The effect of the grade of surgeon on blood loss in fractured neck-of-femur surgery

Methods of Quantifying Intraoperative Blood Loss in Orthopaedic Trauma Surgery: A Systematic Review

OBJECTIVES

To collect and present the recently published methods of quantifying blood loss (BL) in orthopaedic trauma.

DATA SOURCES

A systematic review of English-language literature in PubMed, Cochrane Library, and Scopus databases was conducted according to the PRISMA guidelines on articles describing the methods of determining BL in orthopaedic trauma published since 2010.

STUDY SELECTION

English, full-text, peer-reviewed articles documenting intraoperative BL in an adult patient population undergoing orthopaedic trauma surgery were eligible for inclusion.

DATA EXTRACTION

Two authors independently extracted data from the included studies. Articles were assessed for quality and risk of bias using the Cochrane Collaboration's tool for assessing risk of bias and ROBINS-I.

DATA SYNTHESIS

The included studies proved to be heterogeneous in nature with insufficient data to make data pooling and analysis feasible.

CONCLUSIONS

Eleven methods were identified: 6 unique formulas with multiple variations, changes in hemoglobin and hematocrit levels, measured suction volume and weighed surgical gauze, transfusion quantification, cell salvage volumes, and hematoma evacuation frequency. Formulas included those of Gross, Mercuriali, Lisander, Sehat, Foss, and Stahl, with Gross being the most common (25%). All formulas used blood volume estimation, determined by equations from Nadler (94%) or Moore (6%), and measure change in preoperative and postoperative blood counts. This systematic review highlights the variability in BL estimation methods published in current orthopaedic trauma literature. Methods of quantifying BL should be taken into consideration when designing and evaluating research.

The potential value of surrogate performance markers at caesarean section for the assessment of surgical competence

OBJECTIVES

We hypothsised that surrogate markers of competence (procedure time and estimated surgical blood loss) could be of value when assessing competence for trainees learning to undertake lower segment caesarean section (LSCS). The study aim was to investigate differences in surrogate markers of surgical competence at LSCS between different training grades of primary surgeon and for different grades of surgical assistant; to assess the potential value of using these surrogate markers in overall assessments of surgical competence.

STUDY DESIGN

Operating records for elective LSCS were reviewed from January 2007 to January 2015. Uncomplicated LSCS where a junior trainee (ST2/ST3) or a senior trainee (ST6+) was the primary surgeon were included. Inclusion criteria were LSCS with body mass index less than 35, singleton pregnancy, greater than 34 weeks' gestation, no more than one previous caesarean section and no low-lying placenta. Procedure time, estimated blood loss and the effect of the grade of surgical assistant (consultant or trainee) on these were compared overall for all surgeons at ST2 level, ST3 level and senior level (ST6+) using Student's t test and effect size calculation (Cohen test).

RESULTS

During the study period 3099 uncomplicated LSCS were performed by 60 trainees: 1367 by ST2, 1085 by ST3 and 646 by senior trainees (ST6+). Mean procedure times and recorded estimated blood loss decreased significantly for each level of training (p < 0.05). The degree of experience of the surgical assistant was also associated with reduced procedure times and blood loss, this was significant for trainees in ST2 when assisted by a consultant (p < 0.05).

CONCLUSIONS

Training progression is associated with a reduction in procedure time and estimated blood loss, which are both surrogate markers of competence at LSCS. Current objective structured assessments of technical competence for trainees (OSATS) do not take these metrics into account when assessing performance. An enhanced assessment of trainees undertaking LSCS is suggested, reviewing both objective structured assessments of technical performance (OSATS) and surrogate markers of performance recorded in a surgical logbook to provide a more comprehensive assessment of overall competence.

The weekend effect for hip fracture surgery

INTRODUCTION

Increased mortality rates have been reported for emergency admissions during weekends and outside office hours. Research on the weekend effect in hip fracture patients is however limited and demonstrates conflicting results. The aim of this study was to determine the effect of weekend admission and weekend surgery on 30-day and 1-year mortality following hip fracture surgery.

PATIENTS AND METHODS

All patients who underwent hip fracture surgery in our hospital between 2004 and 2015 were included in this retrospective study. Patient characteristics including age, gender, fracture type, American Society of Anesthesiologists (ASA) score, Nottingham Hip Fracture Score (NHFS), Charlson Comorbidity Index (CCI) and length of stay were collected. Information on admission and surgery date and time of day was recorded, as were in-hospital, 30-day and 1-year mortality. Multivariable logistic regression analysis was performed to identify independent predictors of 30-day and 1-year mortality.

RESULTS

A total of 1803 patients were included, 546 patients (30.3%) were admitted during the weekend. Patient characteristics did not differ between weekday and weekend admissions. Surgical delay was less frequent in patients undergoing weekend surgery. Multivariable analysis demonstrated that older age, higher ASA score, higher NHFS and increased surgical delay were independently associated with 30-day mortality. One-year mortality was associated with age, gender, ASA score, CCI and surgical delay. Weekend admission and weekend surgery were not associated with increased 30-day or 1-year mortality.

CONCLUSIONS

There was no weekend effect for hip fracture patients in our study. These results indicate an adequate level of perioperative care outside weekday office hours within our health care system.