This Article  • References  • Full text PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (137)  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Social Bookmarking   What's this?

A Randomized Trial

Pamela Williams-Russo, MD, MPH; Nigel E. Sharrock, MBChB; Steven Mattis, PhD; Ted P. Szatrowski, MD; Mary E. Charlson, MD

JAMA. 1995;274(1):44-50.

Abstract
Objective.
—To compare the effect of epidural vs general anesthesia on the incidence of long-term cognitive dysfunction after total knee replacement surgery in older adults.

Design.
—Randomized controlled clinical trial.

Setting.
—Orthopedic specialty academic hospital.

Patients.
—A total of 262 patients undergoing elective primary total knee replacement with a median age of 69 years; 70% women.

Intervention.
—Random assignment to either epidural or general anesthesia.

Main Outcome Measures.
—A thorough neuropsychological assessment was performed preoperatively and repeated at 1 week and 6 months postoperatively. Cognitive outcome was assessed by within-patient change on 10 tests of memory, psychomotor, and language skills. Prospective standardized surveillance for cardiovascular complications was performed to allow simultaneous assessment of anesthetic effects on cognitive and cardiovascular outcomes.

Results.
—The two groups were similar at baseline in terms of age, sex, comorbidity, and cognitive function. There were no significant differences between the epidural and general anesthesia groups in within-subject change from baseline on any of the 10 cognitive test results at either 1 week or 6 months. Overall, 5% of patients showed a long-term clinically significant deterioration in cognitive function. There was no difference between the anesthesia groups in the incidence of major cardiovascular complications (3% overall).

Conclusions.
—The type of anesthesia, general or epidural, does not affect the magnitude or pattern of postoperative cognitive dysfunction or the incidence of major cardiovascular complications in older adults undergoing elective total knee replacement. This is the largest trial of the effects of general vs regional anesthesia on cerebral function reported to date, with more than 99% power to detect a clinically significant difference on any of the neuropsychological tests.

(JAMA. 1995;274:44-50)

Author Affiliations
From the Departments of Medicine (Drs Williams-Russo, Szatrowski, and Charlson), Anesthesia (Dr Sharrock), and Psychiatry (Dr Mattis), Hospital for Special Surgery, New York Hospital, Cornell University Medical College, New York, NY.

Footnotes
Presented in part as a Henry Christian Memorial Award presentation to the American Federation for Clinical Research Foundation, Washington, DC, May 1, 1993.

Reprint requests to 515 E 71st St, S-900, Cornell University Medical College, New York, NY 10021 (Dr Williams-Russo).

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Postoperative delirium and cognitive dysfunction
Deiner and Silverstein
Br J Anaesth 2009;103:i41-i46.
ABSTRACT | FULL TEXT  

A Study of Cognitive Dysfunction in Patients Having Carotid Endarterectomy Performed with Regional Anesthesia
Heyer et al.
Anesth. Analg. 2008;107:636-642.
ABSTRACT | FULL TEXT  

Cerebral Fat Microembolism and Cognitive Decline After Hip and Knee Replacement
Koch et al.
Stroke 2007;38:1079-1081.
ABSTRACT | FULL TEXT  

Is depth of anesthesia, as assessed by the bispectral index, related to postoperative cognitive dysfunction and recovery?
Farag et al.
Anesth. Analg. 2006;103:633-640.
ABSTRACT | FULL TEXT  

Neurologic complications in noncardiac surgery.
Murkin
SEMIN CARDIOTHORAC VASC ANESTH 2006;10:125-127.
ABSTRACT  

Nitrous oxide does not change the incidence of postoperative delirium or cognitive decline in elderly surgical patients
Leung et al.
Br J Anaesth 2006;96:754-760.
ABSTRACT | FULL TEXT  

The role of postoperative analgesia in delirium and cognitive decline in elderly patients: a systematic review.
Fong et al.
Anesth. Analg. 2006;102:1255-1266.
ABSTRACT | FULL TEXT  

Postoperative delirium: the importance of pain and pain management.
Vaurio et al.
Anesth. Analg. 2006;102:1267-1273.
ABSTRACT | FULL TEXT  

Are Preoperative Depressive Symptoms Associated With Postoperative Delirium in Geriatric Surgical Patients?
Leung et al.
Journals of Gerontology Series A: Biological Sciences and Medical Sciences 2005;60:1563-1568.
ABSTRACT | FULL TEXT  

Contradicted and Initially Stronger Effects in Highly Cited Clinical Research
Ioannidis
JAMA 2005;294:218-228.
ABSTRACT | FULL TEXT  

Regional Anesthesia in Cardiac Surgery: A Friend or A Foe?
Djaiani et al.
SEMIN CARDIOTHORAC VASC ANESTH 2005;9:87-104.
ABSTRACT  

Long term cognitive dysfunction in older people after non-cardiac surgery
Selwood and Orrell
BMJ 2004;328:120-121.
FULL TEXT  

Postoperative hypoxia is a contributory factor to cognitive impairment after cardiac surgery
Browne et al.
J. Thorac. Cardiovasc. Surg. 2003;126:1061-1064.
ABSTRACT | FULL TEXT  

Priorities in Perioperative Geriatrics
Cook and Rooke
Anesth. Analg. 2003;96:1823-1836.
FULL TEXT  

Prevalence of Fat Embolism Following Bilateral Simultaneous and Unilateral Total Hip Arthroplasty
Patel et al.
JBJS 2003;85:1164-1165.
FULL TEXT  

Care after Coronary-Artery Bypass Surgery
Charlson and Isom
NEJM 2003;348:1456-1463.
FULL TEXT  

Preoperative Factors Associated with Postoperative Change in Confusion Assessment Method Score in Hip Fracture Patients
Zakriya et al.
Anesth. Analg. 2002;94:1628-1632.
ABSTRACT | FULL TEXT  

Protecting the Brain in Coronary Artery Bypass Graft Surgery
Mark and Newman
JAMA 2002;287:1448-1450.
FULL TEXT  

The systemic factor: the comparative roles of cardiopulmonary bypass and off-pump surgery in the genesis of patient injury during and following cardiac surgery
Menasche
Ann. Thorac. Surg. 2001;72:S2260-2265.
ABSTRACT | FULL TEXT  

Report of the Substudy Assessing the Impact of Neurocognitive Function on Quality of Life 5 Years After Cardiac Surgery Editorial Comment
Newman et al.
Stroke 2001;32:2874-2881.
ABSTRACT | FULL TEXT  

Long-term consequences of repeated pentobarbital anaesthesia on choice reaction time performance in ageing rats
Blokland et al.
Br J Anaesth 2001;87:781-783.
ABSTRACT | FULL TEXT  

Minimizing perioperative adverse events in the elderly{dagger}
Jin and Chung
Br J Anaesth 2001;87:608-624.
ABSTRACT | FULL TEXT  

How well is the clinical importance of study results reported? An assessment of randomized controlled trials
Chan et al.
CMAJ 2001;165:1197-1202.
ABSTRACT | FULL TEXT  

Neurocognitive Function after Coronary-Artery Bypass Surgery
Mack et al.
NEJM 2001;345:543-545.
FULL TEXT  

Effect of postoperative analgesia on surgical outcome
Kehlet and Holte
Br J Anaesth 2001;87:62-72.
ABSTRACT | FULL TEXT  

Exposure to anaesthetic agents, cognitive functioning and depressive symptomatology in the elderly
ANCELIN et al.
Br. J. Psychiatry 2001;178:360-366.
ABSTRACT | FULL TEXT  

Coronary-Artery Bypass Surgery and the Brain
Selnes and McKhann
NEJM 2001;344:451-452.
FULL TEXT  

Psychomotor recovery in very old patients after total intravenous or balanced anaesthesia for cataract surgery
Kubitz* et al.
Br J Anaesth 2001;86:203-208.
ABSTRACT | FULL TEXT  

Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials
Rodgers et al.
BMJ 2000;321:1493-1493.
ABSTRACT | FULL TEXT  

Outcomes Research in Regional Anesthesia and Analgesia
Wu and Fleisher
Anesth. Analg. 2000;91:1232-1242.
FULL TEXT  

Is Diabetes Associated With Cognitive Impairment and Cognitive Decline Among Older Women?
Gregg et al.
Arch Intern Med 2000;160:174-180.
ABSTRACT | FULL TEXT  

Cognitive decline after major noncardiac operations: a preliminary prospective study
Grichnik et al.
Ann. Thorac. Surg. 1999;68:1786-1791.
ABSTRACT | FULL TEXT  

IS CARDIOPULMONARY BYPASS STILL THE CAUSE OF COGNITIVE DYSFUNCTION AFTER CARDIAC OPERATIONS?
Taggart et al.
J. Thorac. Cardiovasc. Surg. 1999;118:414-420.
ABSTRACT | FULL TEXT  

Determinants of cognitive change after coronary artery bypass surgery: a multifactorial problem
Selnes et al.
Ann. Thorac. Surg. 1999;67:1669-1676.
ABSTRACT | FULL TEXT  

Neurobehavioral Outcomes of Cardiac Surgery
McKhann et al.
SEMIN CARDIOTHORAC VASC ANESTH 1999;3:25-29.
ABSTRACT  

Preoperative Cardiac Evaluation for Elective Noncardiac Surgery
Potyk and Raudaskoski
Arch Fam Med 1998;7:164-173.
ABSTRACT | FULL TEXT  

Cognitive Effects After Epidural vs General Anesthesia
Witt
JAMA 1995;274:1510-1510.
ABSTRACT  

IMPROVEMENT OF OUTCOMES AFTER CORONARY ARTERY BYPASS: A randomized trial comparing intraoperative high versus low mean arterial pressure
Gold et al.
J. Thorac. Cardiovasc. Surg. 1995;110:1302-1314.
ABSTRACT | FULL TEXT  

EPIDURAL VS. GENERAL ANESTHESIA: A COIN FLIP
JWatch General 1995;1995:1-1.
FULL TEXT