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Published on: May 26, 2023
Monitored Anesthesia Care-Soft Tissue Infiltration With Local Anesthesia (MAC-STILA) Decreases Incidence of
Nina D Fisher1, Matthew T Kingery1, Lauren Merrell1
1Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY.
Objective:
To determine whether the occurrence of short-term postoperative altered mental status (AMS) was lower in geriatric patients undergoing operative repair of hip fractures with Monitored Anesthesia Care and Soft Tissue Infiltration with Local Anesthesia (MAC-STILA) when compared with those undergoing operative repair of hip fractures with general anesthesia (GA).
Design:
Retrospective cohort study.
Setting:
Two US hospitals within a single academic medical center.
Patient Selection Criteria:
Geriatric patients with hip fractures (AO/OTA 31A and 31B) undergoing operative repair were identified. Propensity matching was performed in a 1:2 ratio to minimize selection bias (age, sex, body mass index, American Society of Anesthesiology class, fracture pattern, fixation construct, preinjury ambulatory status, and assistive device use).
Outcome Measures:
Patients who underwent surgical fixation with MAC-STILA were compared with those who underwent surgical fixation with GA. Primary outcome was postoperative AMS, defined as missing ≥1 items on the alert and oriented assessment (person, place, and time) at any point from postoperative days 0-3.
Results:
After matching, 228 patients (76 MAC-STILA: 152 GA) were included in the analysis. The average age of patients in both groups was 83 years. In the MAC-STILA group, 62% were women and 33% had baseline dementia, while in the GA group 66% were women and 29% had baseline dementia. Treating patients with MAC-STILA was associated with 72% lower odds of having AMS than treating patients with GA, controlling for baseline comorbidity and dementia (odds ratio: 0.28. 95% confidence interval: 0.09-0.075, P = 0.016). Among patients with baseline dementia, the rate of AMS was lower in patients treated with MAC-STILA than in patients treated with GA (64.0% vs. 95.3%, P = 0.001).
Conclusions:
MAC-STILA was associated with lower odds of short-term postoperative AMS than GA in patients with hip fracture undergoing operative repair. Given the high rate of postoperative AMS and complications associated with a geriatric patient with hip fracture, MAC-STILA should be considered for use in patients with increased risk of postoperative AMS, particularly in the setting of preoperative dementia.
Level Of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Insights
Monitored Anesthesia Care and Soft Tissue Infiltration with Local Anesthesia (MAC-STILA) significantly reduced postoperative altered mental status (AMS) in geriatric hip fracture patients compared to general anesthesia (GA). This approach is particularly beneficial for patients with preoperative dementia.
Area of Science:
- Geriatric Anesthesiology
- Orthopedic Surgery
- Neuroscience
Background:
- Geriatric hip fracture patients are at high risk for postoperative altered mental status (AMS).
- General anesthesia (GA) is a common anesthetic technique for hip fracture repair.
- Short-term postoperative AMS can lead to significant complications in elderly patients.
Purpose of the Study:
- To compare the incidence of short-term postoperative AMS in geriatric hip fracture patients undergoing repair with Monitored Anesthesia Care and Soft Tissue Infiltration with Local Anesthesia (MAC-STILA) versus general anesthesia (GA).
Main Methods:
- Retrospective cohort study involving geriatric patients with hip fractures (AO/OTA 31A and 31B).
- Propensity matching (1:2 ratio) was used to minimize selection bias.
- Primary outcome was postoperative AMS, defined as failure to correctly identify person, place, and time on postoperative days 0-3.
Main Results:
- After matching, 228 patients (76 MAC-STILA, 152 GA) were analyzed.
- MAC-STILA was associated with 72% lower odds of postoperative AMS compared to GA (OR: 0.28, P = 0.016).
- In patients with baseline dementia, MAC-STILA showed a significantly lower rate of AMS (64.0% vs. 95.3%, P = 0.001).
Conclusions:
- Monitored Anesthesia Care and Soft Tissue Infiltration with Local Anesthesia (MAC-STILA) is associated with reduced short-term postoperative altered mental status (AMS) compared to general anesthesia (GA) in geriatric hip fracture patients.
- MAC-STILA should be considered for patients at increased risk of postoperative AMS, especially those with preoperative dementia.
- This anesthetic approach may help mitigate serious complications associated with postoperative AMS in this vulnerable population.
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