Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults.
Journal
The New England journal of medicine
ISSN: 1533-4406
Titre abrégé: N Engl J Med
Pays: United States
ID NLM: 0255562
Informations de publication
Date de publication:
25 11 2021
25 11 2021
Historique:
pubmed:
9
10
2021
medline:
15
12
2021
entrez:
8
10
2021
Statut:
ppublish
Résumé
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. 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. 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). 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. (Funded by the Patient-Centered Outcomes Research Institute; REGAIN ClinicalTrials.gov number, NCT02507505.).
Sections du résumé
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. (Funded by the Patient-Centered Outcomes Research Institute; REGAIN ClinicalTrials.gov number, NCT02507505.).
Identifiants
pubmed: 34623788
doi: 10.1056/NEJMoa2113514
doi:
Banques de données
ClinicalTrials.gov
['NCT02507505']
Types de publication
Comparative Study
Journal Article
Multicenter Study
Pragmatic Clinical Trial
Randomized Controlled Trial
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
2025-2035Subventions
Organisme : Patient-Centered Outcomes Research Institute
ID : 1406-18876
Pays : United States
Investigateurs
Mark D Neuman
(MD)
Rui Feng
(R)
Jeffrey L Carson
(JL)
Lakisha J Gaskins
(LJ)
Derek Dillane
(D)
Daniel I Sessler
(DI)
Frederick Sieber
(F)
Jay Magaziner
(J)
Edward Marcantonio
(E)
Sabry Ayad
(S)
Trevor Stone
(T)
Steven Papp
(S)
Eric Schwenk
(E)
Mitchell Marshall
(M)
J Douglas Jaffe
(JD)
Charles Luke
(C)
Balram Sharma
(B)
Syed Azim
(S)
Robert Hymes
(R)
Ki-Jinn Chin
(KJ)
Richard Sheppard
(R)
Barry Perelman
(B)
Joshua Sappenfield
(J)
Ellen Hauck
(E)
Mark A Hoeft
(MA)
Mark Giska
(M)
Yatish Ranganath
(Y)
Tiffany Tedore
(T)
Stephen Choi
(S)
Jinlei Li
(J)
M Kwesi Kwofie
(MK)
Antoun Nader
(A)
Robert Sanders
(R)
Brian F S Allen
(BFS)
Kamen Vlassakov
(K)
Stephen Kates
(S)
Nabil Elkassabany
(N)
Lee A Fleisher
(LA)
Samir Mehta
(S)
James Dattilo
(J)
Ann Tierney
(A)
Diane Menio
(D)
Alisa J Stephens-Shields
(AJ)
Susan Ellenberg
(S)
Thomas Looke
(T)
Sandra Bent
(S)
Ariana Franco-Mora
(A)
Pamela Hedrick
(P)
Matthew Newbern
(M)
Advent Health
(A)
Rafik Tadros
(R)
Karen Pealer
(K)
Carolyn Buckley
(C)
Lauren Gavin
(L)
Svetlana Gorbatov
(S)
James Gosnell
(J)
Talora Steen
(T)
Avery Vafai
(A)
Jose Zeballos
(J)
Jennifer Hruslinski
(J)
Louis Cardenas
(L)
Ashley Berry
(A)
John Getchell
(J)
Nicholas Quercetti
(N)
Christiana Hospital
(C)
Manal Hassan
(M)
Gauasan Bajracharya
(G)
Damien Billow
(D)
Michael Bloomfield
(M)
Evis Cuko
(E)
Mehrun K Elyaderani
(MK)
Robert Hampton
(R)
Hooman Honar
(H)
Dilara Khoshknabi
(D)
Daniel Kim
(D)
David Krahe
(D)
Michael M Lew
(MM)
Conjeevram B Maheshwer
(CB)
Azfar Niazi
(A)
Partha Saha
(P)
Ahmed Salih
(A)
Robert J de Swart
(RJ)
Andrew Volio
(A)
Kelly Bolkus
(K)
Matthew DeAngelis
(M)
Gregory Dodson
(G)
Jeffrey Gerritsen
(J)
Brian McEniry
(B)
Ludmil Mitrev
(L)
Anne Belliveau
(A)
Flynn Bonazza
(F)
Vera Lloyd
(V)
Izabela Panek
(I)
Jared Dabiri
(J)
Chris Chavez
(C)
Jason Craig
(J)
Todd Davidson
(T)
Chad Dietrichs
(C)
Cheryl Fleetwood
(C)
Mike Foley
(M)
Chris Getto
(C)
Susie Hailes
(S)
Sarah Hermes
(S)
Andy Hooper
(A)
Greg Koener
(G)
Kate Kohls
(K)
Leslie Law
(L)
Adam Lipp
(A)
Allison Losey
(A)
William Nelson
(W)
Mario Nieto
(M)
Pam Rogers
(P)
Steve Rutman
(S)
Garrett Scales
(G)
Barbara Sebastian
(B)
Tom Stanciu
(T)
Gregg Lobel
(G)
Michelle Giampiccolo
(M)
Dara Herman
(D)
Margit Kaufman
(M)
Bryan Murphy
(B)
Clara Pau
(C)
Thomas Puzio
(T)
Marlene Veselsky
(M)
Kelly Apostle
(K)
Dory Boyer
(D)
Brenda Chen Fan
(BC)
Susan Lee
(S)
Mike Lemke
(M)
Richard Merchant
(R)
Farhad Moola
(F)
Kyrsten Payne
(K)
Bertrand Perey
(B)
Darius Viskontas
(D)
Mark Poler
(M)
Patricia D'Antonio
(P)
Greg O'Neill
(G)
Amer Abdullah
(A)
Jamie Fish-Fuhrmann
(J)
Hartford Hospital
(H)
Christina Fidkowski
(C)
Stuart Trent Guthrie
(ST)
William Hakeos
(W)
Lillian Hayes
(L)
Joseph Hoegler
(J)
Katherine Nowak
(K)
Jeffery Beck
(J)
Jaslynn Cuff
(J)
Greg Gaski
(G)
Sharon Haaser
(S)
Michael Holzman
(M)
A Stephen Malekzadeh
(AS)
Lolita Ramsey
(L)
Jeff Schulman
(J)
Cary Schwartzbach
(C)
Tangwan Azefor
(T)
Arman Davani
(A)
Mahmood Jaberi
(M)
Courtney Masear
(C)
Syed Basit Haider
(SB)
Carolyn Chungu
(C)
Ali Ebrahimi
(A)
Karim Fikry
(K)
Andrew Marcantonio
(A)
Anitha Shelvan
(A)
David Sanders
(D)
Collin Clarke
(C)
Abdel Lawendy
(A)
Gary Schwartz
(G)
Mohit Garg
(M)
Joseph Kim
(J)
Juan Caruci
(J)
Ekow Commeh
(E)
Randy Cuevas
(R)
Germaine Cuff
(G)
Lola Franco
(L)
David Furgiuele
(D)
Matthew Giuca
(M)
Melissa Allman
(M)
Omid Barzideh
(O)
James Cossaro
(J)
Armando D'Arduini
(A)
Anita Farhi
(A)
Jason Gould
(J)
John Kafel
(J)
Anuj Patel
(A)
Abraham Peller
(A)
Hadas Reshef
(H)
Mohammed Safur
(M)
Fiore Toscano
(F)
Michael Akerman
(M)
Eric Brumberger
(E)
Sunday Clark
(S)
Rachel Friedlander
(R)
Anita Jegarl
(A)
Joseph Lane
(J)
John P Lyden
(JP)
Nili Mehta
(N)
Matthew T Murrell
(MT)
Nathan Painter
(N)
William Ricci
(W)
Kaitlyn Sbrollini
(K)
Rahul Sharma
(R)
Peter A D Steel
(PAD)
Michele Steinkamp
(M)
Roniel Weinberg
(R)
David Stephenson Wellman
(DS)
Paul Fitzgerald
(P)
Michaela Ritz
(M)
Greg Bryson
(G)
Alexandra Craig
(A)
Cassandra Farhat
(C)
Braden Gammon
(B)
Wade Gofton
(W)
Nicole Harris
(N)
Karl Lalonde
(K)
Allan Liew
(A)
Bradley Meulenkamp
(B)
Kendra Sonnenburg
(K)
Eugene Wai
(E)
Geoffrey Wilkin
(G)
Ottawa Hospital
(O)
Karen Troxell
(K)
Mary Ellen Alderfer
(ME)
Jason Brannen
(J)
Christopher Cupitt
(C)
Stacy Gerhart
(S)
Renee McLin
(R)
Julie Sheidy
(J)
Katherine Yurick
(K)
Reading Hospital
(R)
Fei Chen
(F)
Karen Dragert
(K)
Geza Kiss
(G)
Halina Malveaux
(H)
Deborah McCloskey
(D)
Scott Mellender
(S)
Sagar S Mungekar
(SS)
Helaine Noveck
(H)
Carlos Sagebien
(C)
Luat Biby
(L)
Gail McKelvy
(G)
Anna Richards
(A)
Ramon Abola
(R)
Brittney Ayala
(B)
Darcy Halper
(D)
Ana Mavarez
(A)
Sabeen Rizwan
(S)
Imad Awad
(I)
Brendan Flynn
(B)
Patrick Henry
(P)
Richard Jenkinson
(R)
Lilia Kaustov
(L)
Elizabeth Lappin
(E)
Paul McHardy
(P)
Amara Singh
(A)
Joanne Donnelly
(J)
Meera Gonzalez
(M)
Christopher Haydel
(C)
Jon Livelsberger
(J)
Theresa Pazionis
(T)
Bridget Slattery
(B)
Maritza Vazquez-Trejo
(M)
Jaime Baratta
(J)
Michael Cirullo
(M)
Brittany Deiling
(B)
Laura Deschamps
(L)
Michael Glick
(M)
Daniel Katz
(D)
James Krieg
(J)
Jennifer Lessin
(J)
Jeffrey Mojica
(J)
Marc Torjman
(M)
Rongyu Jin
(R)
Mary Jane Salpeter
(MJ)
Mark Powell
(M)
Jeffrey Simmons
(J)
Prentiss Lawson
(P)
Promil Kukreja
(P)
Shanna Graves
(S)
Adam Sturdivant
(A)
Ayesha Bryant
(A)
Sandra Joyce Crump
(SJ)
Michelle Verrier
(M)
James Green
(J)
Matthew Menon
(M)
Richard Applegate
(R)
Ana Arias
(A)
Natasha Pineiro
(N)
Jeffrey Uppington
(J)
Phillip Wolinsky
(P)
Amy Gunnett
(A)
Jennifer Hagen
(J)
Sara Harris
(S)
Kevin Hollen
(K)
Brian Holloway
(B)
Mary Beth Horodyski
(MB)
Trevor Pogue
(T)
Ramachandran Ramani
(R)
Cameron Smith
(C)
Anna Woods
(A)
Matthew Warrick
(M)
Kelly Flynn
(K)
Paul Mongan
(P)
Sean Fernholz
(S)
Esperanza Ingersoll-Weng
(E)
Anil Marian
(A)
Melinda Seering
(M)
Zita Sibenaller
(Z)
Lori Stout
(L)
Allison Wagner
(A)
Alicia Walter
(A)
Cynthia Wong
(C)
Denise Orwig
(D)
Trina Brown
(T)
Cassandra Dinh
(C)
Derek Donegan
(D)
Annamarie Horan
(A)
Maithri Goud
(M)
Chris Helker
(C)
Lydia Mezenghie
(L)
Brittany Montgomery
(B)
Peter Preston
(P)
J Sanford Schwartz
(JS)
Ramona Weber
(R)
Jacques E Chelly
(JE)
Shiv Goel
(S)
Wende Goncz
(W)
Touichi Kawabe
(T)
Sharad Khetarpal
(S)
Amy Monroe
(A)
Vladislav Shick
(V)
Max Breidenstein
(M)
Timothy Dominick
(T)
Alexander Friend
(A)
Donald Mathews
(D)
Richard Lennertz
(R)
Helen Akere
(H)
Tyler Balweg
(T)
Amber Bo
(A)
Christopher Doro
(C)
David Goodspeed
(D)
Gerald Lang
(G)
Maggie Parker
(M)
Amy Rettammel
(A)
Mary Roth
(M)
Marissa White
(M)
Paul Whiting
(P)
Tracie Baker
(T)
Debra Craven
(D)
Matt McEvoy
(M)
Teresa Turnbo
(T)
Melanie Morgan
(M)
Teresa Willoughby
(T)
Wade Weigel
(W)
David Auyong
(D)
Ellie Fox
(E)
Tina Welsh
(T)
Bruce Cusson
(B)
Sean Dobson
(S)
Christopher Edwards
(C)
Lynette Harris
(L)
Daryl Henshaw
(D)
Kathleen Johnson
(K)
Glen McKinney
(G)
Scott Miller
(S)
Jon Reynolds
(J)
B Scott Segal
(BS)
Jimmy Turner
(J)
David VanEenenaam
(D)
Robert Weller
(R)
Miriam Treggiari
(M)
Shamsuddin Akhtar
(S)
Marcelle Blessing
(M)
Chanel Johnson
(C)
Michael Kampp
(M)
Kimberly Kunze
(K)
Mary O'Connor
(M)
Jeffrey Carson
(J)
Stephen Papp
(S)
Barry Perlman
(B)
Ki Jinn Chin
(KJ)
Mark Neuman
(M)
Brian F S Allen
(BFS)
Duminda N Wijeysundera
(DN)
Sachin Kheterpal
(S)
Reneé H Moore
(RH)
Alexander K Smith
(AK)
Laura L Tosi
(LL)
Robert A Hymes
(RA)
Daniel Sessler
(D)
Lee Fleisher
(L)
Christine Langlois
(C)
Samuel Oduwole
(S)
Thomas Rose
(T)
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