General Anesthesia versus Conscious Sedation in Mechanical Thrombectomy.
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ABSTRACT: Background and purpose
Anesthesia regimen in patients undergoing mechanical thrombectomy (MT) is still an unresolved issue.Methods
We compared the effect of anesthesia regimen using data from the German Stroke Registry-Endovascular Treatment (GSR-ET) between June 2015 and December 2019. Degree of disability was rated by the modified Rankin Scale (mRS), and good outcome was defined as mRS 0-2. Successful reperfusion was assumed when the modified thrombolysis in cerebral infarction scale was 2b-3.Results
Out of 6,635 patients, 67.1% (n=4,453) patients underwent general anesthesia (GA), 24.9% (n=1,650) conscious sedation (CS), and 3.3% (n=219) conversion from CS to GA. Rate of successful reperfusion was similar across all three groups (83.0% vs. 84.2% vs. 82.6%, P=0.149). Compared to the CA-group, the GA-group had a delay from admission to groin (71.0 minutes vs. 61.0 minutes, P<0.001), but a comparable interval from groin to flow restoration (41.0 minutes vs. 39.0 minutes). The CS-group had the lowest rate of periprocedural complications (15.0% vs. 21.0% vs. 28.3%, P<0.001). The CS-group was more likely to have a good outcome at follow-up (42.1% vs. 34.2% vs. 33.5%, P<0.001) and a lower mortality rate (23.4% vs. 34.2% vs. 26.0%, P<0.001). In multivariable analysis, GA was associated with reduced achievement of good functional outcome (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.71 to 0.94; P=0.004) and increased mortality (OR, 1.42; 95% CI, 1.23 to 1.64; P<0.001). Subgroup analysis for anterior circulation strokes (n=5,808) showed comparable results.Conclusions
We provide further evidence that CS during MT has advantages over GA in terms of complications, time intervals, and functional outcome.
SUBMITTER: Feil K
PROVIDER: S-EPMC7900389 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Background Endovascular therapy is the standard of care for severe acute ischemic stroke caused by large-vessel occlusion in the anterior circulation, but there is uncertainty regarding the optimal anesthetic approach during this therapy. Meta-analyses of observational studies suggest that general anesthesia increases morbidity and mortality compared with conscious sedation. We performed a systematic review and meta-analysis of randomized clinical trials to examine the effect of anesthetic strategy during endovascular treatment for acute ischemic stroke. Methods and Results Systematic review and meta-analysis according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines has been registered with the PROSPERO (International Prospective Register of Ongoing Systematic Reviews) ( CRD 42018103684). Medline, EMBASE, and CENTRAL databases were searched through August 1, 2018. Meta-analyses were conducted using a random-effects model to pool odds ratio with corresponding 95% CI . The primary outcome was 90-day functional independence (modified Rankin Scale 0-2). In the results, 3 trials with a total of 368 patients were selected. Among patients with ischemic stroke undergoing endovascular therapy, general anesthesia was significantly associated with higher odds of functional independence (odds ratio 1.87, 95% CI 1.15-3.03, I2=17%) and successful recanalization (odds ratio 1.94, 95% CI 1.13-3.3) compared with conscious sedation. However, general anesthesia was associated with a higher risk of 20% mean arterial pressure decrease (odds ratio 10.76, 95% CI 5.25-22.07). There were no significant differences in death, symptomatic intracranial hemorrhage, anesthesiologic complication, intensive care unit length of stay, pneumonia, and interventional complication. Conclusions Moderate-quality evidence suggests that general anesthesia results in significantly higher rates of functional independence than conscious sedation in patients with ischemic stroke undergoing endovascular therapy. Large randomized clinical trials are required to confirm the benefit.
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Project description:BACKGROUND:Two common methods of treating pediatric dental patients with severe early childhood caries (S-ECC) are general anesthesia (GA) and conscious sedation (CS). We sought to first evaluate the cost-effectiveness of treating S-ECC with GA versus CS and then compare the cost-effectiveness at 2 time points: 2011 and 2015. METHODS:We used a decision tree model to produce 2-y estimates of costs and outcomes from the Medicaid perspective. The model cohort consisted of healthy 3-y-olds with S-ECC in need of a theoretical set of dental treatments to be performed under either a single GA visit or 3 CS visits. Outcomes were measured in caries-free months. Costs were evaluated in 2015 US dollars. Costs, probabilities, and outcomes were estimated from published data, expert opinion, and Medicaid billing at an academic health center. One-way and probabilistic sensitivity analyses were performed. RESULTS:As compared with CS, GA resulted in 4 additional caries-free months per child. The cost of a caries-free month for GA versus CS rose from $596 in 2011 to $881 in 2015. These findings were sensitive to loss to follow-up for subsequent CS visits and total cost of GA. CONCLUSIONS:Comprehensive S-ECC treatment had better outcomes when performed under GA versus CS. However, GA was not cost saving when compared with CS. While the cost of dental treatment increased for both GA and CS from 2011 to 2015, the cost rose faster for GA. These results have important implications due to the increasing cost to Medicaid insurance and the rising number of young children being treated for S-ECC under GA. KNOWLEDGE TRANSFER STATEMENT:Medicaid policy makers can use the results of this study to evaluate the cost-effectiveness of dental treatment for young children with S-ECC at 2 time points: 2011 and 2015. Compared with CS, GA resulted in a longer amount of time during which children were free from dental caries but at a higher cost. The cost difference rose from 2011 to 2015.
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Project description:BackgroundAbsence of interlobar collateral ventilation using the Chartis measurement is the key predictor for successful endobronchial valve treatment in severe emphysema. Chartis was originally validated in spontaneous breathing patients under conscious sedation (CS); however, this can be challenging due to cough, mucus secretion, mucosal swelling, and bronchoconstriction. Performing Chartis under general anesthesia (GA) avoids these problems and may result in an easier procedure with a higher success rate. However, using Chartis under GA with positive pressure ventilation has not been validated.ObjectivesIn this study we investigated the impact of anesthesia technique, CS versus GA, on the feasibility and outcomes of Chartis measurement.MethodsWe retrospectively analyzed all Chartis measurements performed at our hospital from October 2010 until December 2017.ResultsWe analyzed 250 emphysema patients (median forced expiratory volume in 1 s 26%, range 12-52% predicted). In 121 patients (48%) the measurement was performed using CS, in 124 (50%) using GA, and in 5 (2%) both anesthesia techniques were used. In total, 746 Chartis readings were analyzed (432 CS, 277 GA, and 37 combination). Testing under CS took significantly longer than GA (median 19 min [range 5-65] vs. 11 min [3-35], p < 0.001) and required more measurements (3 [1-13] vs. 2 [1-6], p < 0.001). There was no significant difference in target lobe volume reduction after treatment (-1,123 mL [-3,604 to 332] in CS vs. -1,251 mL [-3,333 to -1] in GA, p = 0.35).ConclusionsIn conclusion, Chartis measurement under CS took significantly longer and required more measurements than under GA, without a difference in treatment outcome. We recommend a prospective trial comparing both techniques within the same patients to validate this approach.
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Project description:ObjectivesThe aims of this study were to examine variation in the use of conscious sedation (CS) for transcatheter aortic valve replacement (TAVR) across hospitals and over time and to evaluate outcomes of CS compared with general anesthesia (GA) using instrumental variable analysis, a quasi-experimental method to control for unmeasured confounding.BackgroundDespite increasing use of CS for TAVR, contemporary data on utilization patterns are lacking, and existing studies evaluating the impact of sedation choice on outcomes may suffer from unmeasured confounding.MethodsAmong 120,080 patients in the TVT (Transcatheter Valve Therapy) Registry who underwent transfemoral TAVR between January 2016 and March 2019, the relationship between anesthesia choice and TAVR outcomes was evaluated using hospital proportional use of CS as an instrumental variable.ResultsOver the study period, the proportion of TAVR performed using CS increased from 33% to 64%, and CS was used in a median of 0% and 91% of cases in the lowest and highest quartiles of hospital CS use, respectively. On the basis of instrumental variable analysis, CS was associated with decreases in in-hospital mortality (adjusted risk difference: 0.2%; p = 0.010) and 30-day mortality (adjusted risk difference: 0.5%; p < 0.001), shorter length of hospital stay (adjusted difference: 0.8 days; p < 0.001), and more frequent discharge to home (adjusted risk difference: 2.8%; p < 0.001) compared with GA. The magnitude of benefit for most endpoints was less than in a traditional propensity score-based approach, however.ConclusionsIn contemporary U.S. practice, the use of CS for TAVR continues to increase, although there remains wide variation across hospitals. The use of CS for TAVR is associated with improved outcomes (including reduced mortality) compared with GA, although the magnitude of benefit appears to be less than in previous studies.
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Project description:BackgroundThe impact of anesthesia strategy on the outcomes of acute ischemic stroke (AIS) patients undergoing endovascular treatment is currently controversy. Thus, we performed this meta-analysis to compare the differences of clinical and angiographic outcomes between general anesthesia (GA) and conscious sedation (CS).MethodsA literature search in PubMed, Embase, and Web of Knowledge databases through February 2019 was conducted for related records on GA and CS of AIS undergoing endovascular treatment. The results of the studies were pooled and meta-analyzed with fixed- or random-effect model based on heterogeneity test in total and subgroup analyses.ResultsTwenty-three studies including 6703 patients were analyzed in this meta-analysis. We found that patients in the GA group have lower odds of favorable functional outcome (mRS scores ≤2) compared with the CS group (odds ratio [OR] = 0.62, 95% confidence interval [CI]: 0.49-0.77), and higher risk of mortality (OR = 1.68, 95% CI: 1.49-1.90), pneumonia (OR = 1.78, 95% CI: 1.40-2.26), symptomatic intracranial hemorrhage (OR = 1.64, 95% CI: 1.13-2.37). However, no significant differences were seen between the groups in the rate of recanalization (OR = 1.07, 95% CI: 0.89-1.28), vessel dissection or perforation (OR = 1.00, 95% CI: 0.98-1.03) and asymptomatic intracranial hemorrhage (OR = 1.19, 95% CI: 0.96-1.47). While in the RCT subgroup analysis, we found patients in the GA group does not show lower rate of favorable functional outcome compared with the CS group (OR = 1.84, 95% CI: 1.17-2.89). And there was no significant difference in the rate of mortality between GA and CS groups during RCT subgroup analysis (OR = 0.74, 95% CI: 0.43-1.27).ConclusionsAIS patients performed endovascular treatment under GA compared with CS was associated with worse functional outcome and increased rate of mortality, but differences in worsened outcomes do not exist when one looks into the GA vs. CS RCTs. Moreover, these findings are mainly based on the retrospective studies and additional multi-center randomized controlled trials to definitively address these issues is warranted.
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Project description:BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) is used to diagnose and treat pancreatic and biliary disease. The current standard is to conduct ERCP under conscious sedation (CS). Patient movement and agitation during ERCP under CS can result in procedure failure and complications. Aiming to reduce procedure failure rates and complications, Kelowna General Hospital (KGH) in British Columbia, Canada transitioned to performing ERCP under general anesthesia (GA) as the practice standard.ObjectiveTo determine if conducting ERCP under GA compared to CS decreases procedure complications, particularly post-ERCP pancreatitis (PEP).MethodsThe charts of 2,198 patients who underwent ERCP at KGH between 2015 and 2020 were reviewed. Before September 17, 2017, ERCP was performed under CS (n = 1,316). Afterwards, ERCP was conducted under GA (n = 882). Demographic, clinical, and procedural data were extracted. The data were analyzed using univariate and multivariate statistical analysis.ResultsProcedure failure rates (CS = 9 percent, GA = 3 percent, P < 0.001) decreased in the GA cohort after adjusting for age, sex, and co-morbidities. Thirty-day mortality, intensive care unit (ICU) transfer, returns post-discharge, PEP, and cholangitis rates were similar between cohorts.ConclusionPerforming ERCP under GA compared to CS resulted in an increase in procedural success rates. Other complication rates were similar between groups.
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Project description:Background and purposeRadiologic selection criteria to identify patients likely to benefit from endovascular stroke treatment are still controversial. In this post hoc analysis of the recent randomized Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) trial, we aimed to investigate the impact of sedation mode (conscious sedation versus general anesthesia) on the predictive value of collateral status.Materials and methodsUsing imaging data from SIESTA, we assessed collateral status with the collateral score of Tan et al and graded it from absent to good collaterals (0-3). We examined the association of collateral status with 24-hour improvement of the NIHSS score, infarct volume, and mRS at 3 months according to the sedation regimen.ResultsIn a cohort of 104 patients, the NIHSS score improved significantly in patients with moderate or good collaterals (2-3) compared with patients with no or poor collaterals (0-1) (P = .011; mean, -5.8 ± 7.6 versus -1.1 ± 10.7). Tan 2-3 was also associated with significantly higher ASPECTS before endovascular stroke treatment (median, 9 versus 7; P < .001) and smaller mean infarct size after endovascular stroke treatment (median, 35.0 versus 107.4; P < .001). When we differentiated the population according to collateral status (0.1 versus 2.3), the sedation modes conscious sedation and general anesthesia were not associated with significant differences in the predictive value of collateral status regarding infarction size or functional outcome.ConclusionsThe sedation mode, conscious sedation or general anesthesia, did not influence the predictive value of collaterals in patients with large-vessel occlusion anterior circulation stroke undergoing thrombectomy in the SIESTA trial.
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Project description:Background and purposeA number of studies have suggested that anesthesia type (conscious sedation versus general anesthesia) during intra-arterial treatment for acute ischemic stroke has implications for patient outcomes. We performed a systematic review and meta-analysis of studies comparing the clinical and angiographic outcomes of the 2 anesthesia types.Materials and methodsIn March 2014, we conducted a computerized search of MEDLINE and EMBASE for reports on anesthesia and endovascular treatment of acute ischemic stroke. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome (mRS ≤ 2), asymptomatic and symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, time to groin, and time from symptom onset to recanalization.ResultsNine studies enrolling 1956 patients (814 with general anesthesia and 1142 with conscious sedation) were included. Compared with patients treated by using conscious sedation during stroke intervention, patients undergoing general anesthesia had higher odds of death (OR = 2.59; 95% CI, 1.87-3.58) and respiratory complications (OR = 2.09; 95% CI, 1.36-3.23) and lower odds of good functional outcome (OR = 0.43; 95% CI, 0.35-0.53) and successful angiographic outcome (OR = 0.54; 95% CI, 0.37-0.80). No difference in procedure time (P = .28) was seen between the groups. Preintervention NIHSS scores were available from 6 studies; in those, patients receiving general anesthesia had a higher average NIHSS score.ConclusionsPatients with acute ischemic stroke undergoing intra-arterial therapy may have worse outcomes with general anesthesia compared with conscious sedation. However, the difference in stroke severity at the onset may confound the comparison in the available studies; thus, a randomized trial is necessary to confirm this association.
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Project description:Different anesthetic protocols may influence endobronchial ultrasound-guided needle aspiration (EBUS-TBNA) outcomes, patient comfort, and even safety. In this study, two anesthesia techniques were assessed and compared for EBUS-TBNA. A prospective, multicenter study was carried out. Patients were allocated to Group 1 (general anesthesia with neuromuscular blockade and controlled ventilation) and Group 2 (intravenous sedation). EBUS-TBNA accuracy was the primary outcome. Safety, patient comfort and satisfaction, and operators' difficulties were defined as secondary outcomes. Of the 115 patients enrolled (Group 1 = 59, Group 2 = 56), EBUS-TBNA was performed for hilar or mediastinal lesion diagnosis and lung cancer staging in, respectively, 77 (67%) and 38 (33%) patients. The numbers of lymph nodes stations (1.8 ± 1.0 vs. 1.7 ± 1.0, p = 0.472) and punctures per station (6.9 ± 3.1 vs. 6.0 ± 2.5, p = 0.084) were similar between groups. Adequate samples were obtained from 109 patients (97.3%) with similar diagnostic accuracy. Procedure duration was not significantly different (p = 0.348). Hemodynamic parameters and systolic and diastolic blood pressures were higher in Group 1 at the beginning and at the end of the procedure. Adverse events were equally distributed, and no significant differences were found regarding patient satisfaction and bronchoscopist/anesthesiologist difficulties. The type of anesthesia used did not influence EBUS-TBNA outcomes. EBUS-TBNA performed under sedation or general anesthesia did not affect the diagnostic yield, complication rate, and patients' comfort and satisfaction.
| S-EPMC6262282 | biostudies-literature
Project description:IntroductionIschemic cerebrovascular disease (ICVD) is a serious health problem in which brain tissue suffers from hypoxic damage due to obstruction in cerebral vessels. Mechanical thrombectomy is a commonly used method in the treatment of these patients. However, the effects of local anesthesia (LA) and conscious sedation (CS) during thrombectomy are still unclear. We evaluated whether there was a relationship between the two anesthesia regimens in terms of 90-day modified Rankin Scale (mRS) scores.MethodsIn this study, a retrospective observational study was conducted to evaluate the effects of LA and CS used during mechanical thrombectomy in four comprehensive stroke centers among ICVD patients. Patients were divided into the LA group and the CS group. Statistical analysis was performed before and after 1:1 matching under propensity score matching (PSM) analysis. The primary outcome measure was an mRS score of 0-2 at 90 days. Secondary outcomes were procedure times, recanalization rates, symptomatic and asymptomatic hemorrhage rates, and procedural complications.ResultsA total of 193 patients (118 patients with LA and 75 patients with CS) were included in the final analysis before PSM. After 1:1 PSM, 98 patients-49 patients from each group-were included in the study. There was no difference in clinical outcomes between the LA- and CS-applied groups (p = 0.543). When blood pressure (BP) values at follow-up after endovascular treatment (EVT) were compared, the lowest systolic and lowest diastolic BP were found to be lower in the CS group (p = 0.001 and p = 0.009). There was no significant difference between the two groups in terms of recanalization rates, symptomatic intracranial hemorrhage (sICH) rates, 90-day mRS, and procedure-related complication rates (p = 0.617, p = 0.274, p = 0.543, and p = 1.000).ConclusionThis study did not reveal the superiority of CS applied during EVT on 90-day mRS, sICH, recanalization rates, or procedural complications. However, the risk of developing hypotension during the CS application was found to be high.
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