Leo I. Stemp

Anesthetic depth and long-term mortality.

As I read Cohen’s editorial about anesthetic depth and long term mortality (1), I was waiting for him to ask the obvious question: What about regional anesthesia? Although studies have arguably failed to show a lack of short-term mortality benefit associated with regional anesthesia compared with general anesthesia, what about long term outcome 1 or 2 yr after surgery? Further, if anesthetic depth has a negative effect on long term patient outcome, then it is logical to conclude that any anesthetic “depth” is deleterious to health—it’s only a matter of statistical degree. And if that is the case, then the obligatory conclusion is that general anesthesia is deleterious to health and should be avoided if a suitable alternative exists. Of course, everything is relative, and regional anesthesia certainly has its own morbidity and mortality rates (2). As an anesthesiologist who is also an internist and critical care physician, the priority in my own practice has long been not to avoid intraoperative anesthetic complications but to maximize patients’ short-term and long-term functional status (and thereby quality of life). This is particularly important in older patients, especially the frail and those with organic brain disease and deteriorating mentation. As a result, regional anesthesia—or more precisely, avoiding general anesthesia when possible—is the obvious choice to me, for almost anyone. Even so, a secondary issue is that there are commonly conflicts and technical problems that require “pushing the envelope” when it comes to using regional anesthesia. Two examples are, first, the elderly frail patient who presents for colectomy: such an operation is easily accomplished with regional anesthesia but often requires some sedation that may impair the airway and/or expose the patient to the risk of aspiration. Too, such an anesthetic is often quite a bit more laborious for the anesthetist than a simple general anesthetic. The second example is typified by a patient who presented to me the other day for an urgent below-knee amputation: a frail elderly man with mild dementia and significant lung disease that left him with labored breathing. It was clear to me that general anesthesia would very likely be a life-changing event for him, both from a mental status and a respiratory standpoint. But he was also anticoagulated with a platelet inhibitor, so a spinal was seemingly “contraindicated.” What to do? A narrow gauge spinal, after a long discussion of risk versus benefits with the family, did fine. So ultimately, how far is it acceptable to “push the envelope” to avoid general anesthesia? Clearly, we need more information and more data to fully and responsibly analyze the risk-benefit equation and be able to elucidate it to our patients and their families. I would like to see the authors of some of the well known comparison studies (3–5) go back and follow up their patients to see if we could gain further information about long-term functional and mortality outcomes, comparing those who had regional anesthesia (alone) versus general anesthesia.

Effect of Modafinil on Cognitive Function in Intensive Care Unit Patients: A Retrospective Cohort Study

Modafinil therapy, a nonamphetamine cognition‐enhancing agent, holds the potential to improve recovery from cognitive impairment after intensive care unit (ICU) admission. To date, however, there is a paucity of data on modafinil use in the ICU setting. The purpose of this study was to explore the role of modafinil for improvement in cognition in ICU patients. This retrospective cohort study evaluated a total of 60 ICU patients with any ventilatory support who started on modafinil during their ICU stay from January 1, 2010, to March 19, 2016. The requirements of opioids and sedatives, as well as the lowest and average scores of the Glasgow Coma Scale (GCS) and Riker Sedation‐Agitation Scale (SAS), were recorded during 48 hours before and after the start of modafinil therapy in 6‐hour periods. The average daily modafinil dose of 170 mg was given for a median duration of 9 days. Modafinil administration was associated with a small, nonsignificant increase in GCS by 0.34 points after controlling for age, baseline severity of illness, and changes in sedation and analgesia over time (95%CI, −0.34 to 0.73 points; P = .0743). No major modafinil‐associated adverse effects were observed. Modafinil administration did not significantly improve cognitive function in ICU patients within 48 hours of initiation. However, because of lack of robust evidence, the impact of modafinil on overall patient outcomes in the ICU remains unclear and needs further investigation.