Letter to the Editor: Anesthesia Selection and Postoperative Outcomes in the Elderly

I read with great interest the article by Chen et al. regarding the impact of general anesthesia (GA) versus epidural anesthesia (EA) on postoperative outcomes in elderly patients undergoing lower limb orthopedic surgery 1. The authors reported that EA significantly reduces the incidence of postoperative pulmonary infections (PPIs) and ICU admission rates. While these findings provide valuable data for geriatric anesthesia, these results should be evaluated in the context of high-level evidence from recent meta-analyses and modern perioperative strategies. Although Chen et al. found that GA was associated with a 2.2-fold increase in the risk of pulmonary infection 1, large-scale meta-analyses, such as those by the ICAROS group and Zheng et al., found no significant difference in 30-day mortality or major morbidity between neuraxial and general anesthesia 2, 3. This suggests that adverse pulmonary outcomes may be influenced by specific pharmacological protocols rather than the anesthetic technique itself. In modern geriatric practice, adopting opioid-sparing or opioid-free techniques and protective ventilation strategies during GA plays a pivotal role in reducing PPI risks 4. Another critical issue is postoperative delirium (POD). Chen et al. reported no significant difference in mental abnormalities between the two groups 1. However, preventing delirium requires more than just technique selection; it necessitates personalized anesthesia management, including opioid use or sparing, frailty screening, depth of anesthesia monitoring (e.g., processed EEG), and goal-directed fluid therapy 5. Furthermore, the quality of recovery (QoR) must be addressed not only through complication rates but also via the patient's subjective comfort. Taflan et al. demonstrated that regional techniques significantly improved early recovery scores (QoR-15) compared to GA 6. In this regard, the reliance on traditional intramuscular analgesia in the study by Chen et al. 1 underscores the need for multimodal analgesia protocols to minimize systemic opioid consumption and its associated side effects. In addition, not only epidural anesthesia, but also spinal anesthesia, either alone or in combination with nerve blocks, is an anesthetic method for hip fractures 7. Therefore, epidural anesthesia should be compared not only with general anesthesia but also with spinal anesthesia and spinal anesthesia combined with nerve blocks. In conclusion, while regional anesthesia offers pulmonary benefits in high-risk elderly patients, optimizing GA with opioid restriction and delirium prevention strategies can enhance safety for both methods. Anesthetic management in the elderly should be a dynamic process focused on the patient's individual risks and personalized care. The author has nothing to report. The author has nothing to report. The author has nothing to report. The author has nothing to report. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.