Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery: The RAGA Randomized Trial

• Published in: JAMA : the journal of the American Medical Association 2022-01, Vol.327 (1), p.50-58
• Main Authors: Li, Ting, Li, Jun, Yuan, Liyong, Wu, Jinze, Jiang, Chenchen, Daniels, Jane, Mehta, Rajnikant Laxmishanker, Wang, Mingcang, Yeung, Joyce, Jackson, Thomas, Melody, Teresa, Jin, Shengwei, Yao, Yinguang, Wu, Jimin, Chen, Junping, Smith, Fang Gao, Lian, Qingquan
• Format: Article
• Language: English
• Subjects: Adults; Adverse events; Aged; Aged, 80 and over; Anesthesia; Anesthesia, Conduction - adverse effects; Anesthesia, General - adverse effects; Complications; Delirium; Dementia disorders; Emergence Delirium - epidemiology; Emergence Delirium - etiology; Emergence Delirium - prevention & control; Female; Fractures; Fragility; General anesthesia; Hip; Hip Fractures - surgery; Humans; Hypotension; Incidence; Intravenous administration; Local anesthesia; Male; Mental disorders; Nausea; Older people; Online First; Original Investigation; Pain; Patients; Postoperative Complications - epidemiology; Postoperative Complications - etiology; Regional anesthesia; Single-Blind Method; Surgery; Vomiting
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.2021.22647

IMPORTANCE: In adults undergoing hip fracture surgery, regional anesthesia may reduce postoperative delirium, but there is uncertainty about its effectiveness. OBJECTIVE: To investigate, in older adults undergoing surgical repair for hip fracture, the effects of regional anesthesia on the incidence of postoperative delirium compared with general anesthesia. DESIGN, SETTING, AND PARTICIPANTS: A randomized, allocation-concealed, open-label, multicenter clinical trial of 950 patients, aged 65 years and older, with or without preexisting dementia, and a fragility hip fracture requiring surgical repair from 9 university teaching hospitals in Southeastern China. Participants were enrolled between October 2014 and September 2018; 30-day follow-up ended November 2018. INTERVENTIONS: Patients were randomized to receive either regional anesthesia (spinal, epidural, or both techniques combined with no sedation; n = 476) or general anesthesia (intravenous, inhalational, or combined anesthetic agents; n = 474). MAIN OUTCOMES AND MEASURES: Primary outcome was incidence of delirium during the first 7 postoperative days. Secondary outcomes analyzed in this article include delirium severity, duration, and subtype; postoperative pain score; length of hospitalization; 30-day all-cause mortality; and complications. RESULTS: Among 950 randomized patients (mean age, 76.5 years; 247 [26.8%] male), 941 were evaluable for the primary outcome (6 canceled surgery and 3 withdrew consent). Postoperative delirium occurred in 29 (6.2%) in the regional anesthesia group vs 24 (5.1%) in the general anesthesia group (unadjusted risk difference [RD], 1.1%; 95% CI, –1.7% to 3.8%; P = .48; unadjusted relative risk [RR], 1.2 [95% CI, 0.7 to 2.0]; P = .57]). Mean severity score of delirium was 23.0 vs 24.1, respectively (unadjusted difference, –1.1; 95% CI, –4.6 to 3.1). A single delirium episode occurred in 16 (3.4%) vs 10 (2.1%) (unadjusted RD, 1.1%; 95% CI, –1.7% to 3.9%; RR, 1.6 [95% CI, 0.7 to 3.5]). Hypoactive subtype in 11 (37.9%) vs 5 (20.8%) (RD, 11.5; 95% CI, –11.0% to 35.7%; RR, 2.2 [95% CI, 0.8 to 6.3]). Median worst pain score was 0 (IQR, 0 to 20) vs 0 (IQR, 0 to 10) (difference 0; 95% CI, 0 to 0). Median length of hospitalization was 7 days (IQR, 5 to 10) vs 7 days (IQR, 6 to 10) (difference 0; 95% CI, 0 to 0). Death occurred in 8 (1.7%) vs 4 (0.9%) (unadjusted RD, –0.8%; 95% CI, –2.2% to 0.7%; RR, 2.0 [95% CI, 0.6 to 6.5]). Adverse events were reported in 106 episodes in the regio