Spinal or General Anesthesia for Hip Fracture (NEJM)
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- čas přidán 29. 08. 2024
- In the October 2021 issue of NEJM, Neuman and colleagues reported no difference in the major outcome of patients with hip fractures who were randomized to receive spinal or general anesthesia. In a large prospective study that included 1,600 patients with hip fracture, the study concluded that spinal was not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days, or the incidence of postoperative delirium. In this video with expert clinicians' testimonials, Dr. Hadzic argues that the methodology was biased against spinal anesthesia. He explains how the inclusion bias of healthier population, mandatory intraoperative sedation for patients having spinal anesthesia, the lack of standardization of the premedication for positioning for spinal, and the apparent lack of the regional anesthesia skills (15% failure to administer spinal) skewed the outcome. Likewise, the selection of primary outcome variables missed capturing the ubiquitously observed advantages of spinal anesthesia in hip fracture patients who often present for surgery with severe comorbidities where avoidance of general anesthesia is beneficial. Watch the video as Dr. Hadzic breaks the study down, to make your own opinion of whether this study’s findings are relevant to your own practice.
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Medicine is an ever-changing science. As new research and clinical experience broaden, changes in treatment and drug therapy are required. The authors and publishers have checked with sources believed to be reliable in efforts to provide accurate information within the available or accepted standards of care. However, given the possibility of human error or changes in medical practice, neither the authors nor the publisher, nor any other party involved in the preparation of this platform warrants that the information contained herein is in every aspect accurate or complete, and they disclaim all responsibility for any errors or omissions for the results obtained from the use of the information contained in this work. Readers are advised to confirm the information contained herein with other sources. For example, readers are advised to check the product information of each drug mentioned, and that any information contained on NYSORA's CZcams channel is accurate.
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One important point, is that we should learn how to read an article.
Thank you for this lecture.
Thank you for your comment. Indeed, must interpret the study to see how it fits your own practice. Few studies are universally applicable.
The importance between statistical significance and clinical significance!
Definitivamente la anestesia espinal es mejor vrs la anestesia general. Y lo vemos día a día con nuestros pacientes. Creo que la experiencia de parte del anestesiologo es vital para este tipo de técnica !!! Gracias Dr. Hazic por su gran aporte 🙏🏻🙏🏻🙏🏻
Thanks for the information and in my 30yrs of Anaesthesia practice never given GA for hip # I prefer giving unilateral SA with Bupivicaine heavy 10mg without any premedication excellent results and better Post operative outcome.
Thank you Chaitanya! Glad you like the video. Thank you for watching. Do subscribe to this channel and share with your colleagues; a lot more videos are coming up - let's share our clinical experience!
I couldn’t agree more, Dr. Hadzic
I can't stop all your videos Dr. Hadzic.
Very happy you find it helpful and interesting!
Nevertheless, this is one best studies on a very difficult topic. All studies have their limitations and the authors have been very transparent. You mention many large studies in favor of regional, but many of those studies are flawed in terms of their designs and data reporting (which you do not discuss) - selection bias, randomization, changes in primary and secondary outcomes, and poor control for confounders-to name a few issues. You raise some valid points but while criticizing this article, you should discuss the shortcomings of the “pro-regional” literature and how almost none of those were well enough performed to be considered to be published in the NEJM vs. a much lower impact anesthesiology journal. As for me, I will do what is safest for the patient. In fact with the rise in anti-platelet and anticoagulation therapy in older adults, which precludes neuraxial approaches, this REGAIN study gives me some reassurance that GA in a hip fracture setting is no worse than regional (neuraxial) anesthesia. Bottom line is that no study is perfect but we must be careful here not to throw the “baby out with the bathwater”
These comments are all high-level and spot on. Thank you. I do not know who this is, but I can not disagree. And, admittedly - it is easier to criticize then produce own study. “As it was easy - everyone would do it!”. A quote by Jerry Vloka that I swear by. My disappointment with the study is, that this work is likely richly sponsored by grants, as the disclosure suggest. This is an experienced team of investigators who know how to get grants by asking major, simple, albeit - limited to overly crude questions to settle the debate. But it many ways it was not the best use of grant $ as they primarily outcomes are so radical. In fact, if you used these primary variables for safety of Pancuronium vs Rocuronium, Chloroform vs Sevoflurane, Tetracaine vs Ropivacaine, Mask-ventilation vs LMA or intubation, you would likely conclude that there is NO difference whatsoever and the patients should make a choice between these drugs and interventions based on their own preference, rather than anticipated outcomes. And yet, we do know that the latter innovations do make a difference.
I do agree with you that for the subset of patients that are similar to those in the NEJM study, the anesthesia practitioners, their results suggest that you should not feel bad if you do can not do a spinal or the spinal is contraindicated. But where the expertise is available, the difference is obvious to those in the trenches and the earlier work of the same authors support spinal (Neuman 2012: “In a review of 18,000 patients, regional anesthesia decreased major pulmonary complications and death in 25%-29%).
@@DRBLUESNYC thanks for your reply. We need more constructive debate like this to do what’s best. I use a tremendous amount of regional anesthesia in my practice and will continue to do so. I agree that this paper will not change my practice much because I do believe that just avoiding the airway in an older patient is still a major advantage. That said, there are times (e.g., anticoagulant rx, patient refusal, or uncooperative patient) that regional cannot be used and this paper makes me feel a bit better about using GA in those situations. I really appreciate your channel, I have learned a tremendous amount about regional, and I thank you for the lively, constructive (and professional) discussion.
Great review, we must guide our residents who do not yet have this critical reasoning when reading articles.
Hi Bruno! Indeed. Thank you for your comment! Make sure you subscribe to the channel so that you do not miss some super educational upcoming videos!
A really fantastic discussion (and highly entertaining!). Please keep up the great work!
Thank you for your great feedback!
In Germany a lot of these patients take NOAKs (apixaban) and the guideline recommendation is to operate within 24 hours, thus you actually do not have the option of a spinal.
But if regional/spinal is possible we do as many as possible.
SOP: 5 mü Sufentanil, Femoral Bock, spinal/ Bupivacain 0,5% hyperbaric 3-3,5 ml
Indeed. Good point.
Does this not cause a problem with surgical blood loss as well as the spinal?
Second comment I see in this channel suggesting this massive dose of intrathecal LA for hip surgery. Are you fellow anesthesiologists really still using as much as 15 mg of bupivacaine for anything?
According to the German Fachinformation 10-20 mg is the recommended dose with an onset within 5-8 min and a duration of 1,5 to 3 h. To prolong the effect we add 5 mcg of Sufentanil or 15 mcg of Clonidin. However Clonidin oft cause more sympaticolysis, this we normally use Sufentanil.
@@sskfrey Germany is not the only country were the approved sheet for bupivacaine recommends those dosages, Spain is the case also. But you have plenty of papers published supporting lower doses, as low as 4.5 mg for C-section. I have never ever used more than 12 mg, motor blockade is just too long and haemodynamic effects too important. Nowadays in my daily practice 8 mg is the maximum I would use in any case and 2.5 mg the minimum, and I barely ever complement that with an opioid. Complement these doses with different positions, baricities and points of insertion. Just give it a try, 1 mg less every day 👍
Excellent article review and please continue to do more of these! This is gold!
Thanks, will do!
It’s indisputable that spinal anesthesia is better than GA, but this study is important to discourage some colleagues who force spinal anesthesia in patients receiving anti platelet or anti coagulant medications without respecting suspension intervals
Also agree. Must weigh risks/benefits ratio. Greetings.
Really appreciate your deciphering of this article. In my experience, spinal does bring better outcome among the hip fracture patients. What a shame that a reputable journal as New England Journal of medicine published this misleading article!
I would not say a shame, as there is some useful information. It is just that it is limited to the conditions of their study/methodology. What I am surprised is that the generalization in the recommendations - something that would not fly in any anesthesiology journal.
Best regards
@@DRBLUESNYC Truly appreciated your input and all you do! I have learned so much from your CZcams videos. At our hospital, a lot of the ortho surgeons are already anti spinal for hip fractures, cuz they say there are not enough relaxation from the spinals. 🤔. Just reading the generalized conclusion from this article can further mislead them. I wish New England Journal had been more careful during their reviewing process and asking for more clarifications when prudent.
Such studies could be deceiving
Inspite of such studies, our experience and practice using spinal anaesthesia along with femoral or Supra inguinal fascia iliaca block for hip surgery, would not change except in some patients with low EF , well explained dr hadzic 👌👍
Very informative, hope to see more of this type of content.
More to come!
Thank you for bringing this topic forward for discussion. Unfortunately, these types of studies can lend to more broader surgeon advocacy of General Anesthesia for indiscriminate expediency as you inferred here. These papers do not help in actual patient care from a societal or population point of view. It really undermines the care needed by some very ill or elderly patients with very unique needs.
This also highlights the difficulties that many of us face in the community settings: different depth of surgical skills. These issues create a complex professional dynamic that we all have to navigate with nuance, especially in a small community. I even recently had a surgeon pop in to interrupt during a very difficult spinal anesthesia(17 min) for an ELECTIVE anterior hip replacement to coerce/intimidate me to lower my threshold to switch to a General Anesthetic. The case wound up taking over 5.5 hrs overall!!
Keep up the great work you are doing here. The techniques and information that you share are instrumental in giving old and new practitioners the confidence to stay the course to do the right thing for our patients.
I think that GA is recommended only when there is a contraindication to spinal anesthesia as Pt on antiplatlet (like clopidogrel) that need to be stopped for 5 to 7 days before hip repair surgery under spinal anaesthesia and all recommend to do surgery within 48 hrs..excellent video. Thank you
Hey Eslam! Greetings! And thanks for watching. Do subscribe to this channel as there's more coming up. And let's share the collective experience so that we all get better in what we do!
Very well discussed about hip surgery anaesthesia .As out come and mortality seems same with general or spinal, longer duration hip surgery patients may be more stable with GA or? USG guided hip pNB nerve BLOCKS (which many are not familiar) . Thankyou very much sir for a highly useful information about hip anaesthesia fortrauma and orthopaedics
Good question. Again, it all depends on the individual practice - how applicable the recommendations of any study are. In our centers, hip fracture surgery is under 60 minutes in most cases. Greetings and thank you for your comment.
i think this study is more geared toward the average anesthesiologist at a community hospital. you're looking at it from a highly specialized regional anesthetic point of view.
Why do they do ga on prostate operations instead of spinal tab .
Full agreement. For me, contraindications to spinal anesthesia in hip fracture surgery are coagulation disorders, severe heart defects and purulent skin lesions on the back. For 30 years we have been performing spinal anesthesia for such procedures with good results. 15% of the conversion to general anesthesia sounds like a joke. Greetings from Poland.
Hi Regen! Thank you so much for your kind words; we really appreciate your feedback.
Well done! Thank you Dr H.
Glad it was helpful!
Thanks Admir !!!
Our pleasure!
Because of the lack of good previous RCT in the litterature, I am wondering why they have chosen a pragmatic approach rather than an explanatory one?
Very good point. In fact, if you apply composite death as the primary outcome variable, it may not matter how you treat the hip - conservatively vs. operatively, as the data does not exist on this to my knowledge. However, patients who have surgery immediately feel better than their counterparts who are treated conservatively. So, the choice of primary outcome variables are crucial for the relevance of any study.
In Germany due to the excessive use of the NOAKs(rivaroxaban,…) and since there is a recommendation to do surgery within 24 hours
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Completely agree with you Admir
Thanks a lot for this lecture
Thank you for watching. Greetings!
Great analysis of that (controversial) article👏
I agree, hypoactive delirium is asociated whit general anesthesia
Hello I prefer spinal but I can' t agree with the conclusion that a spinal is better than a general if you do not specify a general anesthesia : is it with volatiles of TCI, is it with intubation or laryngeal mask, it is OFA of with lots of opioids, is it with curare and monitoring(certainly in older patients rocuronium has a great variability and when not monitored gives lung complications); is it combined with LIA or PENG. And then I am not talking about the many combinations.
Well, i haven't read it this way. The way i saw it is that if i really think that a patient needs a general anesthesia i will use general anesthesia without feeling guilty, like i did something bad or incorect for the patient. I still think that spinal is usually the right choice.
Our surgeons prefer patients in spinal anesthesia because it speeds up time between cases and they notice less bleeding, less nausea and vomiting after cases, which leads to faster ambulation. Nevertheless, fine discussion. In our facitility, rate of spinal anesthesia failure is definitely less than 1%. 15% is A LOT. And not every patient is sedated, some of them prefer to be awake.
I choose Spinal anesthesia with bupivacain hyperbaric 0.5 % 20 mg with adjuvan 50 mikrogram morfin for hip surgery in indonesia. More speed onset and dense motoric block, low cost and more safety in comorbid COPD caused smoking and Tuberculosis and coroner artery disease that many in geriatric patient hip surgery in our country. For positioning In SAB depend in patient: siting position or lateral decubitus. Before positioning we give bolus fentanyl intravena 50 ug for comfortable in positioning.
Great...
thanks
You're welcome!
dont analyze it
just spinalyze it
lol. Funny and well said. The trouble is really that it the generalists feel uncomfortable being told that the SPINAL is standard, if they are not skilled at it. Of of my cardiac anesthesiology colleagues once said - "I do regional only when general fails". lol. Greetings.
I'm not sure what level he's refering to but find it difficult to believe that any "competent generalist" anaesthetic trainee has a lack of regional skills - how do they do obstetrics? I'm also slightly confused due to him saying at different points in the video that death was increased by 3x or that it was the same...
Hi Tom. All your points are valid. However, you can imagine that if you only need to do 40 spinals to graduate - there will be folks graduating with those skills. And many practices struggle with staffing - not everyone is skilled with spinal and neuraxial analgesia for OB. The best analogy that comes to mind is - if you want your wrist fracture fixed - it'd be in your interest that you consult a hand surgeon. Although a general ortho surgeon can fix your wrist as well, and your chance of buying or not being able to use your hand for 3 minutes may not be different, there are quality benefits that are not measured by the crude primary outcome variables used in the study. The death in hospital difference is in the table in that NEJM and the other article by Neuman - listed in the video. By design, the authors of NEJM could not dig into discussions of the differences in complication rates between spinal and GA, but the authors do an honest job of limiting their findings by saying: "Limitations of our trial include a considerable amount of missing outcome data; however, the results of sensitivity analyses that accounted for missing data were similar to those in the primary
analysis. The primary outcome occurred in a lower percentage of patients than had been anticipated when the trial was planned. This reduced power and may have occurred as a result of enrollment of patients into the trial who were healthier than anticipated. Although approximately 15% of the patients who had been randomly assigned to receive spinal anesthesia crossed over to general anesthesia, our main findings persisted in an instrumental variable analysis that accounted for nonadherence to the assigned treatment. Nevertheless, the rate of nonadherence may have reduced the power to detect differences between the groups. An inability to place a spinal block was the most common reason for nonadherence". However, the title of the paper is wrong, as is the recommendation that based on what they published in NEJM, the choice of anesthesia technique should be patient's preference".
@@DRBLUESNYC interesting how different a speciality with the same name can be in different parts of the world (which itself may be a factor in applicability of a study). That said patient refusal and/or anticoagulation will always result in a "failure to provide a regional" so that too may be part of that group.
@@tomriley5790 so true!
Usually the fleas I work with say, “GA contraindicated. Do spinal”
Good day doctor, i recently discovered your channel and i am really enjoying it... but i am struggling to find out videos on GA on its own. Forgive me if i deviate from the topic of his video. Many thanks in advance.
Hi JC RHVMP! Great. Thank you for sharing. And make sure you subscribe to this CZcams channel - we have a lot more really interesting videos coming up soon.
Sir, what if patient is unstable, is GA is preferred over spinal??
Thank you very much for video. May you share article or where can I find?
Hi Ali! You can find the article here www.nejm.org/doi/full/10.1056/NEJMoa2113514
Great sir
Thank you!
I BEGGED for them to use spinal anesthesia for hip replacements and they wouldn’t even discuss it.
What do you say when a patient says They don’t want to hear what the surgeon is doing?
Here, have these headphones and listen to some music
@@MsGasGirl This is exactly what we do. Headphones and judicious sedation - propofol only.
thanks guys
In my hospital, we use headphones and VR goggles so you can listen to music and watch a movie. It is very effective. You should try it out as a study in your hospital!
@@orsomethinglike wow that’s awesome! Are you in US? I’m a new practitioner and have only seen propofol infusions if one says they don’t want to hear OR sounds.
Questionable composite outcome, lack of standardization of confounding factors, and an underpowered study due to lower than anticipated rate of outcomes - going to pass on these results!
I love nysora tko dr