Incidence of postoperative cognitive dysfunction after general or spinal anaesthesia for extracorporeal shock wave lithotripsyB.S.Silbert 1,2*,L.A.Evered 1,2and D.A.Scott 1,21Centre for Anaesthesia and Cognitive Function,Department of Anaesthesia,St Vincent’s Hospital,Melbourne,PO Box 2900,Fitzroy,VIC 3065,Australia2Anaesthesia,Perioperative and Pain Medicine Unit,Melbourne Medical School,University of Melbourne,Australia*Corresponding author.E-mail:brendan.silbert@svhm.org.auEditor’s key points †Aspects of general anaesthesia might contribute to postoperative cognitive dysfunction (POCD).†This study found that avoiding general anaesthesia did not reduce the risk of POCD.†Other factors,perhaps the inflammatory response to surgery,and hospitalization,might contribute to POCD.Background.Since general anaesthesia invariably accompanies surgery,the contribution ofeach to the development of postoperative cognitive dysfunction (POCD)has been difficult toidentify.Methods.A prospective randomized controlled trial was undertaken in elderly patients undergoing extracorporeal shock wave lithotripsy (ESWL).Between 2005and 2011,2706individuals were screened to recruit 100eligible patients.Patients were randomly assigned to receive general or spinal anaesthesia alone.A battery of eight neuropsychological tests was administered before operation and at 7days and 3months after operation.The reliable change index was used to calculate the incidence of POCD.Intention-to-treat analysis was used to compare rates of POCD.Results.Futility analysis led to stopping of the trial after recruitment of 100patients.Fifty patients were randomly assigned to general anaesthesia,and 48patients to spinal anaesthesia without sedation or postoperative opioids.At 3months,POCD was detected in 6.8%[95%confidence interval (CI):1.4–18.7%]of patients in the general anaesthesia group and 19.6%(95%CI:9.4–33.9%)in the spinal group (P ¼0.07).At 7days after operation,the incidence of POCD was 4.1%(95%CI:0.5–14%)in the general anaesthesiagroup and 11.9%(95%CI:4.0–26.6%)in the spinal group (P ¼0.16).Conclusions.We found no significant difference in the rates of POCD when comparing generalanaesthesia with spinal anaesthesia,suggesting that the surgical or procedural process itselfmay contribute to the development of POCD.Clinical trial registration.Australian Clinical Trials Registry number ACTRN12605000150640.Keywords:cognition;general anaesthesia;postoperative cognitive dysfunction;spinalanaesthesiaAccepted for publication:2March 2014Postoperative cognitive dysfunction (POCD)is a decrease in cognition measured by neuropsychological tests after anaes-thesia and surgery.It is difficult to separate the effects of surgery from anaesthesia because the administration of general anaesthesia without surgery poses ethical problems,and surgery without anaesthesia is unacceptable.In the clinical setting,the closest approach to separating general anaesthesia from the surgical process is to administer regional anaesthesia.However,reviews on the incidence of POCD after neuraxial block compared with general anaesthesia have failed to show a decrease in the incidence of POCD.12There are a number of issues with study design which have confounded these studies.First,sedatives may be associated with POCD 3and yet no trial has specifically excluded sedation.Secondly,postoperative analgesics may confound the incidence of POCD,yet previous studies have not documented the use of postoperative opioids.Thirdly,many of the randomized trials were not blinded.Finally,selection and analysis of neuropsycho-logical tests may lead to discrepancies in the calculation of POCD.4To overcome these issues,we undertook a trial comparing the incidence of POCD in older patients who underwent extra-corporeal shock wave lithotripsy (ESWL)under general anaes-thesia with patients receiving spinal anaesthesia which specifically excluded sedation and postoperative opioid anal-gesia.ESWL uses high-energy acoustic shock waves generated outside the body to break stones in the kidney.5The procedure is painful and requires either intense analgesia or anaesthesia and represents a surgical stress without a surgical incision.At our institution,we routinely administer either general or British Journal of Anaesthesia Page 1of 8doi:10.1093/bja/aeu163&The Author 2014.Published by Oxford University Press on behalf of the British Journal of Anaesthesia.All rights reserved.For Permissions,please email:journals.permissions@oup.comBJA Advance Access published June 27, 2014 at Yale University on June 30, 2014http://bja.oxfordjournals.org/Downloaded from

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