Hypobaric Unilateral Spinal Anesthesia Versus General Anesthesia for Hip Fracture Surgery in the Elderly: A Randomized Controlled Trial

Abstract

BACKGROUND: Hypotension during surgery is frequent in the elderly population and is associated with acute kidney and myocardial injury, which are, themselves, associated with increased 30-day mortality. The present study compared the hemodynamic effects of hypobaric unilateral spinal anesthesia (HUSA) to general anesthesia (GA) in patients ≥70 years of age undergoing hip fracture surgery. METHODS: We conducted a single-center, prospective, randomized study. In the HUSA group, patients were positioned with the operated hip above, and the hypobaric anesthetic solution was composed of 9 mg ropivacaine, 5 µg sufentanil, and 1 mL of sterile water. Anesthesia was adjusted for the GA group. Mean arterial pressure (MAP) was measured with a noninvasive blood pressure upper arm cuff every 3 minutes. Hypotension was treated with a bolus of ephedrine and then a continuous intravenous of norepinephrine to obtain a MAP ≥65 mm Hg. Primary outcome was the occurrence of severe hypotension, defined as a MAP <65 mm Hg for >12 consecutive minutes. RESULTS: A total of 154 patients were included. Severe hypotension was more frequent in the GA group compared to the HUSA group (odds ratio, 5.6; 95% confidence interval, 2.7-11.7; P < .001). There was no significant difference regarding the short-term outcomes between the HUSA and GA groups: acute kidney injury (respectively, 5.1% vs 11.3%; P = .22), myocardial injury (18.0% vs 14.0%; P = .63), and 30-day mortality (2.4% vs 4.7%; P = .65). CONCLUSIONS: HUSA leads to fewer episodes of severe intraoperative hypotension compared to GA in an elderly population undergoing hip fracture surgery.

Physiological Remarks on Spinal Anesthesia, Drug Baricity, and Clinical Results

“…Several studies point out the benefits of regional techniques, even in terms of mortality, although these results have not been reproduced in large reviews. The study by Simonin et al 1 reinforces this theory, and we would like to share several considerations about the methods and results of their study.…”

“…We read with full interest the article “Hypobaric Unilateral Spinal Anesthesia Versus General Anesthesia for Hip Fracture Surgery in the Elderly: A Randomized Controlled Trial” by Simonin et al, 1 as they provide very interesting data regarding anesthetic management for hip fracture surgery. The choice between general anesthesia (GA) and spinal anesthesia (SA) can be tricky due to the high burden of comorbidity, the frequency of agitation, or the usual prescription of drugs that affect hemostasis in these patients.…”

“…Then a unilateral selective block can be easily achieved by positioning the patient on the operating room table with a slight anti-Trendelenburg position and lateral tilting toward the surgical side. This would also make it essential to perform a preoperative block for patient mobilization, as done by Simonin et al in their study, 1 although other techniques, such as pericapsular nerve group block, could have even a better profile. Additionally, the advantages of performing an SA in the sitting position must not be ignored, as it greatly eases the technique.…”

Less Blood Pressure But Not Less AKI

“…To the Editor W e read with great interest the article by Simonin et al 1 in the December 2022 issue of the journal comparing the incidence of hypotension with hypobaric unilateral spinal anesthesia (HUSA) and general anesthesia patients in patients undergoing hip fracture surgery. A significant reduction of hypotensive episodes was observed in the HUSA group compared to the general anesthesia group (odds ratio, 5.6; confidence interval, 2.7-11.7; P < .001).…”

“…To the Editor W e read with interest the article by Karam et al, 1 which compared the use of total intravenous anesthesia (TIVA) with propofol versus inhalational anesthesia with sevoflurane on respiratory adverse events for pediatric patients after laryngeal mask airway removal. The authors should be commended for their work.…”