【罂粟摘要】 老年患者在腰麻或全身麻醉下行髋关节手术的比较

老年患者在腰麻或全身麻醉下行髋关节手术的比较

贵州医科大学  麻醉与心脏电生理课题组

翻译：黄岁岁  编辑：马艳燕  审校：曹莹

  背景  

与全身麻醉相比，腰麻对接受髋部骨折手术老年人行走能力的影响尚未得到很好的研究。

  方法  

本研究在美国和加拿大的46家医院进行了一项随机优势试验，以评估腰麻与全身麻醉的效果，这些患者以前在美国和加拿大的46家医院接受髋部骨折手术，年龄在50岁或以上。患者按1：1的比例随机分配接受腰麻或全身麻醉。主要结局指标是随机分组60天内死亡及60天时不能独立步行10英尺(3米)、或需使用助行器、拐杖才能步行10英尺(3米)。次要结局指标包括随机分组60天内死亡、谵妄、出院时间和60天时不能独立步行。

  结果  

该研究共纳入1600名患者；分配795名患者接受腰麻，805名患者接受全身麻醉。平均年龄78岁，女性占67.0%。最后两组各有666名患者(83.8%)接受腰麻，769名患者(95.5%)接受全身麻醉。在可获得数据的改良意向治疗人群中，腰麻组712名患者中有132名(18.5%)及全麻组733名患者中132名(18.0%)出现主要结局指标(相对危险度为1.03；95%CI为0.84~1.27；P=0.83)。腰麻组684名患者中有104名(15.2%)及全麻组702名患者中有101名(14.4%)在60天时不能独立行走(相对危险度为1.06；95%CI为0.82~1.36)。腰麻组和全麻组60d内死亡率分别为30/768(3.9%)和32/784(4.1%)(相对危险度为0.97；95%CI为0.59~1.57)。腰麻组633例患者中有130例(20.5%)发生谵妄，全麻组629例患者中124例(19.7%)发生谵妄(相对危险度为1.04；95%CI为0.84~1.30)。

  结论  

老年患者在腰麻下行髋关节手术在60天内存活率和行走能力恢复方面并不优于全身麻醉，两种麻醉方法术后谵妄发生率相似。   

原始文献来源：

M.D. Neuman, R. Feng, J.L. Carson, L.J. Gaskins, et al. Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults.[J].N Engl J Med. 2021 Oct 9. doi: 10.1056/NEJMoa2113514. Online ahead of print.

英文原文    

Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults

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.

Method: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).

Conclusion: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.

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