Higher total perioperative complications seen with regional vs general anesthesia for hip fracture treatment

However, researcher noted method of anesthesia for patients should be determined on a case-by-case basis.

Issue: February 2015

TAMPA, Fla. — In a database study of patients who underwent surgical treatment for hip fractures, researchers discovered those who received regional anesthesia had 1.43-times higher odds for minor complications and 1.24-times higher odds for total perioperative complications compared with patients who received general anesthesia.

“Several studies have advocated regional anesthesia instead of general anesthesia as a means of reducing complications after hip fracture surgery,” Paul S. Whiting, MD, orthopedic trauma fellow at Vanderbilt University, said during his presentation at the Orthopedic Trauma Association Annual Meeting. “Our study provides a significant counterpoint to recently published systematic reviews and meta-analyses and adds to the growing literature of large-scale database analyses looking at this specific question.”

General vs regional anesthesia

Using the American College of Surgeons National Surgical Quality Improvement Program database, Whiting and his colleagues identified 7,764 patients who underwent hip fracture surgery between 2005 and 2011 and were administered general anesthesia or regional anesthesia during their procedures. Researchers recorded and categorized perioperative complications as minor which included wound dehiscence, superficial surgical site infection, urinary tract infection or pneumonia or major (which included deep wound infection, deep venous thrombosis, pulmonary embolism, septic shock, peripheral nerve injury, death and myocardial infarction). In their multivariate analysis, the investigators controlled for age, medical comorbidities, American Society of Anesthesiologists status, operative time and baseline functional status.

Compared with patients who received general anesthesia, results showed a statistically significantly higher risk of total complications and minor complications among patients who received regional anesthesia. However, there was no significant difference in the risk for major complications between the groups. Specific complications contributing to the increased odds included superficial surgical site infections, urinary tract infection and coma.

“We lumped together all the various complications that can follow hip fracture surgery, and when you consider all the complications together, the rate of complications is higher with regional anesthesia compared with general anesthesia,” Whiting told Orthopedics Today. “Anesthesiologists and orthopedic surgeons together need to decide on a case-by-case basis what the best method of anesthesia is for each hip fracture patient. We cannot just say that regional anesthesia is always better and will always lead to lower rates of complications.”

Surprising findings

The fact that regional anesthesia had a higher complication rate surprised Whiting and his colleagues, who were expecting to find little or no difference between the two methods.

“One of the conclusions was that urinary tract infections occurred at a significantly higher rate in the regional anesthesia group, and the implication of that might be that prolonged urinary catheterization in patients receiving regional anesthesia might be accounting for that difference [in complication rates],” Whiting said. “Most likely, the patients with regional anesthesia are not able to mobilize as quickly as patients who have had general anesthesia because their lower extremities are numb for quite some time.”

According to Whiting, the next step in their research is to reproduce these findings using other large databases.

“What would need to be done in order to answer the question definitively is a large scale, prospective, randomized trial, but such a study would be difficult to carry out due to the wide variety of medical comorbidities affecting patients with hip fractures,” Whiting said. “We would want a large scale, prospective study to have wide enough inclusion criteria to make it generalizable to a typical hip fracture population, but doing so would necessarily require us to include patients of a wide variety of medical comorbidities.” – by Casey Tingle

Reference:

Thakore RV. Paper #55. Presented at: Orthopedic Trauma Association Annual Meeting; Oct. 16-18, 2014; Tampa, Fla.

For more information:

Paul S. Whiting, MD, can be reached at Vanderbilt University, 2201 West End Ave., Nashville, TN 37235; email: paul.s.whiting@vanderbilt.edu.
Disclosure: Whiting has no relevant financial disclosures.