• THERE IS EVIDENCE THAT EPIDURAL ANESTHESIA
FACILITATES EARLY RECOVERY IN ABDOMINAL SURGICAL
PATIENTS
SELESAI