老年人髋部骨折手术使用腰椎麻醉并不优于全身麻醉
2021-10-14   阅读:526   来源:新英格兰医学杂志

美国宾夕法尼亚大学佩雷尔曼医学院Mark D. Neuman团队比较了腰椎麻醉与全身麻醉对老年人髋部手术预后的影响。相关论文于2021年10月9日发表在《新英格兰医学杂志》上。

腰椎麻醉与全身麻醉相比,对老年髋部骨折手术患者行走能力的影响尚未得到充分研究。

研究组进行了一项实用的、随机的劣效性试验,在美国和加拿大46家医院招募接受髋部骨折手术的50岁及以上的既往门诊患者,以评估比较腰椎麻醉与全身麻醉的影响。将患者按1:1的比例随机分配,分别接受腰椎麻醉或全身麻醉。主要结局为随机分组后60天死亡或独立行走约10英尺(3米)或使用助行器或拐杖行走。次要结局包括60天内死亡、谵妄、出院时间和60天下床活动。

研究组共纳入1600例患者,其中795例接受腰椎麻醉,805例接受全身麻醉。平均年龄78岁,女性占67.0%。最终共666例(83.8%)患者接受腰椎麻醉,769例(95.5%)接受全身麻醉。在可获得数据的改良意向治疗人群中,腰椎麻醉组712名患者中有132名(18.5%)出现综合主要结局,全身麻醉组733名患者中有132名(18.0%),组间差异不显著。

腰椎麻醉组684名患者中有104名(15.2%)在60天内无法独立行走,全身麻醉组702名患者中有101名(14.4%);腰椎麻醉组768名患者中有30名(3.9%)在60天内死亡,全身麻醉组784名患者中有32名(4.1%);腰椎麻醉组633名患者中有130名(20.5%)出现谵妄,全身麻醉组629名患者中有124名(19.7%),组间差异均不显著。

研究结果表明,老年人髋部骨折手术腰椎麻醉在60天的存活率和行走能力恢复方面并不优于全身麻醉。

附:英文原文

Title: Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults | NEJM

Author: Mark D. Neuman, M.D.,, Rui Feng, Ph.D.,, Jeffrey L. Carson, M.D.,, Lakisha J. Gaskins, M.H.S.,, Derek Dillane, M.D.,, Daniel I. Sessler, M.D.,, Frederick Sieber, M.D.,, Jay Magaziner, Ph.D., M.S.Hyg.,, Edward R. Marcantonio, M.D.,, Samir Mehta, M.D.,, Diane Menio, M.S.,, Sabry Ayad, M.D.,, Trevor Stone, M.D.,, Steven Papp, M.D.,, Eric S. Schwenk, M.D.,, Nabil Elkassabany, M.D.,, Mitchell Marshall, M.D.,, J. Douglas Jaffe, D.O.,, Charles Luke, M.D.,, Balram Sharma, M.D.,, Syed Azim, M.D.,, Robert A. Hymes, M.D.,, Ki-Jinn Chin, M.D.,, Richard Sheppard, M.D.,, Barry Perlman, M.D., Ph.D.,, Joshua Sappenfield, M.D.,, Ellen Hauck, D.O., Ph.D.,, Mark A. Hoeft, M.D.,, Mark Giska, M.D.,, Yatish Ranganath, M.D.,, Tiffany Tedore, M.D.,, Stephen Choi, M.D.,, Jinlei Li, M.D., Ph.D.,, M. Kwesi Kwofie, M.D.,, Antoun Nader, M.D.,, Robert D. Sanders, M.D.,, Brian F.S. Allen, M.D.,, Kamen Vlassakov, M.D.,, Stephen Kates, M.D.,, Lee A. Fleisher, M.D.,, James Dattilo, B.S.,, Ann Tierney, M.S.,, Alisa J. Stephens-Shields, Ph.D.,, and Susan S. Ellenberg, Ph.D.

Issue&Volume: 2021-10-09

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.

DOI: 10.1056/NEJMoa2113514

 

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