Reduce the common delirium local anesthesia or general anesthesia after surgery?

With age, the risk of fractures in the elderly increases, and hip fractures are more common

Generally, when the patient's physical condition permits, surgical treatment is often chosen in clinics

Postoperative delirium is a common complication.

However, some studies have found that after hip fractures, patients with delirium may have nothing to do with the use of anesthetics

The study found that compared with general anesthesia, the use of local anesthesia without sedation for hip fracture surgery patients ≥65 years of age did not significantly reduce the incidence of postoperative delirium

The team of professors Jin Shengwei, Li Ting, and Gao Fang from the Department of Anesthesia and Perioperative Medicine of the Second Affiliated Hospital of Wenzhou Medical University and Yuying Children's Hospital is the first unit of the thesis

The research team enrolled 950 patients from 9 university teaching hospitals in southeastern China

ASA surgical classification: Class I is healthy, Class II is mild systemic disease, Class III is severe systemic disease, and Class IV is continuous life-threatening severe systemic disease

According to the age of the patient, whether there is preoperative delirium, whether there is dementia stratification and other factors, the participants were randomly divided into groups and received local anesthesia (spinal anesthesia, epidural anesthesia or a combination of the two techniques, but no sedation, n=476) Or general anesthesia (intravenous anesthesia, inhalation anesthesia or combined anesthesia, n=474)

The researchers used the Confusion Assessment Method (CAM) and the 30-point Simple Mental State Examination Scale to diagnose delirium; the severity and subtypes of delirium were analyzed based on the Delirium Rating Scale (DRS-R-98) )

The researchers obtained the main outcome data of 471 patients with local anesthesia and 470 patients with general anesthesia

There was no statistically significant difference in the incidence of one or more delirium in the first 7 days after surgery: among the patients in the local anesthesia group, the proportion was 6.

The average severity score of delirium was not significantly different between groups (23.

The incidence of multiple episodes of postoperative delirium was similar, with 13 cases (2.

There was no significant difference in 30-day all-cause mortality between the two groups (8 cases in the local anesthesia group [1.

There was no significant difference in the worst pain score and length of stay between the local anesthesia group and the general anesthesia group

There were 106 adverse events (17.
6%) in the local anesthesia group and 102 (16.
8%) adverse events 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%])
.

The paper pointed out that for hip fracture patients over 65 years old, compared with general anesthesia, local anesthesia without sedation can not significantly reduce the number of postoperative delirium in the first 7 days after surgery
.
Moreover, there were no significant differences in the severity, frequency or subtype of delirium that occurred 7 days after surgery, as well as the worst pain score, length of hospital stay, or 30-day all-cause mortality
.

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Image source: 123RF

The JAMA editorial at the same time pointed out: The study is consistent with the previous conclusion that avoiding the use of sedative anesthetics has nothing to do with the incidence of postoperative delirium
.
However, other previous studies have shown that too deep anesthesia may be harmful.
During the operation, reducing the depth of anesthesia may reduce the incidence of postoperative delirium in patients
.

There is increasing evidence that general anesthesia surgery is not associated with persistent neurocognitive impairment
.
This trial adds important evidence to common clinical problems and provides evidence support for various secondary outcomes related to delirium, thereby ensuring that patients and clinicians can reasonably choose anesthesia or sedation for hip fracture surgery.
Does not increase the risk of early delirium after surgery
.

Reference

[1] Li T, Li J, Yuan L, et al.
Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery: The RAGA Randomized Trial.
(2021).
JAMA.
Published online December 20, 2021.
doi:10.
1001/jama.
2021.
22647

[2] Michael S.
et al.
, General Anesthesia and Postoperative Neurocognitive Outcomes.
(2021).
JAMA.
Published online December 20, 2021.
doi:10.
1001/jama.
2021.
22465

[3] China-wide study will boost understanding of fatal surgical complication.
Retrieved December 21, 2021, from https://