Regional anesthesia does not lower mortality after hip fracture surgery

By Will Boggs MD

NEW YORK (Reuters Health) - Compared with general anesthesia, regional anesthesia for hip fracture surgery "modestly" reduces length of hospital stay but does not improve 30-day mortality, according to results from a retrospective study.

"Current guidelines recommend that all patients be offered a choice of regional or general anesthesia for hip fracture surgery with clear information about risks and benefits," Dr. Mark D. Neuman from Perelman School of Medicine at the University of Pennsylvania in Philadelphia told Reuters Health by email. "Our study offers information that we think will be helpful to patients and physicians in making these choices. It also highlights the need for prospective, randomized controlled trials to provide still better evidence to inform these decisions."

Previous studies regarding the association of anesthesia technique with hip fracture surgery outcomes have shown conflicting results.

Dr. Neuman and colleagues assessed the association of anesthesia technique (general versus spinal or epidural blockade) with 30-day mortality and hospital length of stay in a retrospective cohort study of 56,729 older adults undergoing hip fracture surgery in New York between 2004 and 2011.

The overall 30-day mortality rate was 5.3%, and it did not differ between patients who underwent regional anesthesia and those who underwent general anesthesia (5.3% vs. 5.4%, respectively; P=0.55), according to the June 25 JAMA report.

Regional anesthesia was, however, associated with a hospital stay that averaged 0.2 days less than that for general anesthesia.

In a variety of other analyses designed to account for differences in patients and hospitals, there remained no association between anesthesia type and mortality, and the shorter length of hospital stay for regional anesthesia persisted.

"Hip fracture is a major public health issue and improving anesthesia care, along with other facets of pre- and post-operative management, has potential to make a positive impact on outcomes after hip fracture," Dr. Neuman said.

"Beyond the outcomes we looked at in this study, other studies have found regional anesthesia to be associated with lower rates of confusion and major pulmonary complications after hip fracture surgery compared to general anesthesia," Dr. Neuman added.

Dr. Michael E. McBrien from Royal Victoria Hospital in Belfast, UK has also studied anesthesia technique and hip fracture surgery outcomes. He told Reuters Health by email, "The major factors contributing to favorable outcomes in the elderly are maintenance of blood pressure during anesthesia and surgery, avoidance of long acting opiates by using nerve blocks for post operative analgesia, and careful administration of intravenous fluids. All of these apply whether general or regional anesthesia is used, and if done so correctly, differences in outcome between regional and general anesthesia will be impossible to detect."

"There is a subgroup of patients who will benefit from regional anesthesia, and a subgroup who will benefit from general anesthesia," Dr. McBrien concluded. "It is impossible to provide an ideal recipe for all hip fracture patients. Each must be evaluated and managed individually."

Dr. Stuart M. White from Brighton and Sussex University Hospitals NHS Trust in Brighton, East Sussex, UK has done similar research. He told Reuters Health via email, "It's not that surprising that a 2-hour anesthetic does not affect death rates 30 days later. Instead, we need to focus on problems occurring within days after anesthesia and then see exactly what methods of regional or general anesthesia are best at reducing patient confusion and pain, for example, or enabling patients to get back on their feet quickly and out of hospital."

Dr. Iain Moppett from The University of Nottingham in the UK has contributed research on this subject. He told Reuters Health by email, "The most robust evidence is for reduction in postoperative confusion in patients receiving regional anesthesia. There may be a clinically insignificant reduction in intra-operative blood loss. The data also support a reduced risk of intra-operative hypotension with spinal anesthesia compared with general anesthesia."

"There may be small differences in length of stay with regional anesthesia but major patient related outcomes seem not to be affected," Dr. Moppett concluded. "This is perhaps unsurprising given that only 2 hours are directly affected by choice of anesthesia compared with days and weeks affected by early, effective rehabilitation."

SOURCE: http://bit.ly/1o0D539

JAMA 2014;311:2508-2517.

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