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.

Echocardiographic findings in a patient with tamponade due to anterior mediastinal hematoma

A patient with blunt trauma to the sternum had clinical evidence of cardiac tamponade and echocardiographic findings highly suggestive of pericardial effusion. Bloody fluid was obtained by precordial pericardiocentesis. With the clinical diagnosis of pericardial tamponade, operation showed a large anterior mediastinal hematoma. In patients with anterior mediastinal hematoma, echocardiography could be misleading, and if pericardiocentesis is needed it should be done via a subxyphoid approach to help differentiate between these two entities.

Effects of alpha-fetoprotein on murine immune responses. II. Studies on rats

In vitro and in vivo experiments failed to identify a consistent "immunosuppressive" or "immunoregulatory" role for alpha-fetoprotein (AFP) in the rat. Both normal and AFP-rich sera inhibited Con A, PHA, and MLR proliferation responses of lymphocyte cultures in vitro equally well, in spite of up to 100,000-fold differences in AFP concentration. AFP-rich sera also had no effect on the antibody response of the rat in vivo. Purified AFP from amniotic fluid inhibited the PHA response at concentrations of 100 in chemical contexts is converted to microgram/ml. Purified albumin was also inhibitory, but at 1 log higher concentration. Purified AFP from tumor sera was not inhibitory at 100 in chemical contexts is converted to microgram/ml for Con A, PHA, or MLR reactions and only inhibited PHA stimulation at medium concentrations greater than 1000 in chemical contexts is converted to microgram/ml. The role of AFP as an immunosuppressive agent, particularly in reference to survival of mammalian fetuses, should be reconsidered.

Effects of α-Fetoprotein on Murine Immune Responses

In vitro and in vivo experiments failed to identify a consistent “immunosuppressive” or “immunoregulatory” role for α-fetoprotein (AFP) in the rat. Both normal and AFP-rich sera inhibited Con A, PHA, and MLR proliferation responses of lymphocyte cultures in vitro equally well, in spite of up to 100,000-fold differences in AFP concentration. AFP-rich sera also had no effect on the antibody response of the rat in vivo. Purified AFP from amniotic fluid inhibited the PHA response at concentrations of 100 µg/ml. Purified albumin was also inhibitory, but at 1 log higher concentration. Purified AFP from tumor sera was not inhibitory at 100 µg/ml for Con A, PHA, or MLR reactions and only inhibited PHA stimulation at medium concentrations greater than 1000 µg/ml. The role of AFP as an immunosuppressive agent, particularly in reference to survival of mammalian fetuses, should be reconsidered.