We retrospectively analyzed 257 hip fracture patients to determine mortality rates and factors affecting patient mortality, according to three anesthesia techniques.
ASA physical scale status is commonly used to classify the preoperative status of the hip fracture patients [18
]. Hamlet et al. [18
] reported that 3-year mortality was significantly less for ASA I and II patients (23%) than for ASA III, IV, and V patients (39%). Michel et al. [19
] reported that in 114 patients treated for hip fracture, high ASA status (3 or 4) conferred a nine times increased risk for mortality at one year. However, in the review for anesthetic risk factors, Haljamäe [21
] stated that because ASA classification considers only physical status factors, other risk-predictive factors such as age and sex of the patient and the type, site, and duration of surgery should also be included for individual cases. Our patients' hip fractures were either femoral neck or intertrochanteric femur fracture. Because of different surgery modalities for these fractures, we could not take into consideration the perioperative blood loss and duration of surgery, that are the major limitations of our study. Also, in our recent research about predictors of mortality after hip fracture [14
], we did not find any relationship between comorbidities (systemic diseases) and mortality. So, rather than the quantity (count), we preferred the significance of the diseases, which is reflected better with ASA. But, besides ASA, we included the age, sex, and delay in surgery as risk factors for mortality in multivariate analysis. We found that ASA, age, and delay in surgery were significant predictors of mortality.
When the three groups of patients were compared, there were no significant differences for sex, delay in surgery, mean followup, and Barthel score. Similar to other studies [12
], delay in surgery is associated with increased mortality in this study, but has no emphasis for comparison of these three groups' mortality. However, the mean age of the NB patients was significantly younger than GA and CPNB patients, which would decrease the mortality of NB patients [2
]. Also, the ASA status of CPNB patients was significantly worse than GA and NB patients, that would increase the mortality of CPNB patients according to other studies [18
The one-month mortality rate was not significantly different for the three (GA, NB, and CPNB) groups. However, both one-year and overall mortality rates were decreased for the regional group (NB + CPNB). Also estimated survival time was higher for regional group. In several studies, the reduction in morbidity and mortality had been shown with regional anesthesia [12
]. Although there was no significant difference, the one-month mortality rates were 19.1%, 8%, and 17.4% for GA, NB, and CPNB patients, respectively. We believe that the younger mean age and better ASA status of NB patients than CPNB patients caused this one-month difference. However, by the time, if the highrisk patients succeeded in surviving for one month, the survival rate of CPNB patients became almost equal to the NB patients, even though they were older than the NB patients (). Confirming this, CPNB choice was an independent variable of decreased mortality; however, NB choice was not in multivariate Cox regression analyses ().
Naja et al. [10
] treated 60 patients for hip fracture, 30 patients with general anesthesia, and 30 patients with combined sciatic-paravertebral nerve block. They reported that both the incidence of intraoperative hypotension and the postoperative need for intensive care unit admission was significantly reduced in patients treated with combined sciatic-paravertebral nerve block compared to patients receiving general anesthesia. Similarly, in their prospective randomized study, de Visme et al. [6
] treated 29 patients for hip fracture, 15 patients received combined lumbar and sacral plexus block, and 14 patients received spinal anesthesia. They found that hypotension was to be longer lasting after spinal anesthesia and of a larger magnitude in patients over 85 years of age. CLSB, as a rising trend, is correlated with minimal hemodynamic disturbance and so less affected cardiovascular stability [6
]. These advantages of CPNB promote us to operate high-risk (ASA III AND IV) hip fracture patients earlier without seeking medical treatment modalities for their systemic diseases.
In conclusion, to decrease the mortality rate after hip fracture, since age and ASA status are patient-dependent factors that cannot be changed, the patients must be operated as soon as possible. Because CPNB is an encouraging technique to operate patients earlier, we recommend CPNB technique in hip fracture patients, especially for patients with poor general health status. Considering the retrospective nature of the study and the effects of personal characteristics, it is hard for us to claim that “CPNB technique decreases mortality.” Nevertheless, our hypothesis and results at least may form the basis and show the need for future randomized prospective studies.