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Abdelfatah FA, Elhadad MA. Effect of bupivacaine concentration on ultrasound-guided pericapsular group nerve block efficacy in hip surgery patients: comparative, randomized, double-blinded clinical trial. Br J Pain 2024; 18:425-432. [PMID: 39355572 PMCID: PMC11440524 DOI: 10.1177/20494637241262516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2024] Open
Abstract
Background The pericapsular nerve group (PENG) block offers effective postoperative pain relief following hip fracture surgery. This research investigated three doses of bupivacaine, all administered in the same total volume, for performing ultrasound-guided PENG blocks during hip fracture procedures. Methods This randomized, double-blinded clinical trial was conducted on 135 patients aged between 18 and 70 years of both sexes who underwent hip fracture surgeries. Participants were randomized into three groups (n = 45). Ultrasound-guided PENG block was applied, the groups received 20 mL of local anesthetics. The first group received 0.5% bupivacaine, the second group received 0.375% bupivacaine, and the third group received 0.25% bupivacaine. The following parameters were recorded: onset of sensory block, resting NRS after passively raising the limb by 15° half an hour post-procedure, quality of recovery score (QoR-15) at 24 h postoperative. Results The 0.25% bupivacaine group exhibited a longer sensory block onset than the other groups (p ≤ .05). Significant differences were demonstrated between the groups regarding the time to 1st analgesia (p = .033) and total morphine consumption (p = .025). NRS at baseline and T30 post-block did not show significant differences between the studied groups. No significant differences were detected postoperatively in rest and dynamic NRS (p ≤ .05). Patient satisfaction, QoR-15 score, and ease of spinal positioning did not differ between the groups. Conclusion Compared to 0.25% bupivacaine, PENG block with 0.5% and 0.375% bupivacaine provided a rapid onset sensory block, delayed first analgesic requirements, and reduced total morphine consumption after hip surgeries. Protocol Registration The trial was registered at the clinicaltrials.gov with study number (Trial ID: NCT05788458).
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Affiliation(s)
| | - Mona Ahmed Elhadad
- Department of Anesthesia and Surgical Intensive Care, Benha University, Benha, Egypt
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2
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Çağıran Z, Vahabi A, Özgül KK, Aljasim O, Karaman S, Özkayın N, Aktuğlu K, Sertöz N. Unilateral Spinal Anesthesia in Hip Fracture Surgery for Geriatric Patients With High Cardiovascular Risk due to Aortic Stenosis is Safe and Effective. Geriatr Orthop Surg Rehabil 2024; 15:21514593241280908. [PMID: 39220252 PMCID: PMC11366102 DOI: 10.1177/21514593241280908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 07/10/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024] Open
Abstract
Introduction Aortic stenosis is a cause of mortality or morbidity. It complicates the selection and management of anesthetic procedures. The aim of this study was to evaluate the efficacy, hemodynamic effects and postoperative outcome of unilateral spinal anesthesia in geriatric patients with hip fractures with moderate or severe aortic stenosis. Material and Method A retrospective observational study was conducted on geriatric high-risk patients with cardiac conditions who underwent surgery for hip fractures under unilateral spinal anesthesia with low-dose hyperbaric bupivacaine. The study period spanned from January 2018 to December 2021. The inclusion criteria were individuals with moderate to severe aortic stenosis, as defined by the American Heart Association Criteria. Data on demographic information, cardiac pathologies, hemodynamic data, data on motor and sensory block, perioperative complications, and mortality rates at 30th and 180th days were collected. Results Mortality rates at the 30th day and 180th day were 8.9% (n:4) and 24.4% (n:11), respectively. T6 level was predominantly obtained level of anesthesia (44.4%). Motor and sensory block formation times averaged 7.6 and 4.8 minutes, respectively. Surgical procedures were performed mostly within 1 hour (66.7%), and complications were rare (11.1% hypotension). Initial analgesic effect showed a rapid resolution, with 64.4% of patients requiring analgesic within the first hour postoperatively. Conclusion In elderly patients with moderate to severe aortic stenosis scheduled for hip fracture surgery, we posit that unilateral spinal anesthesia with ultra-low dose is safe and effective option.
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Affiliation(s)
- Zeynep Çağıran
- Department of Anesthesiology and Reanimation, Ege University School of Medicine, Izmir, Turkey
| | - Arman Vahabi
- Department of Orthopaedics and Traumatology, Ege University School of Medicine, Izmir, Turkey
| | - Kazım Koray Özgül
- Department of Anesthesiology and Reanimation, Ege University School of Medicine, Izmir, Turkey
| | - Omar Aljasim
- Department of Orthopedics and Traumatology, Medical Park Gebze Hospital, Kocaeli, Turkey
| | - Semra Karaman
- Department of Anesthesiology and Reanimation, Ege University School of Medicine, Izmir, Turkey
| | - Nadir Özkayın
- Department of Orthopaedics and Traumatology, Ege University School of Medicine, Izmir, Turkey
| | - Kemal Aktuğlu
- Department of Orthopaedics and Traumatology, Ege University School of Medicine, Izmir, Turkey
| | - Nezih Sertöz
- Department of Anesthesiology and Reanimation, Ege University School of Medicine, Izmir, Turkey
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3
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Diulus SC, Mucharraz C, Schmitt DR, Brown NM. Morbidity and Mortality Following Total Hip and Knee Arthroplasty With Spinal Versus General Anesthesia: A Retrospective Analysis. J Arthroplasty 2024:S0883-5403(24)00418-2. [PMID: 38703926 DOI: 10.1016/j.arth.2024.04.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND The optimal anesthetic mode in total joint arthroplasty (TJA) has yet to be clearly identified. Patients undergoing TJA may recieve spinal anesthesia (SA) or general anesthesia (GA). While arthroplasty literature indicates differences in postoperative morbidity, hip fracture literature does not show clear superiority of SA or GA. The purpose of this study was to further investigate this relationship and determine if there is a significant difference in morbidity and mortality between GA and SA in patients undergoing primary total joint arthroplasty. METHODS Patients undergoing primary THA or TKA from February 2007 to February 2021 were retrospectively reviewed, creating four cohorts: THA/GA (n = 1,266), THA/SA (n = 1,084), TKA/GA (n = 882), and THA/SA (n = 2,067). Readmission within 90 days, mortality within 365 days, and thromboembolic events within 30 days postoperatively were compared using logistic regression, controlling for age, body mass index, and Charlson Comorbidity Index. RESULTS The odds of experiencing a deep venous thrombosis within 30 days postoperatively were elevated in the analysis of both the THA/GA (odds ratio (OR) = 3.1; 95% confidence interval (CI): 1.5 to 7.0; P = .004) and the TKA/GA (OR = 1.9; 95% CI: 1.2 to 3.0; P = .005) groups. Similarly, the risk of pulmonary embolism as higher in the THA/GA cohort (OR = 3.9; 95% CI: 1.2 to 17.3; P = .04). There were also higher odds of mortality within 365 days postoperatively in THA/GA patients (OR = 4.3; 95% CI: 1.7 to 13.0; P = .004). No other differences existed among TKA patients. CONCLUSIONS Based upon these data, both SA and GA are reasonable options for primary TKA with similar risk profiles. However, GA may be associated with higher rates of deep venous thrombosis in TJA and pulmonary embolism in THA. General anesthesia (GA) was also loosely associated with increased mortality within 1 year of THA, but this result should be considered with caution. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Samantha C Diulus
- Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Carlos Mucharraz
- Department of Anesthesiology, University of Colorado, Aurora, Colorado
| | - Daniel R Schmitt
- Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Nicholas M Brown
- Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, Illinois
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Essa S, Venter S, Jordaan JD. The effect of a post-anaesthesia high-care unit (PAHCU) admission on mobilization, length of stay and in-hospital mortality post-surgery in low energy neck of femur fracture patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1389-1396. [PMID: 38194124 PMCID: PMC10980606 DOI: 10.1007/s00590-023-03799-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/25/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE/AIM With an ageing population and an increase in fragility fractures of the hip (FFH), the role of an anaesthetist is evolving to include more peri-operative care. A post-anaesthesia high-care unit (PAHCU) should enhance care in post-operative patients. To our knowledge, there are no studies that have investigated the effect of a PAHCU admission on post-operative outcomes after FFH. This study aimed to compare post-operative outcomes of FFH patients admitted to PAHCU versus a standard post-operative orthopaedic ward (POOW). METHODOLOGY A retrospective cohort study was conducted on adult patients with FFH who underwent surgery between January 2019 and December 2020 at our institution. Data were sourced from electronic medical records. SPSS version 28 was used to analyse data. RESULTS A total of 231 patients were included. The PAHCU group (n = 35) displayed a higher burden of chronic illness and higher peri-operative risk scores as compared to the POOW group (n = 196). Median time to mobilize (TTM) in PAHCU was 84 h vs. 45 h in POOW group (p = 0.013). Median length of stay (LOS) in PAHCU was 133 h vs. 94 h in POOW (p = 0.001). The in-hospital mortality was 2.9% (n = 1) for PAHCU and 3.6% (n = 7) for POOW (p = 1). The 30-day mortality was 11.8% (n = 4) for PAHCU and 10.1% (n = 19) in POOW. CONCLUSION PAHCU admission resulted in delayed time to surgery and TTM, together with prolonged LOS, compared to those managed in POOW. However, these mortality rates remained comparable in both groups. This study contributes valuable insights into post-operative care of FFH patients in a resource-poor setting.
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Affiliation(s)
- S Essa
- Department of Anaesthesia and Critical Care, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - S Venter
- Department of Anaesthesia and Critical Care, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - J D Jordaan
- Department of Orthopaedic Surgery, Faculty Health Sciences, Stellenbosch University, Cape Town, South Africa
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Girombelli A, Vetrone F, Saglietti F, Galimberti A, Fusaro A, Umbrello M, Pezzi A. Pericapsular nerve group block and lateral femoral cutaneous nerve block versus fascia iliaca block for multimodal analgesia after total hip replacement surgery: A retrospective analysis. Saudi J Anaesth 2024; 18:218-223. [PMID: 38654885 PMCID: PMC11033891 DOI: 10.4103/sja.sja_881_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/05/2023] [Accepted: 12/14/2023] [Indexed: 04/26/2024] Open
Abstract
Background Optimal pain control with limited muscle weakness is paramount for a swift initiation of physical therapy and early discharge. Fascia iliaca compartment block (FICB) has been recommended since it offers good pain control with a low risk of motor block. Pericapsular nerve group (PENG) block with lateral femoral cutaneous block (LFCN) has been proposed as an effective alternative to FICB that offers better pain control with a considerably lower risk of motor block. We aimed to compare the aforementioned blocks and determine which one yielded the lowest numeric rating scale (NRS) score. Methods We designed a retrospective analysis of patients undergoing elective total hip arthroplasty. The primary outcome was the NRS score at 6, 12, and 24 hours. The secondary outcomes were total opioid consumption, time to first PRN opioid, and time to first postoperative ambulation. Results 52 patients were recruited, (13 PENG plus LFCN, 39 FICB). PENG plus LCFN resulted in a lower NRS at all three-time points (mean difference and 95%CI at 6 h 0.378 [-0.483; 1.240], at 12 h 0.336 [-0.378; 1.050], and at 24 h 0.464 [0.013; 0.914] P = 0.02). Moreover, less PRN opioids were requested in the PENG plus LCFN vs. FICB group (0 [0;7.5] vs 60 [15;80] milligrams of morphine equivalents, P = 0.001). No delay in the first ambulation or initiation of physical rehabilitation was reported in either group. Conclusions PENG plus LCFN seems to offer better pain control and lead to less PRN opioids. Neither block hindered physical therapy nor ambulation. These results need to be confirmed with a larger prospective and randomized study.
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Affiliation(s)
- Alessandro Girombelli
- Department of Anesthesiology, Division of Anesthesiology, Intensive Care and Emergency Medicine, EOC, Ospedale Regionale di Lugano, Lugano, Switzerland
| | - Francesco Vetrone
- Department of Surgery and Emergency, Anesthesiology and Critical Care Medicine, ASST Nord Milano, Bassini Hospital, Cinisello Balsamo (MI), Italy
| | - Francesco Saglietti
- Department of Anesthesiology and Critical Care Medicine, Azienda Ospedaliera S. Croce e Carle, Cuneo (CN), Italy
| | - Andrea Galimberti
- Department of Surgery and Emergency, Anesthesiology and Critical Care Medicine, ASST Nord Milano, Bassini Hospital, Cinisello Balsamo (MI), Italy
| | - Andrea Fusaro
- Orthopedic Surgery Division, ASST Nord Milano, Ospedale Bassini, Cinisello Balsamo (MI), Italy
| | - Michele Umbrello
- Anesthesiology and Critical Care Medicine, SC Anestesia e Rianimazione II, ASST Santi Paolo e Carlo – Polo Universitario, Ospedale San Carlo Borromeo, Milano (MI), Italy
| | - Angelo Pezzi
- Department of Surgery and Emergency, Anesthesiology and Critical Care Medicine, ASST Nord Milano, Bassini Hospital, Cinisello Balsamo (MI), Italy
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Feng J, Tang G, Shui Y, Xiang J, Qin Z. Effects of ultrasound-guided lumbar plexus and sacral plexus block combined with general anesthesia on the anesthetic efficacy and surgical outcomes in elderly patients undergoing intertrochanteric fracture surgery: a randomized controlled trial. J Orthop Surg Res 2024; 19:171. [PMID: 38448954 PMCID: PMC10918949 DOI: 10.1186/s13018-023-04469-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/13/2023] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Surgery for intertrochanteric fractures in elderly patients is challenging due to the risk of severe pain and significant stress responses. We investigated the effects of a combined approach of ultrasound-guided lumbar plexus and sacral plexus block with general anesthesia on anesthetic efficacy and surgical outcomes in these patients. METHODS A randomized controlled trial was conducted involving 150 elderly patients, divided into two groups: the combined anesthesia group (receiving ultrasound-guided lumbar plexus and sacral plexus block along with general anesthesia) and the general anesthesia alone group. Outcome measures included hemodynamic parameters, postoperative pain levels (VAS scores), postoperative recovery times, and incidence of adverse reactions. RESULTS In the combined anesthesia group, the patients had more stable intraoperative hemodynamics, lower postoperative VAS scores at 1, 3, and 6 h, and faster recovery times (eye-opening upon command and return of respiratory function) compared to the general anesthesia group. Furthermore, the incidence of adverse reactions was significantly lower in the combined anesthesia group. CONCLUSIONS Ultrasound-guided lumbar plexus and sacral plexus block combined with general anesthesia enhanced the anesthetic efficacy and improved surgical outcomes in elderly patients undergoing intertrochanteric fracture surgery.
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Affiliation(s)
- Ji Feng
- Department of Anesthesiology, Sichuan Province Orthopedic Hospital, 132 West First Ring Road, Wuhou District, Chengdu City, 610041, Sichuan, China
| | - Guangyan Tang
- Department of Radiology, Sichuan Province Orthopedic Hospital, Chengdu City, 610041, Sichuan, China
| | - Yunhua Shui
- Department of Anesthesiology, Sichuan Province Orthopedic Hospital, 132 West First Ring Road, Wuhou District, Chengdu City, 610041, Sichuan, China
| | - Jilin Xiang
- Department of Anesthesiology, Sichuan Province Orthopedic Hospital, 132 West First Ring Road, Wuhou District, Chengdu City, 610041, Sichuan, China
| | - Zhijun Qin
- Department of Anesthesiology, Sichuan Province Orthopedic Hospital, 132 West First Ring Road, Wuhou District, Chengdu City, 610041, Sichuan, China.
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Nabatame M, Takeuchi M, Takeda C, Kawakami K. Association between sedation during spinal anesthesia and mortality in older patients undergoing hip fracture surgery: A nationwide retrospective cohort study in Japan. J Clin Anesth 2024; 92:111322. [PMID: 37952283 DOI: 10.1016/j.jclinane.2023.111322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/13/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
STUDY OBJECTIVE Intraoperative sedation plays an important role in the management of regional anesthesia. Few studies have investigated the association of sedation during spinal anesthesia with postoperative mortality in older patients as a primary outcome. This study aimed to test the hypothesis that sedation during spinal anesthesia increases postoperative mortality in older patients undergoing hip fracture surgery. DESIGN Retrospective, cohort study. SETTING Acute and subacute care hospitals in Japan. PATIENTS Patients aged 65 years and older who received hip fracture surgery under spinal anesthesia between April 2014 and May 2022. EXPOSURE Sedation during spinal anesthesia. MEASUREMENTS Postoperative in-hospital all-cause mortality within 30 days. MAIN RESULTS In total, 25,554 eligible patients were identified. Propensity score matching created 4735 pairs, and baseline patient characteristics were acceptably balanced between the sedation and non-sedation groups. There was no significant difference in 30-day postoperative mortality between the two groups (hazard ratio [95% CIs]: 0.92 [0.59-1.44]). CONCLUSIONS There was no association between sedation during hip fracture surgery in older patients under spinal anesthesia and postoperative mortality. However, these results are limited to our population, and further prospective studies are needed to determine the safety of sedation.
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Affiliation(s)
- Maki Nabatame
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan
| | - Masato Takeuchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan
| | - Chikashi Takeda
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan; Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan.
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Al-Husinat L, Al Sharie S, Araydah M, Al Modanat Z, Ismail MIA, Heilat HB, Dawod MS, Sawaftah KA, De Rosa S, Battaglini D. Clinical Characteristics of Spinal versus General Anaesthesia in Older Patients Undergoing Hip Fracture Repair Surgery in Jordan: A Multicentre Study. J Pers Med 2023; 13:1611. [PMID: 38003926 PMCID: PMC10672458 DOI: 10.3390/jpm13111611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/09/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND The primary aim of this study was to examine the clinical characteristics and outcomes of older patients who underwent hip fracture repair surgery. The secondary aims were to assess the predictors of the choice of spinal or general anaesthesia and to explore the risk factors for all-cause mortality. METHODS This three-tertiary centres study was conducted at a tertiary care centre in Jordan. Clinical data include previous fracture history; medication details; comorbidities; surgical approach; and postoperative pain management. RESULTS Overall, 1084 patients who underwent hip fracture repair were included in this study. The mean age of patients was 78 years, and 55.2% were women. Twenty-four were treated with bisphosphonates before the fracture, whereas 30 were in steroid therapy. Overall, 61.8% of patients underwent spinal anaesthesia, whereas 38.2% underwent general anaesthesia. Spinal anaesthesia group had a lower prevalence of cardiovascular accidents (16.3% vs. 22.3%, p = 0.014) and Alzheimer's (3.4% vs. 1.4%, p = 0.049) than the general anaesthesia group. In the spinal anaesthesia group, postoperative opioid administration (p = 0.025) and postoperative blood transfusion (p = 0.011) occurred more frequently than general anaesthesia group. In hospital, 30-day and all-cause mortality were comparable between both groups. Diabetes mellitus (HR = 2.6; 95%CI = 1.5-4.4; p = 0.001); cemented hip hemiarthroplasty (HR = 2.4; 95%CI = 1.1-5.1; p = 0.025); deep venous thrombosis/pulmonary embolism (HR = 5.0; 95%CI = 1.2-12.9; p = 0.001); and readmission within 1 month from surgery (HR = 3.6; 95%CI = 2.0-6.3; p < 0.001) were all significant predictors of mortality. CONCLUSIONS This study provides insights into the outcomes and factors associated with different anaesthesia types in hip fracture repair surgery. The anaesthesia type does not affect all-cause mortality in patients undergoing hip fracture repair.
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Affiliation(s)
- Lou’i Al-Husinat
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (Z.A.M.); (H.B.H.)
| | - Sarah Al Sharie
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan
| | - Mohammad Araydah
- Department of Internal Medicine, Istishari Hospital, Amman 11942, Jordan;
| | - Zaid Al Modanat
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (Z.A.M.); (H.B.H.)
| | | | - Hadeel B. Heilat
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan; (Z.A.M.); (H.B.H.)
| | - Mohd Said Dawod
- Department of Special Surgery, College of Medicine, Mutah University, Al-Karak 61710, Jordan;
| | | | - Silvia De Rosa
- Centre for Medical Sciences—CISMed, University of Trento, 38122 Trento, Italy;
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, 38122 Trento, Italy
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
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Testa EJ, Albright AJ, Morrissey P, Orman S, Clippert D, Antoci V. Local anesthetic with monitored anesthesia care in cephalomedullary nailing of proximal femur fractures. Orthop Traumatol Surg Res 2023; 109:103619. [PMID: 37044244 DOI: 10.1016/j.otsr.2023.103619] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 03/16/2023] [Accepted: 03/30/2023] [Indexed: 04/14/2023]
Abstract
INTRODUCTION Proximal femur fractures have high rates of morbidity, mortality, and perioperative complications. Limiting anesthesia, especially in the elderly population, is a priority from a medical perspective. The goal of the current study is to present a technique of using local anesthetic with monitored anesthesia care (MAC) for the fixation of intertrochanteric (IT) femur fractures with cephalomedullary nailing (CMN), provide early clinical results in a small series of patients, and evaluate the safety, efficiency, and anesthetic efficacy of our technique. HYPOTHESIS The use of only local anesthetic with MAC for the fixation of IT fractures is safe and leads to decreased operative times when compared to spinal and general anesthesia. MATERIALS AND METHODS Patients undergoing cephalomedullary nailing (CMN) with a long nail for IT femur fractures by a single surgeon from January 2020 to June 2021 were identified retrospectively from a prospectively-collected patient registry. Patient demographics, operative time, length of hospital stay, perioperative medication use, and complications were collected. Analysis of variance, Chi2, linear regression, and two-sampled T-tests were performed to analyze potential differences between the local anesthesia group and the general or spinal anesthesia group. RESULTS Thirty-seven patients were identified. Eleven patients underwent CMN using local anesthesia with MAC, 11 using spinal anesthesia, and 15 using general anesthesia. The local anesthesia group demonstrated significantly lower operating room times and anesthesia induction to incision time compared to other anesthesia techniques. The local anesthesia group also trended towards less need for vasopressors during surgery and less postoperative delirium. No differences were identified in intraoperative narcotic use, complications, patient mortality, or hospital readmissions. CONCLUSIONS Local anesthesia with MAC for the treatment of IT fractures with CMN was associated with decreased operating room times and had similar complication rates including blood transfusions, readmissions, and mortalities, when compared to spinal and general anesthesia. LEVEL OF EVIDENCE III, therapeutic.
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Affiliation(s)
- Edward J Testa
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA.
| | - Alex J Albright
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Patrick Morrissey
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Sebastian Orman
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | | | - Valentin Antoci
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
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10
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Blood-Transfusion Risk Factors after Intramedullary Nailing for Extracapsular Femoral Neck Fracture in Elderly Patients. J Funct Morphol Kinesiol 2023; 8:jfmk8010027. [PMID: 36810511 PMCID: PMC9945124 DOI: 10.3390/jfmk8010027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/11/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Extracapsular femoral neck fractures (eFNF) are the third most common type of fracture in traumatology. Intramedullary nailing (IMN) is one of the most frequently used ortho-pedic treatments for eFNF. Blood loss is one of the main complications of this treatment. This study aimed to identify and evaluate the perioperative risk factors that lead to blood transfusion in frail patients with eFNF who undergo IMN. METHODS From July 2020 to December 2020, 170 eFNF-affected patients who were treated with IMN were enrolled and divided into two groups according to blood transfusion: NBT (71 patients who did not need a blood transfusion), and BT (72 patients who needed blood transfusion). Gender, age, BMI, pre-operative hemoglobin levels, in-ternational normalized ratio (INR) level, number of blood units transfused, length of hospital stay, surgery duration, type of anesthesia, pre-operative ASA score, Charlson Comorbidity Index, and mortality rate were assessed. RESULTS Cohorts differed only for pre-operatively Hb and surgery time (p < 0.05). CONCLUSION Patients who have a lower preoperative Hb level and longer surgery time have a high blood-transfusion risk and should be closely followed peri-operatively.
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11
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Siow WS, Tay L, Mah CL. Quality improvement initiative: how the setting up of an anaesthesia consultant-led perioperative outreach service addressed anaesthesia-specific issues to improve anaesthesia consult and surgery timings for hip fracture patients. BMJ Open Qual 2022; 11:bmjoq-2021-001738. [PMID: 35940697 PMCID: PMC9364401 DOI: 10.1136/bmjoq-2021-001738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 07/24/2022] [Indexed: 11/04/2022] Open
Abstract
BackgroundSurgery is recommended within 48 hours of hip fractures for better perioperative outcomes. Yet, such targets still commonly remain a challenge. Our institution is no exception.As part of a hospital-wide initiative, our anaesthesia department focused on improving perioperative processes with aims to reduce the time to first anaesthesia consult and surgery for hip fracture patients. Acknowledging multiple causes for surgical delay, we decided first to address anaesthesia-specific factors—(a) first anaesthetist contact usually happens after surgery is offered which leaves a short runway for preoptimisation, (b) this is compounded by varying degrees of anaesthetist involvement for follow-up thereafter. (c) There is a need to calibrate our perioperative care standards and (d) enforce more consistent auditing in quality assurance. This project was conducted in a 1000-bed hospital serving eastern Singapore.InterventionWe created an integrated anaesthesia consultant-led outreach service for hip fracture patients, based on a perioperative workflow system to provide proactive anaesthetist consults within 24 hours of admission in advance of surgical decision. This was streamlined with a coordinated follow-up system for preoptimisation until surgery.MethodsOur quality improvement project applied the iterative Plan-Do-Study-Act model from pilot to sustainability stage. We collected data at baseline followed by 6-monthly audits from electronic databases.Primary outcomes measured were time to first anaesthesia consult and surgery. Secondary outcomes included rate of critical care reviews and admission, mortality rate, length of stay and time to nerve blocks.ResultsPost implementation, our service reviewed >600 hip fracture patients. Median time to anaesthesia consult reduced significantly from 35.3 hours (2019) to 21.5 hours (2021) (p=0.029). Median time to surgery was reduced from 61.5 hours (2019) to 50 hours (2021) (p=0.897) with a 13.6% increase in patients operated <48 hours. Critical care admissions, 6-monthly and 12-monthly mortality rates and time to nerve block were reduced with a greater percentage of patients discharged within 10 days.ConclusionOur project focused on improving anaesthesia perioperative processes to address surgical delays in hip fracture patients. Our consultant-led anaesthesia service ensured that proactive anaesthesia care was delivered to provide sufficient time for preoptimisation with greater standardisation to follow-up, better communication and quality assurance.
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Affiliation(s)
- Wei Shyan Siow
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
| | - Leeanna Tay
- ValueCare Programme Office, Centre of Performance Excellence, Changi General Hospital, Singapore
| | - Chou Liang Mah
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
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Brooks DE, Ritchie-McLean SN, Chevannes W, Parker MJ, Griffiths R. Hip fracture specialists facilitate low-dose spinal anaesthesia in fractured neck of femur surgery. Acta Orthop Belg 2022; 88:311-317. [DOI: 10.52628/88.2.8978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Fractured neck of femur is a common but potentially devastating complication of frailty. In other surgical specialities, there is an inverse relationship between surgical experience and duration of surgery; however, this has not been quantified in hip trauma. In perioperative hip fracture care, prolonged surgery may be associated with increased morbidity and significantly impacts on the conduct of anaesthesia. Specifically, low-dose spinal anaesthesia, which is associated with improved haemodynamic stability, cannot be used if surgery is likely to be prolonged. We studied the duration of hip fracture surgery undertaken in our institution and compared this to surgical expertise. We retrospectively explored our theatre database to identify patients who underwent hip fracture surgery in our hospital over a 62-month period, recording duration of surgery and primary operating surgeon. Surgeons were classified into one of 3 groups: Consultant hip surgeon (specialist interest in hip surgery), Consultant orthopaedic surgeon but non-hip specialist, or Non-consultant (trainee or non-training grade). We identified 1426 hip fracture procedures. Consultant hip surgeons performed all types of hip fracture surgery faster, and with reduced variation in surgical duration, than did either non-hip specialist consultants or non-consultant grades. Consultant hip surgeons consistently performed hip fracture surgery in under 60 minutes. Specialist consultant hip surgeons make low-dose spinal anaesthesia (with shorter block duration but increased haemodynamic stability) feasible. Our data supports the development of dedicated hip fracture trauma lists where patients should be operated on by specialist hip surgeons or trainees directly under their supervision.
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Li T, Li J, Yuan L, Wu J, Jiang C, Daniels J, Mehta RL, Wang M, Yeung J, Jackson T, Melody T, Jin S, Yao Y, Wu J, Chen J, Smith FG, Lian Q. Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery: The RAGA Randomized Trial. JAMA 2022; 327:50-58. [PMID: 34928310 PMCID: PMC8689436 DOI: 10.1001/jama.2021.22647] [Citation(s) in RCA: 154] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE In adults undergoing hip fracture surgery, regional anesthesia may reduce postoperative delirium, but there is uncertainty about its effectiveness. OBJECTIVE To investigate, in older adults undergoing surgical repair for hip fracture, the effects of regional anesthesia on the incidence of postoperative delirium compared with general anesthesia. DESIGN, SETTING, AND PARTICIPANTS A randomized, allocation-concealed, open-label, multicenter clinical trial of 950 patients, aged 65 years and older, with or without preexisting dementia, and a fragility hip fracture requiring surgical repair from 9 university teaching hospitals in Southeastern China. Participants were enrolled between October 2014 and September 2018; 30-day follow-up ended November 2018. INTERVENTIONS Patients were randomized to receive either regional anesthesia (spinal, epidural, or both techniques combined with no sedation; n = 476) or general anesthesia (intravenous, inhalational, or combined anesthetic agents; n = 474). MAIN OUTCOMES AND MEASURES Primary outcome was incidence of delirium during the first 7 postoperative days. Secondary outcomes analyzed in this article include delirium severity, duration, and subtype; postoperative pain score; length of hospitalization; 30-day all-cause mortality; and complications. RESULTS Among 950 randomized patients (mean age, 76.5 years; 247 [26.8%] male), 941 were evaluable for the primary outcome (6 canceled surgery and 3 withdrew consent). Postoperative delirium occurred in 29 (6.2%) in the regional anesthesia group vs 24 (5.1%) in the general anesthesia group (unadjusted risk difference [RD], 1.1%; 95% CI, -1.7% to 3.8%; P = .48; unadjusted relative risk [RR], 1.2 [95% CI, 0.7 to 2.0]; P = .57]). Mean severity score of delirium was 23.0 vs 24.1, respectively (unadjusted difference, -1.1; 95% CI, -4.6 to 3.1). A single delirium episode occurred in 16 (3.4%) vs 10 (2.1%) (unadjusted RD, 1.1%; 95% CI, -1.7% to 3.9%; RR, 1.6 [95% CI, 0.7 to 3.5]). Hypoactive subtype in 11 (37.9%) vs 5 (20.8%) (RD, 11.5; 95% CI, -11.0% to 35.7%; RR, 2.2 [95% CI, 0.8 to 6.3]). Median worst pain score was 0 (IQR, 0 to 20) vs 0 (IQR, 0 to 10) (difference 0; 95% CI, 0 to 0). Median length of hospitalization was 7 days (IQR, 5 to 10) vs 7 days (IQR, 6 to 10) (difference 0; 95% CI, 0 to 0). Death occurred in 8 (1.7%) vs 4 (0.9%) (unadjusted RD, -0.8%; 95% CI, -2.2% to 0.7%; RR, 2.0 [95% CI, 0.6 to 6.5]). Adverse events were reported in 106 episodes in the regional anesthesia group and 102 in the general anesthesia group; the most frequently reported adverse events were nausea and vomiting (47 [44.3%] vs 34 [33.3%]) and postoperative hypotension (13 [12.3%] vs 10 [9.8%]). CONCLUSIONS AND RELEVANCE In patients aged 65 years and older undergoing hip fracture surgery, regional anesthesia without sedation did not significantly reduce the incidence of postoperative delirium compared with general anesthesia. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02213380.
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Affiliation(s)
- Ting Li
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- Clinical Research Unit, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jun Li
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Liyong Yuan
- Department of Anesthesiology and Perioperative Medicine, Ningbo No. 6 Hospital, Ningbo, Zhejiang, China
| | - Jinze Wu
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Wenzhou Medical University, The First Provincial Wenzhou Hospital of Zhejiang, Wenzhou, Zhejiang, China
| | - Chenchen Jiang
- Clinical Research Unit, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | | | - Mingcang Wang
- Department of Anesthesiology and Perioperative Medicine, Taizhou Hospital of Zhejiang Province, Taizhou, Zhejiang, China
| | - Joyce Yeung
- Warwick Clinical Trials Unit, University of Warwick, Warwick, United Kingdom
- University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Thomas Jackson
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Teresa Melody
- University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Shengwei Jin
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yinguang Yao
- Department of Anesthesia and Critical Care, Lishui Municipal People’s Hospital, Lishui Central Hospital, and Fifth Affiliated Hospital of Wenzhou Medical College, Lishui, Zhejiang, China
| | - Jimin Wu
- Department of Anesthesia and Critical Care, Lishui City People's Hospital, Lishui, Zhejiang, China
| | - Junping Chen
- Department of Anesthesia and Critical Care, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo No. 2 Hospital, Ningbo, Zhejiang, China
| | - Fang Gao Smith
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
- University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Qingquan Lian
- Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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De Vincentis A, Behr AU, Bellelli G, Bravi M, Castaldo A, Galluzzo L, Iolascon G, Maggi S, Martini E, Momoli A, Onder G, Paoletta M, Pietrogrande L, Roselli M, Ruggeri M, Ruggiero C, Santacaterina F, Tritapepe L, Zurlo A, Antonelli Incalzi R. Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus. Aging Clin Exp Res 2021; 33:2405-2443. [PMID: 34287785 DOI: 10.1007/s40520-021-01898-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues. AIM To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF. METHODS A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence. RESULTS A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics). CONCLUSION These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.
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Ashken T, West S. Regional anaesthesia in patients at risk of bleeding. BJA Educ 2021; 21:84-94. [PMID: 33664977 PMCID: PMC7892354 DOI: 10.1016/j.bjae.2020.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 01/10/2023] Open
Affiliation(s)
- T. Ashken
- Chelsea and Westminster Hospital, London, UK
| | - S. West
- University College London Hospitals NHS Foundation Trust, London, UK
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