Anesthetic Methods for Hip Fracture

PURPOSE OF REVIEW

To review the benefits, risks, and contraindications of traditional and new anesthesia approaches for hip fracture surgery and describe what is known about the impact of these approaches on postoperative outcomes.

RECENT FINDINGS

This review describes general and spinal anesthesia, peripheral nerve block techniques used for pain management, and novel, local anesthesia approaches which may provide significant benefit compared with traditional approaches by minimizing high-risk induction time and decreasing respiratory suppression and short- and long-term cognitive effects. Hip fracture surgery places a large physiologic stress on an already frail patient, and anesthesia choice plays an important role in managing risk of perioperative morbidity. New local anesthesia techniques may decrease morbidity and mortality, particularly in higher-risk patients.

Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial

BACKGROUND

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.

OBJECTIVE

To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.

DESIGN

Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).

SETTING

46 U.S. and Canadian hospitals.

PARTICIPANTS

Patients aged 50 years or older undergoing hip fracture surgery.

INTERVENTION

Spinal or general anesthesia.

MEASUREMENTS

Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.

RESULTS

A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.

LIMITATION

Missing outcome data and multiple outcomes assessed.

CONCLUSION

Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

Standardized Preoperative Pathways Determining Preoperative Echocardiogram Usage Continue to Improve Hip Fracture Quality

Introduction

The purpose of this study was to assess the hospital quality measures and outcomes of operative hip fracture patients before and after implementation of an anesthesiology department protocol assigning decision for a preoperative transthoracic echocardiogram (TTE) to the hospitalist co-managing physician.

Materials and Methods

Demographics, injury details, hospital quality measures, and outcomes were reviewed for a consecutive series of patients presenting to our institution with an operative hip fracture. In May of 2019, a new protocol assigning the responsibility to indicate a patient for preoperative TTE was mandated to the co-managing hospitalist at the institution. Patients were split into pre-protocol and post-protocol cohorts. Linear regression modeling and comparative analyses were conducted with a Bonferroni adjusted alpha as appropriate.

Results

Between September 2015 and June 2021, 1002 patients presented to our institution and were diagnosed with a hip fracture. Patients in the post-protocol cohort were less likely to undergo a preoperative echocardiogram, experienced a shorter time (days) to surgery, shorter length of stay, an increase in amount of home discharges, and lower complication risks for urinary tract infection and acute blood loss anemia as compared to those in the pre-protocol cohort. There were no differences seen in inpatient or 30-day mortality. Multivariable linear regression demonstrated a patient’s comorbidity profile (Charlson Comorbidity Index (CCI)) and their date of presentation (pre- or post-protocol), were both associated with (P<0.01) a patients' time to surgery.

Conclusion

A standardized preoperative work flow protocol regarding which physician evaluates and determines which patients require a preoperative TTE allows for a streamlined perioperative course for hip fracture patients. This allows for a shortened time to surgery and length of stay with an increase in home discharges and was associated with a reduced risk of common index hospitalization complications including UTI and anemia.

Regional anesthesia for nonunion surgery with iliac crest bone grafting results in an increase in same day discharge

INTRODUCTION

The purpose of this study was to evaluate the outcomes of fracture nonunion repair with autogenous iliac crest bone graft (ICBG) under regional anesthesia alone or in combination with other techniques compared to other anesthesia techniques.

MATERIALS AND METHODS

Overall, 137 patients were identified who underwent ICBG as part of a repair of a long bone fracture nonunion between January 1, 2013 and October 1, 2020. Surgical and anesthetic records were reviewed to classify patients by anesthesia type. General, spinal, and regional anesthetics were used as either the primary anesthetic or as a combination of regional nerve block with general or spinal anesthesia.

RESULTS

Administration of regional anesthesia alone or in combination with general or spinal anesthesia (RA) and general or spinal anesthesia only (GS) groups differed in nonunion site distribution (p < 0.001). RA patients were discharged the same day more often than GS patients (30.9% vs 10.0%, p = 0.009) and experienced fewer postoperative complications (p = 0.021). The RA group achieved union sooner than the GS group (by 5.3 ± 3.2 months vs. by 6.8 ± 3.2 months, p = 0.006). Mean morphine equivalent dose was similar between groups (p = 0.23). Regional anesthesia use increased from 2013 to 2020, and same day discharge surgeries simultaneously increased over the same time period.

CONCLUSION

Regional anesthesia use increased in nonunion repair surgery with ICBG from 2013 to 2020. This was associated with an increase in same day discharge, sooner time to union, and decreased postoperative complications. There was not a need for increased opioid prescription in patients that underwent regional anesthesia.

Regional anesthesia for clavicle fracture surgery is safe and effective

BACKGROUND

Historically, clavicle fracture repairs have been performed with patients under general anesthesia. However, in the past few years, the combination of an interscalene brachial plexus block and a modified superficial cervical plexus block has been described to provide adequate anesthesia for clavicle fracture surgery, with the added benefit of postoperative analgesia. In March 2013, members of our anesthesiology department began using this block with sedation for a subset of patients undergoing clavicle fracture fixation.

METHODS

This study was a retrospective review of patients who underwent clavicle fracture repair at a single institution between June 2014 and November 2017. The decision on the type of anesthesia (regional vs. general) was made jointly by the patient, anesthesiologist, and surgeon. Demographic data, relevant perioperative times, and intraoperative pain medication consumption were recorded, and comparisons of these variables were made between the regional and general anesthesia groups.

RESULTS

A total of 110 patients with 110 fractures were included. Of these patients, 52 received only regional anesthesia with the combined block whereas 58 received general anesthesia with an interscalene brachial plexus block. No major anesthetic-related complications were noted in any patients, and there were no cases in which regional anesthesia had to be converted to general anesthesia because of block failure. The anesthesia start time was significantly longer in the general anesthesia group (29 minutes vs. 20 minutes, P = .022), as was the total case time (164 minutes vs. 131 minutes, P < .001). Patients in the general anesthesia group required significantly more intraoperative fentanyl to be administered (207 μg vs. 141 μg, P = .002).

CONCLUSION

Regional anesthesia using a combined brachial plexus and modified superficial cervical plexus block is a reliable, efficacious technique. The combined block appears to be a reasonable alternative to general anesthesia with an interscalene brachial plexus block, and it may have benefits regarding the anesthesia start time and total case time.