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Guo J, Xu X, Geng Q, Wang T, Xu K, He J, Long Y, Zhang Q, Jing W, Li Z, Pan Y, Xu P, Hou Z. Efficacy of surgical intervention over conservative management in intertrochanteric fractures among nonagenarians and centenarians: a prospective cohort study. Int J Surg 2024; 110:2708-2720. [PMID: 38376871 DOI: 10.1097/js9.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/25/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Optimal treatment strategy for nonagenarians and centenarians with hip fractures (NCHF) remained unknown. The authors aimed to compare the outcomes of surgical and conservative management in NCHF. METHODS A prospective cohort study was conducted based on CPMHF database with NCHF patients hospitalized during 2014-2020. Comorbidities were evaluated by mECM score and restricted cubic spline was utilized to visually assess the dose-effect relationship between the mECM and outcomes. Propensity score matching was performed to balance baseline characteristics between nonsurgical and surgical groups. Multivariate logistic regression, Cox proportional hazard analysis, and survival analysis were employed for unfavorable outcomes (UFO) evaluation. Competing risk of death were analyzed based on Fine and Gray's hazard model and then constructed nomogram models for predicting survival rates. Subgroup analyses were used to determine potential population heterogeneity and sensitivity analyses were performed to test robustness of the results. RESULTS The authors found increasing trends for UFO with the increase in the mECM score, and that high mECM score (HMS, ≥3) was independently associated with a 2.42-fold (95% CI: 2.07-3.54; P =0.024) increased risk of UFO, which remained significant after considering the competing role of death and were more pronounced in nonsurgical treatment, women, no insurance, and patients with spouse (all P for interaction <0.05). Surgical intervention was identified to be significant protective factors for UFO (RR, 0.59; 95% CI: 0.46-0.75; P <0.001) and severe complications (RR, 0.63; 95% CI: 0.41-0.96; P =0.033) after propensity score matching, as well as survival (HR, 0.40, 95% CI: 0.28-0.58; P <0.001), which remained significant after considering the competing role of death and in all sensitivity analyses and were more pronounced in HMS participants ( P for interaction=0.006). Subgroup analyses revealed surgical patients with HMS had a significantly higher UFO rate (excluding death, P <0.001) while nonsurgical patients with HMS had higher mortality rate as compared to the others ( P =0.005). CONCLUSION Surgical treatment for NCHF yields better outcomes compared to conservative treatment.
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Affiliation(s)
- Junfei Guo
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi
| | - Xin Xu
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi
| | | | - Tao Wang
- Department of Orthopedic Surgery
| | - Ke Xu
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi
| | - Jinwen He
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi
| | | | | | - Wensen Jing
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi
| | - Zheng Li
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi
| | - Ying Pan
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi
| | - Peng Xu
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi
| | - Zhiyong Hou
- Department of Orthopedic Surgery
- NHC Key Laboratory of Intelligent Orthopedic Equipment (Third Hospital of Hebei Medical University)
- Orthopaedic Research Institute of Hebei Province, Shijiazhuang, Hebei, People's Republic of China
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Liu S, Chen J, Shi H, Li J, Zeng G, Liu W, Hu W, Li S, Gao W, Song W, Liang A, Chen Y. Comparing perioperative outcomes between regional anesthesia and general anesthesia in patients undergoing hip fracture surgery: a systematic review and meta-analysis. Can J Anaesth 2024:10.1007/s12630-024-02696-3. [PMID: 38418761 DOI: 10.1007/s12630-024-02696-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 03/02/2024] Open
Abstract
PURPOSE Nearly all patients with hip fractures undergo surgical treatment. The use of different anesthesia techniques during surgery may influence the clinical outcomes. The optimal anesthetic technique for patients undergoing hip fracture surgery is still controversial. We performed this updated systematic review and meta-analysis to compare clinical outcomes of patients undergoing hip fracture surgery with different anesthesia techniques. SOURCE Articles published from 2000 to May 2023 were included from MEDLINE, Embase, Web of Science, and the Cochrane Library. We included randomized controlled trials and observational studies comparing general anesthesia (GA) with regional anesthesia (RA) for the outcomes of 30-day mortality, 90-day mortality, in-hospital mortality, perioperative complications, length of hospital stay, and length of surgery in patients undergoing hip fracture surgery. Subgroup analyses were performed for the outcomes based on study design (randomized controlled trials or observational studies). We used a random-effects model for all analyses. PRINCIPAL FINDINGS In this meta-analysis, we included 12 randomized controlled trials. There was no difference in postoperative 30-day mortality between the two groups (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.44 to 1.74; I2 = 0%). The incidence of intraoperative hypotension was lower in patients who received RA vs GA (OR, 0.52; 95% CI, 0.38 to 0.72; I2 = 0%). No significant differences were observed in 90-day mortality, in-hospital mortality, postoperative delirium, pneumonia, myocardial infarction, venous thromboembolism, length of surgery, and length of hospital stay. CONCLUSION In this updated systematic review and meta-analysis, RA did not reduce postoperative 30-day mortality in hip fracture surgery patients compared to GA. Fewer patients receiving RA had intraoperative hypotension than those receiving GA did. Apart from intraoperative hypotension, the data showed no differences in complications between the two anesthetic techniques. STUDY REGISTRATION PROSPERO (CRD42023411854); registered 7 April 2023.
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Affiliation(s)
- Song Liu
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jianan Chen
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huihong Shi
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jianhong Li
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Gang Zeng
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenzhou Liu
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenjun Hu
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shaoguang Li
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenjie Gao
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Weidong Song
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Anjing Liang
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanbo Chen
- Department of Orthopedics, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Yingfeng Road, 33th Haizhu District, Guangzhou, 510000, China.
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Wang SH, Chang CW, Chai SW, Huang TS, Soong R, Lau NC, Chien CY. Surgical intervention may provides better outcomes for hip fracture in nonagenarian patients: A retrospective observational study. Heliyon 2024; 10:e25151. [PMID: 38322977 PMCID: PMC10844277 DOI: 10.1016/j.heliyon.2024.e25151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 01/02/2024] [Accepted: 01/22/2024] [Indexed: 02/08/2024] Open
Abstract
Background Hip fracture is a common disease in the elderly. Among these patients, surgical intervention for hip fracture should be carefully considered because of old age and multiple comorbidities. There are still insufficient comparisons between nonagenarian patients treated with surgery and those treated non-surgically. We studied hip fracture nonagenarian patients to compare the different outcomes between surgical and non-surgical treatments. Materials and methods Nonagenarian patients visiting the emergency department with hip fractures between March 2010 and December 2020 were identified. Overall survival was estimated using multivariate Cox proportional hazards models. The mortality rates, the length of hospital stay, complication and readmission rates were also recorded. Results A total of 173 patients who underwent surgery and 32 who received conservative treatments were included. The median survival time was 58.47 months in the OP group, which was significantly higher than the 24.28 months in the non-OP group. After adjusting for covariates, including age, sex, Charlson Comorbidity Index (CCI), injury severity score, and fracture type, the risk of death was reduced by surgery (hazard ratio [HR] = 0.427; 95 % confidence interval [CI]: 0.207-0.882; p = 0.021). CCI was also an independent risk factor for poor survival rate (HR = 1.3; 95 % CI: 1.115-1.515; p = 0.001). After adjusting for several factors, surgery within 48 h improved overall survival (HR: 2.518; 95 % CI: 1.299-4.879; p = 0.006) in operative group. Conclusion Our study suggests that surgical treatment may provide better survival for nonagenarian patients with hip fractures than non-operation, especially patients with less concurrent comorbidities.
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Affiliation(s)
- Suo-Hsien Wang
- Department of Surgery, New Taipei Municipal Tucheng Hospital, New Taipei City, 23652, Taiwan
| | - Chia-Wei Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shion-Wei Chai
- Department of General Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
- Department of General Surgery, Jen Ai Hospital, Taichung, 400, Taiwan
| | - Ting-Shuo Huang
- Department of General Surgery, Jen Ai Hospital, Taichung, 400, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Rueyshyang Soong
- Division of Transplantation, Department of Surgery, Taipei Municipal Wan-Fang Hospital, Taiwan
| | - Ngi-Chiong Lau
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chih-Ying Chien
- Department of General Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taiwan
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Salgado-García D, Díaz-Álvarez A, González-Rodríguez JL, López-Iglesias MR, Sánchez-López E, Sánchez-Ledesma MJ, Martínez-Trufero MI. Comparison of the Analgesic Efficacy between Levobupivacaine 0.25% and Ropivacaine 0.375% for PENG (Pericapsular Nerve Group) Block in the Context of Hip Fracture Surgery of Elderly Patients: A Single-Center, Randomized, and Controlled Clinical Trial. J Clin Med 2024; 13:770. [PMID: 38337464 PMCID: PMC10856763 DOI: 10.3390/jcm13030770] [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: 01/16/2024] [Revised: 01/20/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Previous studies have compared levobupivacaine versus ropivacaine in various peripheral nerve blocks in terms of block duration, quality of analgesia, and onset time, but this has not occurred in the PENG block. Here, a single-center, randomized, and controlled clinical trial is presented. One hundred and twenty patients older than 65 years suffering from hip fractures and surgically treated at our institution under spinal anesthesia were eligible for participation; of them, one hundred and eight were analyzed. Patients were randomized to receive ultrasound-guided PENG blocks using 20 mL of either 0.25% levobupivacaine or 0.375% ropivacaine (both of which are equipotent concentrations). The primary endpoint was to compare the analgesic duration (time to first rescue) and analgesic quality (pain scores using the VAS, PAINAD, and AlgoPlus scales) between the groups. Secondary endpoints included comparing the onset time, describing the need for and type of rescue analgesics, and possible associated adverse effects. There were no statistically significant differences in analgesic duration between levobupivacaine (median 861.0, IQR 960) and ropivacaine (median 1205.0, IQR 1379; p = 0.069). Likewise, the quality of analgesia and onset time were comparable among the groups. A small number of patients required opioids as rescue analgesics (4.6%). The possible associated adverse effects included postoperative infection (11.1%) and delirium (2.8%).
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Affiliation(s)
- Daniel Salgado-García
- Department of Anesthesiology and Critical Care, Salamanca University Hospital, Gerencia Regional de Salud de Castilla y León (SACYL), Paseo de la Transición Española, 37007 Salamanca, Castilla y León, Spain; (D.S.-G.); (J.L.G.-R.); (M.R.L.-I.); (E.S.-L.); (M.J.S.-L.); (M.I.M.-T.)
| | - Agustín Díaz-Álvarez
- Department of Anesthesiology and Critical Care, Salamanca University Hospital, Gerencia Regional de Salud de Castilla y León (SACYL), Paseo de la Transición Española, 37007 Salamanca, Castilla y León, Spain; (D.S.-G.); (J.L.G.-R.); (M.R.L.-I.); (E.S.-L.); (M.J.S.-L.); (M.I.M.-T.)
- Department of Surgery, Faculty of Medicine, Salamanca University, Calle Alfonso X el Sabio, 37007 Salamanca, Castilla y León, Spain
- Instituto de Investigación Biomédica de Salamanca de la FIESCYL (IBSAL-FIESCYL), Paseo de San Vicente 182, 37007 Salamanca, Castilla y León, Spain
| | - José Luis González-Rodríguez
- Department of Anesthesiology and Critical Care, Salamanca University Hospital, Gerencia Regional de Salud de Castilla y León (SACYL), Paseo de la Transición Española, 37007 Salamanca, Castilla y León, Spain; (D.S.-G.); (J.L.G.-R.); (M.R.L.-I.); (E.S.-L.); (M.J.S.-L.); (M.I.M.-T.)
- Instituto de Investigación Biomédica de Salamanca de la FIESCYL (IBSAL-FIESCYL), Paseo de San Vicente 182, 37007 Salamanca, Castilla y León, Spain
| | - María Rocío López-Iglesias
- Department of Anesthesiology and Critical Care, Salamanca University Hospital, Gerencia Regional de Salud de Castilla y León (SACYL), Paseo de la Transición Española, 37007 Salamanca, Castilla y León, Spain; (D.S.-G.); (J.L.G.-R.); (M.R.L.-I.); (E.S.-L.); (M.J.S.-L.); (M.I.M.-T.)
- Instituto de Investigación Biomédica de Salamanca de la FIESCYL (IBSAL-FIESCYL), Paseo de San Vicente 182, 37007 Salamanca, Castilla y León, Spain
| | - Eduardo Sánchez-López
- Department of Anesthesiology and Critical Care, Salamanca University Hospital, Gerencia Regional de Salud de Castilla y León (SACYL), Paseo de la Transición Española, 37007 Salamanca, Castilla y León, Spain; (D.S.-G.); (J.L.G.-R.); (M.R.L.-I.); (E.S.-L.); (M.J.S.-L.); (M.I.M.-T.)
| | - Manuel Jesús Sánchez-Ledesma
- Department of Anesthesiology and Critical Care, Salamanca University Hospital, Gerencia Regional de Salud de Castilla y León (SACYL), Paseo de la Transición Española, 37007 Salamanca, Castilla y León, Spain; (D.S.-G.); (J.L.G.-R.); (M.R.L.-I.); (E.S.-L.); (M.J.S.-L.); (M.I.M.-T.)
- Department of Surgery, Faculty of Medicine, Salamanca University, Calle Alfonso X el Sabio, 37007 Salamanca, Castilla y León, Spain
- Instituto de Investigación Biomédica de Salamanca de la FIESCYL (IBSAL-FIESCYL), Paseo de San Vicente 182, 37007 Salamanca, Castilla y León, Spain
| | - María Isabel Martínez-Trufero
- Department of Anesthesiology and Critical Care, Salamanca University Hospital, Gerencia Regional de Salud de Castilla y León (SACYL), Paseo de la Transición Española, 37007 Salamanca, Castilla y León, Spain; (D.S.-G.); (J.L.G.-R.); (M.R.L.-I.); (E.S.-L.); (M.J.S.-L.); (M.I.M.-T.)
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5
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Zabawa L, Choubey AS, Drake B, Mayo J, Mejia A. Dementia and Hip Fractures: A Comprehensive Review of Management Approaches. JBJS Rev 2023; 11:01874474-202312000-00002. [PMID: 38079493 DOI: 10.2106/jbjs.rvw.23.00157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
» The elderly population is the fastest growing demographic, and the number of dementia cases in the United States is expected to double to 10 million by 2050.» Patients with dementia are at 3× higher risk of hip fractures and have higher morbidity and mortality after hip fractures.» Hip fracture patients with dementia benefit from early analgesia and timely surgical fixation of fracture.» Early and intensive inpatient rehabilitation is associated with improved postoperative outcomes in patients with dementia.» Coordination of care within a "orthogeriatric" team decreases mortality, and fracture liaison services show potential for improving long-term outcomes in hip fracture patients with dementia.
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Affiliation(s)
- Luke Zabawa
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Apurva S Choubey
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Brett Drake
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Joel Mayo
- University of Illinois College of Medicine, Chicago, Illinois
| | - Alfonso Mejia
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
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Lin H, Zhu Y, Ren C, Ma T, Li M, Li Z, Xu Y, Wang Q, Hu J, Zhang K. Comparing the Effect of Spinal and General Anesthesia for Hip Fracture Surgery in Older Patients: A Meta-analysis of Randomized Clinical Trials. Orthop Surg 2023; 15:3254-3262. [PMID: 37753546 PMCID: PMC10693995 DOI: 10.1111/os.13895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/28/2023] Open
Abstract
OBJECTIVE Hip fractures are the most common fractures among older adults, with most patients undergoing surgery. The debate regarding the type of anesthetic technique for hip fracture surgery is still ongoing. This meta-analysis aimed to compare the intraoperative and postoperative outcomes of spinal and general anesthesia in older patients undergoing hip fracture surgery. METHODS Eligible studies that compared the effects of spinal and general anesthesia were systematically searched from PubMed, Embase, and the Cochrane Library until May 27, 2022. The intraoperative and postoperative outcomes of the two anesthesia techniques were compared. Quality assessment, heterogeneity analysis, and publication bias of the studies were also assessed. RESULTS Nine articles of methodological quality were included in the meta-analysis. The pooled results revealed that there were significant differences in hypotension (risk ratio [RR] (95% confidence interval [CI]) = 0.81 (0.68, 0.97), p = 0.02) and ephedrine dose (weighted mean difference [WMD] [95%CI] = -20.94 [-37.50, -4.37] mg, p = 0.01) between the spinal and general anesthesia groups. However, no significant differences were observed in the use of ephedrine (RR [95% CI] = 0.77 [0.19, 3.05]), blood loss (WMD [95%CI] = -34.38 [-89.56, 20.80) mL], myocardial infarction (RR [95% CI] = 0.78 [0.31, 1.94] mL), heart failure (RR [95% CI] = 0.87 [0.17, 4.36] mL), stroke (RR [95%CI) = 0.65 [0.22, 1.95] mL), postoperative nausea and vomiting (RR [95% CI] = 0.88 [0.17, 4.35] mL), delirium (RR [95% CI] = 1.08 [0.89, 1.31] mL), and mortality (RR [95% CI] = 1.10 [0.72, 1.68] mL) (all p < 0.05). No publication bias was observed in any of the included studies. CONCLUSION Compared to general anesthesia, spinal anesthesia was associated with a lower risk of intraoperative hypotension and lower doses of ephedrine in older patients undergoing hip fracture surgery.
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Affiliation(s)
- Hua Lin
- Department of Orthopedic Trauma, Honghui HospitalXi'an Jiaotong UniversityXi'anChina
| | - Ying Zhu
- Department of Neurology, Honghui HospitalXi'an Jiaotong UniversityXi'anChina
| | - Cheng Ren
- Department of Orthopedic Trauma, Honghui HospitalXi'an Jiaotong UniversityXi'anChina
| | - Teng Ma
- Department of Orthopedic Trauma, Honghui HospitalXi'an Jiaotong UniversityXi'anChina
| | - Ming Li
- Department of Orthopedic Trauma, Honghui HospitalXi'an Jiaotong UniversityXi'anChina
| | - Zhong Li
- Department of Orthopedic Trauma, Honghui HospitalXi'an Jiaotong UniversityXi'anChina
| | - Yibo Xu
- Department of Orthopedic Trauma, Honghui HospitalXi'an Jiaotong UniversityXi'anChina
| | - Qian Wang
- Department of Orthopedic Trauma, Honghui HospitalXi'an Jiaotong UniversityXi'anChina
| | - Jing Hu
- Department of Nursing, Honghui HospitalXi'an Jiaotong UniversityXi'anChina
| | - Kun Zhang
- Department of Orthopedic Trauma, Honghui HospitalXi'an Jiaotong UniversityXi'anChina
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Huang YY, Hui CK, Lau NC, Ng YT, Lin TY, Chen CH, Wang YC, Tang HC, Chen DWC, Chang CW. Total intravenous anesthesia for geriatric hip fracture with severe systemic disease. Eur J Trauma Emerg Surg 2023; 49:2139-2145. [PMID: 37354341 PMCID: PMC10520204 DOI: 10.1007/s00068-023-02291-z] [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: 12/23/2022] [Accepted: 05/23/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE Our study aimed to determine the impact of a novel technique of anesthesia administration on the clinical outcomes and complications in geriatric patients with severe systemic disease undergoing hip surgery. METHODS We retrospectively identified patients aged > 65 years with severe systemic disease that was a constant of life [American Society of Anesthesiologists (ASA) IV] who underwent surgery for hip fracture between January 2018 and January 2020. The patients were divided into two groups: Group I [fascia iliaca compartment block plus propofol-based total intravenous anesthesia (FICB + TIVA)] and Group II [general anesthesia (GA)]. The primary outcomes were 30-day and 1-year mortality. The secondary outcomes included length of hospital stay, length of intensive care unit (ICU) stay, postoperative morbidity, Visual Analog Scale score, and consumption of analgesics. RESULTS There was no significant difference in the 30-day mortality (5 vs. 3.8%, p = 0.85) and 1-year mortality (15 vs. 12%, p = 0.73) between the groups. Group I had significantly lower ICU requirements (p = 0.01) and shorter lengths of ICU stay (p < 0.001) and hospital stay (p < 0.001). Moreover, a smaller proportion of patients in Group I required postoperative morphine or oral opiates. CONCLUSION Geriatric patients who underwent hip surgery under FICB + TIVA required fewer ICU admissions, shorter lengths of ICU and hospital stay, and had lesser postoperative opioid consumption than those who were under GA. Hence, we recommend the novel FICB + TIVA technique for hip fracture surgery in geriatric patients with poor general health status and high surgical risks (ASA IV).
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Affiliation(s)
- Yu-Yi Huang
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, No. 222, Maijin Rd., Anle Dist., Keelung City, 204 Taiwan
- College of Medicine, Chang Gung University, No. 259, Wunhua 1st Rd., Guishan Dist., Taoyuan City, 333 Taiwan
| | - Chung-Kun Hui
- Department of Anesthesiology, Chang Gung Memorial Hospital, No. 222, Maijin Rd., Anle Dist., Keelung City, 204 Taiwan
| | - Ngi-Chiong Lau
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, No. 222, Maijin Rd., Anle Dist., Keelung City, 204 Taiwan
- College of Medicine, Chang Gung University, No. 259, Wunhua 1st Rd., Guishan Dist., Taoyuan City, 333 Taiwan
| | - Yuet-Tong Ng
- Department of Anesthesiology, Chang Gung Memorial Hospital, No. 222, Maijin Rd., Anle Dist., Keelung City, 204 Taiwan
| | - Tung-Yi Lin
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, No. 222, Maijin Rd., Anle Dist., Keelung City, 204 Taiwan
- College of Medicine, Chang Gung University, No. 259, Wunhua 1st Rd., Guishan Dist., Taoyuan City, 333 Taiwan
| | - Chien-Hao Chen
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, No. 222, Maijin Rd., Anle Dist., Keelung City, 204 Taiwan
- College of Medicine, Chang Gung University, No. 259, Wunhua 1st Rd., Guishan Dist., Taoyuan City, 333 Taiwan
| | - Ying-Chih Wang
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, No. 222, Maijin Rd., Anle Dist., Keelung City, 204 Taiwan
- College of Medicine, Chang Gung University, No. 259, Wunhua 1st Rd., Guishan Dist., Taoyuan City, 333 Taiwan
| | - Hao-Che Tang
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, No. 222, Maijin Rd., Anle Dist., Keelung City, 204 Taiwan
- College of Medicine, Chang Gung University, No. 259, Wunhua 1st Rd., Guishan Dist., Taoyuan City, 333 Taiwan
| | - Dave Wei-Chih Chen
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, No. 222, Maijin Rd., Anle Dist., Keelung City, 204 Taiwan
- College of Medicine, Chang Gung University, No. 259, Wunhua 1st Rd., Guishan Dist., Taoyuan City, 333 Taiwan
| | - Chia-Wei Chang
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung Branch, No. 222, Maijin Rd., Anle Dist., Keelung City, 204 Taiwan
- College of Medicine, Chang Gung University, No. 259, Wunhua 1st Rd., Guishan Dist., Taoyuan City, 333 Taiwan
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Tay HY, Wu WT, Peng CH, Liu KL, Yu TC, Chen IH, Yao TK, Chang CM, Chua JY, Wang JH, Yeh KT. COVID-19 Infection Was Associated with the Functional Outcomes of Hip Fracture among Older Adults during the COVID-19 Pandemic Apex. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1640. [PMID: 37763759 PMCID: PMC10534880 DOI: 10.3390/medicina59091640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Hip fractures are associated with mortality and poor functional outcomes. The COVID-19 pandemic has affected patterns of care and health outcomes among fracture patients. This study aimed to determine the influence of COVID-19 infection on hip fracture recovery. Materials and Methods: We prospectively collected data on patients with hip fractures who presented at Hualien Tzu Chi Hospital between 9 March 2022 and 9 September 2022. The data included demographic information and functional scores taken before, during, and after surgery. The patients were divided into two groups: COVID-19 (+) and COVID-19 (-). Results: This study recruited 85 patients, 12 of whom (14.12%) were COVID-19 (+). No significant differences in preoperative or perioperative parameters between the two groups were observed. The postoperative Barthel index score was significantly impacted by COVID-19 infection (p = 0.001). The incidence of postoperative complications was significantly correlated with general anesthesia (p = 0.026) and the length of stay (p = 0.004) in hospital. Poor postoperative functional scores were associated with lower preoperative Barthel index scores (p < 0.001). Male sex (p = 0.049), old age (p = 0.012), a high American Society of Anesthesiologists grade (p = 0.029), and a high Charlson comorbidity index score (p = 0.028) were associated with mortality. Conclusions: Hip fracture surgeries were not unduly delayed in our hospital during the COVID-19 pandemic, but the patients' postoperative Barthel index scores were significantly influenced by COVID-19 (+). The preoperative Barthel index score may be a good predictive tool for the postoperative functional recovery of these patients.
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Affiliation(s)
- Hua-Yong Tay
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan; (H.-Y.T.); (W.-T.W.); (C.-H.P.); (K.-L.L.); (T.-C.Y.); (I.-H.C.); (T.-K.Y.); (C.-M.C.); (J.-Y.C.)
- Department of Medical Education, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan
| | - Wen-Tien Wu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan; (H.-Y.T.); (W.-T.W.); (C.-H.P.); (K.-L.L.); (T.-C.Y.); (I.-H.C.); (T.-K.Y.); (C.-M.C.); (J.-Y.C.)
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
| | - Cheng-Huan Peng
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan; (H.-Y.T.); (W.-T.W.); (C.-H.P.); (K.-L.L.); (T.-C.Y.); (I.-H.C.); (T.-K.Y.); (C.-M.C.); (J.-Y.C.)
| | - Kuan-Lin Liu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan; (H.-Y.T.); (W.-T.W.); (C.-H.P.); (K.-L.L.); (T.-C.Y.); (I.-H.C.); (T.-K.Y.); (C.-M.C.); (J.-Y.C.)
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
| | - Tzai-Chiu Yu
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan; (H.-Y.T.); (W.-T.W.); (C.-H.P.); (K.-L.L.); (T.-C.Y.); (I.-H.C.); (T.-K.Y.); (C.-M.C.); (J.-Y.C.)
| | - Ing-Ho Chen
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan; (H.-Y.T.); (W.-T.W.); (C.-H.P.); (K.-L.L.); (T.-C.Y.); (I.-H.C.); (T.-K.Y.); (C.-M.C.); (J.-Y.C.)
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
| | - Ting-Kuo Yao
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan; (H.-Y.T.); (W.-T.W.); (C.-H.P.); (K.-L.L.); (T.-C.Y.); (I.-H.C.); (T.-K.Y.); (C.-M.C.); (J.-Y.C.)
| | - Chia-Ming Chang
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan; (H.-Y.T.); (W.-T.W.); (C.-H.P.); (K.-L.L.); (T.-C.Y.); (I.-H.C.); (T.-K.Y.); (C.-M.C.); (J.-Y.C.)
| | - Jian-Yuan Chua
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan; (H.-Y.T.); (W.-T.W.); (C.-H.P.); (K.-L.L.); (T.-C.Y.); (I.-H.C.); (T.-K.Y.); (C.-M.C.); (J.-Y.C.)
| | - Jen-Hung Wang
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan;
| | - Kuang-Ting Yeh
- Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan; (H.-Y.T.); (W.-T.W.); (C.-H.P.); (K.-L.L.); (T.-C.Y.); (I.-H.C.); (T.-K.Y.); (C.-M.C.); (J.-Y.C.)
- Department of Medical Education, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien 97002, Taiwan
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
- Graduate Institute of Clinical Pharmacy, Tzu Chi University, Hualien 970374, Taiwan
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Cheung KYL, Yang TX, Chong DYC, So EHK. Neuraxial versus general anesthesia in elderly patients undergoing hip fracture surgery and the incidence of postoperative delirium: a systematic review and stratified meta-analysis. BMC Anesthesiol 2023; 23:250. [PMID: 37481517 PMCID: PMC10362612 DOI: 10.1186/s12871-023-02196-9] [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: 03/17/2023] [Accepted: 07/03/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND Evidence-based effect of anesthetic regimens on postoperative delirium (POD) incidence after hip fracture surgery is still debated. Randomized trials have reported inconsistent contradictory results largely attributed to small sample size, use of outdated drugs and techniques, and inconsistent definitions of adverse outcomes. The primary objective of this meta-analysis was to investigate the impact of different anesthesia regimens on POD, cognitive impairment, and associated complications including mortality, duration of hospital stay, and rehabilitation capacity. METHODS We identified randomized controlled trials (RCTs) published from 2000 to December 2021, in English and non-English language, comparing the effect of neuraxial anesthesia (NA) versus general anesthesia (GA) in elderly patients undergoing hip fracture surgery, from PubMed, EMBASE, Google Scholar, Web of Science and the Cochrane Library database. They were included if POD incidence, cognitive impairment, mortality, duration of hospital stay, or rehabilitation capacity were reported as at least one of the outcomes. Study protocols, case reports, audits, editorials, commentaries, conference reports, and abstracts were excluded. Two investigators (KYC and TXY) independently screened studies for inclusion and performed data extraction. The risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool. The quality of the evidence for each outcome according to the GRADE working group criteria. The odds ratio (OR) and 95% confidence intervals (CI) were calculated to assess the pooled data. RESULTS A total of 10 RCTs with 3968 patients were included in the present analysis. No significant differences were found in the incidence of POD comparing NA vs GA [OR 1.10, 95% CI (0.89 to 1.37)], with or without including patients with a pre-existing condition of dementia or delirium, POD incidence from postoperative day 2-7 [OR 0.31, 95% CI (0.06 to -1.63)], in mini-mental state examination (MMSE) score [OR 0.07, 95% CI (-0.22 to 0.36)], or other neuropsychological test results. NA appeared to have a shorter duration of hospital stay, especially in patients without pre-existing dementia or delirium, however the observed effect did not reach statistical significance [OR -0.23, 95% CI (-0.46 to 0.01)]. There was no difference in other outcomes, including postoperative pain control, discharge to same preadmission residence [OR 1.05, 95% CI (0.85 to 1.31)], in-hospital mortality [OR 1.98, 95% CI (0.20 to 19.25)], 30-day [OR 1.03, 95% CI (0.47 to 2.25)] or 90-day mortality [OR 1.08, 95% CI (0.53-2.24)]. CONCLUSIONS No significant differences were detected in incidence of POD, nor in other delirium-related outcomes between NA and GA groups and in subgroup analyses. NA appeared to be associated with a shorter hospital stay, especially in patients without pre-existing dementia, but the observed effect did not reach statistical significance. Further larger prospective randomized trials investigating POD incidence and its duration and addressing long-term clinical outcomes are indicated to rule out important differences between different methods of anesthesia for hip surgery. TRIAL REGISTRATION 10.17605/OSF.IO/3DJ6C.
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Affiliation(s)
- Karis Yui-Lam Cheung
- Queen Elizabeth Hospital, Tertiary Hospital in Kowloon, 30 Gascoigne Road, Hong Kong, Hong Kong.
| | - Timothy Xianyi Yang
- Queen Elizabeth Hospital, Tertiary Hospital in Kowloon, 30 Gascoigne Road, Hong Kong, Hong Kong
| | - David Yew-Chuan Chong
- Queen Elizabeth Hospital, Tertiary Hospital in Kowloon, 30 Gascoigne Road, Hong Kong, Hong Kong
| | - Eric Hang-Kwong So
- Queen Elizabeth Hospital, Tertiary Hospital in Kowloon, 30 Gascoigne Road, Hong Kong, Hong Kong
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10
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Zuelzer DA, Weaver D, Zuelzer AP, Hessel EA. Current Strategies in Medical Management of the Geriatric Hip Fracture Patient. J Am Acad Orthop Surg 2023:00124635-990000000-00694. [PMID: 37184459 DOI: 10.5435/jaaos-d-22-00815] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 04/01/2023] [Indexed: 05/16/2023] Open
Abstract
Orthogeriatric hip fractures have high morbidity and mortality rates. Modern management focuses on multidisciplinary collaboration for prompt surgical stabilization, early mobilization with multimodal pain control to avoid opioid consumption, and an enhanced recovery pathway. Despite these advances, postoperative complications and mortality rates remain higher than age-matched control subjects. The authors of this article represent the orthopaedic, anesthesia, and hospitalist medicine members of a multidisciplinary team at a single, Level 1 trauma center. Our goal was to provide an up-to-date comprehensive review of orthogeriatric hip fracture perioperative management from a multidisciplinary perspective that every orthopaedic surgeon should know.
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Affiliation(s)
- David A Zuelzer
- From the Department of Orthopaedic and Sports Medicine (Zuelzer), Department of Internal Medicine (Weaver), Department of Anesthesiology (Zuelzer and Hessel), University of Kentucky, Lexington, KY
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11
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Zhuang X, He Y, Liu Y, Li J, Ma W. The effects of anesthesia methods and anesthetics on postoperative delirium in the elderly patients: A systematic review and network meta-analysis. Front Aging Neurosci 2022; 14:935716. [DOI: 10.3389/fnagi.2022.935716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
Study objectivePostoperative delirium (POD) is one of the serious postoperative complications in elderly patients, which is always related to long-term mortality. Anesthesia is often considered a risk factor for POD. This systematic review and network meta-analysis (NMA) aimed to assess the impact of different anesthesia methods and anesthetics on POD.MeasurementsWe searched for studies published in PubMed, Embase, Web of Science, Scopus, and Cochrane Library (CENTRAL) from inception to 18 March 2022. RevMan 5.3 and CINeMA 2.0.0 were used to assess the risk of bias and confidence. Data analysis using STATA 17.0 and R 4.1.2. STATA 17.0 was used to calculate the surface under the cumulative ranking curve (SUCRA) and provide network plots with CINeMA 2.0.0. NMA was performed with R 4.1.2 software gemtc packages in RStudio.Main resultsThis NMA included 19 RCTs with 5,406 patients. In the pairwise meta-analysis results, only regional anesthesia (RA) with general anesthesia (GA) vs. GA (Log OR: –1.08; 95% CI: –1.54, –0.63) were statistically different in POD incidence. In the NMA results, there was no statistical difference between anesthesia methods, and psoas compartment block (PCB) with bupivacaine was superior to the desflurane, propofol, sevoflurane, and spinal anesthesia with bupivacaine of POD occurrence.ConclusionOur study indicated that RA and GA had no significant effect on POD, and there was no difference between anesthesia methods. Pairwise meta-analysis showed that, except for RA with GA vs. GA, the rest of the results were not statistically different. Besides, PCB with bupivacaine may benefit to reduce POD incidence.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/dis play_record.php?ID=CRD42022319499, identifier PROSPERO 2022 CRD42022319499.
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12
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Zhu X, Yang M, Mu J, Wang Z, Zhang L, Wang H, Yan F. The Effect of General Anesthesia vs. Regional Anesthesia on Postoperative Delirium-A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:844371. [PMID: 35419373 PMCID: PMC8995788 DOI: 10.3389/fmed.2022.844371] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/01/2022] [Indexed: 01/10/2023] Open
Abstract
Background Postoperative delirium (POD) commonly occurs in patients following major surgeries and is associated with adverse prognosis. The modes of anesthesia may be associated with POD occurrence. General anesthesia (GA) causes loss of consciousness in the patient by altering the levels of some neurotransmitters as well as signaling pathways. We conducted this meta-analysis to investigate the effect of GA vs. regional anesthesia (RA) on POD incidence in surgical patients. Methods The databases of Pubmed, Embase, and Cochrane Library were searched till October 22, 2021. The eligible criteria were participants aged 18 years or older, patients undergoing surgery under GA and RA, and articles reporting the effect of GA vs. RA on POD incidence. RevMan 5.3 was used to perform statistical analyses. Results A total of 21 relevant trials with a total of 1,702,151 patients were included. The pooled result using random-effects model with OR demonstrated significant difference in POD incidence between patients with GA and RA (OR = 1.15, 95% CI: [1.02, 1.31], I2 = 83%, p for effect = 0.02). We did not obtain the consistent pooled result after sensitivity analysis (OR = 0.95, 95% CI: [0.83, 1.08], I2 =13%, p for effect = 0.44) and excluded the articles without the information on preoperative cognitive or neuropsychological assessment (OR = 1.12, 95% CI: [1.00, 1.25], I2 =80%, p for effect = 0.05), respectively. Conclusion This meta-analysis could not identify that GA was significantly associated with POD occurrence in surgical patients compared with RA.
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Affiliation(s)
- Xianlin Zhu
- Department of Anesthesiology, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi City, China
| | - Min Yang
- Department of Anesthesiology, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi City, China
| | - Junying Mu
- Department of Anesthesiology, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi City, China
| | - Zaiping Wang
- Department of Anesthesiology, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi City, China
| | - Liang Zhang
- Department of Anesthesiology, Chongqing Hospital of Traditional Chinese Medicine, Chongqing, China
| | - Hongbai Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fuxia Yan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Fukuda T, Imai S, Shimoda S, Maruo K, Nakadera M, Horiguchi H. Aspiration pneumonia and anesthesia techniques in hip fracture surgery in elderly patients: A retrospective cohort study using administrative data. J Orthop Surg (Hong Kong) 2022; 30:10225536221078622. [PMID: 35226565 DOI: 10.1177/10225536221078622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose: Aspiration pneumonia is a critical issue. General anesthesia may suppress the airway's protective reflex. However, aspiration pneumonia is also observed in patients who undergo hip fracture surgery under spinal anesthesia. The aim of this study was to investigate the relationship between anesthesia methods and aspiration pneumonia as well as the predictive factors of aspiration pneumonia in elderly patients undergoing hip fracture surgery. Methods: The medical records of 19,809 patients aged ≥60 years who underwent hip fracture surgery under general or spinal anesthesia were reviewed. After propensity score matching, the anesthesia methods affecting the occurrences of aspiration pneumonia and other complications were investigated via logistic regression and instrumental variable analyses. Predictive factors of aspiration pneumonia were also investigated in all subjects using a multivariable logistic regression analysis. Results: Among the 11,673 general anesthesia patients and 8136 spinal anesthesia patients, aspiration pneumonia occurred in 356 patients (1.8%). Post-propensity score matching the incidences of aspiration pneumonia with general and spinal anesthesia were 1.8% and 1.5%, respectively (p = 0.158); other pulmonary complications were 1.5% and 1.5%, respectively (p = 0.893); and the mortality rates were 1.4% and 1.2%, respectively (p = 0.219). The predictive factors of aspiration pneumonia were advanced age, male sex, lean body, cerebrovascular disease, dementia, and dependency for activities of daily living (eating). Conclusion: Spinal and general anesthesia showed similar incidences of aspiration pneumonia in elderly hip fracture surgery. Regardless of the anesthesia method, great care should be taken, especially in elderly patients with the identified predictive factors.
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Affiliation(s)
- Taeko Fukuda
- Department of Anesthesiology, Faculty of Medicine, 13121University of Tsukuba, Tsukuba, Japan.,Kasumigaura Medical Center Hospital (Tsuchiura Clinical Education and Training Center), 13504National Hospital Organization, Tsuchiura, Japan
| | - Shinobu Imai
- Department of Clinical Data Management and Research, 13504National Hospital Organization Headquarters, Tokyo, Japan.,Department of Drug Safety and Risk Management, School of Pharmacy, 13115Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Shunji Shimoda
- Department of Clinical Data Management and Research, 13504National Hospital Organization Headquarters, Tokyo, Japan
| | - Kazushi Maruo
- Department of Biostatistics, Faculty of Medicine, 38515University of Tsukuba, Tsukuba, Japan
| | - Masaya Nakadera
- Department of Clinical Data Management and Research, 13504National Hospital Organization Headquarters, Tokyo, Japan
| | - Hiromasa Horiguchi
- Department of Clinical Data Management and Research, 13504National Hospital Organization Headquarters, Tokyo, Japan
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