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.

Serial Perioperative Assessment of Free Flap Perfusion With Laser Angiography

Study Design

Prospective cohort study.

Objective

Reconstruction with microvascular free flaps is quite predictable but excessive fluids intraoperatively and excessive use of vasopressors have been implicated in postoperative complications. However, vasopressors assist in limiting fluid administration and counteract vasodilatory effects of general anesthetics, while maintaining proper intravascular volume. This is of paramount importance during surgery to ensure adequate tissue and organ perfusion. The purpose of this study is to quantify perfusion changes in free flaps at specific time points during peri- and postoperative periods, incorporating SPY technology.

Methods

A prospective study of patients who underwent free flap reconstruction was conducted (n = 9), using SPY laser angiography with indocyanine green to assess effects of general anesthetics and vasopressors on flap perfusion. Free flaps were evaluated prior to pedicle division, after inset and anastomosis, and in the immediate postoperative setting. Mean perfusion, mean arterial pressure, total operative time, fluid shifts, and vasopressor use were recorded. Data were analyzed with univariate and multivariable analyses.

Results

Those with major complications in this cohort, on average received less vasopressors, had shorter operation times and less blood loss, however, they received more fluids intraoperatively.

Conclusion

Changes in mean perfusion to the free flap during the intraoperative and immediate postoperative period are nominal.

A Multi-faceted Educational Approach for Pain Metric Recording Prior to Knee and Hip Arthroplasty: Effects on Documentation by an Acute Pain Service

Background

Despite the increased use of electronic medical records (EMRs) in past years, the recording of clinically useful baseline pain information may still be lacking. An educational effort targeted at the acute pain service and reinforced by electronic prompting may be an effective way to promote electronic documentation of relevant pain metrics. The objective of this study was to assess whether an educational effort with electronic prompting in the EMR promotes the documentation of baseline pain scores and preoperative opioid use by an acute pain service (APS).

Methods

A total of 98 patients were included in this study: 49 in the study group and 49 in the control group. The study group consisted of patients who underwent knee and hip arthroplasties after the institution of a multimodal analgesia educational program that also incorporated an electronic prompt to promote behavior change. Primary outcomes were the frequency of documentation of baseline pain scores and preoperative opioid use.

Results

After the implementation of the education initiative, 67% of the patients had baseline pain scores recorded in the preoperative APS documentation, compared to 20% in the control group (p = 0.0001). Preoperative opioid use was recorded in 24% of APS documentation within the control group, but this increased to 73% after the educational intervention (p = 0.0001). Documentation of resting pain scores on the day of surgery also increased from 59% to 87% (p = 0.0014).

Conclusions

The introduction of a multi-dimensional educational effort focused on baseline pain metric recording within the context of an analgesic change of practice increased assessment of both baseline pain and preoperative opioid use by APS. These results can be applied to other settings in which a focused change of practice is required and an electronic medical record already utilized.