| BackgroundPatient suffering a hip fracture are usually elderly.As the aging of population,the incidence of hip fractures rises sharply.Hip fractures can be commonly divided into intracapsular fractures and extracapsular fractures.They are also called fractures within or outside the hip joint capsule.Femoral neck fractures are included in intracapsular fractures,while extracapsular fractures mainly consist of intertrochanteric fractures and a small number of subtrochanteric fractures.Elderly patients with hip fracture often suffer from dysfunction of vital organs,and the ability to withstand surgery and anesthesia is poor.Therefore,the incidence of postoperative complications and mortality are higher among these patients.Common postoperative complications include:delirium,lung infection,venous thrombosis,arrhythmia,myocardial infarction,stroke,etc.These complications can seriously affect the prognosis of patients.Thus,hip fractures are extremely harmful to elderly’s health,and are one of the leading causes of death.Anesthesia is one of the important medical interventions for patients undergoing surgery and may be closely related to the prognosis of patients with hip fracture.At present,intraspinal anesthesia is one of the anesthesia methods for hip fractures.It produces satisfactory results and this method is commonly used in China.However,there are shortcomings such as difficulty in controlling the anesthesia plane,difficulty in puncture or failure.In recent years,the widespread use of anticoagulant therapy has also limited the use of intraspinal anesthesia.General anesthesia is another anesthesia method for hip fracture surgery.It is commonly used in European and American countries,but it may cause large physical interference,and may lead to pulmonary complications.In addition,peripheral nerve blocks technology is also an emerging anesthesia technique.Currently,it is not very widespread in clinical application.The advantage of this technique is that the effect on the whole body is small,the intraoperative hemodynamics is stable,and the postoperative analgesia is quite complete.The disadvantage is that the technical requirements are high,the amount of regional anesthesia needed is large,and the retardation effects are uncertain.There are many studies on the prognostic risk factors of hip fracture.Large sample retrospective studies have been conducted abroad,but the results may not be necessarily applicable to domestic situation in China.However,existing domestic studies mostly involved with small sample size,and with simple data analysis.Therefore,large data is needed to support further study.In addition,there are also many studies involving the anesthesia strategy and the prognosis of patients with hip fracture,which lead to inconsistent results.Some believe that local anesthesia or nerve blocks can reduce postoperative complications or mortality;while some believe that the anesthesia will not affect the patient’s prognosis in short-term or long-term.However,these literatures are mainly observational retrospective studies,and random controlled trials are only few.Question on which anesthesia is more conductive to the prognosis of elderly patients with hip fractures has not been determined and further research is needed to answer this question.Therefore,understanding the role of anesthesia in the prognosis of hip fractures,other risk factors during the perioperative period,and possible postoperative complications will help us to improve the perioperative diagnosis and treatment accordingly,thereby improving the prognosis of elderly hip fractures.In this study,the first step was to collect data on elderly patients with hip fracture in our hospital through a retrospective cohort study to investigate the effects of different anesthesia methods on postoperative complications and mortality,and to analyze the relevant risk factors during perioperative period that may affect the prognosis of patients.Secondly,based on the above retrospective studies,we controlled some risk factors,collected data on factors that may affect the prognosis,and compared whether the two anesthesia strategies affect the prognosis of elderly hip fractures by randomized controlled trials,thereby providing stronger evidence support.Part 1Analysis of risk factors of elderly patients with hip fracturesObjective:To analyze the effects of different anesthesia methods on postoperative complications and mortality,and risk factors associated with prognosis;To provide evidence for clinical diagnosis and treatment,and data support for further research.Method:By reviewing the hospitalization information of patients who underwent hip fracture surgery and the prospectively follow-up survival information of in our hospital from September 2014 to December 2015,following variables were collected:age,gender,type of fracture,preoperative comorbidity,preoperative waiting time,ASA grade,POSSUM Physiological Score,method of anesthesia,blood loss,infusion amount,intraoperative blood pressure,the length of operation time,Possum Operative Score,postoperative complications,length of hospital stay,cost and follow-up one-month,one-year survival status.Data was analyzed after being paired by GA group and RA group in a ratio of 1:2.The primary criteria for pairing was that the difference in preoperative POSSUM physiological score should be the smallest and the difference is ≤±11 if the paring result exceeded 2 patients,we screened them according to the following two secondary criterion:the smaller POSSUM surgical score and the closer in-hospital time,and the redundant cases are excluded.If the paring is not successful,the subject will be excluded.We compared the effects of general anesthesia and local anesthesia on prognostic indicators,and applied logistic regression analyses for risk factors which related to mortality.Results:This study we recruited 1248 patients with a hip fracture.717 of these patients met the inclusion criteria,whereas the rest 531 patients were excluded.And there were 54 patients who were lost follow-up by telephone.Thus,663 patients with complete information were included in this study,where 26%(n=174)of them received general anesthesia,and 74%(n=489)received regional anesthesia.Over the two groups,the average age of the patients who received regional anesthesia were older than those patients received general anesthesia[79(7.7)versus 75(8.7),p value<0.01].There were more patients who received regional anesthesia suffered a femoral neck fracture(53.6%versus 42.5%,p value 0.05).In addition,compared with the general anesthesia group,there were significant higher ratios(p values<0.05)that patients who received regional anesthesia suffered combined respiratory disease(20%versus 6.9%),stroke(15.1%versus 4.0%),and the POSSUM physiological score was significantly higher for patients who received regional anesthesia(27.2 versus 25.4).The one-month mortality(5.8%versus 5.3%)and one-year mortality(17.8%versus 16.6%)have no significant difference over the two anesthesia groups.After the patients being paired into GA and SA group by POSSUM score,patients’ age,type of fracture,POSSUM physiological score,and preoperative comorbidity(respiratory disease,stroke)no longer have significant difference between the two groups.However,compared with the GA group,the rates that patients suffered eurological complications(2.8%versus 8.1%,P value<0.05)and the ICU occupancy rate(2.0%versus 8.0%,P value<0.05)were lower in the SA group.The one-month mortality and one-year mortality remain no significant difference over the two anesthesia groups(P value>0.05).According to the results from logistic regression,we found that advanced age,male,ASA grade>3,preoperative comorbidity(respiratory disease,pulmonary hypertension),postoperative complications(respiratory complication,neurological complication,ICU occupancy)are concluded as the risk factors of both one-month and one-year mortality post operation.Besides,preoperative anemia and intertrochanteric fracture are resulted as the risk factors of postoperative one-month mortality.Conclusion:Compared with general anesthesia,regional anesthesia did not improve the short-term and long-term mortality after surgery for elderly patients who suffered hip fracture.There were potential reduction in complications(respiratory and neurological),and the ICU occupancy rate.It was also demonstrated that advanced age,female,ASA grade>3,preoperative anemia,intertrochanteric fracture,and preoperative comorbidity(respiratory disease,pulmonary hypertension)were the risk factors through this study.Part 2 The Effect of Anesthesia Management Strategy on Prognosis of Elderly Patients with Hip FractureObjective:To compare whether the two anesthesia management strategies affect the prognosis of elderly patients with hip fracture surgery;To provide a basis for further studies in multi-centersMethod:This study was designed as a randomized controlled single-center trial.The protocol for this study is that it only included those elderly patients who were diagnosed as unilateral acute hip fractures before surgery and required surgery.Using the stochastic system "IWRS",we randomized patients with a hip fracture to either regional or general anesthesia,according to the stratification factor on whether the patients’ age is older than 80.General anesthesia group(GA)is defined as performing anesthesia through whole body under combined nerve block,which can be applied using laryngeal mask,tracheal intubation,mechanical ventilation or voluntary ventilation.Regional Anesthesia(RA)is recommended to use analgesia such as nerve block analgesia or opioid before surgery,and then use epidural anesthesia,lumbar anesthesia,combined lumbar anesthesia or nerve block anesthesia.The primary outcome measure for this study was one-year mortality postoperation.The incidence of intraoperative hypotension,blood loss,infusion volume,postoperative complications and its incidence,one-month mortality postoperative delirium,ICU occupancy rate,postoperative pain score,length of hospital stay,total cost of hospital stay were all included as the secondary outcome measure.We set observer blind in order to avoid the subjective bias of the assessor.Results:This study recruited 713 patients who suffered hip fractures,where 402 of the patients met the inclusion criteria and participated in the trial.Among the 402 subjects,there were 12 subjects who violated the protocol,with 10 from GA group and 2 from RA group.Specifically,10 of them violated the randomization rule,one of the patients was not over 65 years old due to age registration mistake,and one cancelled operation temporarily.There were 390 subjects who actually completed the trial,including 199 in the RA group and 191 in the GA group.Patients in RA group were more frequent to occur preoperative comorbidity digestive system disease than GA group.Other indicators,including demongraphic information,fracture type,ASA grade,incidence of senile dementia,preoperative comorbidity of some system(except digestive system),preoperative vital signs(body temperature,systolic blood pressure,diastolic blood pressure,heart rate,oxygen saturation,pain score),hemoglobin,were not statistically different in GA group and RA group.Compared with GA group,the anesthesia time,intraoperative blood loss,blood transfusion,infusion volume,postoperative comorbidity(nausea and vomiting,delirium,hypotension,pulmonary infection,arrhythmia,myocardial infarction,stroke),total medical cost,postoperative one-month mortality and one-year mortality had no significant difference in RA group.However,in RA group,the incidence of intraoperative hypotension showed a ’great reduction(29.6%versus 81.7%,P value<0.01),and the cases of hypotension requiring drug treatment were also lower(28.1%VS 75.4%,P<0.01).The incidence of postoperative hypotension(5.2%VS 7.2,,P value<0.01),postoperative hypoxemia(1%VS 4.7%,P value<0.01),ICU occupancy rate(3.5%versus 8.4%),and the cost of anesthesia(1386 versus 2251,P vakue<0.01)were slightly lower than in GA group.A subgroup analysis of patients older than 80 years also yielded similar results,but the ICU occupancy rate was no longer statistically different between the two groups.Conclusion:Compared with general anesthesia,regional anesthesia did not improve the short-term and long-term mortality after surgery for elderly patients who suffered hip fracture.And the overall rate of complications occurred has not been reduced.However,after operation,the ICU occupancy rate and the incidence of occurring hypoxemia have been declined.In addition,by applying regional anesthesia,there was significant reduction on occurring hypotension during operation. |
