International Orthopaedics (SICOT) DOI 10.1007/s00264-015-2735-5
ORIGINAL PAPER
Regional anaesthesia for hip fracture surgery is associated with significantly more per-ioperative complications compared with general anaesthesia Paul S. Whiting 1 & Cesar S. Molina 1 & Sarah E. Greenberg 1 & Rachel V. Thakore 1 & William T. Obremskey 1 & Manish K. Sethi 1
Received: 6 January 2015 / Accepted: 1 March 2015 # SICOT aisbl 2015
Abstract Introduction Although several studies have advocated the use of regional versus general anaesthesia as a means of reducing peri-operative complications from hip fracture surgery, the ideal method of anaesthesia remains controversial. Our purpose was to investigate the association between anaesthesia type and peri-operative complications in hip fracture surgery. Methods From the 2005–2011 ACS-NSQIP database, all patients with operatively treated hip fractures were identified using CPT codes, and fifteen peri-operative complications were recorded and categorized as either minor or major. Rates of minor, major, and total complications by anaesthesia type were compared using chi-square and Fischer’s exact tests. A multivariate model was used to determine odds of minor,
Electronic supplementary material The online version of this article (doi:10.1007/s00264-015-2735-5) contains supplementary material, which is available to authorized users. * Manish K. Sethi [email protected] Paul S. Whiting [email protected] Cesar S. Molina [email protected] Sarah E. Greenberg [email protected] Rachel V. Thakore [email protected] William T. Obremskey [email protected] 1
The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN 37232, USA
major, and total complications between anaesthesia types. Multivariate analysis was then repeated after combining patients who received regional nerve blocks or spinal anaesthesia. Results A total of 7,764 hip fracture patients were included in our analysis. Spinal anaesthesia had the highest total complication rate (19.6 %), followed by general (17.9 %) and regional nerve blocks (12.6 %). Multivariate analysis demonstrated that spinal anaesthesia was associated with significantly greater odds of minor complications and total complications compared with general anaesthesia. After combining the regional nerve block and spinal anaesthesia groups, multivariate analysis again showed significantly greater odds of minor and total complications with regional versus general anaesthesia. Conclusions Using a large multi-centre database, we demonstrate that regional anaesthesia was associated with significantly greater odds of minor and total peri-operative complications compared with general anaesthesia. Our results challenge the notion that regional anaesthesia is the preferred method of anaesthesia for hip fractures in the elderly.
Keywords Anaesthesia . Geriatrics . Hip fracture . Regional anaesthesia . General anaesthesia
Introduction Geriatric hip fractures occur commonly and represent a major source of morbidity and mortality in the elderly population [1, 2]. Worldwide hip fracture incidence is projected to nearly quadruple from 1.66 million in 1990 to 6.26 million by 2050 [3]. The growing incidence of geriatric hip fractures is attributable in large part to the increasing life expectancy and high prevalence of osteoporosis in the elderly [4]. As geriatric hip
International Orthopaedics (SICOT)
fracture incidence increases, these injuries will consume a growing proportion of available healthcare resources [5, 6]. Effective peri-operative management of geriatric hip fractures necessitates a co-ordinated approach by multiple providers that takes into account the medical comorbidities as well as the unique social needs of this patient population [7]. Efforts to reduce morbidity and mortality and improve outcomes in geriatric hip fractures have focused on numerous perioperative factors including timing of surgery, pain management, DVT prophylaxis, co-management of medical comorbidities, and type of anaesthesia administered [8]. The influence of anaesthesia type on peri-operative complications of hip fracture surgery remains a controversial topic in the literature. For several decades both general anaesthesia and regional anaesthesia have been utilized safely for hip fracture surgery in the elderly, but each is associated with its own attendant risks [9]. Potential complications of general anaesthesia include peri-operative cardiovascular events (including myocardial infarction and stroke), pulmonary complications (including atelectasis, pneumonia, and pulmonary edema), post-operative nausea/vomiting, adverse drug reactions, and injury to the teeth or other upper airway structures [10]. A major concern of regional anaesthesia (a category typically encompassing all forms of regional nerve blocks, spinal, and epidural anaesthesia) is the risk of significant intra-operative hypotension, which may also predispose patients to ischemic cardiovascular events. Other complications associated with spinal or epidural anaesthesia include urinary retention, spinal headache, epidural hematoma, and infection [11]. A meta-analysis of 15 randomized clinical trials comparing regional anaesthesia with general anaesthesia for hip fracture surgery found decreased one-month mortality rates and rates of deep venous thrombosis (DVT) with regional anaesthesia, while shorter operative times were seen with general anaesthesia [12]. There were no significant differences for several other clinical variables investigated. A recent systematic review of the literature also found a significant reduction in early mortality and DVT as well as acute postoperative confusion with regional anaesthesia, while general anaesthesia caused less intra-operative hypotension [10]. However, only three of the 56 studies included were assigned a level I class of evidence, and many studies included small numbers of patients and investigated only a few outcome measures. The most recent Cochrane Database Systematic Review of the subject concluded that there was insufficient evidence to demonstrate any clinically important differences between general and regional anaesthesia for hip fracture surgery [13]. Insufficient high-quality data makes it difficult to draw definitive conclusions regarding the preferred method of anaesthesia for hip fracture surgery. This reality has led some authors to advocate using large-scale, multicentre databases of high quality to address such clinical questions [14, 15]. The American College of Surgeons’ National Surgical Quality
Improvement Program (NSQIP) database represents a large, multicentre, prospectively-collected database of surgical patients from hospitals located in the United States, Europe, and the Middle East. The purpose of our study was to use the NSQIP database to compare rates of peri-operative complications among patients receiving different types of anaesthesia for hip fracture surgery.
Methods Data extraction This investigation was initiated following Institutional Review Board approval. Access to the NSQIP dataset collected between 2005 and 2011 was granted by the American College of Surgeons. The dataset includes 462 hospitals across the United States and 34 hospitals in other countries including Saudi Arabia, Canada, Lebanon, The United Kingdom and The United Arab Emirates. The 135 patient variables reported within the database include pre-operative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures in both inpatient and outpatient settings. At each participating institution, two risk-assessment nurses trained as Surgical Clinical Reviewers (SCR) were appointed to collect data directly from patients’ medical records. Inter-rater reliability disagreement of
ORIGINAL PAPER
Regional anaesthesia for hip fracture surgery is associated with significantly more per-ioperative complications compared with general anaesthesia Paul S. Whiting 1 & Cesar S. Molina 1 & Sarah E. Greenberg 1 & Rachel V. Thakore 1 & William T. Obremskey 1 & Manish K. Sethi 1
Received: 6 January 2015 / Accepted: 1 March 2015 # SICOT aisbl 2015
Abstract Introduction Although several studies have advocated the use of regional versus general anaesthesia as a means of reducing peri-operative complications from hip fracture surgery, the ideal method of anaesthesia remains controversial. Our purpose was to investigate the association between anaesthesia type and peri-operative complications in hip fracture surgery. Methods From the 2005–2011 ACS-NSQIP database, all patients with operatively treated hip fractures were identified using CPT codes, and fifteen peri-operative complications were recorded and categorized as either minor or major. Rates of minor, major, and total complications by anaesthesia type were compared using chi-square and Fischer’s exact tests. A multivariate model was used to determine odds of minor,
Electronic supplementary material The online version of this article (doi:10.1007/s00264-015-2735-5) contains supplementary material, which is available to authorized users. * Manish K. Sethi [email protected] Paul S. Whiting [email protected] Cesar S. Molina [email protected] Sarah E. Greenberg [email protected] Rachel V. Thakore [email protected] William T. Obremskey [email protected] 1
The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200, Medical Center East, South Tower, Nashville, TN 37232, USA
major, and total complications between anaesthesia types. Multivariate analysis was then repeated after combining patients who received regional nerve blocks or spinal anaesthesia. Results A total of 7,764 hip fracture patients were included in our analysis. Spinal anaesthesia had the highest total complication rate (19.6 %), followed by general (17.9 %) and regional nerve blocks (12.6 %). Multivariate analysis demonstrated that spinal anaesthesia was associated with significantly greater odds of minor complications and total complications compared with general anaesthesia. After combining the regional nerve block and spinal anaesthesia groups, multivariate analysis again showed significantly greater odds of minor and total complications with regional versus general anaesthesia. Conclusions Using a large multi-centre database, we demonstrate that regional anaesthesia was associated with significantly greater odds of minor and total peri-operative complications compared with general anaesthesia. Our results challenge the notion that regional anaesthesia is the preferred method of anaesthesia for hip fractures in the elderly.
Keywords Anaesthesia . Geriatrics . Hip fracture . Regional anaesthesia . General anaesthesia
Introduction Geriatric hip fractures occur commonly and represent a major source of morbidity and mortality in the elderly population [1, 2]. Worldwide hip fracture incidence is projected to nearly quadruple from 1.66 million in 1990 to 6.26 million by 2050 [3]. The growing incidence of geriatric hip fractures is attributable in large part to the increasing life expectancy and high prevalence of osteoporosis in the elderly [4]. As geriatric hip
International Orthopaedics (SICOT)
fracture incidence increases, these injuries will consume a growing proportion of available healthcare resources [5, 6]. Effective peri-operative management of geriatric hip fractures necessitates a co-ordinated approach by multiple providers that takes into account the medical comorbidities as well as the unique social needs of this patient population [7]. Efforts to reduce morbidity and mortality and improve outcomes in geriatric hip fractures have focused on numerous perioperative factors including timing of surgery, pain management, DVT prophylaxis, co-management of medical comorbidities, and type of anaesthesia administered [8]. The influence of anaesthesia type on peri-operative complications of hip fracture surgery remains a controversial topic in the literature. For several decades both general anaesthesia and regional anaesthesia have been utilized safely for hip fracture surgery in the elderly, but each is associated with its own attendant risks [9]. Potential complications of general anaesthesia include peri-operative cardiovascular events (including myocardial infarction and stroke), pulmonary complications (including atelectasis, pneumonia, and pulmonary edema), post-operative nausea/vomiting, adverse drug reactions, and injury to the teeth or other upper airway structures [10]. A major concern of regional anaesthesia (a category typically encompassing all forms of regional nerve blocks, spinal, and epidural anaesthesia) is the risk of significant intra-operative hypotension, which may also predispose patients to ischemic cardiovascular events. Other complications associated with spinal or epidural anaesthesia include urinary retention, spinal headache, epidural hematoma, and infection [11]. A meta-analysis of 15 randomized clinical trials comparing regional anaesthesia with general anaesthesia for hip fracture surgery found decreased one-month mortality rates and rates of deep venous thrombosis (DVT) with regional anaesthesia, while shorter operative times were seen with general anaesthesia [12]. There were no significant differences for several other clinical variables investigated. A recent systematic review of the literature also found a significant reduction in early mortality and DVT as well as acute postoperative confusion with regional anaesthesia, while general anaesthesia caused less intra-operative hypotension [10]. However, only three of the 56 studies included were assigned a level I class of evidence, and many studies included small numbers of patients and investigated only a few outcome measures. The most recent Cochrane Database Systematic Review of the subject concluded that there was insufficient evidence to demonstrate any clinically important differences between general and regional anaesthesia for hip fracture surgery [13]. Insufficient high-quality data makes it difficult to draw definitive conclusions regarding the preferred method of anaesthesia for hip fracture surgery. This reality has led some authors to advocate using large-scale, multicentre databases of high quality to address such clinical questions [14, 15]. The American College of Surgeons’ National Surgical Quality
Improvement Program (NSQIP) database represents a large, multicentre, prospectively-collected database of surgical patients from hospitals located in the United States, Europe, and the Middle East. The purpose of our study was to use the NSQIP database to compare rates of peri-operative complications among patients receiving different types of anaesthesia for hip fracture surgery.
Methods Data extraction This investigation was initiated following Institutional Review Board approval. Access to the NSQIP dataset collected between 2005 and 2011 was granted by the American College of Surgeons. The dataset includes 462 hospitals across the United States and 34 hospitals in other countries including Saudi Arabia, Canada, Lebanon, The United Kingdom and The United Arab Emirates. The 135 patient variables reported within the database include pre-operative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures in both inpatient and outpatient settings. At each participating institution, two risk-assessment nurses trained as Surgical Clinical Reviewers (SCR) were appointed to collect data directly from patients’ medical records. Inter-rater reliability disagreement of
