This is a bicentric, prospective, non-pharmacological, randomized study designed to compare the efficacy and safety of awake neuraxial anesthesia with sedation versus general anesthesia in frail patients undergoing elective major laparoscopic or robotic abdominopelvic surgery. A total of 100 frail patients aged over 60 years, with ASA physical status \>2 and evidence of frailty and/or cognitive vulnerability, will be randomized to receive either standard general anesthesia with mechanical ventilation or thoracic neuraxial anesthesia combined with non-GABAergic sedation while maintaining spontaneous breathing. The primary objective is to evaluate the feasibility in terms of recruitment of a RCT conducted in a population of frail or cognitively impaired patients undergoing major laparoscopic abdominal surgery, randomized to a neuraxial or general anesthetic approach in which the effects on the onset of postoperative delirium and postoperative cognitive dysfunction (POCD) will be determined. Secondary outcomes include the occurrence of postoperative organ dysfunction (respiratory, cardiovascular, renal, and metabolic), length of hospital stay, time to recovery after surgery, and postoperative mortality. Patients will undergo comprehensive perioperative clinical, laboratory, and ultrasound assessments, including lung and renal ultrasound evaluations. Neurological and functional status will be assessed during hospitalization, at 1 month, and via telephone follow-up at 1 year after surgery. The aim of the study is to evaluate the feasibility and safety of performing two different anesthetic techniques on fragile patients.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
OTHER
Masking
NONE
Enrollment
100
patients undergo surgery with a neuraxial anesthesia based on spinal or epidural anesthesia using local anesthetics combined with sedation.
patients undergo surgery with a general anesthesia using classical GABAergic-drugs.
Sedation based on dexmedetomidine and low dosage of ketamine, avoiding GABAergic-drugs
General anesthesia using classical GABAergic-drugs such as propofol, remifentanil and rocuronium.
Abdomino-pelvic Surgery managed in general anesthesia needs orotracheal intubation and mechanical ventilation
E.O. Ospedali Galliera
Genova, Italy
AO di Circolo di Melegnano
Vizzolo Predabissi, Italy
Number of patients effectively managed with neuraxial approach
Evaluate feasibility in terms of number of patients recruited and number of patients randomized to neuraxial anesthetic approach effectively managed in neuraxial anesthetic approach throughout all the procedure.
Time frame: Periprocedural
Postoperative cognitive disfunction
Postoperative cognitive dysfunction will be assessed using the Montreal Cognitive assessment (MoCA). A MoCA score \> 26 will be considered normal, where as a score \< 26 will indicated cognitive dysfunction. Lower scores correspond to grater severity of detected cognitive impairment.
Time frame: The moment of enrollement and at 30 days follow-up and one year.
Postoperative delirium.
Postoperative delirium will be assessed using 3D CAM, on a rating scale where a value of 0 indicates no delirium and a maximum value of 7 indicates the most severe degree.
Time frame: The moment of enrollement, post operative 0,1,2,3 and day of discharge.
Polmonary complications.
Pulmonary complications will be assessed through a lung ultrasound (lung pocus), the score of which includes a minimum value of 0 representing normality and a maximum value of 36 describing the presence of widespread consolidation in all 12 lung areas explored.
Time frame: The moment of enrollement, postoperative days 1,2,3.
Renal function
Postoperative renal function is assessed using the KDIGO score, where 1 represents mild renal insufficiency and 3 represents severe renal insufficiency.
Time frame: Day of enrollement, postoperative days 1,2,3.
In hospital lenght of stay
Lenght of stay (n° days)
Time frame: day of discharge (up to 1 month)
Complications
Occurence of short-and medium-term postoperative complications (Clavien -Dindo classification from grade 1 to grade 5).
Time frame: up to 30 days and 1 year
Recovery after surgery
Day to recovery of oral intake (n°) Day to first mobilization (n°) These outcomes aim to evaluate the overall impact to ERAS principles.
Time frame: From date of randomization until the date of first documented progression, assessed up to 1 month.
Renal arterial perfusion
Renal Doppler ultrasound is also performed, calculating the renal resistance index, which is normally \<0.7 (range 0-1)
Time frame: Day of enrollment, postoperative days 1,2,3
Renal congestion
Renal Doppler ultrasound is also performed to assess venous congestion index, which is normally 0 (range 0-1).
Time frame: day of enrollment, postoperative days 1,2,3
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