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Hanson TM, Magder LS, Pellegrini VD. Substantial Improvement in Self-Reported Mental Health Following Total Hip Arthroplasty Occurs Independent of Anesthetic Technique. J Arthroplasty 2024; 39:1220-1225.e1. [PMID: 37977307 DOI: 10.1016/j.arth.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 11/01/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The influence of anesthetic type on mental health after total hip arthroplasty (THA) is poorly understood. Adverse effects of general anesthesia (GA) on cognition following major non-cardiac surgery are well known, but mental health following THA is less well-studied. We hypothesized that neuraxial anesthesia (NA) would provide favorable mental health profiles compared with GA after THA. METHODS Prospectively collected Patient-Reported Outcomes Measurement Information System-10 (PROMIS) Global Mental Health (GMH) scores at preoperative baseline, and 1, 3, and 6 months after THA were accessed on 4,353 patients in the Pulmonary Embolism Prevention After HiP and KneE Replacement (PEPPER) Trial (ClinicalTrials.gov: NCT02810704). Anesthesia was categorized as: general (GA), neuraxial (NA), and neuraxial with peripheral block (NAP). The GMH was assessed longitudinally and compared between groups. RESULTS Postoperative GMH improved (P < .05) over preoperative in every anesthetic group. Groups receiving NA had higher baseline GMH scores. Improvement in GMH was diminished after GA alone and plateaued after 1 month. Adding NA or peripheral nerve block to GA conferred additional benefit to GMH improvement. CONCLUSIONS Patient-perceived mental health improves significantly after THA regardless of anesthetic type. Patients who have higher baseline GMH scores more commonly received NA, likely due to nonsurgical care determinants; these differences in mental wellness persisted at follow-up. Adjunctive NA or peripheral nerve block favored GMH improvement, whereas solitary GA diminished GMH improvement, which plateaued after 1 month. Substantial mental health benefits of THA may overshadow subtle differences in GMH attributable to anesthetic type.
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Affiliation(s)
- Thomas M Hanson
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vincent D Pellegrini
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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Liu S, Chen J, Shi H, Li J, Zeng G, Liu W, Hu W, Li S, Gao W, Song W, Liang A, Chen Y. Comparing perioperative outcomes between regional anesthesia and general anesthesia in patients undergoing hip fracture surgery: a systematic review and meta-analysis. Can J Anaesth 2024:10.1007/s12630-024-02696-3. [PMID: 38418761 DOI: 10.1007/s12630-024-02696-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 03/02/2024] Open
Abstract
PURPOSE Nearly all patients with hip fractures undergo surgical treatment. The use of different anesthesia techniques during surgery may influence the clinical outcomes. The optimal anesthetic technique for patients undergoing hip fracture surgery is still controversial. We performed this updated systematic review and meta-analysis to compare clinical outcomes of patients undergoing hip fracture surgery with different anesthesia techniques. SOURCE Articles published from 2000 to May 2023 were included from MEDLINE, Embase, Web of Science, and the Cochrane Library. We included randomized controlled trials and observational studies comparing general anesthesia (GA) with regional anesthesia (RA) for the outcomes of 30-day mortality, 90-day mortality, in-hospital mortality, perioperative complications, length of hospital stay, and length of surgery in patients undergoing hip fracture surgery. Subgroup analyses were performed for the outcomes based on study design (randomized controlled trials or observational studies). We used a random-effects model for all analyses. PRINCIPAL FINDINGS In this meta-analysis, we included 12 randomized controlled trials. There was no difference in postoperative 30-day mortality between the two groups (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.44 to 1.74; I2 = 0%). The incidence of intraoperative hypotension was lower in patients who received RA vs GA (OR, 0.52; 95% CI, 0.38 to 0.72; I2 = 0%). No significant differences were observed in 90-day mortality, in-hospital mortality, postoperative delirium, pneumonia, myocardial infarction, venous thromboembolism, length of surgery, and length of hospital stay. CONCLUSION In this updated systematic review and meta-analysis, RA did not reduce postoperative 30-day mortality in hip fracture surgery patients compared to GA. Fewer patients receiving RA had intraoperative hypotension than those receiving GA did. Apart from intraoperative hypotension, the data showed no differences in complications between the two anesthetic techniques. STUDY REGISTRATION PROSPERO (CRD42023411854); registered 7 April 2023.
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Affiliation(s)
- Song Liu
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jianan Chen
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huihong Shi
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jianhong Li
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Gang Zeng
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenzhou Liu
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenjun Hu
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shaoguang Li
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenjie Gao
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Weidong Song
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Anjing Liang
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanbo Chen
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Yingfeng Road, 33th Haizhu District, Guangzhou, 510000, China.
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Wang MT, Chang CC, Liu CC, Fan Chiang YH, Shih YRV, Lee YW. General versus Neuraxial Anesthesia on Clinical Outcomes in Patients Receiving Hip Fracture Surgery: An Analysis of the ACS NSQIP Database. J Clin Med 2023; 12:jcm12113827. [PMID: 37298022 DOI: 10.3390/jcm12113827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/26/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
Whether the use of neuraxial anesthesia or general anesthesia leads to more favorable postoperative outcomes in patients receiving hip fracture surgery remains unclear. We used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Data Files between 2016 and 2020 to investigate the association of neuraxial anesthesia and general anesthesia with morbidity and mortality after hip fracture surgery. Inverse probability of treatment weighting (IPTW) was used to balance the baseline characteristics, and multivariable Cox regression models were used to estimate the hazard ratio (HR) with a 95% confidence interval (CI) for postoperative morbidity and mortality among the different anesthesia groups. A total of 45,874 patients were included in this study. Postoperative adverse events occurred in 1087 of 9864 patients (11.0%) who received neuraxial anesthesia and in 4635 of 36,010 patients (12.9%) who received general anesthesia. After adjustment for IPTW, the multivariable Cox regressions revealed that general anesthesia was associated with increased risks of postoperative morbidity (adjusted HR, 1.19; 95% CI, 1.14-1.24) and mortality (adjusted HR, 1.09; 95% CI, 1.03-1.16). The results of the present study suggest that, compared with general anesthesia, neuraxial anesthesia is associated with lower risks of postoperative adverse events in patients undergoing hip fracture surgery.
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Affiliation(s)
- Ming-Tse Wang
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Department of Anesthesiology, Taitung MacKay Memorial Hospital, Taitung 95054, Taiwan
| | - Chuen-Chau Chang
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Chih-Chung Liu
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Yu-Hsuan Fan Chiang
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei 11031, Taiwan
| | - Yu-Ru Vernon Shih
- Department of Orthopaedic Surgery, Duke University, Durham, NC 27708, USA
| | - Yuan-Wen Lee
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
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Nawi SNM, Wong B, Edwards S, Loh X, Maddison J. A retrospective observational study on the types of anaesthesia in hip fracture surgery. J Perioper Pract 2023; 33:15-23. [PMID: 34197241 DOI: 10.1177/17504589211006020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND There is no specific recommendation regarding the type of anaesthesia in hip fracture surgery. OBJECTIVES This study sought to examine the current local anaesthetic practice (general anaesthesia versus regional anaesthesia (RA)) in hip fracture surgery and to analyse their associations with perioperative outcomes. METHODOLOGY A retrospective observational study of hip fracture patients from April to December 2017 was undertaken. Patient characteristics and perioperative outcomes were analysed against the types of anaesthesia using multiple logistic regression. RESULTS One hundred and twelve out of 154 patients (72.7%) had a general anaesthesia. Patients from residential care facilities were more likely to receive general anaesthesia (OR = 2.9, 95% CI: 1.1, 7.4; P = 0.03). There was no significant association between type of anaesthesia and specific postoperative outcomes; however, patients with postoperative delirium and hypotension were more likely to have received general anaesthesia [OR = 1.7, 95% CI: 0.68, 4.38; P = 0.25] and [OR = 1.6, 95% CI: 0.67, 4.04; P = 0.27] respectively). Subgroup analysis showed increased length of stay with patients who underwent general anaesthesia (OR = 1.26, 95% CI:1.04, 1.54; P = 0.02). CONCLUSION Regional anaesthesia may be considered in patients without contraindications in view of increased risk of postoperative delirium and hypotension, and longer length of stay with general anaesthesia. A larger prospective study is needed to confirm these findings.
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Affiliation(s)
- Siti N Mohd Nawi
- Geriatric Medicine Department, Northern Adelaide Local Health Network, Modbury Hospital, Modbury, Australia.,Hospital Universiti Sains Malaysia and School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Bianca Wong
- Geriatric Medicine Department, Northern Adelaide Local Health Network, Modbury Hospital, Modbury, Australia.,Orthogeriatric Service, Northern Adelaide Local Health Network, Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - Suzanne Edwards
- Data, Design and Statistics Service, Adelaide Health Technology Assessment (AHTA), School of Public Health, The University of Adelaide, Adelaide, Australia
| | - Xiang Loh
- Geriatric Medicine Department, Northern Adelaide Local Health Network, Modbury Hospital, Modbury, Australia.,Orthogeriatric Service, Northern Adelaide Local Health Network, Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - John Maddison
- Geriatric Medicine Department, Northern Adelaide Local Health Network, Modbury Hospital, Modbury, Australia.,Orthogeriatric Service, Northern Adelaide Local Health Network, Lyell McEwin Hospital, Elizabeth Vale, Australia
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Zhang G, Chen H, Zha J, Zhang J, Di J, Wang X, Hu X, Xu X, Guo J. Effect of General vs. Regional Anesthesia on Mortality, Complications, and Prognosis in Older Adults Undergoing Hip Fracture Surgery: A Propensity-Score-Matched Cohort Analysis. J Clin Med 2022; 12:jcm12010080. [PMID: 36614881 PMCID: PMC9821019 DOI: 10.3390/jcm12010080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 10/23/2022] [Accepted: 11/14/2022] [Indexed: 12/24/2022] Open
Abstract
The choice of the type of anesthesia (TOA) used in hip fracture surgery in older adults is still controversial. The main question is not whether regional anesthesia (RA) or general anesthesia (GA) is superior, but in which patients the type of anesthesia may affect the outcome after surgery. In this retrospective analysis of surgically treated intertrochanteric fracture patients, we used propensity score matching (PSM) to investigate whether clinically relevant differences in outcomes were observed in mortality, complications, and functional outcomes between RA and GA. After screening 2934 consecutive patients, 2170 were ultimately included, including 841 in the GA group and 1329 in the RA group. After PSM, 808 remained in each group. Patients receiving GA were more prone to have a shorter duration for their operation and higher total hospital costs than patients with RA (p = 0.034 and 0.004, respectively). We also observed that the GA group has a higher rate of pulmonary complications, while the RA group has a higher rate of cardiac complications (p = 0.017 and 0.011, respectively). No significant difference was observed in mortality, functional outcomes, and other complications (all p > 0.05). The clinical innovation of this study was the potential value of GA for patients with cardiac diseases and of RA for patients with pulmonary diseases.
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Affiliation(s)
- Guolei Zhang
- Department of Orthopaedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, China
- Orthopaedic Institute of Hebei Province, Shijiazhuang 050051, China
| | - Huihui Chen
- Department of Nephrology, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, China
| | - Junpu Zha
- Department of Orthopaedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, China
- Orthopaedic Institute of Hebei Province, Shijiazhuang 050051, China
| | - Jingtao Zhang
- Department of Orthopaedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, China
- Orthopaedic Institute of Hebei Province, Shijiazhuang 050051, China
| | - Jun Di
- Department of Orthopaedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, China
- Orthopaedic Institute of Hebei Province, Shijiazhuang 050051, China
| | - Xiaoqing Wang
- Department of Orthopaedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, China
| | - Xin Hu
- Department of Orthopaedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, China
- Orthopaedic Institute of Hebei Province, Shijiazhuang 050051, China
| | - Xin Xu
- Department of Biochemistry and Molecular Biology, College of Basic Medicine, Hebei Medical University, Shijiazhuang 050011, China
- Key Laboratory of Neural and Vascular Biology of Ministry of Education, Shijiazhuang 050011, China
- Key Laboratory of Medical Biotechnology of Hebei Province, Hebei Medical University, Shijiazhuang 050011, China
- Correspondence: (X.X.); (J.G.)
| | - Junfei Guo
- Department of Orthopaedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang 050051, China
- Orthopaedic Institute of Hebei Province, Shijiazhuang 050051, China
- Correspondence: (X.X.); (J.G.)
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6
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Leibold C, Falbo R, Gupta A, Miller R, Pederson JM, Malpe M. A systematic review and meta-analysis of anesthesia type on hip fracture post-surgery outcomes. OTA Int 2022; 5:e204. [PMID: 36425088 PMCID: PMC9580260 DOI: 10.1097/oi9.0000000000000204] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 03/15/2022] [Indexed: 11/30/2022]
Abstract
Objective To compare technical, clinical, and safety outcomes among hip fracture patients treated with procedures supplemented by general anesthesia (GA) or spinal/regional anesthesia (S/R). Data sources We searched for original studies on PubMed, Ovid MEDLINE, Ovid Embase, and Cochrane databases. Study selection Studies that reported clinical outcomes in patients that underwent hip fracture surgery, had available data on type of anesthesia administered, and clinical follow-up data were selected for data extraction. Data extraction The primary outcomes of interest were odds of mortality, including in-hospital, 30-day, 90-day, and 1-year mortality. Various adverse events (AEs) were also compared. Data synthesis Twenty-eight studies met our selection criteria, including 190,394 patients. A total of 107,314 (56.4%) patients were treated with procedures involving GA while 83,080 (43.6%) were treated with procedures involving S/R. There was no difference in 30-day or >1-year mortality rates between the GA and SR groups; however, compared to S/R group, the GA group had a significantly higher odds of in-hospital (P = .004) and 90-day mortality (P = .004). There was no difference in odds of adverse events between the GA and the S/R group. Conclusions Patients administered S/R for hip fracture procedures demonstrate lower risk of in-hospital mortality and 90-day mortality compared to patients administered GA. Level of evidence Therapeutic level III.
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Affiliation(s)
| | - Ryan Falbo
- Department of Orthopedic Surgery, Mercy Health St. Vincent Medical Center
| | | | - Richard Miller
- Department of Orthopedic Surgery, Mercy Health St. Vincent Medical Center
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Vora M, Samineni AV, Sing D, Salavati S, Tornetta P. Spinal Anesthesia Associated With Increased Length of Stay Compared to General Anesthesia for Ankle Open Reduction Internal Fixation: A Propensity-Matched Analysis. J Foot Ankle Surg 2021; 60:350-353. [PMID: 33461921 DOI: 10.1053/j.jfas.2020.08.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/14/2020] [Accepted: 08/17/2020] [Indexed: 02/03/2023]
Abstract
General and spinal anesthesia are both utilized for patients undergoing open reduction internal fixation of the ankle, but there are little data comparing early complication rates. The purpose of this study was to compare duration of surgery, length of stay, and rates of postoperative adverse events within 30 days in patients undergoing open reduction internal fixation of ankle fracture using spinal versus general anesthesia. Adult patients who underwent open reduction internal fixation of a closed ankle fracture from 2012 to 2016 were retrospectively identified from American College of Surgeons National Surgical Quality Improvement Program. Duration of surgery, length of stay, 30-day adverse events, and unplanned readmissions were compared between patients who received general anesthesia and spinal anesthesia. Propensity adjustment with respect to known risk factors for complications and adjunctive regional block was used to match patients. Of the 10,795 patients included after applying the inclusion and exclusion criteria, 9862 (91.36%) received general anesthesia and 933 (8.64%) received spinal anesthesia. Using propensity-scored matching, 841 patients in the spinal cohort were matched to 3364 patients in the general cohort. Spinal anesthesia was associated with increased length of stay (+0.5 days, 95% confidence interval 0.23-0.77, p < .001). There were no differences in the rates of major/minor complications, mortality, transfusions, unplanned readmissions, or duration of surgery. General anesthesia is predominantly used for fixation of ankle fractures. While spinal anesthesia is associated with lower complication rates in hip and knee surgery, we found that it is associated with increased length of stay in patients undergoing open reduction internal fixation of the ankle within 30 days of surgery.
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Affiliation(s)
- Molly Vora
- Medical Student, Boston University School of Medicine, Boston, MA
| | | | - David Sing
- Resident, Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA.
| | - Seroos Salavati
- Anesthesiologist, Director of Regional Anesthesiology, Assistant Professor, Boston Medical Center, Boston, MA
| | - Paul Tornetta
- Orthopaedic Surgeon, Chief, Chair, and Professor of Orthopaedic Surgery, Boston Medical Center, Boston, MA
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8
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Association of Neuraxial Anesthesia With Postoperative Venous Thromboembolism After Noncardiac Surgery: A Propensity-Matched Analysis of ACS-NSQIP Database. Anesth Analg 2019; 128:494-501. [PMID: 29697506 DOI: 10.1213/ane.0000000000003394] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Neuraxial anesthesia improves components of the Virchow's triad (hypercoagulability, venous stasis, and endothelial injury) which are key pathogenic contributors to venous thrombosis in surgical patients. However, whether neuraxial anesthesia reduces the incidence of venous thromboembolism (VTE) remain unclear. We therefore tested the primary hypothesis that neuraxial anesthesia reduces the incidence of 30-day VTE in adults recovering from orthopedic surgery. Secondarily, we tested the hypotheses that neuraxial anesthesia reduces 30-day readmission, 30-day mortality, and the duration of postoperative hospitalization. METHODS Inpatient orthopedic surgeries from American College of Surgeons National Surgical Quality Improvement Program database (2011-2015) in adults lasting more than 1 hour with either neuraxial or general anesthesia were included. Groups were matched 1:1 by propensity score matching for appropriate confounders. Logistic regression model was used to assess the effect of neuraxial anesthesia on 30-day VTE, 30-day mortality, and readmission, while Cox proportional hazard regression model was used to assess its effect on length of stay. RESULTS Neuraxial anesthesia decreased odds of 30-day VTE (odds ratio 0.85, 95% confidence interval, 0.78-0.95; P = .002) corresponding to number-needed-to-treat of 500. Although there was no difference in 30-day mortality, neuraxial anesthesia reduced 30-day readmission (odds ratio 0.90, 98.3% confidence interval, 0.85-0.95; P < .001) corresponding to number-needed-to-treat of 250 and had a shortened hospitalization (2.87 vs 3.11; P < .001). CONCLUSIONS Neuraxial anesthesia appears to provide only weak VTE prophylaxis, but can be offered as an adjuvant to current thromboprophylaxis in high-risk patients.
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Chen DX, Yang L, Ding L, Li SY, Qi YN, Li Q. Perioperative outcomes in geriatric patients undergoing hip fracture surgery with different anesthesia techniques: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e18220. [PMID: 31804347 PMCID: PMC6919429 DOI: 10.1097/md.0000000000018220] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Previous meta-analyses assessing anesthetic techniques in adult patients undergoing hip fractures surgery are available. However, whether the anesthetic technique is associated with risk of mortality and complications in geriatric patients with hip fractures remains unclear. This study was conducted to assess postoperative outcomes of anesthesia technique in geriatric patients undergoing hip fracture surgery. METHODS Cochrane Library, PubMed, EMBASE, MEDLINE, CNKI, and CBM were searched from inception up to May 25, 2018. Observational studies and randomized controlled trials (RCTs) that assessed the perioperative outcomes of technique of anesthesia (general or regional [epidural/spinal/neuraxial]) in geriatric patients (≥60 years old) undergoing hip fracture surgery were included. Two investigators independently screened studies for inclusion and performed data extraction. Heterogeneity was assessed by the I and Chi-square tests. The odds ratio (OR) of the dichotomous data, mean difference (MD) of continuous data, and 95% confidence intervals (CI) were calculated to assess the pooled data. RESULTS Eleven retrospective and 2 RCTs were included. There was no difference in 30-day mortality (OR = 0.96; 95% CI 0.86-1.08; P = .51) between the general and regional anesthesia groups. In-hospital mortality (OR = 1.26; 95% CI 1.17-1.36; P < .001), acute respiratory failure (OR = 2.66; 95% CI 2.34-3.02; P < .001), length of hospital stay (MD = 0.33; 95% CI 0.24-0.42; P < .001), and readmission (OR = 1.09; 95% CI 1.01-1.18; P = .03) were significantly reduced in the regional anesthesia group. Pneumonia (OR = 0.99; 95% CI 0.91-1.07; P = .79), heart failure (OR = 0.97; 95% CI 0.86-1.09; P = .62), acute myocardial infraction (OR = 1.07; 95% CI 0.99-1.16; P = .10), acute renal failure (OR = 1.32; 95% CI 0.97-1.79; P = .07), cerebrovascular accident (OR = 1.08; 95% CI 0.82-1.42; P = .58), postoperative delirium (OR = 1.51; 95% CI 0.16-13.97; P = .72), and deep vein thrombosis/pulmonary embolism (OR = 1.42; 95% CI 0.84-2.38; P = .19) were similar between the two anesthetic techniques. CONCLUSION General anesthesia is associated with increased risk of in-hospital mortality, acute respiratory failure, longer hospital stays, and higher readmission. There is evidence to suggest that regional anesthesia is associated with improved perioperative outcomes. Large RCTs are needed to explore the most optimal anesthetic techniques for geriatric patients with hip fractures before drawing final conclusions. PROSPERO REGISTRATION NUMBER CRD42018093582.
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Affiliation(s)
- Dong Xu Chen
- Department of Anesthesiology, West China Hospital, Sichuan University
| | - Lei Yang
- Department of Anesthesiology, West China Hospital, Sichuan University
| | - Lin Ding
- Department of Anesthesiology, West China Hospital, Sichuan University
| | - Shi Yue Li
- Department of Anesthesiology, West China Hospital, Sichuan University
| | - Ya Na Qi
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qian Li
- Department of Anesthesiology, West China Hospital, Sichuan University
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Ahn EJ, Kim HJ, Kim KW, Choi HR, Kang H, Bang SR. Comparison of general anaesthesia and regional anaesthesia in terms of mortality and complications in elderly patients with hip fracture: a nationwide population-based study. BMJ Open 2019; 9:e029245. [PMID: 31501111 PMCID: PMC6738684 DOI: 10.1136/bmjopen-2019-029245] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To evaluate the effects of anaesthesia on postoperative outcome in elderly patients who underwent hip fracture surgery. SETTING Nationwide National Health Insurance Sharing Service database of Korea. PARTICIPANTS All patients aged ≥65 years old who underwent hip fracture surgery, covered by the Korean National Health Insurance, between 1 January 2009 and 31 December 2015. INTERVENTIONS Hip fracture surgery under general anaesthesia (group GA) or regional anaesthesia (group RA), with a principal diagnosis of femoral fracture. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the anaesthetic-type effect on 30-day mortality and the secondary outcome was postoperative delirium requiring pharmacological intervention. RESULTS Among the 96 289 patients who underwent hip fracture surgery, 25 593 and 70 696 patients received GA and RA, respectively. After propensity score matching, 25 593 remained in each group. Postmatching mortality was lower in the RA than in the GA group (574 (2.24%) vs 654 (2.55%), p=0·0047, 95% CI -0.0099 to 0.0159). Delirium incidence was lower in the RA than in the GA group (5187 (20.27%) vs 5828 (22.77%), p<0·0001, 95% CI 0.019 to 0.045). The incidence of intensive care unit stay and ventilator care was lower in the RA than in the GA group (5838 (22.1%) vs 8055 (31.47%), p<0·0001, 95% CI 0.046 to 0.070 and 459 (1.73%) vs 1207 (4.72%), p<0·0001, 95% CI -0.0024 to 0.023, respectively). CONCLUSION RA was associated with better outcomes than GA, in terms of mortality, delirium, intensive care unit admission and ventilator care, in elderly patients who underwent hip fracture surgery.
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Affiliation(s)
- Eun Jin Ahn
- Department of Anesthesiology and Pain Medicine, Inje University Seoul Paik Hospital, Seoul, Republic of Korea
| | - Hyo Jin Kim
- Department of Anesthesiology and Pain Medicine, Inje University Seoul Paik Hospital, Seoul, Republic of Korea
| | - Kyung Woo Kim
- Department of Anesthesiology and Pain Medicine, Inje University Seoul Paik Hospital, Seoul, Republic of Korea
| | - Hey Ran Choi
- Department of Anesthesiology and Pain Medicine, Inje University Seoul Paik Hospital, Seoul, Republic of Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine and Graduate School of Medicine, Seoul, Republic of Korea
| | - Si Ra Bang
- Department of Anesthesiology and Pain Medicine, Inje University Seoul Paik Hospital, Seoul, Republic of Korea
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Aubrun F, Baillard C, Beuscart JB, Billard V, Boddaert J, Boulanger É, Dufeu N, Friggeri A, Khiami F, Salmon PK, Merloz P, Minville V, Molliex S, Mouchoux C, Pain L, Piriou V, Raux M, Servin F. Recommandation sur l’anesthésie du sujet âgé : l’exemple de fracture de l’extrémité supérieure du fémur. ANESTHÉSIE & RÉANIMATION 2019. [DOI: 10.1016/j.anrea.2018.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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12
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Postoperative outcomes with neuraxial versus general anesthesia in bilateral total hip arthroplasty. J Clin Anesth 2019; 52:71-75. [DOI: 10.1016/j.jclinane.2018.09.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 08/23/2018] [Accepted: 09/08/2018] [Indexed: 12/11/2022]
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13
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Kocum A, Turkoz A, Ulger H, Sener M, Arslan G. Ropivacaine 0.25% is as Effective as Bupivacaine 0.25% in Providing Surgical Anaesthesia for Lumbar Plexus and Sciatic Nerve Block in High-Risk Patients: Preliminary Report. Anaesth Intensive Care 2019; 35:510-4. [DOI: 10.1177/0310057x0703500408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ropivacaine is potentially less cardiotoxic and neurotoxic than bupivacaine. The aim of this study was to compare the effectiveness of ropivacaine 0.25% and bupivacaine 0.25% for surgical anaesthesia and postoperative analgesia during lumbar plexus and sciatic nerve block in high-risk patients. We performed combined lumbar plexus and sciatic nerve blockade on 62 consecutive ASA III or IV patients undergoing unilateral hip or femur surgery. The first 30 patients received bupivacaine (Group 1) and the remaining 32 patients received ropivacaine (Group 2). Perioperative management was otherwise similar. The groups were compared for the time of onset of the block, additional analgesics and sedatives required, time from end of surgery to the first analgesic requirement and the need for rescue analgesia. Ninety percent (29/32) of the patients in the ropivacaine group and 86% (26/30) of the patients in the bupivacaine group reached surgical anaesthesia. The time from the end of the surgery to the first analgesic requirement was similar between the two groups (10.3±5.2 hours for ropivacaine, 11.2±4.6 hours for bupivacaine). There was no statistically significant difference between the two groups in any of the measured variables (P>0.05). The results of this preliminary study suggest that ropivacaine 0.25% is as effective as bupivacaine 0.25% when used for blocking lumbar plexus and sciatic nerve in high-risk patients undergoing hip or femur surgery.
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Affiliation(s)
- A. Kocum
- Department of Anesthesiology and Reanimation, Baskent University Faculty of Medicine, Ankara, Turkey
| | - A. Turkoz
- Department of Anesthesiology and Reanimation, Baskent University Faculty of Medicine, Ankara, Turkey
| | - H. Ulger
- Department of Anesthesiology and Reanimation, Baskent University Faculty of Medicine, Ankara, Turkey
| | - M. Sener
- Department of Anesthesiology and Reanimation, Baskent University Faculty of Medicine, Ankara, Turkey
| | - G. Arslan
- Department of Anesthesiology and Reanimation, Baskent University Faculty of Medicine, Ankara, Turkey
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Patel V, Champaneria R, Dretzke J, Yeung J. Effect of regional versus general anaesthesia on postoperative delirium in elderly patients undergoing surgery for hip fracture: a systematic review. BMJ Open 2018; 8:e020757. [PMID: 30518580 PMCID: PMC6286489 DOI: 10.1136/bmjopen-2017-020757] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 10/17/2018] [Accepted: 10/26/2018] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Older patients with hip fractures who are undergoing surgery are at high risk of significant mortality and morbidity including postoperative delirium. It is unclear whether different types of anaesthesia may reduce the incidence of postoperative delirium. This systematic review will investigate the impact of anaesthetic technique on postoperative delirium. Other outcomes included mortality, length of stay, complications and functional outcomes. DESIGN Systematic review of randomised controlled trials and non-randomised controlled studies. DATA SOURCES Bibliographic databases were searched from inception to June 2018. Web of Science and ZETOC databases were searched for conference proceedings. Reference lists of relevant articles were checked, and clinical trial registers were searched to identify ongoing trials. ELIGIBILITY CRITERIA Studies were eligible if general and regional anaesthesia were compared in patients (aged 60 and over) undergoing hip fracture surgery, reporting primary outcome of postoperative delirium and secondary outcomes of mortality, length of hospital stay, adverse events, functional outcomes, discharge location and quality of life. Exclusion criteria were anaesthetic technique or drug not considered current standard practice; patients undergoing hip fracture surgery alongside other surgery and uncontrolled studies. RESULTS One hundred and four studies were included. There was no evidence to suggest that anaesthesia type influences postoperative delirium or mortality. Some studies suggested a small reduction in length of hospital stay with regional anaesthesia. There was some evidence to suggest that respiratory complications and intraoperative hypotension were more common with general anaesthesia. Heterogeneity precluded meta-analysis. All findings were described narratively and data were presented where possible in forest plots for illustrative purposes. CONCLUSIONS While there was no evidence to suggest that anaesthesia types influence postoperative delirium, the evidence base is lacking. There is a need to ascertain the impact of type of anaesthesia on outcomes with an adequately powered, methodologically rigorous study. PROSPERO REGISTRATION NUMBER CRD42015020166.
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Affiliation(s)
- Vanisha Patel
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Rita Champaneria
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Janine Dretzke
- Biostatistics, Evidence Synthesis and Test Evaluation (BESaTE), Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Joyce Yeung
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Anaesthesia and Critical Care, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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Desai V, Chan PH, Prentice HA, Zohman GL, Diekmann GR, Maletis GB, Fasig BH, Diaz D, Chung E, Qiu C. Is Anesthesia Technique Associated With a Higher Risk of Mortality or Complications Within 90 Days of Surgery for Geriatric Patients With Hip Fractures? Clin Orthop Relat Res 2018; 476:1178-1188. [PMID: 29601378 PMCID: PMC6263607 DOI: 10.1007/s11999.0000000000000147] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Postoperative mortality and complications after geriatric hip fracture surgery remain high despite efforts to improve perioperative care for these patients. One factor of particular interest is anesthetic technique, but prior studies on this are limited by sample selection, competing risks, and incomplete followup. QUESTIONS/PURPOSES (1) Among older patients undergoing surgery for hip fracture, does 90-day mortality differ depending on the type of anesthesia received? (2) Do 90-day emergency department returns and hospital readmissions differ based on anesthetic technique after geriatric hip fracture repairs? (3) Do 90-day Agency for Healthcare Research and Quality (AHRQ) outcomes differ according to anesthetic techniques used during hip fracture surgery? METHODS We conducted a retrospective study on geriatric patients (65 years or older) with hip fractures between 2009 and 2014 using the Kaiser Permanente Hip Fracture Registry. A total of 1995 (11%) of the surgically treated patients with hip fracture were excluded as a result of missing anesthesia information. The final study sample consisted of 16,695 patients. Of these, 2027 (12%) died and 98 (< 1%) terminated membership during followup, which were handled as competing events and censoring events, respectively. Ninety-day mortality, emergency department returns, hospital readmission, deep vein thrombosis (DVT) or pulmonary embolism (PE), myocardial infarction (MI), and pneumonia were evaluated using multivariable competing risk proportional subdistribution hazard regression according to type of anesthesia technique: general anesthesia, regional anesthesia, or conversion from regional to general. Of the 16,695 patients, 58% (N = 9629) received general anesthesia, 40% (N = 6597) received regional anesthesia, and 2.8% (N = 469) patients were converted from regional to general. RESULTS Compared with regional anesthesia, patients treated with general anesthesia had a higher likelihood of overall 90-day mortality (hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.11-1.35; p < 0.001); however, when stratified by before and after hospital discharge but within 90 days of surgery, this higher risk was only observed during the inpatient stay (HR, 3.83; 95% CI, 3.18-4.61; p < 0.001); no difference was observed after hospital discharge (HR, 1.04; 95% CI, 0.94-1.16; p = 0.408). Patients undergoing conversion from regional to general also had a higher overall mortality risk compared with those undergoing regional anesthesia (HR, 1.34; 95% CI 1.04-1.74; p = 0.026), but this risk was only observed during their inpatient stay (HR, 6.84; 95% CI, 4.21-11.11; p < 0.001) when stratifying by before and after hospital discharge. Patients undergoing general anesthesia had a higher risk for all-cause readmission when compared with regional anesthesia (HR, 1.09; 95% CI, 1.01-1.19; p = 0.026). No differences according to anesthesia type were observed for risk of 90-day AHRQ outcomes, including DVT/PE, MI, and pneumonia. CONCLUSIONS We found the use of general anesthesia and conversion from regional to general anesthesia were associated with a higher risk of mortality during the in-hospital stay compared with regional anesthetic techniques, but this higher risk did not persist after hospital discharge. We also found general anesthesia to be associated with a higher risk of all-cause readmission compared with regional, but no other differences were observed in risk for complications. Our findings suggest regional anesthetic techniques may be preferred when possible in this patient population. LEVEL OF EVIDENCE Level III, therapeutic study.
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Meuret P, Bouvet L, Villet B, Hafez M, Allaouchiche B, Boselli E. Hypobaric Unilateral Spinal Anaesthesia versus General Anaesthesia in Elderly Patients Undergoing Hip Fracture Surgical Repair: A Prospective Randomised Open Trial. Turk J Anaesthesiol Reanim 2018; 46:121-130. [PMID: 29744247 DOI: 10.5152/tjar.2018.90699] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 02/06/2018] [Indexed: 11/22/2022] Open
Abstract
Objective Intraoperative hypotension during hip fracture surgery is frequent in the elderly. No study has compared the haemodynamic effect of hypobaric unilateral spinal anaesthesia (HUSA) and standardised general anaesthesia (GA) in elderly patients undergoing hip fracture surgical repair. Methods We performed a prospective, randomised open study, including 40 patients aged over 75 years, comparing the haemodynamic effects of HUSA (5 mg isobaric bupivacaine with 5 μg sufentanil and 1 mL sterile water) and GA (induction with etomidate/remifentanil and maintenance with desflurane/remifentanil). An incidence of severe hypotension, defined by a decrease in systolic blood pressure of >40% from baseline, was the primary endpoint. Results The incidence of severe hypotension was lower in the HUSA group compared with that in the GA group (32% vs. 71%, respectively, p=0.03). The median [IQR] ephedrine consumption was lower (p=0.001) in the HUSA group (6 mg, 0-17 mg) compared with that in the GA group (36 mg, 21-57 mg). Intraoperative muscle relaxation and patients' and surgeons' satisfaction were similar between groups. No difference was observed in 5-day complications or 30-day mortality. Conclusion This study shows that HUSA provides better haemodynamic stability than GA, with lower consumption of ephedrine and similar operating conditions. This new approach of spinal anaesthesia seems to be safe and effective in elderly patients undergoing hip fracture surgery.
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Affiliation(s)
- Pascal Meuret
- Hospices Civils de Lyon, Édouard Herriot Hospital, Department of Anesthesiology, Lyon, France
| | - Lionel Bouvet
- University of Lyon, University Claude Bernard Lyon I, APCSe Vetagro Sup UPSP 2016. A101, Marcy-l'Étoile, France
| | - Benoit Villet
- Hospices Civils de Lyon, Édouard Herriot Hospital, Department of Anesthesiology, Lyon, France
| | - Mohamed Hafez
- Hospices Civils de Lyon, Édouard Herriot Hospital, Department of Orthopedic Surgery, Lyon, France
| | - Bernard Allaouchiche
- University of Lyon, University Claude Bernard Lyon I, APCSe Vetagro Sup UPSP 2016. A101, Marcy-l'Étoile, France
| | - Emmanuel Boselli
- University of Lyon, University Claude Bernard Lyon I, APCSe Vetagro Sup UPSP 2016. A101, Marcy-l'Étoile, France.,Groupement Hospitalier Nord Dauphiné, Pierre Oudot Hospital Center, Department of Anesthesiology, Bourgoin-Jallieu, France
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Impact of Anesthesia on Hospital Mortality and Morbidities in Geriatric Patients Following Emergency Hip Fracture Surgery. J Orthop Trauma 2018; 32:116-123. [PMID: 29461445 DOI: 10.1097/bot.0000000000001035] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the impact of anesthesia type on in-hospital mortality and morbidity for geriatric fragility hip fracture surgery. DESIGN Retrospective cohort study. SETTING Integrates health care delivery system across 38 facilities in the United States. PATIENTS/PARTICIPANTS We identified 16,695 patients 65 years of age and older who underwent emergent hip fracture repairs between 2009 and 2014 through the Kaiser Permanente hip fracture registry and excluded pathologic or bilateral fractures. INTERVENTION Hip fracture surgery with general or regional anesthesia. MAIN OUTCOMES MEASURES Data on in-hospital mortality, time to death, discharge disposition, and length of stay (LOS) were analyzed among the following anesthesia types: general anesthesia (GA), regional anesthesia (RA), and intraoperative conversions from regional to general (Cv). RESULTS Compared with RA, the hazard ratio for GA for in-hospital mortality was 1.38 and 2.23 for the Cv group; the time ratio for GA-associated time to death was 0.97 and 0.89 for the Cv group. The GA-associated time ratio for LOS before discharge was 1.01, and the hazard ratio for home discharge was 0.86, but no significance was found with the Cv group. CONCLUSIONS RA may offer advantages over GA for fragility hip fracture surgeries when possible. In-hospital mortality, time to death, increased LOS, and discharge to an institute rather than home were all adversely influenced by GA. Furthermore, the previously understudied Cv group demonstrated adverse outcomes for in-hospital mortality and time to death. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Perioperative outcomes in the context of mode of anaesthesia for patients undergoing hip fracture surgery: systematic review and meta-analysis. Br J Anaesth 2018; 120:37-50. [DOI: 10.1016/j.bja.2017.09.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 09/15/2017] [Accepted: 09/15/2017] [Indexed: 01/08/2023] Open
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The impact of peripheral nerve blocks on perioperative outcome in hip and knee arthroplasty-a population-based study. Pain 2017; 157:2341-2349. [PMID: 27643835 DOI: 10.1097/j.pain.0000000000000654] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The role of anesthesia techniques on perioperative outcomes on a population level has recently gained widespread interest. Although mainly neuraxial vs general anesthesia has been addressed, population-level data on the impact of peripheral nerve blocks (PNBs) are still lacking. Therefore, we investigated the association between PNB use and outcomes using retrospective data on 1,062,152 recipients of hip and knee arthroplasties (total hip arthroplasty [THA]/total knee arthroplasty [TKA]) from the national Premier Perspective database (2006-2013). Multilevel multivariable logistic regression models measured associations between PNB use and outcomes. Complications included cardiac, pulmonary, gastrointestinal and renal complications, cerebrovascular events, infections, wound complications, thromboembolic complications, inpatient falls, and mortality. Resource utilization variables included blood transfusions, intensive care unit admissions, opioid consumption, cost, and length of stay. Overall, 12.5% of patients received a PNB, with an increase over time particularly among TKAs. Peripheral nerve block use was associated with lower odds for most adverse outcomes mainly among patients with THA. Notable beneficial effects were seen for wound complications (odds ratio 0.60 [95% confidence interval, 0.49-0.74]) among THA recipients and pulmonary complications (odds ratio 0.83 [95% confidence interval, 0.72-0.94]) in patients with TKA. Peripheral nerve block use was significantly (P < 0.0001) associated with a -16.2% and -12.7% reduction in opioid consumption for patients with THA and TKA, respectively. In conclusion, our results indicate that PNBs might be associated with superior perioperative population-level outcomes. In light of the inability to establish a causal relationship and the presence of residual confounding, we strongly advocate for further prospective investigation, ideally in multicenter, randomized trials, to establish the potential impact of PNBs on outcomes on a population level.
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Lončarić-Katušin M, Mišković P, Lavrnja-Skolan V, Katušin J, Bakota B, Žunić J. General versus spinal anaesthesia in proximal femoral fracture surgery - treatment outcomes. Injury 2017; 48 Suppl 5:S51-S55. [PMID: 29122123 DOI: 10.1016/s0020-1383(17)30740-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Proximal femoral fractures are a major public health problem because of the increasing proportion of elderly individuals in the general population. The mode of choice for anaesthesia in surgical treatment of these fractures is still debated in terms of better postoperative outcome. The aim of our study was to compare the effect of general over spinal anaesthesia on mortality in proximal femoral fracture surgery. PATIENTS AND METHODS This study was a retrospective analysis of 115 patients aged at least 70 years who underwent surgery for proximal femoral fracture. The survey was conducted from 1 January to 31 December 2015 at the General Hospital Karlovac, Croatia. Patients were divided into two groups: group 1 - general anaesthesia and group 2 - spinal anaesthesia. The primary outcome measure was the effect of mode of anaesthesia, general versus spinal, on mortality within 30 days, six months and one year after surgery. RESULTS General anaesthesia (EndoTracheal Anaesthesia) was administered in 77 patients (67%; group I - ETA) and spinal anaesthesia in 38 patients (33%; group 2 - SPIN). Both groups had more female than male patients: 69 patients (89.6%) in the ETA group and 32 patients (84.2%) in the SPIN group were female. The mean age in the ETA group was 82.91 years and in the SPIN group was 80.18 years. ASA II status was more common in patients in the SPIN group (25 patients [65.8%]). The average time from hospitalisation to surgery was 53.44 hours in the ETA group and 53.33 hours in the SPIN group. There was no significant difference between groups in the number of comorbidities, or intraoperative and postoperative complications. There was no statistically significant difference in mortality between the groups. Mortality after surgery in the ETA and SPIN groups, respectively, was as follows: 10.4% and 10.5% at 30 days, 23.4% and 15.8% at six months, and 32.5% and 31.6% at one year. CONCLUSION The results indicate that the mode of anaesthesia (general vs spinal) has no effect on postoperative mortality, and that the mode of anaesthesia should be applied on an individual basis in correlation with associated comorbidities.
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Affiliation(s)
- Mirjana Lončarić-Katušin
- Karlovac General Hospital, Department of Anaesthesiology, Resuscitation and Intensive Care Medicine, Karlovac, Croatia.
| | - Petar Mišković
- Karlovac General Hospital, Department of Anaesthesiology, Resuscitation and Intensive Care Medicine, Karlovac, Croatia
| | - Vlasta Lavrnja-Skolan
- Karlovac General Hospital, Department of Anaesthesiology, Resuscitation and Intensive Care Medicine, Karlovac, Croatia.
| | - Juraj Katušin
- Karlovac General Hospital, Department of Surgery, Traumatology Unit, Karlovac, Croatia
| | - Bore Bakota
- Trauma and Orthopaedic Department, Brighton and Sussex University Hospitals, United Kingdom
| | - Josip Žunić
- Karlovac General Hospital, Department of Anaesthesiology, Resuscitation and Intensive Care Medicine, Karlovac, Croatia
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Kahloul M, Nakhli MS, Chouchene A, Chebbi N, Mhamdi S, Naija W. Comparison of two doses of hypobaric bupivacaine in unilateral spinal anesthesia for hip fracture surgery: 5 mg versus 7.5 mg. Pan Afr Med J 2017. [PMID: 29515726 PMCID: PMC5837165 DOI: 10.11604/pamj.2017.28.108.11421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introduction Hip fracture is a frequent and severe disease. Its prognosis depends on the perioperative hemodynamic stability which can be preserved by the unilateral spinal anesthesia especially with low doses of local anesthetics. This study aims to compare the efficacy and hemodynamic stability of two doses of hypobaric bupivacaine (7.5 mg vs 5 mg) in unilateral spinal anesthesia. Methods In this prospective, randomized, double-blind study, 108 patients scheduled for hip fracture surgery under unilateral spinal anesthesia were enrolled to receive either 5 mg (group 1) or 7.5 mg (group 2) of hypobaric bupivacaine. Spinal anesthesia was performed in lateral position. Patients’ socio-demographic characteristics, hemodynamic profile, sensory and motor blocks parameters were recorded. Results Both groups were comparable regarding to demographic data. Two cases of failure occurred in group 1 and one case in group 2 corresponding to a comparable efficiency rates (96.29% and 98.14% respectively; p = 0.5). A higher mean onset and lower mean regression times of sensory block were significantly noted in group 1 (7.79±3.76 min vs 5.75±2.35 min, p < 0.001 and 91.29±31.55 min vs 112.77±18.77 min, p <0.001 respectively). Incidence of bilateralization (29.62% vs 87.03%, p < 0.001), incidence of hypotensive episodes (59.25% vs 92.59%, p < 0.001) and vascular loading (1481.48±411.65 ml vs 2111.11±596.10 ml, p < 0.001) were significantly higher in group 2. Conclusion The dosage of 5mg of hypobaric bupivacaine in unilateral spinal anesthesia is as effective as the dosage of 7.5 mg with lower bilateralization incidence and better hemodynamic stability.
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Affiliation(s)
- Mohamed Kahloul
- Department of Anesthesia and Intensive Care, Sahloul Teaching Hospital; Faculty of Medicine "Ibn El Jazzar", Sousse, Tunisia
| | - Mohamed Said Nakhli
- Department of Anesthesia and Intensive Care, Sahloul Teaching Hospital; Faculty of Medicine "Ibn El Jazzar", Sousse, Tunisia
| | - Amine Chouchene
- Department of Anesthesia and Intensive Care, Sahloul Teaching Hospital; Faculty of Medicine "Ibn El Jazzar", Sousse, Tunisia
| | - Nidhal Chebbi
- Department of Anesthesia and Intensive Care, Sahloul Teaching Hospital; Faculty of Medicine "Ibn El Jazzar", Sousse, Tunisia
| | - Salah Mhamdi
- Department of Anesthesia and Intensive Care, Sahloul Teaching Hospital; Faculty of Medicine "Ibn El Jazzar", Sousse, Tunisia
| | - Walid Naija
- Department of Anesthesia and Intensive Care, Sahloul Teaching Hospital; Faculty of Medicine "Ibn El Jazzar", Sousse, Tunisia
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Steadman J, Catalani B, Sharp C, Cooper L. Life-threatening perioperative anesthetic complications: major issues surrounding perioperative morbidity and mortality. Trauma Surg Acute Care Open 2017; 2:e000113. [PMID: 29766107 PMCID: PMC5887586 DOI: 10.1136/tsaco-2017-000113] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 11/18/2022] Open
Abstract
Perioperative morbidity and mortality related to anesthesia involves multiple factors. Patient characteristics and comorbidities play a role in many of these events, highlighting the importance of preoperative screening. While optimization of patient comorbidities is not always possible, having data regarding those comorbidities can prove life-saving. Equipment and medication considerations also enter into untoward outcomes such as anesthetic interventions outside of the traditional operating room where resources are sometimes lacking and haste creates errors. Ultimately, when surgeons and anesthesiologists cooperate in patient care, communicating concisely but thoroughly, patients are more likely to do well. The language of surgeons is that of diagnosis requiring a surgical intervention, while anesthesiologists are discussing patient comorbidities impacted by anesthetic medications, positive pressure ventilation, neuraxial techniques, ramifications of patient positioning, effects of opiates and so on. Because all of the considerations combine in determining outcomes, it is incumbent on both surgeons and anesthesiologists to understand those elements leading to severe morbid events as well as death. This review touches on many of the most important factors.
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Affiliation(s)
- Joy Steadman
- Department of Anesthesiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Blas Catalani
- Department of Anesthesiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Christopher Sharp
- Department of Anesthesiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lebron Cooper
- Department of Anesthesiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Abstract
Elderly patients increasingly need to undergo surgery under anesthesia, especially following trauma. A timely interdisciplinary approach to the perioperative management of these patients is decisive for the long-term outcome. Orthogeriatric co-management, which includes geriatricians and anesthesiologists from an early stage, is of great benefit for geriatric patients. Patient age, comorbidities and self-sufficiency in activities of daily life are decisive for an anesthesiological assessment of the state of health and preoperative risk stratification. If necessary additional investigations, such as echocardiography must be carried out, in order to guarantee optimal perioperative anesthesiological management. Certain medical factors can delay the initiation of anesthesia and it is absolutely necessary that these are taken into consideration for surgical management. Not every form of anesthesia is equally suitable for every geriatric patient.
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Eyelade O, Sanusi A, Adigun T, Adejumo O. Outcome of anesthesia in elective surgical patients with comorbidities. Ann Afr Med 2016; 15:78-82. [PMID: 27044731 PMCID: PMC5402819 DOI: 10.4103/1596-3519.176204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Presence of comorbidity in surgical patients may be associated with adverse perioperative events and increased the risk of morbidity and mortality. This audit was conducted to determine the frequencies of comorbidities in elective surgical patients and the outcome of anesthesia in a Tertiary Hospital in Nigeria. Materials and Methods: Observational study of a cross-section of adult patients scheduled for elective surgery over a 6-month period. A standardized questionnaire was used to document patients’ demographics, the presence of comorbidity and type, surgical diagnosis, anesthetic technique, intraoperative adverse events, and outcome of anesthesia. The questionnaire was administered pre- and post-operatively to determine the effects of the comorbidities on the outcome of anesthesia. Results: One hundred and sixty-five adult patients aged between 18 and 84 years were studied. There were 89 (53.9%) females and 76 (46.1%) males. Forty-five (27.3%) have at least one comorbidity. Hypertension was the most common (48.8%) associated illness. Other comorbidities identified include anemia (17.8%), asthma (8.9%), diabetes mellitus (6.7%), chronic renal disease (6.7%), and others. The perioperative period was uneventful in majority of patients (80.6%) despite the presence of comorbidities. Intraoperative adverse events include hypotension, hypertension, shivering, and vomiting. No mortality was reported. Conclusion: Hypertension was the most common comorbidity in this cohort of patients. The presence of comorbidity did not significantly affect the outcome of anesthesia in elective surgical patients.
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Affiliation(s)
- Olayinka Eyelade
- Department of Anaesthesia, University College Hospital, Ibadan, Nigeria
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Abstract
Regional anaesthesia is very effective in alleviating pain due to trauma, and is also used to provide anaesthesia for trauma surgery. It has the advantage of producing localized but complete pain relief, whilst avoiding the side effects of systemic analgesics or anaesthetics. However, regional anaesthetic drugs and techniques have potentially life-threatening complications, which the practitioner must be able to manage. This article discusses the use of regional anaesthesia, and the benefits and disadvantages of specific regional techniques in various traumatic conditions.
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Affiliation(s)
- JM Elliot
- Department of Anaesthesia, Good Hope Hospital, Sutton Coldfield, UK
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[Anesthesiological care in orthogeriatric co-management. Perioperative treatment of geriatric trauma patients]. Z Gerontol Geriatr 2016; 49:237-55. [PMID: 27090913 DOI: 10.1007/s00391-016-1057-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 01/25/2016] [Accepted: 02/25/2016] [Indexed: 12/19/2022]
Abstract
Elderly patients increasingly need to undergo surgery under anesthesia, especially following trauma. A timely interdisciplinary approach to the perioperative management of these patients is decisive for the long-term outcome. Orthogeriatric co-management, which includes geriatricians and anesthesiologists from an early stage, is of great benefit for geriatric patients. Patient age, comorbidities and self-sufficiency in activities of daily life are decisive for an anesthesiological assessment of the state of health and preoperative risk stratification. If necessary additional investigations, such as echocardiography must be carried out, in order to guarantee optimal perioperative anesthesiological management. Certain medical factors can delay the initiation of anesthesia and it is absolutely necessary that these are taken into consideration for surgical management. Not every form of anesthesia is equally suitable for every geriatric patient.
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Tung YC, Hsu YH, Chang GM. The Effect of Anesthetic Type on Outcomes of Hip Fracture Surgery: A Nationwide Population-Based Study. Medicine (Baltimore) 2016; 95:e3296. [PMID: 27057897 PMCID: PMC4998813 DOI: 10.1097/md.0000000000003296] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Hip fractures are a global public health problem. During surgery following hip fractures, both general and regional anesthesia are used, but which type of anesthesia offers a better outcome remains controversial. There has been little research evaluating different anesthetic types on mortality and readmission rates for hip fracture surgery using nationwide population-based data.We used nationwide population-based data to examine the effect of anesthetic type on mortality and readmission rates for hip fracture surgery.Retrospective observational study.General acute care hospitals throughout Taiwan.A total of 17,189 patients hospitalized for hip fracture surgery in 2011.Generalized estimating equation models with propensity score weighting were performed after adjustment for patient, surgeon, and hospital characteristics to examine the associations of anesthesia type with 30-day all-cause mortality, 30-day all-cause readmission, and 30-day specific-cause readmission (including surgical site infection, sepsis, acute respiratory failure, acute stroke, acute myocardial infarction, acute renal failure, deep vein thrombosis, pneumonia, and urinary tract infection).Of 17,189 patients, 11,153 (64.9%) received regional anesthesia and 6036 (35.1%) received general anesthesia. Overall, the 30-day mortality rate was 1.7%, and the 30-day readmission rate was 12.3%. Regional anesthesia was not associated with decreased 30-day all-cause mortality (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.67-1.18, P = 0.409), but associated with decreased 30-day all-cause readmission and surgical site infection readmission relative to general anesthesia (OR 0.83, 95% CI 0.75-0.93, P = 0.001 and OR 0.69, 95% CI 0.49-0.97, P = 0.031).Regional anesthesia is not associated with 30-day mortality, but is associated with lower 30-day all-cause and surgical site infection readmission compared with general anesthesia for hip fracture surgery.
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Affiliation(s)
- Yu-Chi Tung
- From the Institute of Health Policy and Management (Y-CT), Institute of Health Policy and Management, National Taiwan University, Taipei (Y-HH), Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan (Y-HH), Department of Family Medicine, Cardinal Tien Hospital, New Taipei City (G-MC), and School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan (G-MC)
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De Andres J, Fabregat-Cid G, Asensio-Samper JM, Sanchis-Lopez N, Moliner-Velazquez S. Management of acute pain in patients on treatment with opioids. Pain Manag 2016; 5:167-73. [PMID: 25971640 DOI: 10.2217/pmt.15.13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The use of opioids for both benign and cancer-related chronic pain has increased exponentially over the last few years. For this reason, increasing numbers of such patients are presenting for surgery. It is known that continuous use of opioids is associated with an increase in postoperative analgesic requirements. This is believed to be mediated by the development of tolerance and opioid-induced hyperalgesia. Patients treated with opioids have special needs in the perioperative setting and it is the anesthesiologist's responsibility to manage these needs optimally. The aim of the present paper is to briefly orient the reader in the management of postoperative pain in patients chronically treated with licit opioids.
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Affiliation(s)
- Jose De Andres
- Multidisciplinary Pain Management Department. Department of Anesthesiology Critical Care & Pain Management, General University Hospital, Valencia, Spain
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Brox WT, Chan PH, Cafri G, Inacio MCS. Similar mortality with general or regional anesthesia in elderly hip fracture patients. Acta Orthop 2016; 87:152-7. [PMID: 26986550 PMCID: PMC4812077 DOI: 10.3109/17453674.2015.1128781] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE There is continuing confusion among practitioners with regard to the optimal choice of anesthetic type for repair of hip fractures. We investigated whether type of anesthetic was associated with short-term mortality after hip fracture surgery. PATIENTS AND METHODS We conducted a retrospective cohort study of patients with surgically treated hip fractures, performed between January 1, 2009 and December 31, 2012. Exposure of interest was anesthesia type (general, spinal/neuroaxial, and mixed). Endpoints were 30-, 90-, and 365-day post-surgery mortality. Multivariable conditional logistic regression models were used and odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS Of the 7,585 participants, 5,412 (71%) were women and the median age was 80 (IQR: 72-85) years old. Of the total cohort, 4,257 (56%) received general anesthesia, 3,059 (40%) received spinal/neuroaxial, and 269 (4%) received mixed anesthesia. Overall, the incidence of 30-, 90-, and 365-day mortality was 4% (n = 307), 8% (n = 583), and 15% (n = 1,126), respectively. When compared with general anesthesia, the 365-day odds of mortality was marginally lower in patients with spinal/neuroaxial anesthesia (OR = 0.84, CI: 0.70-1.0), but it was similar in patients with mixed anesthesia (OR = 1.3, CI: 0.70-2.3). No other statistically significant differences were observed. INTERPRETATION Regarding mortality, this study does not support specific recommendations regarding the type of anesthetic in surgery of fractured hips.
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Affiliation(s)
| | - Priscilla H Chan
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, CA
| | - Guy Cafri
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, CA
| | - Maria C S Inacio
- Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, CA
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Luttrell K, Nana A. Effect of Preoperative Transthoracic Echocardiogram on Mortality and Surgical Timing in Elderly Adults with Hip Fracture. J Am Geriatr Soc 2015; 63:2505-2509. [PMID: 26659463 DOI: 10.1111/jgs.13840] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the effect of preoperative transthoracic echocardiogram (TTE) on mortality, postoperative complications, surgical timing, and length of stay in individuals with surgically treated hip fracture. DESIGN Retrospective chart review of hospital records. SETTING Level I and II trauma centers. PARTICIPANTS Individuals consecutively surgically treated for hip fracture (N = 694). MEASUREMENTS Demographic and injury characteristic, operative timing, preoperative echocardiogram, complications, mortality. Primary outcome measure was in hospital, 30-day, and 1-year mortality. Secondary outcome measures were complications (particularly cardiovascular) and time required for medical clearance and operative treatment. RESULTS Preoperative TTE was performed on 131 individuals (18.9%). There was no difference between the TTE group and the control group in hospital (3.8% vs 1.8%, P = .18), 30-day (6.9% vs 6.6%, P = .90), or 1-year (20.6% versus 20.1%, P = .89) mortality. There was no significant difference in major cardiac complications. Average time from admission to operative treatment was 66.5 hours in the TTE group and 34.8 hours in the control group (P < .001). Average time from admission to medical clearance was 43.2 hours in the TTE group and 12.4 hours in the control group (P < .001). The TTE group also had a significantly longer length of stay (8.68 vs 6.44 days, P < .001). CONCLUSION Preoperative TTE was not associated with lower mortality in elderly adults with hip fracture in the short- or long-term postoperative period. TTE was associated with delayed surgical treatment and longer length of stay and resulted in no cardiac intervention (e.g., cardiac catheterization, stent, stress test).
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Affiliation(s)
- Kevin Luttrell
- Department of Orthopedic Surgery, University of North Texas Health Science Center, Fort Worth, Texas.,John Peter Smith Hospital, Fort Worth, Texas
| | - Arvind Nana
- Department of Orthopedic Surgery, University of North Texas Health Science Center, Fort Worth, Texas.,John Peter Smith Hospital, Fort Worth, Texas.,Harris Methodist Fort Worth Hospital, Fort Worth, Texas
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Cozowicz C, Poeran J, Memtsoudis S. Epidemiology, trends, and disparities in regional anaesthesia for orthopaedic surgery. Br J Anaesth 2015; 115 Suppl 2:ii57-67. [DOI: 10.1093/bja/aev381] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Karademir G, Bilgin Y, Erşen A, Polat G, Buget MI, Demirel M, Balcı HI. Hip fractures in patients older than 75 years old: Retrospective analysis for prognostic factors. Int J Surg 2015; 24:101-4. [PMID: 26563486 DOI: 10.1016/j.ijsu.2015.11.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 11/02/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Proximal femoral fractures are often seen in older patients and are associated with high mortality. Introduction to old age population is latening due to advancements in medical sciences and increasing life expectancy. OBJECTIVES The aim of the study was to evaluate factors affecting mortality in patients above 75 years of age who had been operated because of proximal femur fractures. PATIENTS AND METHODS Patients with age 75 and over who suffers from post-fall proximal femoral fracture who underwent surgery with one of following three methods (hemiarthroplasty, proximal femoral nail or total hip arthroplasty) were evaluated retrospectively. Effects on mortality were examined for factors such as type of surgery, type of anesthesia, preoperative ASA score (American Society of Anesthesiologists Score), need for intensive care, need for blood transfusion, operation waiting time and hospitalization duration. 115 patients who met inclusion criterion were included in the study out of 224 overall. 75 patients were women and 40 were males. RESULTS Mortality rate after first year was found to be 40%. Patients over 85 years old had higher rates of mortality (p = 0,0003) than respectively younger patients (75-85). Sex was found to have no impact on mortality (p = 0.5039). There was no statistically significant difference in terms ASA score (p = 0.1518). Order of applied surgical methods with mortality risk rates was found to be total hip arthroplasty > hemiarthroplasty > proximal femoral nail (p = 0.0003). Type of anesthesia, the use of cement during arthroplasty, operation waiting time and hospitalization duration was not directly related with mortality rate (type of anesthesia p = 0.63, the use of cement during arthroplasty p = 0.223, operation waiting time p = 0.5 and hospitalization duration p = 0.19). CONCLUSIONS Age is the primary risk factor on first year mortality in patients older than 75 years old with hip fractures. Addition to older age, more need to blood transfusions, and arthroplasty are other risk factors for first year mortality. It should be kept in mind that after 75 years old first year mortality may be higher if the patient is treated with arthroplasty.
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Affiliation(s)
- Gökhan Karademir
- Istanbul University, Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Çapa Fatih, Istanbul, 34050, Turkey.
| | - Yücel Bilgin
- Istanbul University, Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Çapa Fatih, Istanbul, 34050, Turkey.
| | - Ali Erşen
- Istanbul University, Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Çapa Fatih, Istanbul, 34050, Turkey.
| | - Gökhan Polat
- Istanbul University, Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Çapa Fatih, Istanbul, 34050, Turkey.
| | - Mehmet I Buget
- Istanbul University, Istanbul Faculty of Medicine, Department of Anesthesiology and Reanimation, Çapa Fatih, Istanbul, 34050, Turkey.
| | - Mehmet Demirel
- Istanbul University, Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Çapa Fatih, Istanbul, 34050, Turkey.
| | - Halil Ibrahim Balcı
- Istanbul University, Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Çapa Fatih, Istanbul, 34050, Turkey.
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Jin J, Wang G, Gong M, Zhang H, Liu J. Retrospective comparison of the effects of epidural anesthesia versus peripheral nerve block on postoperative outcomes in elderly Chinese patients with femoral neck fractures. Clin Interv Aging 2015; 10:1223-31. [PMID: 26300631 PMCID: PMC4535552 DOI: 10.2147/cia.s87020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Geriatric patients with femoral neck fracture (FNF) have unacceptably high rates of postoperative complications and mortality. The purpose of this study was to compare the effects of epidural anesthesia versus peripheral nerve block (PNB) on postoperative outcomes in elderly Chinese patients with FNF. Methods This retrospective study explored mortality and postoperative complications in geriatric patients with FNF who underwent epidural anesthesia or PNB at the Chinese People’s Liberation Army General Hospital from January 2008 to December 2012. The electronic database at the Chinese People’s Liberation Army General Hospital includes discharge records for all patients treated in the hospital. Information on patient demographics, preoperative comorbidity, postoperative complications, type of anesthesia used, and in-hospital, 30-day, and 1-year mortality after surgery was obtained from this database. Results Two hundred and fifty-eight patients were identified for analysis. The mean patient age was 79.7 years, and 71.7% of the patients were women. In-hospital, 30-day, and 1-year postoperative mortality was 4.3%, 12.4%, and 22.9%, respectively, and no differences in mortality or cardiovascular complications were found between patients who received epidural anesthesia and those who received PNB. More patients with dementia or delirium were given PNB. No statistically significant differences were found between groups for other comorbidities or intraoperative parameters. The most common complications were acute cardiovascular events (23.6%), electrolyte disturbances (20.9%), and hypoxemia (18.2%). Patients who received PNB had more postoperative delirium (P=0.027). Postoperative acute respiratory events were more common (P=0.048) and postoperative stroke was less common (P=0.018) in the PNB group. There were fewer admissions to intensive care (P=0.024) in the epidural anesthesia group. Key factors with a negative influence on mortality were acute cardiovascular events, dementia, male sex, age, American Society of Anesthesiologists score, acute respiratory events, intensive care admission, and comorbidities. Conclusion PNB was not associated with lower mortality or lower cardiovascular complication rates when compared with epidural anesthesia in elderly patients with FNF.
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Affiliation(s)
- Jianwen Jin
- Department of Clinical Medicine, Fujian Health College, Fuzhou, People's Republic of China
| | - Gang Wang
- Department of Anesthesiology, Chinese People's Liberation Army 105 Hospital, Hefei, People's Republic of China
| | - Maowei Gong
- Anesthesia and Operation Center, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Hong Zhang
- Anesthesia and Operation Center, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Junle Liu
- Department of Anesthesiology, Chinese People's Liberation Army 105 Hospital, Hefei, People's Republic of China
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Basques BA, Bohl DD, Golinvaux NS, Samuel AM, Grauer JG. General versus spinal anaesthesia for patients aged 70 years and older with a fracture of the hip. Bone Joint J 2015; 97-B:689-95. [PMID: 25922465 DOI: 10.1302/0301-620x.97b5.35042] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to compare the operating time, length of stay (LOS), adverse events and rate of re-admission for elderly patients with a fracture of the hip treated using either general or spinal anaesthesia. Patients aged ≥ 70 years who underwent surgery for a fracture of the hip between 2010 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Of the 9842 patients who met the inclusion criteria, 7253 (73.7%) were treated with general anaesthesia and 2589 (26.3%) with spinal anaesthesia. On propensity-adjusted multivariate analysis, general anaesthesia was associated with slightly increased operating time (+5 minutes, 95% confidence interval (CI) +4 to +6, p < 0.001) and post-operative time in the operating room (+5 minutes, 95% CI +2 to +8, p < 0.001) compared with spinal anaesthesia. General anaesthesia was associated with a shorter LOS (hazard ratio (HR) 1.28, 95% CI 1.22 to 1.34, p < 0.001). Any adverse event (odds ratio (OR) 1.21, 95% CI 1.10 to 1.32, p < 0.001), thromboembolic events (OR 1.90, 95% CI 1.24 to 2.89, p = 0.003), any minor adverse event (OR 1.19, 95% CI 1.09 to 1.32, p < 0.001), and blood transfusion (OR 1.34, 95% CI 1.22 to 1.49, p < 0.001) were associated with general anaesthesia. General anaesthesia was associated with decreased rates of urinary tract infection (OR 0.73, 95% CI 0.62 to 0.87, p < 0.001). There was no clear overall advantage of one type of anaesthesia over the other, and surgeons should be aware of the specific risks and benefits associated with each type.
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Affiliation(s)
- B A Basques
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, 800 Howard Avenue, New Haven, CT, 06510, USA
| | - D D Bohl
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, 800 Howard Avenue, New Haven, CT, 06510, USA
| | - N S Golinvaux
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, 800 Howard Avenue, New Haven, CT, 06510, USA
| | - A M Samuel
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, 800 Howard Avenue, New Haven, CT, 06510, USA
| | - J G Grauer
- Yale School of Medicine , Department of Orthopaedics and Rehabilitation, 800 Howard Avenue, New Haven, CT, 06510, USA
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Propensity Score–matched Comparison of Postoperative Adverse Outcomes between Geriatric Patients Given a General or a Neuraxial Anesthetic for Hip Surgery. Anesthesiology 2015; 123:136-47. [DOI: 10.1097/aln.0000000000000695] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background:
The effects of the mode of anesthesia on major adverse postoperative outcomes in geriatric patients are still inconclusive. The authors hypothesized that a neuraxial anesthetic (NA) rather than a general anesthetic (GA) would yield better in-hospital postoperative outcomes for geriatric patients undergoing hip surgery.
Methods:
The authors used data from Taiwan’s 1997–2011 in-patient claims database to evaluate the effect of anesthesia on in-hospital outcomes. The endpoints were mortality, stroke, transient ischemic stroke, myocardial infarction, respiratory failure, and renal failure. Of the 182,307 geriatric patients who had hip surgery, a GA was given to 53,425 (29.30%) and an NA to 128,882 (70.70%). To adjust for baseline differences and selection bias, patients were matched on propensity scores, which left 52,044 GA and 52,044 NA patients.
Results:
GA-group patients had a greater percentage and higher odds of adverse in-hospital outcomes than did NA-group patients: death (2.62 vs. 2.13%; odds ratio [OR], 1.24; 95% CI, 1.15 to 1.35; P < 0.001), stroke (1.61 vs. 1.38%; OR, 1.18, 95% CI, 1.07 to 1.31; P = 0.001), respiratory failure (1.67 vs. 0.63%; OR, 2.71; 95% CI, 2.38 to 3.01; P < 0.001), and intensive care unit admission (11.03 vs. 6.16%; OR, 1.95; 95% CI, 1.87 to 2.05; P < 0.001), analyzed using conditional logistic regression. Moreover, patients given a GA had longer hospital stays (10.77 ± 8.23 vs. 10.44 ± 6.67 days; 95% CI, 0.22 to 0.40; P < 0.001) and higher costs (New Taiwan Dollars [NT$] 86,606 ± NT$74,162 vs. NT$74,494 ± NT$45,264; 95% CI, 11,366 to 12,859; P < 0.001).
Conclusion:
For geriatric patients undergoing hip surgery, NA was associated with fewer odds of adverse outcomes than GA.
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Wang N, Wang J, Zhang R, Wang F, Wang R. The effects of anaesthetics on postoperative physiological reactions: a meta-analysis. Clin Exp Pharmacol Physiol 2015; 42:1127-34. [PMID: 26016612 DOI: 10.1111/1440-1681.12430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 05/19/2015] [Accepted: 05/20/2015] [Indexed: 10/23/2022]
Abstract
This study aimed to systematically investigate the effects of different anaesthetics on postoperative physiological reactions compared with placebo. The literature search was conducted using three databases: PubMed, EMBASE, and the Cochrane Library. Studies published from January 1990 to January 2015 were screened. The language was restricted to English. Heterogeneity was analyzed by the Q test and I(2) statistic. A fixed-effect model was used for homogenous data and a random-effects model for heterogeneous data. The odds ratio (OR) and 95% confidence interval (CI) were calculated to monitor the incidences of overall adverse events, arterial blood pressure, and cardiac abnormalities. Sensitivity analysis was performed to estimate the strength of the meta-analysis, and publication bias was analyzed using Egger's test. A total of 24 articles were included in this meta-analysis. There were 1,810 and 1,806 cases in the anaesthetic group and the placebo group, respectively. The incidence of overall adverse events was significantly lower in the anaesthetic group compared with the placebo group (OR = 0.57; 95% CI, 0.38-0.84). No publication bias was observed, and no inverse estimates were calculated using sensitivity analysis. There was no significant difference for the incidence of arterial blood pressure (OR = 4.62; 95% CI, 0.90-23.70) and cardiac abnormalities (OR = 1.18; 95% CI, 0.53-2.63) between the two groups. Although the incidence of overall adverse events was decreased in the anaesthetic group, it is impossible to determine whether the use of anaesthetics during surgical operation has a protective effect on postoperative physiological reactions.
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Affiliation(s)
- Na Wang
- Department of Anaesthesiology, First Hospital of Jilin University, Changchun, China
| | - Jinguo Wang
- Department of Urology, First Hospital of Jilin University, Changchun, China
| | - Rui Zhang
- Department of Colorectal Surgery, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Fei Wang
- Department of Anaesthesia, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Rui Wang
- Department of Information Engineering, Jilin Business and Technology College, Changchun, China
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Postoperative cognitive function following general versus regional anesthesia: a systematic review. J Neurosurg Anesthesiol 2015; 26:369-76. [PMID: 25144505 DOI: 10.1097/ana.0000000000000120] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The effect of anesthetic technique on postoperative outcomes remains in question. This systematic review compares the role of regional versus general anesthesia, with a particular focus on postoperative cognitive function. Potentially relevant articles were identified by searching publicly available computerized databases for this systematic review. Any surgical procedure was accepted with the exception of cardiac, carotid, and neurosurgical procedures. Any regional anesthetic technique was accepted unless combined with a general anesthetic or in conjunction with propofol as a sedative. Any measure of postoperative cognitive function was accepted as long as it was performed no sooner than 7 days postoperatively. Sixteen studies met inclusion criteria and were included in the final analysis. Three studies showed some difference in cognitive function between regional and general anesthesia, whereas the remaining 13 showed no difference between regional and general anesthesia on postoperative cognitive function.
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Serghini I, Qamouss Y, Zoubir M, Lalaoui JS, Koulali IK, Boughalem M. [Anesthesia for total hip prosthesis: report of 50 cases]. Pan Afr Med J 2015; 22:379. [PMID: 27047619 PMCID: PMC4796777 DOI: 10.11604/pamj.2015.22.379.6938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 05/27/2015] [Indexed: 11/17/2022] Open
Abstract
La chirurgie de la prothèse totale de la hanche (PTH) est une chirurgie fonctionnelle qui consiste en un remplacement d'une articulation endommagée afin d'améliorer la qualité de vie du patient. L'anesthésie pour PTH exige une préparation rigoureuse à l'intervention, la consultation d'anesthésie sera donc la clef de cette réussite. Nous avons réalisé une étude rétrospective concernant 60 arthroplasties totales de la hanche implantées chez 50 patients adultes, colligée au sevice de Traumatologie et de chirurgie orthopédique à l'Hôpital Militaire Avicenne de Marrakech sur une période étalée de Janvier 2010 au Décembre 2012. Nous avons évalué la prise en charge anesthésique: pré, per et postopératoire des patients opérés pour une PTH. La moyenne d’âge était de 56,5 ans, le sex-ratio était de 1,63 en faveur des hommes. L'indication prédominante était la coxarthrose primitive. L'anesthésie générale était la technique anesthésique la plus utilisée (66% des cas), l'intubation difficile était rencontrée chez 6% de nos patients. La durée moyenne de l'acte chirurgical était de 114 +/- 25,33 mn. 12% de nos patients ont présenté une hypotension artérielle peropératoire. L'incidence de la transfusion homologue perop était de 14%. Nous avons noté 08 cas de complications postop: 03 cas d'infection de la PTH 15 jours après l'intervention, 03 cas de descellement aseptique, 01 cas de luxation de PTH et 01 cas de descellement septique avec un recul moyen de 54 mois.
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Affiliation(s)
- Issam Serghini
- Pôle Anesthésie- Réanimation, Hôpital Militaire Avicenne, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40010 Marrakech, Maroc
| | - Youssef Qamouss
- Pôle Anesthésie- Réanimation, Hôpital Militaire Avicenne, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40010 Marrakech, Maroc
| | - Mohamed Zoubir
- Pôle Anesthésie- Réanimation, Hôpital Militaire Avicenne, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40010 Marrakech, Maroc
| | - Jaafar Salim Lalaoui
- Pôle Anesthésie- Réanimation, Hôpital Militaire Avicenne, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40010 Marrakech, Maroc
| | - Idrissi Khalid Koulali
- Pôle de Traumatologie et Orthopédie, Hôpital Militaire Avicenne, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40010 Marrakech, Maroc
| | - Mohamed Boughalem
- Pôle Anesthésie- Réanimation, Hôpital Militaire Avicenne, Faculté de Médecine et de Pharmacie, Université Cadi Ayyad, 40010 Marrakech, Maroc
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Abstract
Hip fracture is one of the most common orthopedic conditions associated with significant morbidity and mortality. Patients with hip fracture are usually older, with significant comorbidities. Delayed surgical treatment beyond 48 hours after admission is associated with significantly higher mortality. Hereby clinicians are presented with the challenge to optimize the complex hip fracture within a short time period. This article reviews the evidence regarding preoperative, intraoperative, and postoperative considerations, and provides insights into the best strategies with which to optimize the patient's condition and improve perioperative outcomes.
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Affiliation(s)
- Jiabin Liu
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Jaimo Ahn
- Department of Orthopedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Seitz DP, Gill SS, Bell CM, Austin PC, Gruneir A, Anderson GM, Rochon PA. Postoperative Medical Complications Associated with Anesthesia in Older Adults with Dementia. J Am Geriatr Soc 2014; 62:2102-9. [DOI: 10.1111/jgs.13106] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Dallas P. Seitz
- Department of Psychiatry; Queen's University; Kingston Ontario Canada
| | - Sudeep S. Gill
- Department of Medicine; Queen's University; Kingston Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Chaim M. Bell
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Department of Medicine; Mt. Sinai Hospital; Toronto Ontario Canada
| | - Peter C. Austin
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
| | - Andrea Gruneir
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Women's College Research Institute; Women's College Hospital; Toronto Ontario Canada
| | - Geoff M. Anderson
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
| | - Paula A. Rochon
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
- Women's College Research Institute; Women's College Hospital; Toronto Ontario Canada
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Opperer M, Danninger T, Stundner O, Memtsoudis SG. Perioperative outcomes and type of anesthesia in hip surgical patients: An evidence based review. World J Orthop 2014; 5:336-343. [PMID: 25035837 PMCID: PMC4095027 DOI: 10.5312/wjo.v5.i3.336] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 03/24/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
Over the last decades the demand for hip surgery, be it elective or in a traumatic setting, has greatly increased and is projected to expand even further. Concurrent with demographic changes the affected population is burdened by an increase in average comorbidity and serious complications. It has been suggested that the choice of anesthesia not only affects the surgery setting but also the perioperative outcome as a whole. Therefore different approaches and anesthetic techniques have been developed to offer individual anesthetic and analgesic care to hip surgery patients. Recent studies on comparative effectiveness utilizing population based data have given us a novel insight on anesthetic practice and outcome, showing favorable results in the usage of regional vs general anesthesia. In this review we aim to give an overview of anesthetic techniques in use for hip surgery and their impact on perioperative outcome. While there still remains a scarcity of data investigating perioperative outcomes and anesthesia, most studies concur on a positive outcome in overall mortality, thromboembolic events, blood loss and transfusion requirements when comparing regional to general anesthesia. Much of the currently available evidence suggests that a comprehensive medical approach with emphasis on regional anesthesia can prove beneficial to patients and the health care system.
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Patorno E, Neuman MD, Schneeweiss S, Mogun H, Bateman BT. Comparative safety of anesthetic type for hip fracture surgery in adults: retrospective cohort study. BMJ 2014; 348:g4022. [PMID: 24972901 PMCID: PMC4073666 DOI: 10.1136/bmj.g4022] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the effect of anesthesia type on the risk of in-hospital mortality among adults undergoing hip fracture surgery in the United States. DESIGN Retrospective cohort study. SETTING Premier research database, United States. PARTICIPANTS 73,284 adults undergoing hip fracture surgery on hospital day 2 or greater between 2007 and 2011. Of those, 61,554 (84.0%) received general anesthesia, 6939 (9.5%) regional anesthesia, and 4791 (6.5%) combined general and regional anesthesia. MAIN OUTCOME MEASURE In-hospital all cause mortality. RESULTS In-hospital deaths occurred in 1362 (2.2%) patients receiving general anesthesia, 144 (2.1%) receiving regional anesthesia, and 115 (2.4%) receiving combined anesthesia. In the multivariable adjusted analysis, when compared with general anesthesia the mortality risk did not differ significantly between regional anesthesia (risk ratio 0.93, 95% confidence interval 0.78 to 1.11) or combined anesthesia (1.00, 0.82 to 1.22). A mixed effects analysis accounting for differences between hospitals produced similar results: compared with general anesthesia the risk from regional anesthesia was 0.91 (0.75 to 1.10) and from combined anesthesia was 0.98 (0.79 to 1.21). Findings were also consistent in subgroup analyses. CONCLUSIONS In this large nationwide sample of hospital admissions, mortality risk did not differ significantly by anesthesia type among patients undergoing hip fracture surgery. Our results suggest that if the previously posited beneficial effect of regional anesthesia on short term mortality exists, it is likely to be more modest than previously reported.
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Affiliation(s)
- Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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Neuman MD, Rosenbaum PR, Ludwig JM, Zubizarreta JR, Silber JH. Anesthesia technique, mortality, and length of stay after hip fracture surgery. JAMA 2014; 311:2508-17. [PMID: 25058085 PMCID: PMC4344128 DOI: 10.1001/jama.2014.6499] [Citation(s) in RCA: 196] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE More than 300,000 hip fractures occur each year in the United States. Recent practice guidelines have advocated greater use of regional anesthesia for hip fracture surgery. OBJECTIVE To test the association of regional (ie, spinal or epidural) anesthesia vs general anesthesia with 30-day mortality and hospital length of stay after hip fracture. DESIGN, SETTING, AND PATIENTS We conducted a matched retrospective cohort study involving patients 50 years or older who were undergoing surgery for hip fracture at general acute care hospitals in New York State between July 1, 2004, and December 31, 2011. Our main analysis was a near-far instrumental variable match that paired patients who lived at different distances from hospitals that specialized in regional or general anesthesia. Supplementary analyses included a within-hospital match that paired patients within the same hospital and an across-hospital match that paired patients at different hospitals. EXPOSURES Spinal or epidural anesthesia; general anesthesia. MAIN OUTCOMES AND MEASURES Thirty-day mortality and hospital length of stay. Because the distribution of length of stay had long tails, we characterized this outcome using the Huber M estimate with Huber weights, a robust estimator similar to a trimmed mean. RESULTS Of 56,729 patients, 15,904 (28%) received regional anesthesia and 40,825 (72%) received general anesthesia. Overall, 3032 patients (5.3%) died. The M estimate of the length of stay was 6.2 days (95% CI, 6.2 to 6.2). The near-far matched analysis showed no significant difference in 30-day mortality by anesthesia type among the 21,514 patients included in this match: 583 of 10,757 matched patients (5.4%) who lived near a regional anesthesia-specialized hospital died vs 629 of 10,757 matched patients (5.8%) who lived near a general anesthesia-specialized hospital (instrumental variable estimate of risk difference, -1.1%; 95% CI, -2.8 to 0.5; P = .20). Supplementary analyses of within and across hospital patient matches yielded mortality findings to be similar to the main analysis. In the near-far match, regional anesthesia was associated with a 0.6-day shorter length of stay than general anesthesia (95% CI, -0.8 to -0.4, P < .001). Supplementary analyses also showed regional anesthesia to be associated with shorter length of stay, although the observed association was smaller in magnitude than in the main analysis. CONCLUSIONS AND RELEVANCE Among adults in acute care hospitals in New York State undergoing hip repair, the use of regional anesthesia compared with general anesthesia was not associated with lower 30-day mortality but was associated with a modestly shorter length of stay. These findings do not support a mortality benefit for regional anesthesia in this setting.
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Affiliation(s)
- Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia2Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Paul R Rosenbaum
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania3Department of Statistics, the Wharton School, University of Pennsylvania, Philadelphia
| | - Justin M Ludwig
- Center for Outcomes Research, The Children's Hospital of Philadelphia
| | - Jose R Zubizarreta
- Division of Decisions, Risk and Operations, Columbia Business School, New York, New York6Department of Statistics, Columbia University, New York, New York
| | - Jeffrey H Silber
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia2Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania4Center for Outcomes Research, The Children's Hospital of Ph
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Koç M, Saçan Ö, Gamlı M, Taşpınar V, Postacı A, Fikir E, Dikmen B. Retrospective Evaluation of Anaesthesia Techniques for Hip Replacement Operations. Turk J Anaesthesiol Reanim 2014; 42:133-9. [PMID: 27366407 DOI: 10.5152/tjar.2014.07108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 07/05/2013] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE In this retrospective study, we evaluated the demographic characteristics of patients that underwent hip replacement surgery in our orthopedic clinic. Associated diseases, preoperative laboratory findings, intraoperative findings, and the effect of admission or refusal to the intensive care unit on postoperative mortality and morbidity were recorded. Furthermore, we tried to identify surgical and anaesthetic methods applied, intraoperative hemodynamic changes, length of stay in the post-anaesthesia care unit, and postoperative complications. METHODS Demographic characteristics, co-morbidities, preoperative laboratory findings, intraoperative findings, and admission or refusal to the intensive care unit of patients who underwent hip replacement surgery between January 2008-December 2010 were enrolled. RESULTS Out of 500 patients, 33.4% (n=164) were operated under general anaesthesia, 34% (n=170) under combined spinal-epidural anaesthesia, 22.2% (n=111) under spinal anaesthesia, 6.4% (n=32) under combined lomber plexus block and sciatic nerve block, and 4% (n=20) under epidural anaesthesia. Mean hospital stay was 7 days in the general anaesthesia group and 5 days in the regional anaesthesia group. CONCLUSION American Society of Anesthesiologists (ASA) scores and incidence of co-morbidities were higher in the partial hip replacement group. Admission to the intensive care unit was lower in the total hip replacement group. Hospital stay was shorter in the partial hip replacement group. Mortality rates on the 7(th) and 30(th) days were higher in the partial hip replacement group.
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Affiliation(s)
- Murat Koç
- Clinic of Anaesthesia and Reanimation, Karabük State Hospital, Karabük, Turkey
| | - Özlem Saçan
- Clinic of Anaesthesia and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Mehmet Gamlı
- Clinic of Anaesthesia and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Vildan Taşpınar
- Clinic of Anaesthesia and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Aysun Postacı
- Clinic of Anaesthesia and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Emel Fikir
- Clinic of Anaesthesia and Reanimation, Dumlupınar University Evliya Çelebi Training and Research Hospital, Kütahya, Turkey
| | - Bayazit Dikmen
- Clinic of Anaesthesia and Reanimation, Ankara Numune Training and Research Hospital, Ankara, Turkey
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Abstract
Age-related changes in skin contribute to impaired wound healing after surgical procedures. Changes in skin with age include decline in thickness and composition, a decrease in the number of most cell types, and diminished microcirculation. The microcirculation provides tissue perfusion, fluid homeostasis, and delivery of oxygen and other nutrients. It also controls temperature and the inflammatory response. Surgical incisions cause further disruption of the microvasculature of aged skin. Perioperative management can be modified to minimize insults to aged tissues. Judicious use of fluids, maintenance of normal body temperature, pain control, and increased tissue oxygen tension are examples of adjustable variables that support the microcirculation. Anesthetic agents influence the microcirculation of a combination of effects on cardiac output, arterial pressure, and local microvascular changes. The authors examined the role of anesthetic management in optimizing the microcirculation and potentially improving postoperative wound repair in older persons.
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Liu JL, Wang XL, Gong MW, Mai HX, Pei SJ, Yuan WX, Zhang H. Comparative outcomes of peripheral nerve blocks versus general anesthesia for hip fractures in geriatric Chinese patients. Patient Prefer Adherence 2014; 8:651-9. [PMID: 24855341 PMCID: PMC4019620 DOI: 10.2147/ppa.s61903] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Geriatric patients undergoing hemiarthroplasty for hip fractures have unacceptably high rates of postoperative complications and mortality. Whether anesthesia type can affect the outcomes has still been inconclusive. OBJECTIVES We compared general anesthesia (GA) and peripheral nerve blocks (PNBs) on postoperative complications and mortality in elderly patients with femoral neck fractures (FNF) undergoing hemiarthroplasty. MATERIALS AND METHODS This retrospective study involved data collection from an electronic database. Two hundred and seventeen patients underwent hemiarthroplasty for FNF between January 2008 and December 2012 at the Chinese People's Liberation Army General Hospital. Data on mortality within in-hospital, 30-day, and 1-year, complications, comorbidities, blood loss and transfusion, operative time, postoperative hospital length of stay, intensive care unit admission, and hospital charge were collected and analyzed. Univariate and multivariate Cox regression analyses of all variables were used for 30-day and 1-year mortality. RESULTS Seventy-two patients receiving GA and 145 receiving PNBs were eventually submitted and analyzed. Mortality was 6.9%, 14.7%, and 23.5% at in-hospital, 30-day, and 1-year, respectively postoperatively, while mortality and cardiovascular complications did not differ between the two anesthetic techniques. Preoperative comorbidities and intraoperative parameters were not statistically different except that patients receiving GA were more likely to have dementia (χ (2)=10.45, P=0.001). The most common complications were acute cardiovascular events, electrolyte disturbances, and delirium. Postoperative acute respiratory events and hypoxemia both were also common, but no differences were found between groups (χ (2)=0.68, P=0.410; χ (2)=3.42, P=0.065, respectively). Key factors negatively influencing mortality included: age, male gender, American Society of Anesthesiologists status, dementia, perioperative cardiovascular events and respiratory events, postoperative stroke, myocardial infarction, and hypoxia. CONCLUSION Mortality and postoperative complications are not statistically significantly different between PNBs and GA among eldery patients undergoing hemiarthroplasty for FNF.
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Affiliation(s)
- Jun Le Liu
- Anesthesia and Operation Center, Chinese People’s Liberation Army General Hospital and Medical School of Chinese People’s Liberation Army, Beijing, People’s Republic of China
| | - Xiao Lin Wang
- Anesthesia and Operation Center, Chinese People’s Liberation Army General Hospital and Medical School of Chinese People’s Liberation Army, Beijing, People’s Republic of China
| | - Mao Wei Gong
- Anesthesia and Operation Center, Chinese People’s Liberation Army General Hospital and Medical School of Chinese People’s Liberation Army, Beijing, People’s Republic of China
| | - Hai Xing Mai
- Department of Urology, Affiliated Hospital of Academy of Military Medical Sciences, Beijing, People’s Republic of China
| | - Shu Jun Pei
- Anesthesia and Operation Center, Chinese People’s Liberation Army General Hospital and Medical School of Chinese People’s Liberation Army, Beijing, People’s Republic of China
| | - Wei Xiu Yuan
- Anesthesia and Operation Center, Chinese People’s Liberation Army General Hospital and Medical School of Chinese People’s Liberation Army, Beijing, People’s Republic of China
| | - Hong Zhang
- Anesthesia and Operation Center, Chinese People’s Liberation Army General Hospital and Medical School of Chinese People’s Liberation Army, Beijing, People’s Republic of China
- Correspondence: Hong Zhang, Anesthesia and Operation Center, Chinese People’s Liberation Army General Hospital, Fuxing Road 28th, Beijing, People’s Republic of China, Tel +86 10 6693 8051, Fax +86 10 8827 1427, Email
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Rastogi B, Gupta K, Rastogi A, Gupta PK, Singhal AB, Singh I. Hemiarthroplasty in high risk elderly patient under epidural anesthesia with 0.75% ropivacaine-fentanyl versus 0.5% bupivacaine-fentanyl: Clinical trial. Saudi J Anaesth 2013; 7:142-5. [PMID: 23956712 PMCID: PMC3737688 DOI: 10.4103/1658-354x.114058] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Anesthetic management of elderly patients is a challenge as aging makes them more susceptible to hemodynamic fluctuations during regional anesthesia. This study was aimed to compare the clinical efficacy of epidural 0.75% ropivacaine fentanyl (RF)– with 0.5% bupivacaine–fentanyl (BF) for hemiarthroplasty in high-risk elderly patients. Methods: Sixty elderly consented patients of either sex with American Society of Anesthesiologist ASA II and III, scheduled for elective hemiarthroplasty were randomized into two Groups of 30 patients to receive epidural study solution of 15 mL of 0.75% Ropivacaine or 0.5% Bupivacaine with 1 mL fentanyl (50 μg). The hemodynamic variability with onset and duration of sensory and motor blocks were recorded. The adequacy and quality of surgical anesthesia were assessed. The post-epidural nausea and vomiting, shivering, respiratory parameters, or any other side effects were also recorded. Results: There was no difference in the demographic profile between groups. The mean onset time to achieve sensory block to the T10 dermatome was rapid in the Group BF (12.4±6.9 vs. 17.5±3.7 min in Group RF). The mean time to achieve motor block was 17.5±3.4 min in Group BF versus 21.7±7.8 min in Group RF. The intraoperative hemodynamic fluctuations showed statistically significant differences between groups. The pruritis was observed in five patients but post-epidural shivering, nausea, vomiting, respiratory depression, or urinary retention were not observed in any patient. Conclusion: Epidural 0.75% Ropivacaine with fentanyl showed better clinical profile as compared to 0.5% Bupivacaine with fentanyl for hemiarthroplasty in elderly patients.
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Affiliation(s)
- Bhawna Rastogi
- Department of Anaesthesiology and Critical Care, N.S.C.B., Subharti Medical College, Subhartipuram, Meerut, Uttar Pradesh, India
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Hip fracture surgery: does type of anesthesia matter? BIOMED RESEARCH INTERNATIONAL 2013; 2013:252356. [PMID: 23819114 PMCID: PMC3684036 DOI: 10.1155/2013/252356] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 05/11/2013] [Indexed: 01/24/2023]
Abstract
BACKGROUND Hip fracture surgery is a common procedure, and the geriatric population with its multiple comorbid conditions is at most at risk of developing anesthesia-related complications. Data on the impact of type anesthesia on postoperative morbidity and mortality is limited. The effects of regional and general anesthesia on postoperative outcomes need to be clearly elucidated. METHODS In this study, all patients who underwent dynamic hip screw (DHS) fixation for intertrochanteric fractures, between January 2005 and December 2010, at the Aga Khan University Hospital, were included. Patients were divided into two groups; group A included those patients who received general anesthesia, and group B consisted of patients who had received regional anesthesia. The two groups were compared for differences in morbidity, mortality, and intraoperative complications based on the type of anesthesia administered. RESULTS During this period, 194 patients underwent DHS fixation. One hundred and seven patients received general anesthesia whereas eighty-seven patients received regional anesthesia. The mean operative time was significantly lower in the group receiving regional anesthesia (1.25 ± 0.39 hrs) as compared to those who received general anesthesia (1.54 ± 0.6 hrs) (P < 0.05). There were no statistically significant differences in the rates of wound infections, length of hospital stay, postoperative ambulation status, intraoperative blood loss, postoperative complications, and mortality between the regional and general anesthesia groups. CONCLUSION Even though administration of regional anesthesia was positively correlated with shorter operative duration, the type of anesthesia was not found to affect surgical outcomes in the two study groups. Based on these results, we recommend that anesthesia should be tailored to individual patient requirements.
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Memtsoudis SG, Sun X, Chiu YL, Stundner O, Liu SS, Banerjee S, Mazumdar M, Sharrock NE. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology 2013; 118:1046-58. [PMID: 23612126 PMCID: PMC3956038 DOI: 10.1097/aln.0b013e318286061d] [Citation(s) in RCA: 295] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND The impact of anesthetic technique on perioperative outcomes remains controversial. We studied a large national sample of primary joint arthroplasty recipients and hypothesized that neuraxial anesthesia favorably influences perioperative outcomes. METHODS Data from approximately 400 hospitals between 2006 and 2010 were accessed. Patients who underwent primary hip or knee arthroplasty were identified and subgrouped by anesthesia technique: general, neuraxial, and combined neuraxial-general. Demographics, postoperative complications, 30-day mortality, length of stay, and patient cost were analyzed and compared. Multivariable analyses were conducted to identify the independent impact of choice of anesthetic on outcomes. RESULTS Of 528,495 entries of patients undergoing primary hip or knee arthroplasty, information on anesthesia type was available for 382,236 (71.4%) records. Eleven percent were performed under neuraxial, 14.2% under combined neuraxial-general, and 74.8% under general anesthesia. Average age and comorbidity burden differed modestly between groups. When neuraxial anesthesia was used, 30-day mortality was significantly lower (0.10, 0.10, and 0.18%; P < 0.001), as was the incidence of prolonged (>75th percentile) length of stay, increased cost, and in-hospital complications. In the multivariable regression, neuraxial anesthesia was associated with the most favorable complication risk profile. Thirty-day mortality remained significantly higher in the general compared with the neuraxial or neuraxial-general group for total knee arthroplasty (adjusted odds ratio [OR] of 1.83, 95% CI 1.08-3.1, P = 0.02; OR of 1.70, 95% CI 1.06-2.74, P = 0.02, respectively). CONCLUSIONS The utilization of neuraxial versus general anesthesia for primary joint arthroplasty is associated with superior perioperative outcomes. More research is needed to study potential mechanisms for these findings.
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Affiliation(s)
- Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA.
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Lilot M, Meuret P, Bouvet L, Caruso L, Dabouz R, Deléat-Besson R, Rousselet B, Thouverez B, Zadam A, Allaouchiche B, Boselli E. Hypobaric spinal anesthesia with ropivacaine plus sufentanil for traumatic femoral neck surgery in the elderly: a dose-response study. Anesth Analg 2013; 117:259-64. [PMID: 23592605 DOI: 10.1213/ane.0b013e31828f29f8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In this randomized, prospective trial, we sought to determine the effective dose of hypobaric ropivacaine with sufentanil providing 95% success (ED95) in spinal anesthesia for traumatic femoral neck surgery in the elderly. METHODS Sixty-eight elderly patients with unilateral hip fracture randomly received 6, 8, 10, or 12 mg spinal hypobaric ropivacaine combined with 5 µg sufentanil. Patients remained in a lateral position for 15 minutes after spinal injection. The dose was considered successful if a unilateral sensory block >T12 was achieved, and there was no need for additional analgesia or conversion to general anesthesia. The ED95 was determined using logit analysis. The incidence of severe and very severe hypotension (systolic blood pressure decrease by >30% and >40% baseline, respectively) and the use of remifentanil were compared among groups using χ(2) test for trend. RESULTS Three patients were excluded because of failure to reach the subarachnoid space. No differences in baseline demographic data were observed among groups. The ED95 for hypobaric ropivacaine was determined to be 9 mg (95% confidence interval, 8-14). Increasing doses of ropivacaine (6, 8, 10, and 12 mg) demonstrated a positive trend with respect to incidence of hypotension (53%, 47%, 87%, and 81%, P = 0.0004) and a negative trend with respect to the use of remifentanil (41%, 12%, 0%, and 0%, P = 0.0004). A significant difference in the level of sensory block (P < 0.0001) was observed among operative and nonoperative sides but not among ropivacaine dosing groups (P = 0.16). No difference in motor blockade, incidence of very severe hypotension, total dose of ephedrine, duration of surgery, patient satisfaction, operating conditions, or surgeon satisfaction scores was observed among groups. No cases of bradycardia were observed. No patient had a preoperative sensory level <T12 after 15 minutes in the lateral decubitus position, and no cases were converted to general anesthesia. There was no difference in undesirable outcomes or postoperative troponin values among groups. CONCLUSIONS The effective dose of hypobaric ropivacaine combined with sufentanil 5 µg providing 95% success in spinal anesthesia for traumatic femoral neck surgery in the elderly is ED95 = 9 mg (95% confidence interval, 8-14). Using doses exceeding the ED95 may increase the incidence of hypotension. If doses less than the ED95 are chosen, the use of additional analgesia may be necessary.
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Affiliation(s)
- Marc Lilot
- Service d'anesthésie-réanimation, Hôpital Édouard Herriot, 5 place d'Arsonval, 69003 Lyon, France.
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