Mark D Neuman1, Rui Feng1, Jeffrey L Carson1, Lakisha J Gaskins1, Derek Dillane1, Daniel I Sessler1, Frederick Sieber1, Jay Magaziner1, Edward R Marcantonio1, Samir Mehta1, Diane Menio1, Sabry Ayad1, Trevor Stone1, Steven Papp1, Eric S Schwenk1, Nabil Elkassabany1, Mitchell Marshall1, J Douglas Jaffe1, Charles Luke1, Balram Sharma1, Syed Azim1, Robert A Hymes1, Ki-Jinn Chin1, Richard Sheppard1, Barry Perlman1, Joshua Sappenfield1, Ellen Hauck1, Mark A Hoeft1, Mark Giska1, Yatish Ranganath1, Tiffany Tedore1, Stephen Choi1, Jinlei Li1, M Kwesi Kwofie1, Antoun Nader1, Robert D Sanders1, Brian F S Allen1, Kamen Vlassakov1, Stephen Kates1, Lee A Fleisher1, James Dattilo1, Ann Tierney1, Alisa J Stephens-Shields1, Susan S Ellenberg1. 1. From the Departments of Anesthesiology and Critical Care (M.D.N., L.J.G., N.E., L.A.F.), Biostatistics, Epidemiology, and Informatics (R.F., A.J.S.-S., S.S.E.), and Orthopedic Surgery (S.M.) and the Centers for Perioperative Outcomes Research and Transformation (M.D.N., L.J.G., N.E., L.A.F.) and Clinical Epidemiology and Biostatistics (R.F., J.D., A.T., A.J.S.-S., S.S.E.), University of Pennsylvania Perelman School of Medicine, the Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University (E.S.S.), the Center for Advocacy for the Rights and Interests of the Elderly (D.M.), and the Department of Anesthesiology, Lewis Katz School of Medicine at Temple University (E.H.), Philadelphia; the Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (J.L.C.); the Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton (D.D.), the Department of Orthopaedics, University of British Columbia, Vancouver (T.S.), the Division of Orthopaedics, Ottawa Hospital Civic Campus, Ottawa (S.P.), the Department of Anesthesiology and Pain Medicine, University of Toronto (K.-J.C.), and the Department of Anesthesia, Sunnybrook Health Sciences Centre (S.C.), Toronto, and the Department of Anesthesia, Pain Management, and Perioperative Medicine, Dalhousie University, Halifax NS (M.K.K.) - all in Canada; the Department of Outcomes Research, Cleveland Clinic, Cleveland (D.I.S., S. Ayad); the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions (F.S.), and the Department of Epidemiology and Public Health, University of Maryland School of Medicine (J.M.) - both in Baltimore; the Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (E.R.M.), and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School (K.V.), Boston, and the Department of Anesthesiology, Lahey Hospital and Medical Center, Burlington (B.S.) - all in Massachusetts; the Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Health (M.M.), and the Department of Anesthesiology, New York-Presbyterian/Weill Cornell Medical Center (T.T.), New York, and the Department of Anesthesiology, Stony Brook University, Stony Brook (S. Azim) - all in New York; the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC (J.D.J.); the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh (C.L.); the Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church (R.A.H.), and the Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond (S.K.) - both in Virginia; the Department of Anesthesiology, Hartford Hospital, Hartford (R.S.), and the Department of Anesthesiology, Yale University School of Medicine, New Haven (J.L.) - both in Connecticut; Division of Hospital Medicine, Oregon Health and Science University, Portland (B.P.); the Department of Anesthesiology, University of Florida College of Medicine, Gainesville (J.S.); the Department of Anesthesiology, University of Vermont Larner School of Medicine, Burlington, VT (M.A.H.); the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health System, Detroit (M.G.); the Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City (Y.R.); the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago (A.N.); Specialty of Anaesthetics, University of Sydney, Sydney (R.D.S.); and the Division of Multispecialty Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville (B.F.S.A.).
Abstract
BACKGROUND: The effects of spinal anesthesia as compared with general anesthesia on the ability to walk in older adults undergoing surgery for hip fracture have not been well studied. METHODS: We conducted a pragmatic, randomized superiority trial to evaluate spinal anesthesia as compared with general anesthesia in previously ambulatory patients 50 years of age or older who were undergoing surgery for hip fracture at 46 U.S. and Canadian hospitals. Patients were randomly assigned in a 1:1 ratio to receive spinal or general anesthesia. The primary outcome was a composite of death or an inability to walk approximately 10 ft (3 m) independently or with a walker or cane at 60 days after randomization. Secondary outcomes included death within 60 days, delirium, time to discharge, and ambulation at 60 days. RESULTS: A total of 1600 patients were enrolled; 795 were assigned to receive spinal anesthesia and 805 to receive general anesthesia. The mean age was 78 years, and 67.0% of the patients were women. A total of 666 patients (83.8%) assigned to spinal anesthesia and 769 patients (95.5%) assigned to general anesthesia received their assigned anesthesia. Among patients in the modified intention-to-treat population for whom data were available, the composite primary outcome occurred in 132 of 712 patients (18.5%) in the spinal anesthesia group and 132 of 733 (18.0%) in the general anesthesia group (relative risk, 1.03; 95% confidence interval [CI], 0.84 to 1.27; P = 0.83). An inability to walk independently at 60 days was reported in 104 of 684 patients (15.2%) and 101 of 702 patients (14.4%), respectively (relative risk, 1.06; 95% CI, 0.82 to 1.36), and death within 60 days occurred in 30 of 768 (3.9%) and 32 of 784 (4.1%), respectively (relative risk, 0.97; 95% CI, 0.59 to 1.57). Delirium occurred in 130 of 633 patients (20.5%) in the spinal anesthesia group and in 124 of 629 (19.7%) in the general anesthesia group (relative risk, 1.04; 95% CI, 0.84 to 1.30). CONCLUSIONS: Spinal anesthesia for hip-fracture surgery in older adults was not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days. The incidence of postoperative delirium was similar with the two types of anesthesia. (Funded by the Patient-Centered Outcomes Research Institute; REGAIN ClinicalTrials.gov number, NCT02507505.).
BACKGROUND: The effects of spinal anesthesia as compared with general anesthesia on the ability to walk in older adults undergoing surgery for hip fracture have not been well studied. METHODS: We conducted a pragmatic, randomized superiority trial to evaluate spinal anesthesia as compared with general anesthesia in previously ambulatory patients 50 years of age or older who were undergoing surgery for hip fracture at 46 U.S. and Canadian hospitals. Patients were randomly assigned in a 1:1 ratio to receive spinal or general anesthesia. The primary outcome was a composite of death or an inability to walk approximately 10 ft (3 m) independently or with a walker or cane at 60 days after randomization. Secondary outcomes included death within 60 days, delirium, time to discharge, and ambulation at 60 days. RESULTS: A total of 1600 patients were enrolled; 795 were assigned to receive spinal anesthesia and 805 to receive general anesthesia. The mean age was 78 years, and 67.0% of the patients were women. A total of 666 patients (83.8%) assigned to spinal anesthesia and 769 patients (95.5%) assigned to general anesthesia received their assigned anesthesia. Among patients in the modified intention-to-treat population for whom data were available, the composite primary outcome occurred in 132 of 712 patients (18.5%) in the spinal anesthesia group and 132 of 733 (18.0%) in the general anesthesia group (relative risk, 1.03; 95% confidence interval [CI], 0.84 to 1.27; P = 0.83). An inability to walk independently at 60 days was reported in 104 of 684 patients (15.2%) and 101 of 702 patients (14.4%), respectively (relative risk, 1.06; 95% CI, 0.82 to 1.36), and death within 60 days occurred in 30 of 768 (3.9%) and 32 of 784 (4.1%), respectively (relative risk, 0.97; 95% CI, 0.59 to 1.57). Delirium occurred in 130 of 633 patients (20.5%) in the spinal anesthesia group and in 124 of 629 (19.7%) in the general anesthesia group (relative risk, 1.04; 95% CI, 0.84 to 1.30). CONCLUSIONS: Spinal anesthesia for hip-fracture surgery in older adults was not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days. The incidence of postoperative delirium was similar with the two types of anesthesia. (Funded by the Patient-Centered Outcomes Research Institute; REGAIN ClinicalTrials.gov number, NCT02507505.).
Authors: Gulraj S Matharu; Anjali Shah; Samuel Hawley; Antony Johansen; Dominic Inman; Iain Moppett; Michael R Whitehouse; Andrew Judge Journal: BMC Med Date: 2022-09-26 Impact factor: 11.150