Response to Xue and Colleagues

To the Editor: We thank Dr. Xue et al.1 for their interest in our article and appreciate the opportunity to respond to their questions regarding our study.2 Individuals with dementia are frequently excluded from surgical clinical trials. Observational studies such as ours provide important information for clinicians about the effect of anesthesia on early postoperative outcomes that would otherwise be unavailable. In response to the specific questions that Xue and colleagues raise, we would like first to address the questions regarding blood transfusions and acute kidney injury. Previous meta-analyses of randomized controlled trials have failed to find a significant difference in the risk of red blood cell transfusions or acute kidney injury associated with anesthetic technique for hip fracture surgery.3, 4 Therefore, although both of these adverse outcomes after hip fracture are potentially important, it was decided not to include them in the analysis. Functional status preceding surgery is a known risk factor for poor postoperative outcomes after hip fracture surgery.5, 6 Most administrative databases, including the ones used for the current study, do not contain detailed measures of functional impairment. A previous study that examined the effect of functional impairment measures on predicting hip fracture outcomes found that measures of functional impairment can improve prediction of adverse outcomes after hip fracture surgery but that the magnitude of improved predictive ability is less than in a model that includes only age, sex, and medical comorbidities.5 Therefore, although there may have been confounding due to unmeasured functional impairment in our study, functional impairment is unlikely to have had a significant effect on outcomes observed in our study.2 It was hypothesized that anesthetic technique might lead to some intraoperative complications that Xue and colleagues mentioned (e.g., hypotension, hypoxemia), which would then act as mediators of major postoperative complications such as mortality and intensive care unit admission. Therefore, adjusting for these intraoperative complications, which are in the causal pathway between anesthesia and outcomes, would obscure any associations between anesthetic technique and major early postoperative outcomes, which was the focus of our study.2 Although Xue and colleagues raised several important points regarding our study, the results of the study are valid, and there appears to be little difference in early major postoperative adverse outcomes associated between general anesthesia and regional anesthesia in older adults with dementia undergoing hip fracture surgery.

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