CORR Insights®: Is Anesthesia Technique Associated With a Higher Risk of Mortality or Complications Within 90 Days of Surgery for Geriatric Patients With Hip Fractures?
Year: 2018
Type: article
Abstract: Where Are We Now? Gone are the days when hip fracture care is managed by an orthopaedic surgeon, acting alone. We now recognize that this critical patient event is best managed by a well-rounded team, consisting of geriatricians, anesthesiologists, non-physician providers, social workers/case managers, surgeons, and families. Emblematic of this recognition, we recently have seen important articles in a general medical journal about time to hip fracture surgery affecting mortality [3] and nutritional supplementation using calcium and vitamin D [7]. Within this context, pain-control and safety are two critical element of patient care and specifically those that require close collaboration between the patient/family, surgeon and anesthesiologists. This is where the choice of surgical anesthetic mode—mainly, general systemic, neuraxial regional, or both—becomes important. To summarize several careers’ worth of investigation into one sentence, it is my impression that most of these reviews have broadly supported the idea that either method is safe and effective, with a recent systematic review and meta-analysis suggesting that in-hospital mortality may be decreased using neuraxial methods, although overall 30-day mortality did not seem affected [6]. Desai and colleagues [2] queried the validated Kaiser Permanente Hip Fracture Registry (16,695 patients between 2009 and 2015) and performed an analysis of potential associations between the type of anesthesia (neuraxial, general, neuraxial converted to general) and (1) 90-day mortality, (2) 90-day emergency department returns and readmissions, and (3) Agency for Healthcare Research and Quality outcomes of deep vein thrombosis/pulmonary embolism, myocardial infarction, pneumonia, and surgical site infection. They concluded that general anesthesia and conversion to general anesthesia were associated with greater in-hospital mortality, but not out-of-hospital 90-day mortality when compared to neuraxial anesthesia. Without getting into the fine details of the methods, two structural strengths of the study included a large number of patients and the use of propensity score adjusted modeling to account for confounding by indication. Furthermore, the contemporaneous and similar findings among independent studies using differing methodologies strengthen their conclusions [2, 6]. But what does it mean to have a difference in the hospital acutely, but not so at 1 month or 3 or more and how can we use this data to move forward? Where Do We Need To Go? Our ultimate goals should be restoring function as fully as possible, and helping patients return to preinjury quality of life. That a particular anesthetic mode could decrease in-hospital mortality tells us that death after hip fracture is an outcome that we can potentially influence for the better. We need to not only validate this finding independently, but also use it as a call to identify and investigate the fundamental variables of care that allow for life-saving and life-enhancing measures—and to extend those effects to 30, 60, 90 days, and beyond. That said, the avoidance of death alone is not what patients and families desire; we must better understand return to function, as a reflection of mode of anesthesia and otherwise [1]. As a somewhat obvious example and related to the anesthetic debate, we must treat something as “simple” as pain, better [4]. How Do We Get There? I will naively suggest what most of us would conclude is needed here: A large multicenter randomized clinical trial (one of which is currently under way https://clinicaltrials.gov/ct2/show/NCT02507505 [5]) to understand mortality and functional outcome differences between general and neuraxial anesthetic methods. A high-quality study will likely influence practice across the world, and importantly, reduce mortality and increase function/well-being. Additionally, I suggest the need for a national hip fracture registry such that we will have the power of millions rather than thousands. This kind of database is more likely than even the best randomized clinical trial to help us identify and investigate the fundamental variables of care that will lead to yet unknown hypotheses. A national hip fracture registry can potentially allow us to help our patients not just extend their lives, but improve them.
Author: Jaimo Ahn
Institution: University of Pennsylvania
Language: English
Topic: Hip and Femur Fractures
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2811194367