ESRA Journal Club

ESRA UPDATES journal club invites leading experts in (regional) anesthesia to select one (or more) article(s) which for him/her were/are important, interesting or changed his/her clinical practice. This choice can be a general big randomized study but can also be very personal. For this edition our choice went to Andrea Saporito (MD, MBA, DESA, EDRA) and his colleague Roberto Dossi.

Dr Saporito is the vice-Chair of Anesthesia and Operating Rooms Manager at Southern Switzerland Cantonal Hospital Trust (EOC) c/o Bellinzona Regional Hospital (Bellinzona, Switzerland).
He is a clinical researcher in the fields of anesthesiology and perioperative medicine, with particular expertise in regional anesthesia and the economics and management of the perioperative processes. Several publications in international, peer-reviewed medical journals.
He is the secretary of the Swiss Association of Regional Anesthesia (SARA), faculty member of the European Society of Regional Anesthesia (ESRA). And he got a master degree in Healthcare Economics and Management (MHA) at the University of Southern Switzerland (USI).

Spinal versus general anesthesia for hip fracture surgery: show must go on!

We have read with great interest the meta-analysis by Dr Kunutsor and Colleagues on clinical effectiveness and safety outcomes of spinal anesthesia compared to general anesthesia in hip fracture surgery, published in the British Journal of Anesthesia last September.

Comparison of regional anesthesia and general anesthesia with regard to -more or less- meaningful outcomes has originated a longstanding and contentious debate during the last decade, which is currently living a revival, particularly after the publication, by Dr Neuman and Colleagues on the New England Journal of Medicine, of their paper ‘Spinal Anesthesia or General Anesthesia for Hip Surgery’, in November 2021.

Neuman conducted a superiority trial in 46 North American hospitals, randomly assigning 1600 patients, undergoing hip fracture repair, either to spinal or general anesthesia. Primary outcome was an original composite death or inability to walk three meters two months after enrollment one. Secondary outcomes were –more understandably- 2 months mortality, delirium, length of hospital stay and ambulation at 60 days. The study failed to demonstrate a statistically significant superiority of spinal over general anesthesia with regard to all these outcomes, making a good deal of sensation within the regional anesthesia community on both side of the ocean.

When interpreting the results of this trial, regional anesthesia enthusiasts likely tend to dilute the actual clinical impact of its findings, arguing that the fact that spinal anesthesia failed to show a superiority in terms of mortality or functional recovery, does not mean it does not have a series of other both clinical and practical potential advantages, ranging from a short term optimal pain control to the avoidance of mechanical ventilation in patients at high risk for severe pulmonary complications, to the cost-effectiveness profile, related to operating room time utilization and an increased requirement of intensive postoperative surveillance in more fragile patients.

We hoped that Kunutsor and Colleagues might have shed a slightly more tangential light on the otherwise black and with picture presented by Neuman, highlighting more effectively the many shades of gray of this complex topic. Their use of a consensus-based core outcome set and public involvement defined outcomes is interesting, as it focuses on less commonly investigated aspects, like time from injury to surgery, incidence of acute coronary syndrome, hypotension, acute kidney injury, pneumonia and pain. Their systematic review is methodologically sound, tough finally including only 15 studies, for a total of 3866 patients. Unfortunately, it seems that most of them reported only few outcomes of the core outcome set initially identified (the most frequent being –again- mortality, delirium, hypotension and acute coronary syndrome) and that 12 out of 15 showed a high risk of bias when tested with the Cochrane Risk of Bias tool. Much to the chagrin of those hoping for a spinal revenge, the results of the meta-analysis -once again- showed no significant differences between spinal and general anesthesia for hip fracture surgery in any of the above-mentioned outcomes but acute kidney injury.

Should regional anesthesia enthusiasts admit defeat and just take note of the fact that probably general anesthesia has (fortunately) being evolving over time, reaching to an equivalent safety and effectiveness profile?

We leave the question open. But we also leave the readers with two personal considerations:

1. clinical conclusions on such an important topic can presently be drawn on the basis of just a small bunch of trials (the majority of which with a high risk of bias);
2. to use the Authors’ words ‘few (trials, ed.) reported outcomes important to patients, which should be considered when designing future RCTs’.

References

• Neuman MD, Feng R, Carson JL et al. Spinal anesthesia or general anesthesia for hip surgery in older adult, N Engl J Med 2021; 385:2025-35.
• Kunutsor SK, Hamal PB, Tomassini S et al. Clinical effectiveness and safety of spinal anaesthesia compared with general anaesthesia in patients undergoing hip fracture surgery using a consensus-based core outcome set and patient- and public-informed outcomes: a systemic review and meta-analysis of randomised controlled trials. Brit J Anaesth 2022; 129(5): 788-800.