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

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.

Retrospective cohort study of decision-to-delivery interval and neonatal outcomes according to the type of anaesthesia for code-red emergency caesarean sections in a tertiary care obstetric unit in France.

BACKGROUND: Non-elective caesarean sections may be classified using a three-colour coding system, from code-green caesarean section corresponding to non-urgent delivery (no maternal of foetal compromise) to code-red caesarean section corresponding to emergency caesarean section due to immediate life-threatening maternal or foetal situations. Decision-to-delivery interval≤15min has been advocated in France for code-red caesarean section. This retrospective cohort study aimed to assess the decision-to-delivery interval and the neonatal outcomes according to the anaesthetic technique performed for code red caesarean section in a French tertiary care obstetric unit. METHODS: All women undergoing code-red caesarean section between January 2013 and December 2015 were included. Demographic characteristics and anaesthetic, obstetrical and neonatal outcomes were collected from the patient's electronic medical records. RESULTS: Among 194 code-red caesarean sections analysed, 127 (65%) were performed under epidural anaesthesia and 67 (35%) under primary general anaesthesia. The median decision-to-delivery interval was 10 [8-12.5] min, and the interval was≤15min in 174 (90%) women. Effective epidural top-up and epidural top-up requiring supplemental sedation were associated with the shortest decision-to-delivery interval. Primary general anaesthesia was independently associated with depressed 5minutes Apgar score. CONCLUSION: The decision-to-delivery interval was≤15min in most women, suggesting that optimised organisation ensures short decision-to-delivery interval independently of the anaesthetic technique performed. As general anaesthesia was associated with worse neonatal outcomes, our results support the early insertion of an epidural catheter whenever there is any potential concern that an emergency caesarean section may be required.