【Literature Reading】Effects of regional anesthesia and general anesthesia on the incidence of delirium after hip fracture surgery in the elderly

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Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery

Effect of regional and general anesthesia on the incidence of delirium after hip fracture surgery in the elderly

IMPORTANCE

IMPORTANCE In adults undergoing hip fracture surgery, regional anesthesia may reduce postoperative delirium, but there is uncertainty about its effectiveness.

Importance Regional anaesthesia may reduce postoperative delirium in adults undergoing hip fracture surgery, but its effectiveness is uncertain
.

OBJECTIVE

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.

Objective To investigate the effect of regional anesthesia on the incidence of
postoperative delirium compared with general anesthesia in elderly people undergoing surgical repair of hip fracture.

DESIGN, SETTING, AND PARTICIPANTS

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.

Design, setup, and pairing A randomized, distribution-hidden, open-label, multicenter clinical trial of 950 patients aged 65 years of age, with or without previous dementia, and patients with fragility hip fractures requiring surgical repair
from nine university teaching hospitals in southeastern China.
Participants were registered between October 2014 and September 2018 and followed up to 30 days as of November
2018.

INTERVENTIONS

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).

Intervention: Patients were randomized to receive regional anaesthesia (lumbar anaesthesia, epidural, or a combination of both, without sedation, n=476) or general anaesthesia (intravenous, inhalation, or combination anaesthetic, n=474).

MAIN OUTCOMES AND MEASURES

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.

Primary Results and Measurements The primary outcome is the incidence
of delirium in the first 7 days after surgery.
Secondary outcomes analysed here included severity, duration, and subtype of delirium; Postoperative pain score; length of hospital stay; 30-day all-cause mortality and complications
.

RESULTS

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% to3.
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%]).

Results: Of the 950 patients (mean age 76.
5 years; 247 (26.
8%) males), 941 were assessable for the main outcome (6 cancelled and 3 withdrew consent).

Delirium occurred postoperatively in 29 cases (6.
2%) in the regional anaesthesia group and 24 (5.
1%) in the general anaesthesia 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])
。 The mean severity scores of delirium were 23.
0 and 24.
1 (unadjusted difference -1.
1; 95% confidence interval -4.
6~3.
1),
respectively.
16 (3.
4%) versus 10 (2.
1%) had 1 delirium (unadjusted RD, 1.
1%; 95%CI，-1.
7%~3.
9%； RR 1.
6[95%CI，0.
7~3.
5])
。 11 cases (37.
9%) vs5 cases (20.
8%) (RD, 11.
5; 95%CI, -11.
0%~35.
7%; RR，2.
2[95%CI，0.
8~6.
3])
。 The median of the most severe pain scores were 0 (IQR, 0~20) and 0 (IQR, 0~10) (difference 0; 95%CI，0~0)
。 The median length of hospital stay was 7 days (IQR, 5~10) and 7 days (IQR, 6~10), respectively (difference 0; 95%CI，0~0)
。 8 deaths (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]).

A total of 106 and 102 adverse events were reported in the regional anaesthesia and general anaesthesia groups, respectively, with the most common adverse events being nausea and vomiting (47 [44.
3%] versus 34 [33.
3%]) and postoperative hypotension (13 [12.
3%] versus 10 [9.
8%]).

CONCLUSIONS AND RELEVANCE

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.

Conclusion and relevance: Regional anesthesia without sedation did not significantly reduce the incidence
of postoperative delirium compared with general anesthesia in patients aged 65 years and older who underwent hip fracture surgery.

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