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Barnwell N, Padfield K. Ultra-low-dose spinal anaesthesia for elective hip arthroplasty in a patient with severe pulmonary hypertension. Anaesth Rep 2020; 8:116-119. [PMID: 33313508 DOI: 10.1002/anr3.12067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2020] [Indexed: 11/08/2022] Open
Abstract
Pulmonary hypertension is a complex chronic cardiopulmonary disease. The condition is an independent risk-factor for peri-operative morbidity and mortality in patients undergoing non-cardiac surgery, with mortality rates of up to 18%. Due to this, patients with pulmonary hypertension are frequently counselled against undergoing all but essential surgery. In this report, we describe the use of ultra-low-dose spinal anaesthetic delivered via intrathecal catheter to allow a patient with severe pulmonary hypertension to safely undergo an elective primary hip arthroplasty for osteoarthritis which was causing intolerable pain. The use of an intrathecal catheter avoided general anaesthesia in a patient who may not have tolerated positive pressure ventilation. The technique also allowed the use of ultra-low doses of spinal anaesthesia, with the option of titrating to effect and duration of surgery. Invasive monitoring allowed proactive management of the haemodynamic effects of neuraxial anaesthesia, specifically the fall in systemic vascular resistance that may be associated with higher doses of spinal anaesthesia. While this report describes a patient with severe pulmonary hypertension, the technique may also be considered for patients with other obstructive cardiac lesions including severe aortic or mitral stenosis.
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Affiliation(s)
- N Barnwell
- Department of Anaesthesia Mater Misericordiae University Hospital Dublin Ireland
| | - K Padfield
- Department of Anaesthesia Mater Misericordiae University Hospital Dublin Ireland
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52
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Mostafa M, Hasanin A, Mostafa M, Taha MY, Elsayad M, Haggag FA, Taalab O, Rady A, Abdelhamid B. Hemodynamic effects of norepinephrine versus phenylephrine infusion for prophylaxis against spinal anesthesia-induced hypotension in the elderly population undergoing hip fracture surgery: a randomized controlled trial. Korean J Anesthesiol 2020; 74:308-316. [PMID: 33121228 PMCID: PMC8342837 DOI: 10.4097/kja.20519] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/29/2020] [Indexed: 11/10/2022] Open
Abstract
Background Elderly population are at increased risk of spinal anesthesia-induced hypotension increasing their risk for postoperative morbidity and mortality. This study aimed to compare the hemodynamic effects of prophylactic infusion of norepinephrine (NE) versus phenylephrine (PE) in elderly patients undergoing hip fracture surgery under spinal anesthesia. Methods Elderly patients scheduled for hip fracture surgery were randomized to receive either NE infusion (8 µg/min) (NE group, n = 31) or PE infusion (100 µg/min) (PE group, n = 31) after spinal anesthesia. Outcomes included mean heart rate, mean blood pressure, cardiac output, incidence of spinal anesthesia-induced hypotension, incidence of bradycardia, and incidence of hypertension. Results Sixty-two patients with a mean age of 71 ± 6 years were included in the final analysis (31 patients in each group). The NE group showed a higher mean heart rate and cardiac output than the PE group. The NE group had a lower incidence of reactive bradycardia (10% vs. 36%, P = 0.031) and hypertension (3% vs. 36%, P = 0.003) than the PE group. No study participant developed hypotension, and the mean blood pressure was comparable between the two groups. Conclusions Both NE and PE infusions effectively prevented spinal anesthesia-induced hypotension in elderly patients undergoing hip fracture surgery. However, NE provided more hemodynamic stability than PE; maintaining the heart rate, higher cardiac output, less reactive bradycardia, and hypertension.
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Affiliation(s)
- Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mahmoud Mostafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mai Y Taha
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Elsayad
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | | | - Omar Taalab
- Department of Orthopedic Surgery, Cairo University, Cairo, Egypt
| | - Ashraf Rady
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Bassant Abdelhamid
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
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53
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Yoo S, Jang EJ, Jo J, Jo JG, Nam S, Kim H, Lee H, Ryu HG. The association between hospital case volume and in-hospital and one-year mortality after hip fracture surgery. Bone Joint J 2020; 102-B:1384-1391. [DOI: 10.1302/0301-620x.102b10.bjj-2019-1728.r3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Aims Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery. Methods Data for all patients who underwent surgery for hip fracture from January 2008 to December 2016 were extracted from the Korean National Healthcare Insurance Service database. According to mean annual case volume of surgery for hip fracture, hospitals were classified into very low (< 30 cases/year), low (30 to 50 cases/year), intermediate (50 to 100 cases/year), high (100 to 150 cases/year), or very high (> 150 cases/year) groups. The association between hospital case volume and in-hospital mortality or one-year mortality was assessed using the logistic regression model to adjust for age, sex, type of fracture, type of anaesthesia, transfusion, comorbidities, and year of surgery. Results Between January 2008 and December 2016, 269,535 patients underwent hip fracture surgery in 1,567 hospitals in Korea. Compared to hospitals with very high volume, in-hospital mortality rates were significantly higher in those with high volume (odds ratio (OR) 1.10, 95% confidence interval ((CI) 1.02 to 1.17, p = 0.011), low volume (OR 1.22, 95% CI 1.14 to 1.32, p < 0.001), and very low volume (OR 1.25, 95% CI 1.16 to 1.34, p < 0.001). Similarly, hospitals with lower case volume showed higher one-year mortality rates compared to hospitals with very high case volume (low volume group, OR 1.15, 95% CI 1.11 to 1.19, p < 0.001; very low volume group, OR 1.10, 95% CI 1.07 to 1.14, p < 0.001). Conclusion Higher hospital case volume of hip fracture surgery was associated with lower in-hospital mortality and one-year mortality in a dose-response fashion. Cite this article: Bone Joint J 2020;102-B(10):1384–1391.
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Affiliation(s)
- Seokha Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Eun Jin Jang
- Department of Information Statistics, Andong National University, Andong, Gyeongsangbuk-do, South Korea
| | - Junwoo Jo
- Department of Statistics, Kyungpook National University, Daegu, South Korea
| | - Jun Gi Jo
- Department of Statistics, Kyungpook National University, Daegu, South Korea
| | - Seungpyo Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Hansol Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Hannah Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Ho Geol Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
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54
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Ojeda-Thies C, Brent L, Currie CT, Costa M. Fragility Fracture Audit. ACTA ACUST UNITED AC 2020. [DOI: 10.1007/978-3-030-48126-1_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
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55
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Rinehart J, Lee S, Saugel B, Joosten A. Automated Blood Pressure Control. Semin Respir Crit Care Med 2020; 42:47-58. [PMID: 32746471 DOI: 10.1055/s-0040-1713083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Arterial pressure management is a crucial task in the operating room and intensive care unit. In high-risk surgical and in critically ill patients, sustained hypotension is managed with continuous infusion of vasopressor agents, which most commonly have direct α agonist activity like phenylephrine or norepinephrine. The current standard of care to guide vasopressor infusion is manual titration to an arterial pressure target range. This approach may be improved by using automated systems that titrate vasopressor infusions to maintain a target pressure. In this article, we review the evidence behind blood pressure management in the operating room and intensive care unit and discuss current and potential future applications of automated blood pressure control.
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Affiliation(s)
- Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California
| | - Sean Lee
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Outcomes Research Consortium, Cleveland, Ohio
| | - Alexandre Joosten
- Department of Anesthesiology, Erasme Hospital, Brussels, Belgium.,Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital De Bicêtre, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
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56
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Morley RL, Elliott L, Rees J, Rudd S, Mouton R, Hinchliffe RJ. Scoping review of mode of anaesthesia in emergency surgery. Br J Surg 2020; 107:e17-e25. [PMID: 31903585 DOI: 10.1002/bjs.11424] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/03/2019] [Accepted: 10/10/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Emergency surgery encompasses more than 50 per cent of the surgical workload; however, research efforts are disproportionally low. The mode of anaesthesia used during emergency surgery may affect outcomes, but the extent of research and the impact of the different modes of anaesthesia used are unclear. METHODS MEDLINE and Embase were searched using scoping review methodology with a rapid systematic search strategy, identifying any study comparing locoregional (local, nerve block, subarachnoid, epidural) anaesthesia with general anaesthesia. All studies describing outcomes of emergency surgery with differing modes of anaesthesia were identified. Excluded were: studies published before 2003, studies enrolling patients aged less than 18 years and studies using sedation only. RESULTS Forty-two studies were identified, describing 11 surgical procedures. Most publications were retrospective cohort studies (32). A very broad range of clinical and patient-reported outcomes were described, with wide variation in the outcomes reported in different studies. CONCLUSION Reporting of mode of anaesthesia is inconsistent across different procedures and is often absent. There is a need for directed research efforts to improve the reporting standards of anaesthesia interventions, to understand the role of different modes of anaesthesia in specific emergency surgical procedures, and to standardize outcome reporting using core outcome sets.
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Affiliation(s)
- R L Morley
- Centre for Surgical Research, University of Bristol, Bristol, UK.,Vascular Surgery, Bristol, UK
| | - L Elliott
- Centre for Surgical Research, University of Bristol, Bristol, UK.,General Surgery, University Hospital Bristol NHS Foundation Trust, Bristol, UK
| | - J Rees
- Centre for Surgical Research, University of Bristol, Bristol, UK.,General Surgery, University Hospital Bristol NHS Foundation Trust, Bristol, UK
| | - S Rudd
- Library and Knowledge Service, Bristol, UK
| | - R Mouton
- Anaesthesia, North Bristol NHS Trust, Bristol, UK
| | - R J Hinchliffe
- Centre for Surgical Research, University of Bristol, Bristol, UK.,Vascular Surgery, Bristol, UK
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57
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Olsen F, Hård Af Segerstad M, Nellgård B, Houltz E, Ricksten SE. The role of bone cement for the development of intraoperative hypotension and hypoxia and its impact on mortality in hemiarthroplasty for femoral neck fractures. Acta Orthop 2020; 91:293-298. [PMID: 32237931 PMCID: PMC8023921 DOI: 10.1080/17453674.2020.1745510] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The bone cement implantation syndrome characterized by hypotension and/or hypoxia is a well-known complication in cemented arthroplasty. We studied the incidence of hypotension and/or hypoxia in patients undergoing cemented or uncemented hemiarthroplasty for femoral neck fractures and evaluated whether bone cement was an independent risk factor for postoperative mortality.Patients and methods - In this retrospective cohort study, 1,095 patients from 2 hospitals undergoing hemiarthroplasty with (n = 986) and without (n = 109) bone cementation were included. Pre-, intra-, and postoperative data were obtained from electronic medical records. Each patient was classified for grade of hypotension and hypoxia during and after prosthesis insertion according to Donaldson's criteria (Grade 1, 2, 3). After adjustments for confounders, the hazard ratio (HR) for the use of bone cement on 1-year mortality was assessed.Results - The incidence of hypoxia and/or hypotension was higher in the cemented (28%) compared with the uncemented group (17%) (p = 0.003). The incidence of severe hypotension/hypoxia (grade 2 or 3) was 6.9% in the cemented, but not observed in the uncemented group. The use of bone cement was an independent risk factor for 1-year mortality (HR 1.9, 95% CI 1.3-2.7), when adjusted for confounders.Interpretation - The use of bone cement in hemiarthroplasty for femoral neck fractures increases the incidence of intraoperative hypoxia and/or hypotension and is an independent risk factor for postoperative 1-year mortality. Efforts should be made to identify patients at risk for BCIS and alternative strategies for the management of these patients should be considered.
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Affiliation(s)
- Fredrik Olsen
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mathias Hård Af Segerstad
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bengt Nellgård
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Erik Houltz
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden,Correspondence:
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58
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Shelton C, White S. Anaesthesia for hip fracture repair. BJA Educ 2020; 20:142-149. [PMID: 33456943 PMCID: PMC7808106 DOI: 10.1016/j.bjae.2020.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 01/24/2020] [Accepted: 02/04/2020] [Indexed: 01/13/2023] Open
Affiliation(s)
- C. Shelton
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Lancaster Medical School, Lancaster University, Lancaster, UK
| | - S. White
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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59
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Diakomi M, Papaioannou M, Georgoudis G, Argyra E, Mela A, Siafaka I, Makris A. The impact of fascia iliaca compartment block on chronic postsurgical pain in patients undergoing hip fracture repair. J Clin Anesth 2020; 64:109801. [PMID: 32334292 DOI: 10.1016/j.jclinane.2020.109801] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 02/12/2020] [Accepted: 04/04/2020] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE Chronic postsurgical pain (CPSP), i.e. pain persisting >3 months, may appear after any type of surgery. There is a paucity of literature addressing CPSP development after hip fracture repair and the impact of any analgesic intervention on the development of CPSP in patients after hip fracture surgery. This study is the first aiming to examine the impact of ultrasound-guided fascia iliaca compartment block (USG FICB) on the development of CPSP after hip fracture repair. DESIGN Prospective randomized study. SETTING Operating room. PATIENTS 182 patients scheduled for hip fracture surgery. INTERVENTIONS Patients were randomized to receive a USG FICB (FICB group) or a sham saline injection (sham FICB group), twenty minutes before positioning for spinal anesthesia. MEASUREMENTS The hip - related characteristic pain intensity (CPI) at 3- months post-surgery was the primary outcome measure. Presence and severity of hip-related pain at 3- and 6-months post-surgery, numeric rating pain scale (NRS) scores at 6, 24, 36, 48 postoperative hours, total 24-hour tramadol PCA administration and timing of the first tramadol dose, were documented as well. MAIN RESULTS FICB group presented with lower CPI scores 3- months postoperatively (p < 0.01), as well as lower percentage of patients with high-grade CPSP, 3 and 6 months postoperatively (p < 0.001). FICB group also showed significantly lower NRS scores in all instances, lower total 24 - hour tramadol consumption and higher mean time to first tramadol dose (p < 0.05). The overall sample of 182 patients reported a considerably high incidence of hip -related CPSP (60% at 3 months, 45% at 6 months). CONCLUSIONS USG FICB in the perioperative setting may reduce the incidence, intensity and severity of CPSP at 3 and 6 months after hip fracture surgery, providing safe and effective postoperative analgesia.
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Affiliation(s)
- Maria Diakomi
- Department of Anesthesiology, Asklepieion Hospital of Voula, Athens, Greece
| | | | | | - Erifili Argyra
- Department of Anesthesiology, Aretaieion University Hospital, Athens, Greece
| | - Argyro Mela
- Department of Anesthesiology, Asklepieion Hospital of Voula, Athens, Greece
| | - Ioanna Siafaka
- Department of Anesthesiology, Aretaieion University Hospital, Athens, Greece
| | - Alexandros Makris
- Department of Anesthesiology, Asklepieion Hospital of Voula, Athens, Greece.
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60
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Beecham G, Cusack R, Vencken S, Crilly G, Buggy DJ. Hypotension during hip fracture surgery and postoperative morbidity. Ir J Med Sci 2020; 189:1087-1096. [PMID: 32056158 PMCID: PMC7363730 DOI: 10.1007/s11845-020-02175-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/20/2020] [Indexed: 11/29/2022]
Abstract
Background Hip fracture is a growing healthcare challenge, with 6–8% 30-day mortality and 20–30% of patients incurring major morbidity, including impaired mobilisation and ability to live independently. While observational studies have shown no benefit of general versus spinal anaesthesia on 30-day mortality, intraoperative hypotension during hip fracture surgery is associated with increased 30-day mortality regardless of anaesthetic technique. Although a recent trial on younger patients demonstrated reduced postoperative complications by maintaining intraoperative arterial blood pressure close to preoperative baseline, there are no data correlating intraoperative hypotension during hip fracture surgery with postoperative morbidity. Objective We evaluated the hypothesis that duration and severity of intraoperative hypotension during hip fracture surgery is associated with increased postoperative morbidity. Methods A retrospective analysis was carried out on n = 52 patients undergoing hip fracture surgery between January and June 2017. Measurements of patients’ intraoperative systolic arterial pressure (SAP) and mean arterial pressure (MAP) during anaesthesia, logged electronically through an anaesthesia information management system, were reviewed. We calculated the total duration of time where SAP or MAP were below pre-defined thresholds for hypotension (MAP < 75 mmHg, MAP < 55 mmHg, SAP ≤ 80% admission baseline or SAP ≤ 80% pre-induction baseline). Univariate and bivariate descriptive statistics were generated for all relevant variables. With multivariable regression models containing known predictors, cumulative duration of hypotension was correlated with postoperative comorbidities as quantified by the Clavien-Dindo and Comprehensive Complication Indices. Results Mean age (± SD) was 78 ± 13 years, 75% were female, 87% were ASA II or III and 60% underwent spinal anaesthesia. Mean Comprehensive Complication Index was 20.4 ± 19.2. Lowest absolute SAP and MAP values were 82 ± 18 mmHg and 55 ± 12 mmHg respectively. Cumulative time of SAP < 80% pre-induction value adjusted to gender, age and the Charlson Comorbidity Index was associated with progression to a higher Clavien-Dindo classification (odds ratio 1.020 per additional minute; 95% CI 1.008–1.035; P = 0.003). Conclusions In this exploratory retrospective analysis, the cumulative time of hypotension during hip fracture surgery correlated with extensive postoperative morbidity when adjusting to other known predictors. Intraoperative cumulative time of hypotension may be a good candidate for larger prediction studies as a predictor of postoperative complications. A randomised controlled trial evaluating the effect of actively minimising intraoperative hypotension on postoperative morbidity in hip fracture patients seems warranted.
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Affiliation(s)
- Gabriel Beecham
- Department of Anaesthesiology & Perioperative Medicine, Mater Misericordiae University Hospital, Dublin, Ireland and School of Medicine, University College Dublin, Dublin, Ireland
| | - Rachael Cusack
- Department of Anaesthesiology & Perioperative Medicine, Mater Misericordiae University Hospital, Dublin, Ireland and School of Medicine, University College Dublin, Dublin, Ireland.
| | - Sebastian Vencken
- Clinical Research Centre, School of Medicine, University College Dublin, Dublin, Ireland
| | - Grace Crilly
- Department of Anaesthesiology & Perioperative Medicine, Mater Misericordiae University Hospital, Dublin, Ireland and School of Medicine, University College Dublin, Dublin, Ireland
| | - Donal J Buggy
- Department of Anaesthesiology & Perioperative Medicine, Mater Misericordiae University Hospital, Dublin, Ireland and School of Medicine, University College Dublin, Dublin, Ireland.,Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
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61
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Wiles MD. Is blood pressure maintenance more important than type of anaesthesia for patients undergoing mechanical thrombectomy after ischaemic stoke? Anaesthesia 2020; 75:716-719. [DOI: 10.1111/anae.14974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2019] [Indexed: 12/25/2022]
Affiliation(s)
- M. D. Wiles
- Department of Anaesthesia and Operating Services Sheffield Teaching Hospitals NHS Foundation Trust Sheffield UK
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62
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White SM, Griffiths R. Problems defining ‘hypotension’ in hip fracture anaesthesia. Br J Anaesth 2019; 123:e528-e529. [DOI: 10.1016/j.bja.2019.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/14/2019] [Accepted: 09/03/2019] [Indexed: 02/05/2023] Open
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63
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Radinovic K, Markovic Denic L, Milan Z, Cirkovic A, Baralic M, Bumbasirevic V. Impact of intraoperative blood pressure, blood pressure fluctuation, and pulse pressure on postoperative delirium in elderly patients with hip fracture: A prospective cohort study. Injury 2019; 50:1558-1564. [PMID: 31279476 DOI: 10.1016/j.injury.2019.06.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 05/18/2019] [Accepted: 06/24/2019] [Indexed: 02/02/2023]
Abstract
AIM Postoperative delirium (PD) is a frequent complication of hip fracture surgery, but its pathophysiology remains poorly understood. We investigated the impact of a single episode of intraoperative hyper/hypotension, blood pressure (BP) fluctuation (ΔMAP), and pulse pressure (PP) on hyper/hypoactive PD in elderly patients undergoing surgery for hip fracture. We also assessed the effect of PD on clinical outcomes. METHODS This was a prospective 1-year follow-up study of patients over 60 years of age with a primary diagnosis of acute low-energy hip fracture. Perioperative delirium was assessed using the Confusion Assessment Method (CAM); the development of PD and the type, hyperactive or hypoactive PD, were recorded. Cognitive assessment was evaluated using the Short Portable Mental Status Questionnaire (SPMSQ). The lowest and highest BP values were extracted from the patients' anaesthesia charts. Postoperative complications, reinterventions and 1-month mortality were recorded. RESULTS PD occurred in 148 (53%) patients during the first postoperative week, with 75% of the cases diagnosed as hypoactive PD. Patients developing PD of any type were older, had a lower body mass index, higher SPMSQ and Charlson scores, more severe systemic diseases, a lower lowest intraoperative BP, a higher ΔMAP, a lower PP, and a higher postoperative pain score. They also took more drugs and received more blood transfusion intraoperatively. Multivariate logistic regression analyses showed that a higher MAP min had a protective effect on the occurrence of any type of PD, as well as hypoactive and hyperactive. PD had negative effect on outcomes. CONCLUSION Our results provide evidence of an association between maximal hypotension, the lowest intraoperative mean blood pressure (MAP), ΔMAP, PP, and PD. A progressive decrease in MAP during surgery was associated with the increased odds of developing either type of PD.
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Affiliation(s)
| | - Ljiljana Markovic Denic
- Institute of Epidemiology, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Andja Cirkovic
- Institute of Medical Statistics and Medical Informatics, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marko Baralic
- Clinic for Nephrology, Clinical Center of Serbia, Belgrade, Serbia
| | - Vesna Bumbasirevic
- Clinic of Anesthesiology, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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64
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Davies SJ, Yates DR, Wilson RJT, Murphy Z, Gibson A, Allgar V, Collyer T. A randomised trial of non-invasive cardiac output monitoring to guide haemodynamic optimisation in high risk patients undergoing urgent surgical repair of proximal femoral fractures (ClearNOF trial NCT02382185). Perioper Med (Lond) 2019; 8:8. [PMID: 31406569 PMCID: PMC6686254 DOI: 10.1186/s13741-019-0119-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/30/2019] [Indexed: 01/08/2023] Open
Abstract
Background Hip fracture is a procedure with high mortality and complication rates, and there exists a group especially at risk of these outcomes identified by their Nottingham Hip Fracture Score (NHFS). Meta-analysis suggests a possible benefit to this patient group from intravascular volume optimisation. We investigated whether intraoperative fluid and blood pressure optimisation improved complications in this group. Methods Patients with a NHFS ≥ 5 were enrolled into this multicentre observer-blinded randomised control trial. Patients were allocated to either standard care or a combination of fluid optimisation and blood pressure control using a non-invasive system. The primary outcome was the number of patients with one or more complications in each group. Secondary outcomes included hospital length of stay (LOS), incidence of hypotension and fluid and vasopressor usage. Results Forty-six percent of patients in the intervention group suffered one or more complications compared to the 51% in the control group (OR 0.82 (95% CI 0.49–1.36)). Per-protocol analysis improved the OR to 0.73 (95% CI 0.43–1.24). Median LOS was the same between both groups; however, the mean LOS on a per-protocol analysis was longer in the control group compared to the intervention group (23.2 (18.0) days vs. 18.5 (16.5), p = 0.047). Conclusions Haemodynamic optimisation including blood pressure management in high-risk patients undergoing repair of a hip fracture did not result in a statistically significant reduction in complications; however, a potential reduction in length of stay was seen. Trial registration A randomised trial of non-invasive cardiac output monitoring to guide haemodynamic optimisation in high risk patients undergoing urgent surgical repair of proximal femoral fractures (ClearNOF trial NCT02382185).
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Affiliation(s)
- S J Davies
- 1Department of Anaesthesia, Critical Care and Perioperative Medicine, York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE UK
| | - D R Yates
- 1Department of Anaesthesia, Critical Care and Perioperative Medicine, York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE UK
| | - R J T Wilson
- 1Department of Anaesthesia, Critical Care and Perioperative Medicine, York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE UK
| | - Z Murphy
- 1Department of Anaesthesia, Critical Care and Perioperative Medicine, York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE UK
| | - A Gibson
- Clinical Research Network: Yorkshire and Humber, York Teaching Hospitals Foundation Trust, Wigginton Road, York, UK
| | - V Allgar
- 3Hull York Medical School/Department of Health Sciences, University of York, York, UK
| | - T Collyer
- 4Department of Anaesthesia, Critical Care and Perioperative Medicine, Harrogate and District NHS Foundation Trust, Harrogate, UK
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Dooley J, Armstrong RA, Jepson M, Squire Y, Hinchliffe RJ, Mouton R. Qualitative study of clinician and patient perspectives on the mode of anaesthesia for emergency surgery. Br J Surg 2019; 107:e142-e150. [PMID: 31368512 PMCID: PMC6973173 DOI: 10.1002/bjs.11243] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/29/2019] [Accepted: 04/29/2019] [Indexed: 12/23/2022]
Abstract
Background Although delivering a chosen mode of anaesthesia for certain emergency surgery procedures is potentially beneficial to patients, it is a complex intervention to evaluate. This qualitative study explored clinician and patient perspectives about mode of anaesthesia for emergency surgery. Methods Snowball sampling was used to recruit participants from eight National Health Service Trusts that cover the following three emergency surgery settings: ruptured abdominal aortic aneurysms, hip fractures and inguinal hernias. A qualitative researcher conducted interviews with clinicians and patients. Thematic analysis was applied to the interview transcripts. Results Interviews were conducted with 21 anaesthetists, 21 surgeons, 14 operating theatre staff and 23 patients. There were two main themes. The first, impact of mode of anaesthesia in emergency surgery, had four subthemes assessing clinician and patient ideas about: context and the ‘best’ mode of anaesthesia; balance in choosing it over others; change and developments in anaesthesia; and the importance of mode of anaesthesia in emergency surgery. The second, tensions in decision‐making about mode of anaesthesia, comprised four subthemes: clinical autonomy and guidelines in anaesthesia; conforming to norms in mode of anaesthesia; the relationship between expertise, preference and patient involvement; and team dynamics in emergency surgery. The results highlight several interlinking factors affecting decision‐making, including expertise, preference, habit, practicalities, norms and policies. Conclusion There is variation in practice in choosing the mode of anaesthesia for surgery, alongside debate as to whether anaesthetic autonomy is necessary or results in a lack of willingness to change.
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Affiliation(s)
- J Dooley
- Department of Population Health Sciences, Bristol Medical School, Bristol, UK
| | - R A Armstrong
- Anaesthetic Department, Southmead Hospital, Bristol, UK
| | - M Jepson
- Department of Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Y Squire
- Anaesthetic Department, Southmead Hospital, Bristol, UK
| | - R J Hinchliffe
- Bristol Surgical Trials Centre, Bristol Medical School, Bristol, UK
| | - R Mouton
- Anaesthetic Department, Southmead Hospital, Bristol, UK
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66
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Jakobsson J, Kalman SH, Lindeberg-Lindvet M, Bartha E. Is postspinal hypotension a sign of impaired cardiac performance in the elderly? An observational mechanistic study. Br J Anaesth 2019; 119:1178-1185. [PMID: 29040402 DOI: 10.1093/bja/aex274] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2017] [Indexed: 11/13/2022] Open
Abstract
Background We have previously reported that stroke volume is reduced in a majority of elderly patients undergoing surgical repair of hip fracture before and after intrathecal injection of anaesthetic. We aimed to investigate these observations further in a prospective study of elderly patients undergoing elective hip or knee arthroplasty under spinal anaesthesia. Methods Patients ≥65 yr undergoing elective arthroplasty were monitored with LiDCOplus™ preoperatively (baseline), before and continuously for 45 min after spinal anaesthesia. Postspinal hypotension was defined as systolic blood pressure (bp) < 100 mm Hg or > 30% decrease from baseline. Associations between post-spinal hypotension and haemodynamic changes before (i.e. between baseline and before injection) spinal anaesthesia were analysed by logistic regression analysis. Results Twenty patients with a mean age of 74 (range 66-89) yr were included. Stroke volume index decreased by 14% (95% CI 9.3%-19%) before spinal anaesthesia. When patients were categorised according to post-spinal hypotension (Y/N) the patterns of haemodynamic changes differed. In the hypotensive patients, cardiac index progressively decreased whereas it increased initially in the non-hypotensive patients. Reduction of cardiac index from baseline before spinal anaesthesia was associated with increased risk of hypotension: OR 0.79 (95% CI 0.60, 0.91). The predictive value of reduced cardiac index was good (AUC under ROC curve 0.91). Conclusions A decrease in cardiac output from baseline before spinal anaesthesia and an inability to increase it after induction may be important features of postspinal hypotension in elderly patients.
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Affiliation(s)
- J Jakobsson
- Division of Anaesthesia and Intensive Care, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet and Department of Perioperative Medicine.,Intensive Care, Karolinska University Hospital Huddinge, SE-141 86, Stockholm, Sweden
| | - S H Kalman
- Division of Anaesthesia and Intensive Care, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet and Department of Perioperative Medicine.,Intensive Care, Karolinska University Hospital Huddinge, SE-141 86, Stockholm, Sweden
| | - M Lindeberg-Lindvet
- Division of Anaesthesia and Intensive Care, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet and Department of Perioperative Medicine.,Intensive Care, Karolinska University Hospital Huddinge, SE-141 86, Stockholm, Sweden
| | - E Bartha
- Division of Anaesthesia and Intensive Care, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet and Department of Perioperative Medicine.,Intensive Care, Karolinska University Hospital Huddinge, SE-141 86, Stockholm, Sweden
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Abstract
PURPOSE OF REVIEW There is an urge to improve care for patients with hip fracture. The present review will compare the efficacy of spinal versus general anesthesia for patients requiring hip fracture surgery. RECENT FINDINGS The present review gives an overview with particular emphasis on literature published during the past 24 months. SUMMARY So far, no clear evidence form randomized trials exists to identify the best anesthesia technique for hip fracture surgery. However, several large-scale pragmatic trials are ongoing and will provide future guidance.
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White SM, Griffiths R. Anaesthesia type and cement reactions in hip fracture surgery. Anaesthesia 2019; 74:543-544. [PMID: 30847911 DOI: 10.1111/anae.14623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- S M White
- Royal Sussex County Hospital, Brighton, UK
| | - R Griffiths
- Peterborough and Stamford Hospitals NHS Trust, Peterborough, UK
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Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery. Br J Anaesth 2019; 122:563-574. [PMID: 30916004 DOI: 10.1016/j.bja.2019.01.013] [Citation(s) in RCA: 325] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 12/07/2018] [Accepted: 01/09/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Intraoperative mortality is now rare, but death within 30 days of surgery remains surprisingly common. Perioperative myocardial infarction is associated with a remarkably high mortality. There are strong associations between hypotension and myocardial injury, myocardial infarction, renal injury, and death. Perioperative arterial blood pressure management was thus the basis of a Perioperative Quality Initiative consensus-building conference held in London in July 2017. METHODS The meeting featured a modified Delphi process in which groups addressed various aspects of perioperative arterial pressure. RESULTS Three consensus statements on intraoperative blood pressure were established. 1) Intraoperative mean arterial pressures below 60-70 mm Hg are associated with myocardial injury, acute kidney injury, and death. Injury is a function of hypotension severity and duration. 2) For adult non-cardiac surgical patients, there is insufficient evidence to recommend a general upper limit of arterial pressure at which therapy should be initiated, although pressures above 160 mm Hg have been associated with myocardial injury and infarction. 3) During cardiac surgery, intraoperative systolic arterial pressure above 140 mm Hg is associated with increased 30 day mortality. Injury is a function of arterial pressure severity and duration. CONCLUSIONS There is increasing evidence that even brief durations of systolic arterial pressure <100 mm Hg and mean arterial pressure <60-70 mm Hg are harmful during non-cardiac surgery.
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Seidel R, Barbakow E. [Surgical treatment of proximal femoral fractures in high-risk geriatric patients under peripheral regional anesthesia : A clinical case series]. Anaesthesist 2019; 68:108-114. [PMID: 30721327 DOI: 10.1007/s00101-019-0537-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/23/2018] [Accepted: 12/24/2018] [Indexed: 11/30/2022]
Abstract
The authors describe in a clinical case series (n = 7) of older (age 78-95 years) high-risk patients the successful surgical treatment of proximal femoral fractures in a peripheral regional anesthesia technique. After positioning on the non-fractured side, a double injection technique (dual guidance concept: sonography plus nerve stimulation) was chosen. The injections were performed parasacrally (blockade of the sacral plexus under the piriformis muscle) and lumbar-paravertebrally (psoas compartment block and transmuscular quadratus lumborum block). Per block 15 ml ropivacaine 0.5% or 20 ml ropivacaine 0.375% was administered. The total dose of 225 mg ropivacaine was never exceeded. In 5 out of 7 cases a supplemental medication with 2 times 5 μg sufentanil (n = 2) and/or 1-1.5 mg/kg body weight and h propofol (n = 4) was administered with spontaneous breathing. In addition to potential benefits, the authors also discuss limitations of the procedure, for example by the use of oral anticoagulants.
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Affiliation(s)
- R Seidel
- Klinik für Anästhesiologie, HELIOS-Kliniken Schwerin, Wismarsche Straße 393-7, 19049, Schwerin, Deutschland.
| | - E Barbakow
- Klinik für Anästhesiologie, HELIOS-Kliniken Schwerin, Wismarsche Straße 393-7, 19049, Schwerin, Deutschland
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Sieber F, Neufeld KJ, Gottschalk A, Bigelow GE, Oh ES, Rosenberg PB, Mears SC, Stewart KJ, Ouanes JPP, Jaberi M, Hasenboehler EA, Wang NY. Depth of sedation as an interventional target to reduce postoperative delirium: mortality and functional outcomes of the Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients randomised clinical trial. Br J Anaesth 2019; 122:480-489. [PMID: 30857604 DOI: 10.1016/j.bja.2018.12.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 12/12/2018] [Accepted: 12/21/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The Strategy to Reduce the Incidence of Postoperative Delirium in the Elderly trial tested the hypothesis that limiting sedation during spinal anaesthesia decreases in-hospital postoperative delirium after hip fracture repair. This manuscript reports the secondary outcomes of this trial, including mortality and function. METHODS Two hundred patients (≥65 yr) undergoing hip fracture repair with spinal anaesthesia were randomised to heavier [modified Observer's Assessment of Alertness/Sedation score (OAA/S) 0-2] or lighter (OAA/S 3-5) sedation, and were assessed for postoperative delirium. Secondary outcomes included mortality and return to pre-fracture ambulation level at 1 yr. Kaplan-Meier analysis, multivariable Cox proportional hazard model, and logistic regression were used to evaluate intervention effects on mortality and odds of ambulation return. RESULTS One-year mortality was 14% in both groups (log rank P=0.96). Independent risk factors for 1-yr mortality included: Charlson comorbidity index [hazard ratio (HR)=1.23, 95% confidence interval (CI), 1.02-1.49; P=0.03], instrumental activities of daily living [HR=0.74, 95% CI, 0.60-0.91; P=0.005], BMI [HR=0.91, 95% CI 0.84-0.998; P=0.04], and delirium severity [HR=1.20, 95% CI, 1.03-1.41; P=0.02]. Ambulation returned to pre-fracture levels, worsened, or was not obtained in 64%, 30%, and 6% of 1 yr survivors, respectively. Lighter sedation did not improve odds of ambulation return at 1 yr [odds ratio (OR)=0.76, 95% CI, 0.24-2.4; P=0.63]. Independent risk factors for ambulation return included Charlson comorbidity index [OR=0.71, 95% CI, 0.53-0.97; P=0.03] and delirium [OR=0.32, 95% CI, 0.10-0.97; P=0.04]. CONCLUSIONS This study found that in elderly patients having hip fracture surgery with spinal anaesthesia supplemented with propofol sedation, heavier intraoperative sedation was not associated with significant differences in mortality or return to pre-fracture ambulation up to 1 yr after surgery. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT00590707.
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Affiliation(s)
- Frederick Sieber
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.
| | - Karin J Neufeld
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan Gottschalk
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA; Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - George E Bigelow
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, BPRU, JV Brady Behavioral Biology Research Center, Baltimore, MD, USA
| | - Esther S Oh
- Division of Geriatric Medicine and Gerontology, Psychiatry and Behavioral Sciences and Neuropathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul B Rosenberg
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Simon C Mears
- Department of Orthopedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kerry J Stewart
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jean-Pierre P Ouanes
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mahmood Jaberi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Erik A Hasenboehler
- Adult and Trauma Surgery, Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Nae-Yuh Wang
- Departments of Medicine, Johns Hopkins University, Baltimore, MD, USA; Biostatistics, Johns Hopkins University, Baltimore, MD, USA; Epidemiology, Johns Hopkins University, Baltimore, MD, USA
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Yonekura H, Ide K, Onishi Y, Nahara I, Takeda C, Kawakami K. Preoperative Echocardiography for Patients With Hip Fractures Undergoing Surgery. Anesth Analg 2019; 128:213-220. [DOI: 10.1213/ane.0000000000003888] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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O'Donnell C, Black N, McCourt K, McBrien M, Clarke M, Patterson C, Blackwood B, McAuley D, Shields M. Development of a Core Outcome Set for studies evaluating the effects of anaesthesia on perioperative morbidity and mortality following hip fracture surgery. Br J Anaesth 2019; 122:120-130. [DOI: 10.1016/j.bja.2018.08.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 08/02/2018] [Accepted: 08/17/2018] [Indexed: 12/31/2022] Open
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Freundlich R, Boncyk C. Clearly-defined outcomes improve the quality of health outcomes research. Br J Anaesth 2019; 122:14-16. [DOI: 10.1016/j.bja.2018.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 11/02/2018] [Accepted: 11/04/2018] [Indexed: 12/11/2022] Open
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Patel V, Champaneria R, Dretzke J, Yeung J. Effect of regional versus general anaesthesia on postoperative delirium in elderly patients undergoing surgery for hip fracture: a systematic review. BMJ Open 2018; 8:e020757. [PMID: 30518580 PMCID: PMC6286489 DOI: 10.1136/bmjopen-2017-020757] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 10/17/2018] [Accepted: 10/26/2018] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Older patients with hip fractures who are undergoing surgery are at high risk of significant mortality and morbidity including postoperative delirium. It is unclear whether different types of anaesthesia may reduce the incidence of postoperative delirium. This systematic review will investigate the impact of anaesthetic technique on postoperative delirium. Other outcomes included mortality, length of stay, complications and functional outcomes. DESIGN Systematic review of randomised controlled trials and non-randomised controlled studies. DATA SOURCES Bibliographic databases were searched from inception to June 2018. Web of Science and ZETOC databases were searched for conference proceedings. Reference lists of relevant articles were checked, and clinical trial registers were searched to identify ongoing trials. ELIGIBILITY CRITERIA Studies were eligible if general and regional anaesthesia were compared in patients (aged 60 and over) undergoing hip fracture surgery, reporting primary outcome of postoperative delirium and secondary outcomes of mortality, length of hospital stay, adverse events, functional outcomes, discharge location and quality of life. Exclusion criteria were anaesthetic technique or drug not considered current standard practice; patients undergoing hip fracture surgery alongside other surgery and uncontrolled studies. RESULTS One hundred and four studies were included. There was no evidence to suggest that anaesthesia type influences postoperative delirium or mortality. Some studies suggested a small reduction in length of hospital stay with regional anaesthesia. There was some evidence to suggest that respiratory complications and intraoperative hypotension were more common with general anaesthesia. Heterogeneity precluded meta-analysis. All findings were described narratively and data were presented where possible in forest plots for illustrative purposes. CONCLUSIONS While there was no evidence to suggest that anaesthesia types influence postoperative delirium, the evidence base is lacking. There is a need to ascertain the impact of type of anaesthesia on outcomes with an adequately powered, methodologically rigorous study. PROSPERO REGISTRATION NUMBER CRD42015020166.
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Affiliation(s)
- Vanisha Patel
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Rita Champaneria
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Janine Dretzke
- Biostatistics, Evidence Synthesis and Test Evaluation (BESaTE), Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Joyce Yeung
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Anaesthesia and Critical Care, Birmingham Heartlands Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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76
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Moppett IK, White SM, Griffiths R. Standards for hip fracture anaesthesia - a reply. Anaesthesia 2018; 72:407-408. [PMID: 28176310 DOI: 10.1111/anae.13822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- I K Moppett
- University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - S M White
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Kowark A, Adam C, Ahrens J, Bajbouj M, Bollheimer C, Borowski M, Dodel R, Dolch M, Hachenberg T, Henzler D, Hildebrand F, Hilgers RD, Hoeft A, Isfort S, Kienbaum P, Knobe M, Knuefermann P, Kranke P, Laufenberg-Feldmann R, Nau C, Neuman MD, Olotu C, Rex C, Rossaint R, Sanders RD, Schmidt R, Schneider F, Siebert H, Skorning M, Spies C, Vicent O, Wappler F, Wirtz DC, Wittmann M, Zacharowski K, Zarbock A, Coburn M. Improve hip fracture outcome in the elderly patient (iHOPE): a study protocol for a pragmatic, multicentre randomised controlled trial to test the efficacy of spinal versus general anaesthesia. BMJ Open 2018; 8:e023609. [PMID: 30341135 PMCID: PMC6196806 DOI: 10.1136/bmjopen-2018-023609] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/24/2018] [Accepted: 09/12/2018] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Hip fracture surgery is associated with high in-hospital and 30-day mortality rates and serious adverse patient outcomes. Evidence from randomised controlled trials regarding effectiveness of spinal versus general anaesthesia on patient-centred outcomes after hip fracture surgery is sparse. METHODS AND ANALYSIS The iHOPE study is a pragmatic national, multicentre, randomised controlled, open-label clinical trial with a two-arm parallel group design. In total, 1032 patients with hip fracture (>65 years) will be randomised in an intended 1:1 allocation ratio to receive spinal anaesthesia (n=516) or general anaesthesia (n=516). Outcome assessment will occur in a blinded manner after hospital discharge and inhospital. The primary endpoint will be assessed by telephone interview and comprises the time to the first occurring event of the binary composite outcome of all-cause mortality or new-onset serious cardiac and pulmonary complications within 30 postoperative days. In-hospital secondary endpoints, assessed via in-person interviews and medical record review, include mortality, perioperative adverse events, delirium, satisfaction, walking independently, length of hospital stay and discharge destination. Telephone interviews will be performed for long-term endpoints (all-cause mortality, independence in walking, chronic pain, ability to return home cognitive function and overall health and disability) at postoperative day 30±3, 180±45 and 365±60. ETHICS AND DISSEMINATION: iHOPE has been approved by the leading Ethics Committee of the Medical Faculty of the RWTH Aachen University on 14 March 2018 (EK 022/18). Approval from all other involved local Ethical Committees was subsequently requested and obtained. Study started in April 2018 with a total recruitment period of 24 months. iHOPE will be disseminated via presentations at national and international scientific meetings or conferences and publication in peer-reviewed international scientific journals. TRIAL REGISTRATION NUMBER DRKS00013644; Pre-results.
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Affiliation(s)
- Ana Kowark
- Department of Anaesthesiology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Christian Adam
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Klinikverbund St. Antonius und St. Josef GmbH, Wuppertal, Germany
| | - Jörg Ahrens
- Department of Anaesthesiology and Intensive Care, Medical University Hannover, Hannover, Germany
| | - Malek Bajbouj
- Psychiatry and Affective Neurosciences, Campus Benjamin Franklin, Charité Center Neurology, Neurosurgery and Psychiatry, Berlin, Germany
| | - Cornelius Bollheimer
- Department of Geriatric Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Matthias Borowski
- Institute of Biostatistics and Clinical Research, University of Muenster, Münster, Germany
| | - Richard Dodel
- Department of Geriatrics, University Hospital Essen, Essen, Germany
| | - Michael Dolch
- Department of Anaesthesiology, Ludwig-Maximilian University (LMU) Munich, Munich, Germany
| | - Thomas Hachenberg
- Department of Anaesthesiology and Intensive Care, University Hospital Magdeburg, Magdeburg, Germany
| | - Dietrich Henzler
- Department of Anaesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr-University Bochum, Klinikum Herford, Herford, Germany
| | - Frank Hildebrand
- Department of Orthopaedic Trauma Surgery, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Ralf-Dieter Hilgers
- Department of Medical Statistics, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Andreas Hoeft
- Department of Anaesthesiology and Operative Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Susanne Isfort
- Center for Translational & Clinical Research Aachen (CTC-A), Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Peter Kienbaum
- Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Mathias Knobe
- Department of Orthopaedic Trauma Surgery, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Pascal Knuefermann
- Department of Anaesthesiology, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - Peter Kranke
- Department of Anaesthesiology, University Hospital Würzburg, Würzburg, Germany
| | - Rita Laufenberg-Feldmann
- Department of Anaesthesiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Carla Nau
- Department of Anaesthesiology and Intensive Care, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Mark D Neuman
- Department of Anaesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cynthia Olotu
- Department of the Geriatric Anaesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christopher Rex
- Department of Anaesthesiology and Intensive Care, Reutlingen Hospital GMBH, Reutlingen, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Robert D Sanders
- Department of Anesthesiology, University of Wisconsin – Madison, Madison, Wisconsin, USA
| | - Rene Schmidt
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty RWTH Aachen University, Stuttgart, Germany
| | - Frank Schneider
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty RWTH Aachen University, Aachen, Germany
- Institute for Neuroscience and Medicine (INM-10), Research Centre Jülich, Jülich, Germany
| | | | - Max Skorning
- Section Patient Safety, Medical Advisory Service of Social Health Insurance, Essen, Germany
| | - Claudia Spies
- Department of Anaesthesiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Vicent
- Department of Anaesthesiology and Intensive Care, University Hospital Dresden, Dresden, Germany
| | - Frank Wappler
- Department of Anaesthesiology and Operative Intensive Care, University Witten/Herdecke, Witten/Herdecke, Germany
| | | | - Maria Wittmann
- Department of Anaesthesiology and Operative Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Mark Coburn
- Department of Anaesthesiology, Medical Faculty RWTH Aachen University, Aachen, Germany
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Meng L, Yu W, Wang T, Zhang L, Heerdt PM, Gelb AW. Blood Pressure Targets in Perioperative Care. Hypertension 2018; 72:806-817. [DOI: 10.1161/hypertensionaha.118.11688] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Lingzhong Meng
- From the Department of Anesthesiology, Yale University School of Medicine, New Haven, CT (L.M., P.M.H.)
| | - Weifeng Yu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, China (W.Y.)
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (T.W.)
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan Province, China (L.Z.)
| | - Paul M. Heerdt
- From the Department of Anesthesiology, Yale University School of Medicine, New Haven, CT (L.M., P.M.H.)
| | - Adrian W. Gelb
- Department of Anesthesia and Perioperative Care, University of California, San Francisco (A.W.G.)
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Currie C. Hip fracture audit: Creating a 'critical mass of expertise and enthusiasm for hip fracture care'? Injury 2018; 49:1418-1423. [PMID: 30135041 DOI: 10.1016/j.injury.2018.06.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 06/21/2018] [Indexed: 02/02/2023]
Abstract
The care of frail older people admitted with hip fracture has improved greatly over the last half-century, largely as a result of combined medical care and surgical care and the rise - over the last four decades - of large-scale hip fracture audit. A series of European initiatives evolved. The first national hip fracture audit was the Swedish Rikshöft in the late 1980s, and the largest so far is the UK National Hip Fracture Database (NHFD), launched in 2007. An external evaluation of the NHFD demonstrated statistically significant increases in survival at up to 1 year associated with improved early care: with rising geriatrician involvement and falling delays to surgery, and from which lessons have been learned. Comparable national audits have emerged since in northern Europe and in Australia and New Zealand, and most recently in Spain and Japan. Like the NHFD, these use the synergy of agreed clinical standards and regular - ideally continuous - audit feedback that can prompt and monitor clinical and service developments, often demonstrating both rising quality and improved cost effectiveness. In addition, important benchmarking studies of hip fracture care have been reported from India and China, both of which face huge challenges in providing care of fragility fractures in populations characterised by first-generation mass ageing. The 'halo effect' of the impact of growing expertise in hip fracture care on the care of other fragility fractures is noteworthy and now relevant globally. Although many national audits have now published encouraging reports of progress, the details of context and process determinants of the initiation and development of effective hip fracture audit have received relatively little attention. To address this, an extended discussion section - based on the author's experience of participation in several substantial audits, variously supporting and observing many others, and from his numerous discussions with audit colleagues over the years - may be of value in offering practical advice on some obvious and less obvious practical issues that arise in the setting up of large-scale hip fracture audits in a variety of healthcare contexts.
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Affiliation(s)
- Colin Currie
- Formerly (1979-2010) of Geriatric Medicine Unit, School of Clinical Sciences and Community Health, College of Medicine and Veterinary medicine, Edinburgh University, Royal infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK.
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80
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White SM, Foss NB, Griffiths R. Anaesthetic aspects in the treatment of fragility fracture patients. Injury 2018; 49:1403-1408. [PMID: 29958684 DOI: 10.1016/j.injury.2018.06.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 06/21/2018] [Indexed: 02/02/2023]
Abstract
As longevity increases globally, the number of older, frailer, comorbid patients requiring fragility fracture surgery will increase. Fundamentally, anaesthesia should aim to maintain these patients' pre-fracture cognitive and physiological trajectories and facilitate early (ie day 1) postoperative recovery. This review describes the 10 general principles of anaesthesia for fragility fracture surgery that best achieve these aims: multidisciplinary care, 'getting it right first time', timely surgery, standardisation, sympathetic anaesthesia, avoiding ischaemia, sympathetic analgesia, re-enablement, data collection and training.
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Affiliation(s)
- S M White
- FRCA, Brighton and Sussex University Hospitals NHS Trust, Eastern Road, Brighton, East Sussex, BN2 5BE, United Kingdom.
| | - N B Foss
- Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegård Allé 30, Hvidovre, Denmark
| | - R Griffiths
- North West Anglia Hospitals NHS FT, Bretton Gate, Peterborough, PE3 9GZ, United Kingdom
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81
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Gremillet C, Jakobsson JG. Acute hip fracture surgery anaesthetic technique and 30-day mortality in Sweden 2016 and 2017: A retrospective register study. F1000Res 2018; 7:1009. [PMID: 30210789 DOI: 10.12688/f1000research.15363.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2018] [Indexed: 12/20/2022] Open
Abstract
Background: Hip fractures affect 1.6 million patients yearly worldwide, often elderly with complex comorbidity. Mortality following surgery for acute hip fracture is high and multifactorial; high age, comorbidities and complication/deterioration in health following surgery. Whether the anaesthesia technique affects the 30-day mortality rate has been studied widely without reaching a consensus. The primary aim of this study was to determine anaesthetic techniques used in Sweden and their impact on the 30-day mortality rate in elderly undergoing acute hip fracture surgery. Other aims were to study the impact of age, gender, ASA class, fracture type and delay in surgery on the 30-day mortality rate. Methods: Data from 13,649 patients ≥50 years old who had undergone acute hip fracture surgery and been reported to Swedish perioperative register (SPOR) between 2016 and 2017 were analysed. Results: The most commonly used anaesthetic technique was neuraxial anaesthesia (NA; 11,257, 82%), followed by general anaesthesia (GA; 2,190, 16%) and combined general and neuraxial anaesthesia (CA; 202, 1.5%) out of the 13,649 studied. The 30-day mortality rate was 7.7% for the entire cohort; GA 7.8%, NA 7.7% and CA 7.4%. Mortality was higher in elderly patients, those with a high ASA class, pertrochanteric fracture and males. Conclusions: The present study showed that NA is by far the most common anaesthetic technique for acute hip fracture surgery in Sweden. However, the anaesthetic technique used during this type of surgery had no impact on the 30-day mortality rate in patients. Increasing age, ASA class and male gender increased the 30-day mortality.
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Affiliation(s)
- Caroline Gremillet
- Department of Anaesthesia & Intensive Care, Institution for Clinical Sciences, Danderyds University Hospital, Karolinska Institutet, Stockholm, 18288, Sweden
| | - Jan G Jakobsson
- Department of Anaesthesia & Intensive Care, Institution for Clinical Sciences, Danderyds University Hospital, Karolinska Institutet, Stockholm, 18288, Sweden
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82
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Gremillet C, Jakobsson JG. Acute hip fracture surgery anaesthetic technique and 30-day mortality in Sweden 2016 and 2017: A retrospective register study. F1000Res 2018; 7:1009. [PMID: 30210789 PMCID: PMC6107981 DOI: 10.12688/f1000research.15363.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2018] [Indexed: 01/26/2023] Open
Abstract
Background: Hip fractures affect 1.6 million patients yearly worldwide, often elderly with complex comorbidity. Mortality following surgery for acute hip fracture is high and multifactorial; high age, comorbidities and complication/deterioration in health following surgery. Whether the anaesthesia technique affects the 30-day mortality rate has been studied widely without reaching a consensus. The primary aim of this study was to determine anaesthetic techniques used in Sweden and their impact on the 30-day mortality rate in elderly undergoing acute hip fracture surgery. Other aims were to study the impact of age, gender, ASA class, fracture type and delay in surgery on the 30-day mortality rate. Methods: Data from 13,649 patients ≥50 years old who had undergone acute hip fracture surgery and been reported to Swedish perioperative register (SPOR) between 2016 and 2017 were analysed. Results: The most commonly used anaesthetic technique was neuraxial anaesthesia (NA; 11,257, 82%), followed by general anaesthesia (GA; 2,190, 16%) and combined general and neuraxial anaesthesia (CA; 202, 1.5%) out of the 13,649 studied. The 30-day mortality rate was 7.7% for the entire cohort; GA 7.8%, NA 7.7% and CA 7.4%. Mortality was higher in elderly patients, those with a high ASA class, pertrochanteric fracture and males. Conclusions: The present study showed that NA is by far the most common anaesthetic technique for acute hip fracture surgery in Sweden. However, the anaesthetic technique used during this type of surgery had no impact on the 30-day mortality rate in patients. Increasing age, ASA class and male gender increased the 30-day mortality.
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Affiliation(s)
- Caroline Gremillet
- Department of Anaesthesia & Intensive Care, Institution for Clinical Sciences, Danderyds University Hospital, Karolinska Institutet, Stockholm, 18288, Sweden
| | - Jan G Jakobsson
- Department of Anaesthesia & Intensive Care, Institution for Clinical Sciences, Danderyds University Hospital, Karolinska Institutet, Stockholm, 18288, Sweden
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83
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Wesselink EM, Kappen TH, Torn HM, Slooter AJC, van Klei WA. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth 2018; 121:706-721. [PMID: 30236233 DOI: 10.1016/j.bja.2018.04.036] [Citation(s) in RCA: 421] [Impact Index Per Article: 70.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/04/2018] [Accepted: 05/02/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Intraoperative hypotension is a common side effect of general anaesthesia and might lead to inadequate organ perfusion. It is unclear to what extent hypotension during noncardiac surgery is associated with unfavourable outcomes. METHODS We conducted a systematic search in PubMed, Embase, Web of Science, and CINAHL, and classified the quality of retrieved articles according to predefined adapted STROBE and CONSORT criteria. Reported strengths of associations from high-quality studies were classified into end-organ specific injury risks, such as acute kidney injury, myocardial injury, and stroke, and overall organ injury risks for various arterial blood pressure thresholds. RESULTS We present an overview of 42 articles on reported associations between various absolute and relative intraoperative hypotension definitions and their associations with postoperative adverse outcomes after noncardiac surgery. Elevated risks of end-organ injury were reported for prolonged exposure (≥10 min) to mean arterial pressures <80 mm Hg and for shorter durations <70 mm Hg. Reported risks increase with increased durations for mean arterial pressures <65-60 mm Hg or for any exposure <55-50 mm Hg. CONCLUSIONS The reported associations suggest that organ injury might occur when mean arterial pressure decreases <80 mm Hg for ≥10 min, and that this risk increases with blood pressures becoming progressively lower. Given the retrospective observational design of the studies reviewed, reflected by large variability in patient characteristics, hypotension definitions and outcomes, solid conclusions on which blood pressures under which circumstances are truly too low cannot be drawn. We provide recommendations for the design of future studies. CLINICAL REGISTRATION NUMBER: (PROSPERO ID). CRD42013005171.
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Affiliation(s)
- E M Wesselink
- Department of Anesthesiology, Utrecht, The Netherlands.
| | - T H Kappen
- Department of Anesthesiology, Utrecht, The Netherlands
| | - H M Torn
- Department of Anesthesiology, Utrecht, The Netherlands
| | - A J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - W A van Klei
- Department of Anesthesiology, Utrecht, The Netherlands
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84
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Shelton C, Goodwin D, Mort M, Nichols W, Smith A. Hip fracture anaesthesia: the importance of inputs. Br J Anaesth 2018; 120:1132-1133. [DOI: 10.1016/j.bja.2018.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/05/2018] [Indexed: 10/17/2022] Open
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85
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Rowlands M, van de Walt G, Bradley J, Mannings A, Armstrong S, Bedforth N, Moppett IK, Sahota O. Femoral Nerve Block Intervention in Neck of Femur Fracture (FINOF): a randomised controlled trial. BMJ Open 2018; 8:e019650. [PMID: 29643155 PMCID: PMC5900449 DOI: 10.1136/bmjopen-2017-019650] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Fractured neck of femur is a severely painful condition with significant mortality and morbidity. We investigated whether early and continuous use of femoral nerve block can improve pain on movement and mobility after surgery in older participants with fragility neck of femur fracture. DESIGN Prospective single-centre, randomised controlled pragmatic trial. SETTING Secondary care, acute National Health Service Trust, UK. PARTICIPANTS Participants admitted with a history and examination suggesting fractured neck of femur. INTERVENTION Immediate continuous femoral nerve block via catheter or standard analgesia. OUTCOME MEASURES Primary outcome measures were Cumulative Dynamic Pain score and Cumulated Ambulation Score from surgery until day 3 postoperatively. Secondary outcome measures included pain scores at rest, cumulative side effects (nausea and constipation), quality of life (measured by EuroQOL 5 D instrument (EQ-5D) score) at day 3 and day 30, and rehabilitation outcome (measured by mobility score). RESULTS 141 participants were recruited, with 23 excluded. No significant difference was detected between Cumulative Dynamic Pain Score (standard care (n=56) vs intervention (n=55) 20 (IQR 15-24) vs 20 (15-23), p=0.51) or Cumulated Ambulation Score (standard care vs intervention 6 (5-9) vs 7 (5-10), p=0.76). There were no statistically different differences in secondary outcomes except cumulative pain at rest: 5 (0.5-6.5) in the standard care group and 2 (0-5) in the intervention group (p=0.043). CONCLUSIONS Early application of continuous femoral nerve block compared with standard systemic analgesia did not result in improved dynamic pain score or superior postoperative ambulation. This technique may provide superior pain relief at rest. Continuous femoral nerve block did not delay initial control of pain or mobilisation after surgery. TRIAL REGISTRATION NUMBER ISRCTN92946117; Pre-results.
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Affiliation(s)
- Martin Rowlands
- Department of Anaesthesia, Sheffield Teaching Hospitals, Sheffield, UK
| | | | - Jim Bradley
- Department of Anaesthesia, Queen’s Medical Centre, Nottingham University Hospitals, Nottingham, UK
| | - Alexa Mannings
- Department of Anaesthesia, Sheffield Teaching Hospitals, Sheffield, UK
| | - Sarah Armstrong
- School of Medicine, Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Nigel Bedforth
- Department of Anaesthesia, Queen’s Medical Centre, Nottingham University Hospitals, Nottingham, UK
| | - Iain K Moppett
- Division of Clinical Neuroscience, Anaesthesia and Critical Care Group, University of Nottingham, Queen’s Medical Centre, Nottingham University Hospitals, Nottingham, UK
| | - Opinder Sahota
- Department of Healthcare of Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
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86
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White SM, Altermatt F, Barry J, Ben-David B, Coburn M, Coluzzi F, Degoli M, Dillane D, Foss NB, Gelmanas A, Griffiths R, Karpetas G, Kim JH, Kluger M, Lau PW, Matot I, McBrien M, McManus S, Montoya-Pelaez LF, Moppett IK, Parker M, Porrill O, Sanders RD, Shelton C, Sieber F, Trikha A, Xuebing X. International Fragility Fracture Network Delphi consensus statement on the principles of anaesthesia for patients with hip fracture. Anaesthesia 2018; 73:863-874. [DOI: 10.1111/anae.14225] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2018] [Indexed: 01/16/2023]
Affiliation(s)
- S. M. White
- Brighton and Sussex University Hospitals NHS Trust; Brighton East Sussex UK
| | - F. Altermatt
- División de Anestesiología; Escuela de Medicina; Pontificia Universidad Católica de Chile; Santiago Chile
| | - J. Barry
- Cairns Hospital; Queensland Australia
| | - B. Ben-David
- University of Pittsburgh Medical Centre; Pittsburgh PA USA
| | - M. Coburn
- Medical Faculty; RWTH Aachen University; Aachen Germany
| | - F. Coluzzi
- Department Medical and Surgical Sciences and Biotechnologies; Sapienza University of Rome; Latina Italy
| | - M. Degoli
- Ospedale Civile di Baggiovara; Azienda Ospedaliero Universitaria di Modena; Modena Italy
| | - D. Dillane
- Anesthesiology and Pain Medicine; University of Alberta; Canada
| | - N. B. Foss
- Department of Anaesthesiology and Intensive Care Medicine; Hvidovre University Hospital; Hvidovre Denmark
| | - A. Gelmanas
- Hospital of Lithuanian University of Health Sciences Kauno klinikos; Lithuania
| | - R. Griffiths
- Peterborough and Stamford Hospitals NHS Trust; Peterborough UK
| | - G. Karpetas
- General University Hospital of Patras; Rio Greece
| | - J.-H. Kim
- Korea University College of Medicine; Seoul South Korea
| | | | - P.-W. Lau
- University of Hong Kong; Hong Kong China
| | - I. Matot
- Critical Care and Pain; Tel Aviv Medical Center; Sackeler School of Medicine; Tel Aviv Israel
| | | | | | - L. F. Montoya-Pelaez
- Department of Anaesthesia and Perioperative Medicine; Groote Schuur Hospital; University of Cape Town; Cape Town South Africa
| | - I. K. Moppett
- Anaesthesia and Critical Care Section; Division of Clinical Neuroscience; Queen's Medical Centre Campus; Nottingham University Hospitals NHS Trust; University of Nottingham; Nottingham UK
| | - M. Parker
- Peterborough and Stamford Hospitals NHS Trust; Peterborough UK
| | - O. Porrill
- New Somerset Hospital; University of Cape Town; South Africa
| | | | - C. Shelton
- Lancaster Medical School and Wythenshawe Hospital; Manchester UK
| | - F. Sieber
- Johns Hopkins Bayview Medical Center; Baltimore MD USA
| | - A. Trikha
- All India Institute of Medical Sciences; New Delhi India
| | - X. Xuebing
- University of Hong Kong-Shenzhen Hospital; Shenzhen China
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87
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Clemmesen CG, Pedersen LM, Hougaard S, Andersson ML, Rosenkvist V, Nielsen HB, Palm H, Foss NB. Cerebral oximetry during preoperative resuscitation in elderly patients with hip fracture: a prospective observational study. J Clin Monit Comput 2018; 32:1033-1040. [PMID: 29404892 DOI: 10.1007/s10877-018-0107-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 01/28/2018] [Indexed: 01/30/2023]
Abstract
This study explores the association between postadmission and intraoperative cerebral oxygenation (ScO2), reflecting systemic perfusion, and postoperative mortality and delirium. Forty elderly (age > 65 years) patients with hip fractures were included in this prospective observational study. The ScO2 was determined using near-infrared spectroscopy at initial resuscitation after patients were admitted to the hospital and during surgery. Postoperative delirium was assessed up to seven days after surgery using the memorial delirium assessment scale and the confusion assessment method. Ten patients (25%) developed postoperative delirium within the first seven postoperative days. At initial resuscitation ScO2 was lower in patients that later developed delirium, but the difference was not significant (p = 0.331). Intraoperative ScO2 values remained similar in the two groups. Mortality regardless of cause was 10% (4 out of 40 patients) after 30 days. At initial resuscitation ScO2 was significant lower in the mortality group than in the surviving group (p = 0.042), and the ScO2 nadir values were also significant lower (p = 0.047). Low ScO2 during initial resuscitation (defined as ScO2 < 55 for a minimum of two consecutive minutes) was also significantly associated with 30-day mortality (p = 0.015). There were no associations between low blood pressure and postoperative delirium or 30-day mortality. We found that low preoperative ScO2 was better associated with 30-day all-cause mortality in elderly patients undergoing surgery for hip fracture than blood pressure measurements. Future studies in preoperative resuscitation of hip fracture patients should focus on perfusion measures as opposed to conventional haemodynamic.
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Affiliation(s)
- C G Clemmesen
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark.
| | - L M Pedersen
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark
| | - S Hougaard
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark
| | - M L Andersson
- Department of Anaesthesiology, Copenhagen University Hospital, Herlev & Gentofte, Denmark
| | - V Rosenkvist
- Department of Respiratory Medicine, Copenhagen University Hospital, Herlev & Gentofte, Denmark
| | - H B Nielsen
- Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| | - H Palm
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - N B Foss
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark
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88
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Suresh S, De Oliveira G. Local anaesthetic dosage of peripheral nerve blocks in children: analysis of 40 121 blocks from the Pediatric Regional Anesthesia Network database. Br J Anaesth 2018; 120:317-322. [DOI: 10.1016/j.bja.2017.10.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 10/27/2017] [Accepted: 12/01/2017] [Indexed: 12/21/2022] Open
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89
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Beh ZY, Au Yong PS, Lye S, Eapen SE, Yoong CS, Woon KL, Cheng Lim JG. Continuous spinal anaesthesia: A retrospective analysis of 318 cases. Indian J Anaesth 2018; 62:765-772. [PMID: 30443059 PMCID: PMC6190429 DOI: 10.4103/ija.ija_387_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background and Aims: Continuous spinal anaesthesia (CSA) is an underutilised anaesthetic technique. Our objectives were to evaluate the use of CSA in our institution, its efficacy, ease to use and safety. Methods: This was a retrospective analysis conducted in a tertiary centre. Records of all patients who underwent surgery and received CSA between December 2008 and July 2017 were reviewed. Their demographic profiles, type and duration of surgery were analysed. The outcomes measured were the success of CSA, technical evaluation and difficulties encountered, intraoperative haemodynamics, usage of vasopressors and any reported complications. Statistical analysis was done using Chi-square test. Results: Three hundred and eighteen patients (94%) successfully underwent surgery using CSA. Twenty cases (6%) had failed CSA, of which five of them had CSA insertion failure, while the rest failed to complete the operation under CSA, thus requiring conversion to general anaesthesia. Patients who have had an initial intrathecal local anaesthetic (LA) volume ≥1.5 ml had higher odds (odds ratio (OR) 2.78; 95% confidence interval [CI], 1.70–4.57) of developing hypotension compared to those who had <1.5 ml (P < 0.001). There were no reported post-dural puncture headache, neurological sequelae or infection. Conclusion: CSA is a useful anaesthetic technique with low failure rate. The key to achieving haemodynamic stability is by giving a small initial bolus, then titrating the block up to required height using aliquots of 0.5 ml of intrathecal LA through the catheter.
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Affiliation(s)
- Zhi Yuen Beh
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Phui Sze Au Yong
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
| | - Siyu Lye
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
| | - Sneha Elizabeth Eapen
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
| | - Chee Seng Yoong
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
| | - Kwee Lian Woon
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
| | - Jimmy Guan Cheng Lim
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
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90
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Perioperative outcomes in the context of mode of anaesthesia for patients undergoing hip fracture surgery: systematic review and meta-analysis. Br J Anaesth 2018; 120:37-50. [DOI: 10.1016/j.bja.2017.09.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 09/15/2017] [Accepted: 09/15/2017] [Indexed: 01/08/2023] Open
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91
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Armstrong RA, Mouton R. Definitions of anaesthetic technique and the implications for clinical research. Anaesthesia 2017; 73:935-940. [PMID: 29280142 DOI: 10.1111/anae.14200] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2017] [Indexed: 11/27/2022]
Affiliation(s)
- R A Armstrong
- Department of Anaesthesia, Southmead Hospital, Bristol, UK
| | - R Mouton
- Department of Anaesthesia, Southmead Hospital, Bristol, UK
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92
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Dawe H. Modernising Hip Fracture Anaesthesia. Open Orthop J 2017; 11:1190-1199. [PMID: 29290856 PMCID: PMC5721325 DOI: 10.2174/1874325001711011190] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/20/2017] [Accepted: 06/22/2017] [Indexed: 12/14/2022] Open
Abstract
Hip fracture carries a 30-day mortality of around 8% in the United Kingdom. This figure has remained relatively unchanged despite modern developments in anaesthetic technique. These range from improvements in perioperative analgesia and mortality scoring systems, changes to intra-operative anaesthetic technique and strategies to reduce the requirement for blood transfusion. In this article, we review the current literature on the perioperative management of patients undergoing hip fracture surgery including some of the current controversies.
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Affiliation(s)
- Hannah Dawe
- St. Georges Hospital, Tooting, SW170QT, London, UK
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93
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ALGUNOS MITOS EN ANESTESIOLOGÍA. REVISTA MÉDICA CLÍNICA LAS CONDES 2017. [DOI: 10.1016/j.rmclc.2017.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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94
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Griffiths R, Surendra Kumar D. Major trauma in older people: implications for anaesthesia and intensive care medicine. Anaesthesia 2017; 72:1302-1305. [PMID: 28832941 DOI: 10.1111/anae.14027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- R Griffiths
- Department of Anaesthesia, North-West Anglia Hospitals NHS Trust, Peterborough, UK
| | - D Surendra Kumar
- Department of Anaesthesia and Intensive Care Medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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95
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Moppett IK, White S, Griffiths R, Buggy D. Tight intra-operative blood pressure control versus standard care for patients undergoing hip fracture repair - Hip Fracture Intervention Study for Prevention of Hypotension (HIP-HOP) trial: study protocol for a randomised controlled trial. Trials 2017; 18:350. [PMID: 28743315 PMCID: PMC5526232 DOI: 10.1186/s13063-017-2066-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 06/24/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypotension during anaesthesia for hip fracture surgery is common. Recent data suggest that there is an association between the lowest intra-operative blood pressure and mortality, even when adjusted for co-morbidities. This is consistent with data derived from the wider surgical population, where magnitude and duration of hypotension are associated with mortality and peri-operative complications. However, there are no trial to data to support more aggressive blood pressure control. METHODS/DESIGN We are conducting a three-centre, randomised, double-blinded pilot study in three hospitals in the United Kingdom. The sample size will be 75 patients (25 from each centre). Randomisation will be done using computer-generated concealed tables. Both participants and investigators will be blinded to group allocation. Participants will be aged >70 years, cognitively intact (Abbreviated Mental Test Score 7 or greater), able to give informed consent and admitted directly through the emergency department with a fractured neck of the femur requiring operative repair. Patients randomised to tight blood pressure control or avoidance of intra-operative hypotension will receive active treatment as required to maintain both of the following: systolic arterial blood pressure >80% of baseline pre-operative value and mean arterial pressure >75 mmHg throughout. All participants will receive standard hospital care, including spinal or general anaesthesia, at the discretion of the clinical team. The primary outcome is a composite of the presence or absence of defined cardiovascular, renal and delirium morbidity within 7 days of surgery (myocardial injury, stroke, acute kidney injury, delirium). Secondary endpoints will include the defined individual morbidities, mortality, early mobility and discharge to usual residence. DISCUSSION This is a small-scale pilot study investigating the feasibility of a trial of tight intra-operative blood pressure control in a frail elderly patient group with known high morbidity and mortality. Positive findings will provide the basis for a larger-scale study. TRIAL REGISTRATION ISRCTN Registry identifier: ISRCTN89812075 . Registered on 30 August 2016.
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Affiliation(s)
- Iain Keith Moppett
- Anaesthesia and Critical Care Section, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Stuart White
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Richard Griffiths
- Department of Anaesthesia, Peterborough & Stamford Hospitals NHS Trust, Peterborough, UK
| | - Donal Buggy
- School of Medicine, Mater Hospital, Eccles Street, Dublin 7, Ireland
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Van Waesberghe J, Stevanovic A, Rossaint R, Coburn M. General vs. neuraxial anaesthesia in hip fracture patients: a systematic review and meta-analysis. BMC Anesthesiol 2017; 17:87. [PMID: 28659127 PMCID: PMC5490182 DOI: 10.1186/s12871-017-0380-9] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 06/21/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hip fracture is a trauma of the elderly. The worldwide number of patients in need of surgery after hip fracture will increase in the coming years. The 30-day mortality ranges between 4 and 14%. Patients' outcome may be improved by anaesthesia technique (general vs. neuraxial anaesthesia). There is a dearth of evidence from randomised studies regarding to the optimal anaesthesia technique. However, several large non-randomised studies addressing this question have been published from the onset of 2010. METHODS To compare the 30-day mortality rate, in-hospital mortality rate and length of hospital stay after neuraxial (epidural/spinal) or general anaesthesia in hip fracture patients (≥ 18 years old) we prepared a systematic review and meta-analysis. A systematic search for appropriate retrospective observational and prospective randomised studies in Embase and PubMed databases was performed in the time-period from 01.01.2010 to 21.11.2016. Additionally a forward searching in google scholar, a level one reference list searching and a formal searching of trial registries was performed. RESULTS Twenty retrospective observational and three prospective randomised controlled studies were included. There was no difference in the 30-day mortality [OR 0.99; 95% CI (0.94 to 1.04), p = 0.60] between the general and the neuraxial anaesthesia group. The in-hospital mortality [OR 0.85; 95% CI (0.76 to 0.95), p = 0.004] and the length of hospital stay were significantly shorter in the neuraxial anaesthesia group [MD -0.26; 95% CI (-0.36 to -0.17); p < 0.00001]. CONCLUSION Neuraxial anaesthesia is associated with a reduced in-hospital mortality and length of hospitalisation. However, type of anaesthesia did not influence the 30-day mortality. In future there is a need for large randomised studies to examine the association between the type of anaesthesia, post-operative complications and mortality.
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Affiliation(s)
- Julia Van Waesberghe
- Department of Anaesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Ana Stevanovic
- Department of Anaesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Mark Coburn
- Department of Anaesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
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Johansen A, Tsang C, Boulton C, Wakeman R, Moppett I. Understanding mortality rates after hip fracture repair using ASA physical status in the National Hip Fracture Database. Anaesthesia 2017; 72:961-966. [DOI: 10.1111/anae.13908] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2017] [Indexed: 01/05/2023]
Affiliation(s)
- A. Johansen
- University Hospital of Wales; Cardiff UK
- National Hip Fracture Database; Royal College of Physicians; London UK
| | - C. Tsang
- Clinical Effectiveness Unit; Royal College of Surgeons of England; London UK
| | - C. Boulton
- Falls and Fragility Fracture Audit Programme; Royal College of Physicians; London UK
| | - R. Wakeman
- National Hip Fracture Database; Royal College of Physicians; London UK
| | - I. Moppett
- Anaesthesia and Critical Care Section; Division of Clinical Neuroscience; Queen's Medical Centre; University of Nottingham; UK
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Moppett I, Moonesinghe S, Grocott M. National audits in the UK: fancy acronyms or real patient benefit? Br J Anaesth 2017; 118:479-482. [DOI: 10.1093/bja/aew437] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Skinner A. Standards for hip fracture anaesthesia. Anaesthesia 2017; 72:406-407. [DOI: 10.1111/anae.13805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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