Anesthesia Technique in COVID-19 Positive Hip Fracture Patients
NCT ID: NCT05133648
Last Updated: 2023-01-09
Study Results
Results pending
The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.
Basic Information
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Recruitment Status
UNKNOWN
Total Enrollment
1000 participants
Study Classification
OBSERVATIONAL
Study Start Date
2023-01-05
Study Completion Date
2023-12-03
Brief Summary
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Patients with COVID undergoing hip fracture repair have high mortality rates. If spinal anesthesia is associated with decreased rates of mortality, this study could provide hypothesis generating data for prospective studies. Investigators hypothesize that spinal anesthesia (SA) is associated with decreased mortality compared to general anesthesia (GA) for patients undergoing hip fracture surgery. The primary objective is to determine for patients undergoing hip surgery with COVID-19 infection, whether SA, as compared to GA, is associated with a lower rate of mortality 30 days postoperatively. The secondary objective is to determine whether SA, as compared to GA, is associated with a lower rate of morbidity 30 days postoperatively. Investigators will be analyzing a data set provided by the National Surgical Quality Improvement Program (NSQIP). Descriptive statistics will be performed. Multivariable logistic regression will be performed for the primary and secondary objectives.
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Detailed Description
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Background: Patients with hip fracture have poor outcomes, attributed to risk factors that include advanced age and higher rates of underlying chronic comorbidities. COVID-19 infection is an independent risk factor for increased mortality in hip fracture patients in the perioperative period. A recent meta-analysis demonstrates COVID-19 infection is associated with higher than seven-fold increase in risk of mortality. Recommended management of hip fracture includes timely surgical repair, multimodal pain control, and multidisciplinary follow-up, to facilitate return to mobility and independent function.
Anesthesia for hip fracture surgery can be achieved by either general anesthesia (GA) or spinal anesthesia (SA). The potential advantages of SA include opioid-sparing effects, lessened impacts on the respiratory and gastrointestinal systems, and reduction in rates of adverse outcomes such as pneumonia, mechanical ventilation, intensive care unit (ICU) admission, venous thromboembolism (VTE), myocardial infarction (MI), stroke, transfusion, readmission, and prolonged postoperative length of stay. However, a recent randomized control trial found no difference between SA and GA for older adults undergoing hip fracture surgery for the primary outcome of survival and recovery of ambulation at 60 days.
While emerging evidence shows COVID-19 infection increases mortality after hip surgery, there is a lack of research examining whether the choice of anesthetic technique modifies the postoperative mortality and morbidity of hip fracture patients with COVID-19 infection. This is particularly important due to the high mortality (35% in COVID-positive patients, vs. 2% in patients without COVID), with the potential for SA to modify this risk by circumventing the need for airway interventions. SA may also offer superiority over general anesthesia for limiting aerosol generation and exposure of operating room staff during the pandemic. While SA may reduce the risk of pulmonary morbidity by reducing the need for airway interventions, its motor block on accessory muscles and the need for sedation may adversely impact ventilation. Investigators hypothesize that spinal anesthesia (SA) is associated with decreased mortality compared to general anesthesia (GA) for patients undergoing hip fracture surgery.
Study Design: The requirement for written informed consent will be waived for use of deidentified data. Patient information will be obtained for the retrospective cohort analysis using the NSQIP® (general dataset linked with the Hip Fracture Procedure Targeted Dataset), a prospectively-collected multicentre dataset with more than 150 clinical variables within 30 days after surgery. The setting of this study will be patient data obtained from the multicentre generated NSQIP Hip Fracture Procedure Targeted Dataset. The period of patient data obtained will include from January 2017 through December 2021. We will omit the data from January 2020 to December 2020 given there was no reporting of COVID status during this period. Data will only be obtained from patients undergoing hip surgery with mortality and morbidity gathered for 30 days postoperatively. In this study, the investigators goal is to evaluate the adjusted association between anesthesia technique and mortality and morbidity after hip fracture surgery for patients who tested positive for COVID-19.
The primary objective is to determine for patients undergoing hip surgery with COVID-19 infection, whether SA, as compared to GA, is associated with a lower rate of mortality 30 days postoperatively.
Our secondary objective is to determine whether SA, as compared to GA, is associated with a lower rate of morbidity 30 days postoperatively. To provide context for interpretation, we will describe the epidemiology of the following rates during versus before the 2020 COVID-19 pandemic (January to December 2021, compared to 2017 to 2019): 1) SA versus GA uti-lization for hip fracture surgery, and 2) mortality and morbidity for hip surgery patients without COVID-19 infection. Finally, we will quantify the mortality and morbidity for pa-tients with versus without COVID-19 infection undergoing hip fracture surgery, stratified by SA and GA.
Purpose: The purpose of this study is to evaluate the adjusted association between anesthesia technique and mortality and morbidity after hip fracture surgery
Population cohorts: The study will be divided into three cohorts: those undergoing hip surgery 1) without COVID-19 infection January to December 2021, 2) with COVID-19 infection January to December 2021, and 3) pre-pandemic from January 2017 to December 2019.
Due to the variable duration of asymptomatic period that can precede symptoms and diagnosis, COVID-19 infection status will be classified as follows.
In the primary analysis, COVID-negative patients will be defined as no preoperative COVID (within 14 days before surgery) and no postoperative COVID, and COVID-positive patients will be defined as yes (lab-confirmed) preoperative COVID and no postoperative COVID. In NSQIP, preoperative COVID status denotes within 14 days be-fore surgery, and patients with preoperative COVID are always coded "No" for postopera-tive COVID. NSQIP does not have previous history of COVID prior to 14 days, which is a major limitation given the increased mortality of patients with recent COVID undergoing surgery (24).
In NSQIP, preoperative COVID status denotes within 14 days before surgery, and patients with preoperative COVID are always coded "No" for postoperative COVID. NSQIP does not have previous history of COVID prior to 14 days, which is a major limitation given the increased mortality of patients with recent COVID undergoing surgery.
As patients with postoperative COVID-positive status are difficult to interpret due to variable incubation period and the possibility of COVID-19 contraction while in hospital postoperatively, investigators will perform sensitivity analysis using alternative definitions for the COVID-positive cohort, including 1) laboratory confirmed preoperatively or postoperatively, 2) laboratory confirmed or symptomatic preoperatively, and 3) suspected and laboratory confirmed anytime preoperatively or postoperatively).
Data analysis: Investigators will be analyzing a data set provided by the National Surgical Quality Improvement Program (NSQIP). Descriptive statistics will be performed. Multivariable logistic regression will be performed for the primary and secondary objectives.
Anesthesia for hip fracture surgery can be achieved by either general anesthesia (GA) or spinal anesthesia (SA). The potential advantages of SA include opioid-sparing effects, lessened impacts on the respiratory and gastrointestinal systems, and reduction in rates of adverse outcomes such as pneumonia, mechanical ventilation, intensive care unit (ICU) admission, venous thromboembolism (VTE), myocardial infarction (MI), stroke, transfusion, readmission, and prolonged postoperative length of stay. However, a recent randomized control trial found no difference between SA and GA for older adults undergoing hip fracture surgery for the primary outcome of survival and recovery of ambulation at 60 days.
While emerging evidence shows COVID-19 infection increases mortality after hip surgery, there is a lack of research examining whether the choice of anesthetic technique modifies the postoperative mortality and morbidity of hip fracture patients with COVID-19 infection. This is particularly important due to the high mortality (35% in COVID-positive patients, vs. 2% in patients without COVID), with the potential for SA to modify this risk by circumventing the need for airway interventions. SA may also offer superiority over general anesthesia for limiting aerosol generation and exposure of operating room staff during the pandemic. While SA may reduce the risk of pulmonary morbidity by reducing the need for airway interventions, its motor block on accessory muscles and the need for sedation may adversely impact ventilation. Investigators hypothesize that spinal anesthesia (SA) is associated with decreased mortality compared to general anesthesia (GA) for patients undergoing hip fracture surgery.
Study Design: The requirement for written informed consent will be waived for use of deidentified data. Patient information will be obtained for the retrospective cohort analysis using the NSQIP® (general dataset linked with the Hip Fracture Procedure Targeted Dataset), a prospectively-collected multicentre dataset with more than 150 clinical variables within 30 days after surgery. The setting of this study will be patient data obtained from the multicentre generated NSQIP Hip Fracture Procedure Targeted Dataset. The period of patient data obtained will include from January 2017 through December 2021. We will omit the data from January 2020 to December 2020 given there was no reporting of COVID status during this period. Data will only be obtained from patients undergoing hip surgery with mortality and morbidity gathered for 30 days postoperatively. In this study, the investigators goal is to evaluate the adjusted association between anesthesia technique and mortality and morbidity after hip fracture surgery for patients who tested positive for COVID-19.
The primary objective is to determine for patients undergoing hip surgery with COVID-19 infection, whether SA, as compared to GA, is associated with a lower rate of mortality 30 days postoperatively.
Our secondary objective is to determine whether SA, as compared to GA, is associated with a lower rate of morbidity 30 days postoperatively. To provide context for interpretation, we will describe the epidemiology of the following rates during versus before the 2020 COVID-19 pandemic (January to December 2021, compared to 2017 to 2019): 1) SA versus GA uti-lization for hip fracture surgery, and 2) mortality and morbidity for hip surgery patients without COVID-19 infection. Finally, we will quantify the mortality and morbidity for pa-tients with versus without COVID-19 infection undergoing hip fracture surgery, stratified by SA and GA.
Purpose: The purpose of this study is to evaluate the adjusted association between anesthesia technique and mortality and morbidity after hip fracture surgery
Population cohorts: The study will be divided into three cohorts: those undergoing hip surgery 1) without COVID-19 infection January to December 2021, 2) with COVID-19 infection January to December 2021, and 3) pre-pandemic from January 2017 to December 2019.
Due to the variable duration of asymptomatic period that can precede symptoms and diagnosis, COVID-19 infection status will be classified as follows.
In the primary analysis, COVID-negative patients will be defined as no preoperative COVID (within 14 days before surgery) and no postoperative COVID, and COVID-positive patients will be defined as yes (lab-confirmed) preoperative COVID and no postoperative COVID. In NSQIP, preoperative COVID status denotes within 14 days be-fore surgery, and patients with preoperative COVID are always coded "No" for postopera-tive COVID. NSQIP does not have previous history of COVID prior to 14 days, which is a major limitation given the increased mortality of patients with recent COVID undergoing surgery (24).
In NSQIP, preoperative COVID status denotes within 14 days before surgery, and patients with preoperative COVID are always coded "No" for postoperative COVID. NSQIP does not have previous history of COVID prior to 14 days, which is a major limitation given the increased mortality of patients with recent COVID undergoing surgery.
As patients with postoperative COVID-positive status are difficult to interpret due to variable incubation period and the possibility of COVID-19 contraction while in hospital postoperatively, investigators will perform sensitivity analysis using alternative definitions for the COVID-positive cohort, including 1) laboratory confirmed preoperatively or postoperatively, 2) laboratory confirmed or symptomatic preoperatively, and 3) suspected and laboratory confirmed anytime preoperatively or postoperatively).
Data analysis: Investigators will be analyzing a data set provided by the National Surgical Quality Improvement Program (NSQIP). Descriptive statistics will be performed. Multivariable logistic regression will be performed for the primary and secondary objectives.
Conditions
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Hip Fractures
COVID-19
General Anesthesia
Spinal Anesthesia
Study Design
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Observational Model Type
COHORT
Study Time Perspective
RETROSPECTIVE
Study Groups
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Hip Surgery without COVID-19 infection
January to December 2021
Hip Fracture Surgery
Intervention Type
PROCEDURE
Hip fracture surgery
Hip Surgery with COVID-19 infection
January to December 2021
Hip Fracture Surgery
Intervention Type
PROCEDURE
Hip fracture surgery
COVID-19 infection
Intervention Type
OTHER
COVID-19 infection
Hip Surgery pre-pandemic
January 2017 to December 2019
Hip Fracture Surgery
Intervention Type
PROCEDURE
Hip fracture surgery
Interventions
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Hip Fracture Surgery
Hip fracture surgery
Intervention Type
PROCEDURE
COVID-19 infection
COVID-19 infection
Intervention Type
OTHER
Eligibility Criteria
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Inclusion Criteria
* Sampled in the NSQIP Hip Fracture Procedure Targeted Dataset from January 2017 through December 2019 and from January 2021 to December 2021.
* undergoing surgical fixation of hip fractures using either general and/or spinal anesthesia.
* In case of reduced Procedure-Targeted data collection during the COVID-19 pandemic, investigators will also create a total open hip fracture cohort using relevant Current Procedural Terminology codes (27244, 27245, 27269, 27236, or 27248)
* undergoing surgical fixation of hip fractures using either general and/or spinal anesthesia.
* In case of reduced Procedure-Targeted data collection during the COVID-19 pandemic, investigators will also create a total open hip fracture cohort using relevant Current Procedural Terminology codes (27244, 27245, 27269, 27236, or 27248)
Exclusion Criteria
* Primary or secondary anesthetic technique listed as local anesthesia alone, local anesthesia with intravenous sedation, epidural, and those with no reported anesthesia technique
* American Society of Anesthesiologists (ASA) Physical Status (PS) V (defined as "5-Moribund"), and
* Ventilator-dependence preoperatively.
* Platelet counts less than 80,000/mm3 within 90 days before surgery,
* International normalized ratio (INR) greater than or equal to 1.5, or
* Partial thromboplastin time (PTT) greater than 35 seconds (likelihood of being ineligible for SA)
* American Society of Anesthesiologists (ASA) Physical Status (PS) V (defined as "5-Moribund"), and
* Ventilator-dependence preoperatively.
* Platelet counts less than 80,000/mm3 within 90 days before surgery,
* International normalized ratio (INR) greater than or equal to 1.5, or
* Partial thromboplastin time (PTT) greater than 35 seconds (likelihood of being ineligible for SA)
Minimum Eligible Age
19 Years
Eligible Sex
ALL
Accepts Healthy Volunteers
Yes
Sponsors
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University of British Columbia
OTHER
Sponsor Role
lead
Responsible Party
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Janny Ke
Clinical Assistant Professor
Responsibility Role
PRINCIPAL_INVESTIGATOR
Principal Investigators
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Janny Xue Chen Ke, MD
Role: PRINCIPAL_INVESTIGATOR
University of British Columbia
Locations
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St. Paul's Hospital
Vancouver, British Columbia, Canada
Site Status
Countries
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Canada
References
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Hu F, Jiang C, Shen J, Tang P, Wang Y. Preoperative predictors for mortality following hip fracture surgery: a systematic review and meta-analysis. Injury. 2012 Jun;43(6):676-85. doi: 10.1016/j.injury.2011.05.017. Epub 2011 Jun 17.
Reference Type
BACKGROUND
Panula J, Pihlajamaki H, Mattila VM, Jaatinen P, Vahlberg T, Aarnio P, Kivela SL. Mortality and cause of death in hip fracture patients aged 65 or older: a population-based study. BMC Musculoskelet Disord. 2011 May 20;12:105. doi: 10.1186/1471-2474-12-105.
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BACKGROUND
Sheikh HQ, Hossain FS, Aqil A, Akinbamijo B, Mushtaq V, Kapoor H. A Comprehensive Analysis of the Causes and Predictors of 30-Day Mortality Following Hip Fracture Surgery. Clin Orthop Surg. 2017 Mar;9(1):10-18. doi: 10.4055/cios.2017.9.1.10. Epub 2017 Feb 13.
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BACKGROUND
De C, Harbham PK, Postoyalko C, Bhavanasi B, Paringe V, Theivendran K. Mortality Following Hip Fracture Surgery During COVID-19 Pandemic Compared to Pre-COVID-19 Period: A Case Matched Cohort Series. Malays Orthop J. 2021 Jul;15(2):107-114. doi: 10.5704/MOJ.2107.016.
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BACKGROUND
Fell A, Malik-Tabassum K, Rickman S, Arealis G. Thirty-day mortality and reliability of Nottingham Hip Fracture Score in patients with COVID19 infection. J Orthop. 2021 Jul-Aug;26:111-114. doi: 10.1016/j.jor.2021.07.009. Epub 2021 Jul 16.
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BACKGROUND
Zamora T, Sandoval F, Demandes H, Serrano J, Gonzalez J, Lira MJ, Klaber I, Carmona M, Botello E, Schweitzer D. Hip Fractures in the Elderly During the COVID-19 Pandemic: A Latin-American Perspective With a Minimum 90-Day Follow-Up. Geriatr Orthop Surg Rehabil. 2021 Jul 9;12:21514593211024509. doi: 10.1177/21514593211024509. eCollection 2021.
Reference Type
BACKGROUND
Cuthbert R, Ferguson D, Kayani B, Haque S, Ali A, Parkar A, Bates P, Vemulapalli K. Evidence-based approach to providing informed consent for hip fracture surgery during the COVID-19 era. World J Orthop. 2021 Jun 18;12(6):386-394. doi: 10.5312/wjo.v12.i6.386. eCollection 2021 Jun 18.
Reference Type
BACKGROUND
Kumar A, Haider Y, Passey J, Khan R, Gaba S, Kumar M. Mortality Predictors in Covid-19 Positive Patients with Fractures: A Systematic Review. Bull Emerg Trauma. 2021 Apr;9(2):51-59. doi: 10.30476/BEAT.2021.87742.
Reference Type
BACKGROUND
Grassi A, Andriolo L, Golinelli D, Tedesco D, Rosa S, Gramegna P, Ciaffi J, Meliconi R, Landini MP, Filardo G, Fantini MP, Zaffagnini S. Higher 90-Day Mortality after Surgery for Hip Fractures in Patients with COVID-19: A Case-Control Study from a Single Center in Italy. Int J Environ Res Public Health. 2021 May 13;18(10):5205. doi: 10.3390/ijerph18105205.
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BACKGROUND
Balakumar B, Nandra RS, Woffenden H, Atkin B, Mahmood A, Cooper G, Cooper J, Hindle P. Mortality risk of surgically managing orthopaedic trauma during the COVID-19 pandemic. Bone Jt Open. 2021 May;2(5):330-336. doi: 10.1302/2633-1462.25.BJO-2020-0189.R1.
Reference Type
BACKGROUND
Alcock H, Moppett EA, Moppett IK. Early mortality outcomes of patients with fragility hip fracture and concurrent SARS-CoV-2 infection : a systematic review and meta-analysis. Bone Jt Open. 2021 May;2(5):314-322. doi: 10.1302/2633-1462.25.BJO-2020-0183.R1.
Reference Type
BACKGROUND
Lim MA, Pranata R. Coronavirus disease 2019 (COVID-19) markedly increased mortality in patients with hip fracture - A systematic review and meta-analysis. J Clin Orthop Trauma. 2021 Jan;12(1):187-193. doi: 10.1016/j.jcot.2020.09.015. Epub 2020 Sep 17.
Reference Type
BACKGROUND
Mittal R, Banerjee S. Proximal femoral fractures: Principles of management and review of literature. J Clin Orthop Trauma. 2012 Jun;3(1):15-23. doi: 10.1016/j.jcot.2012.04.001. Epub 2012 Jun 16.
Reference Type
BACKGROUND
Griffiths R, Babu S, Dixon P, Freeman N, Hurford D, Kelleher E, Moppett I, Ray D, Sahota O, Shields M, White S. Guideline for the management of hip fractures 2020: Guideline by the Association of Anaesthetists. Anaesthesia. 2021 Feb;76(2):225-237. doi: 10.1111/anae.15291. Epub 2020 Dec 2.
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BACKGROUND
Jakobsson J, Johnson MZ. Perioperative regional anaesthesia and postoperative longer-term outcomes. F1000Res. 2016 Oct 11;5:F1000 Faculty Rev-2501. doi: 10.12688/f1000research.9100.1. eCollection 2016.
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Capdevila X, Moulard S, Plasse C, Peshaud JL, Molinari N, Dadure C, Bringuier S. Effectiveness of Epidural Analgesia, Continuous Surgical Site Analgesia, and Patient-Controlled Analgesic Morphine for Postoperative Pain Management and Hyperalgesia, Rehabilitation, and Health-Related Quality of Life After Open Nephrectomy: A Prospective, Randomized, Controlled Study. Anesth Analg. 2017 Jan;124(1):336-345. doi: 10.1213/ANE.0000000000001688.
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Wignall A, Giannoudis V, De C, Jimenez A, Sturdee S, Nisar S, Pandit H, Gulati A, Palan J. The impact of COVID-19 on the management and outcomes of patients with proximal femoral fractures: a multi-centre study of 580 patients. J Orthop Surg Res. 2021 Feb 24;16(1):155. doi: 10.1186/s13018-021-02301-z.
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Cappelleri G, Fanelli A, Ghisi D, Russo G, Giorgi A, Torrano V, Lo Bianco G, Salomone S, Fumagalli R. The Role of Regional Anesthesia During the SARS-CoV2 Pandemic: Appraisal of Clinical, Pharmacological and Organizational Aspects. Front Pharmacol. 2021 Jun 4;12:574091. doi: 10.3389/fphar.2021.574091. eCollection 2021.
Reference Type
BACKGROUND
Maxwell BG, Spitz W, Porter J. Association of Increasing Use of Spinal Anesthesia in Hip Fracture Repair With Treating an Aging Patient Population. JAMA Surg. 2020 Feb 1;155(2):167-168. doi: 10.1001/jamasurg.2019.4471.
Reference Type
BACKGROUND
van Veen JJ, Nokes TJ, Makris M. The risk of spinal haematoma following neuraxial anaesthesia or lumbar puncture in thrombocytopenic individuals. Br J Haematol. 2010 Jan;148(1):15-25. doi: 10.1111/j.1365-2141.2009.07899.x. Epub 2009 Sep 22.
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BACKGROUND
Gulur P, Tsui B, Pathak R, Koury KM, Lee H. Retrospective analysis of the incidence of epidural haematoma in patients with epidural catheters and abnormal coagulation parameters. Br J Anaesth. 2015 May;114(5):808-11. doi: 10.1093/bja/aeu461. Epub 2015 Jan 22.
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BACKGROUND
Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT, Brown DL, Heit JA, Mulroy MF, Rosenquist RW, Tryba M, Yuan CS. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010 Jan-Feb;35(1):64-101. doi: 10.1097/aap.0b013e3181c15c70.
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BACKGROUND
COVIDSurg Collaborative; GlobalSurg Collaborative. Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study. Anaesthesia. 2021 Jun;76(6):748-758. doi: 10.1111/anae.15458. Epub 2021 Mar 9.
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Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, Kusek JW, Eggers P, Van Lente F, Greene T, Coresh J; CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009 May 5;150(9):604-12. doi: 10.7326/0003-4819-150-9-200905050-00006.
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Bujang MA, Sa'at N, Sidik TMITAB, Joo LC. Sample Size Guidelines for Logistic Regression from Observational Studies with Large Population: Emphasis on the Accuracy Between Statistics and Parameters Based on Real Life Clinical Data. Malays J Med Sci. 2018 Jul;25(4):122-130. doi: 10.21315/mjms2018.25.4.12. Epub 2018 Aug 30.
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BACKGROUND
Nourouzpour N, Jen TTH, Bailey J, Jobin PG, Sutherland JM, Ho CM, Prabhakar C, Ke JXC. Association between anesthesia technique and death after hip fracture repair for patients with COVID-19. Can J Anaesth. 2024 Mar;71(3):367-377. doi: 10.1007/s12630-023-02673-2. Epub 2023 Dec 21.
Reference Type
DERIVED
Provided Documents
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Document Type: Study Protocol and Statistical Analysis Plan
Other Identifiers
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H22-03212
Identifier Type: -
Identifier Source: org_study_id
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