1
|
Zeelenberg ML, Den Hartog D, Van Lieshout EMM, Wijnen HH, Willems HC, Gosens T, Steens J, Van Balen R, Zuurmond RG, Loggers SAI, Joosse P, Verhofstad MHJ. The value of preoperative diagnostic testing and geriatric assessment in frail institutionalized elderly with a hip fracture; a secondary analysis of the FRAIL-HIP study. Eur Geriatr Med 2024; 15:753-763. [PMID: 38418712 PMCID: PMC11329590 DOI: 10.1007/s41999-024-00945-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/15/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE The aim of this study was to provide a comprehensive overview of (preoperative and geriatric) diagnostic testing, abnormal diagnostic tests and their subsequent interventions, and clinical relevance in frail older adults with a hip fracture. METHODS Data on clinical consultations, radiological, laboratory, and microbiological diagnostics were extracted from the medical files of all patients included in the FRAIL-HIP study (inclusion criteria: hip fracture, > 70 years, living in a nursing home with malnourishment/cachexia and/or impaired mobility and/or severe co-morbidity). Data were evaluated until hospital discharge in nonoperatively treated patients and until surgery in operatively treated patients. RESULTS A total of 172 patients (88 nonoperative and 84 operative) were included, of whom 156 (91%) underwent laboratory diagnostics, 126 (73%) chest X-rays, and 23 (13%) CT-scans. In 153/156 (98%) patients at least one abnormal result was found in laboratory diagnostics. In 82/153 (50%) patients this did not result in any additional diagnostics or (pharmacological) intervention. Abnormal test results were mentioned as one of the deciding arguments for operative delay (> 24 h) for 10/84 (12%) patients and as a factor in the decision between nonoperative and operative treatment in 7/172 (4%) patients. CONCLUSION A large number and variety of diagnostics were performed in this patient population. Abnormal test results in laboratory diagnostics were found for almost all patients and, in majority, appear to have no direct clinical consequences. To prevent unnecessary diagnostics, prospective research is required to evaluate the clinical consequences and added value of the separate elements of preoperative diagnostic testing and geriatric assessment in frail hip fracture patients.
Collapse
Affiliation(s)
- Miliaan L Zeelenberg
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Hugo H Wijnen
- Department of Clinical Geriatrics, Rijnstate Hospital, Arnhem, The Netherlands
| | - Hanna C Willems
- Department of Internal Medicine and Geriatrics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Taco Gosens
- Department of Orthopedics, Elisabeth Hospital (ETZ), Tilburg, The Netherlands
| | - Jeroen Steens
- Department of Surgery, Dijklander Hospital, Hoorn, The Netherlands
| | - Romke Van Balen
- Department of Public Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Sverre A I Loggers
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Pieter Joosse
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| |
Collapse
|
2
|
Hiraoka E, Tanabe K, Izuta S, Kubota T, Kohsaka S, Kozuki A, Satomi K, Shiomi H, Shinke T, Nagai T, Manabe S, Mochizuki Y, Inohara T, Ota M, Kawaji T, Kondo Y, Shimada Y, Sotomi Y, Takaya T, Tada A, Taniguchi T, Nagao K, Nakazono K, Nakano Y, Nakayama K, Matsuo Y, Miyamoto T, Yazaki Y, Yahagi K, Yoshida T, Wakabayashi K, Ishii H, Ono M, Kishida A, Kimura T, Sakai T, Morino Y. JCS 2022 Guideline on Perioperative Cardiovascular Assessment and Management for Non-Cardiac Surgery. Circ J 2023; 87:1253-1337. [PMID: 37558469 DOI: 10.1253/circj.cj-22-0609] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | - Tadao Kubota
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Amane Kozuki
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | | | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, International University of Health and Welfare Narita Hospital
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Taku Inohara
- Department of Cardiovascular Medicine, Keio University Graduate School of Medicine
| | - Mitsuhiko Ota
- Department of Cardiovascular Center, Toranomon Hospital
| | | | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital
| | - Yumiko Shimada
- JADECOM Academy NP·NDC Training Center, Japan Association for Development of Community Medicine
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tomofumi Takaya
- Department of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital
| | - Kenichi Nakazono
- Department of Pharmacy, St. Marianna University Yokohama Seibu Hospital
| | | | | | - Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | | | | | | | | | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| |
Collapse
|
3
|
Pallesen J, Bhavsar R, Fjølner J, Bakke SA, Krog J, Andersen MAS, Bøndergaard MH, Jessing TD, Mortensen L, Nielsen MB, Vang M, Malachauskiené L, Juhl-Olsen P. The effects of preoperative focused cardiac ultrasound in high-risk patients: A randomised controlled trial (PREOPFOCUS). Acta Anaesthesiol Scand 2022; 66:1174-1184. [PMID: 36054287 DOI: 10.1111/aas.14134] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/07/2022] [Accepted: 08/12/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Surgery is the third most common cause of mortality worldwide. Focused cardiac ultrasound (FOCUS) yields information on cardiac status and discloses the presence of unknown pathology. Preoperative FOCUS changes patient treatment, allowing for a patient-tailored anaesthesia. We hypothesised that preoperative FOCUS would reduce the proportion of patients who were either admitted to hospital for more than 10 days or who were dead within 30 days after high-risk, non-cardiac surgery. METHODS This was a randomised, controlled, multi-center study. Patients ≥65 years of age, admitted for urgent orthopaedic- or abdominal surgery, scheduled for general- or neuraxial anaesthesia and with ASA 3/4 were eligible for inclusion. Patients were randomised in a 1:1 ratio to preoperative FOCUS or no preoperative FOCUS performed in accordance with a predefined protocol. Primary endpoint was the proportion of patients admitted more than 10 days or who were dead within 30 days. Secondary endpoints included major complications, days of admission and changes in anaesthesia handling. RESULTS During the second COVID-19 wave the study monitoring committee terminated the study prematurely. We included 338 patients of which 327 were included in the final analysis. In the FOCUS group, 41/163 (25%) patients met the criteria for the primary endpoint versus 35/164 (21%) for the control group, adjusted odds ratio 1.37 (95% CI 0.86-2.30), p = .36. The proportions of patients who developed major complications did not differ significantly between groups. Length of hospital stay was 4 (3-8) days in the FOCUS group and 4 (3-7) days on the control group (adjusted p = .24). CONCLUSION The routine availability of preoperative FOCUS assessment in this cohort does not appear to reduce the risk for hospitalisation exceeding 10 days or 30-day mortality, although study enrolment was prematurely terminated.
Collapse
Affiliation(s)
- Jan Pallesen
- Department of Anaesthesiology, Randers Regional Hospital, Randers, Denmark
| | - Rajesh Bhavsar
- Department of Anaesthesiology, Hospital of Southern Jutland, Aabenraa, Denmark
| | - Jesper Fjølner
- Department of Surgery & Intensive Care, Regional Hospital Central Jutland, Viborg, Denmark
| | - Skule Arnesen Bakke
- Department of Anaesthesiology, Hospital of Southern Jutland, Aabenraa, Denmark
| | - Jan Krog
- Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | | | - Lone Mortensen
- Department of Anaesthesiology, Randers Regional Hospital, Randers, Denmark
| | | | - Marianne Vang
- Department of Anaesthesiology, Randers Regional Hospital, Randers, Denmark
| | | | - Peter Juhl-Olsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Cardiothoracic and Vascular Surgery, Anaesthesia Section, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
4
|
Esper G, Anil U, Konda S, Furgiuele D, Zaretsky J, Egol K. Standardized Preoperative Pathways Determining Preoperative Echocardiogram Usage Continue to Improve Hip Fracture Quality. Geriatr Orthop Surg Rehabil 2022; 13:21514593221094730. [PMID: 35450301 PMCID: PMC9016569 DOI: 10.1177/21514593221094730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/30/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction The purpose of this study was to assess the hospital quality measures and
outcomes of operative hip fracture patients before and after implementation
of an anesthesiology department protocol assigning decision for a
preoperative transthoracic echocardiogram (TTE) to the hospitalist
co-managing physician. Materials and Methods Demographics, injury details, hospital quality measures, and outcomes were
reviewed for a consecutive series of patients presenting to our institution
with an operative hip fracture. In May of 2019, a new protocol assigning the
responsibility to indicate a patient for preoperative TTE was mandated to
the co-managing hospitalist at the institution. Patients were split into
pre-protocol and post-protocol cohorts. Linear regression modeling and
comparative analyses were conducted with a Bonferroni adjusted alpha as
appropriate. Results Between September 2015 and June 2021, 1002 patients presented to our
institution and were diagnosed with a hip fracture. Patients in the
post-protocol cohort were less likely to undergo a preoperative
echocardiogram, experienced a shorter time (days) to surgery, shorter length
of stay, an increase in amount of home discharges, and lower complication
risks for urinary tract infection and acute blood loss anemia as compared to
those in the pre-protocol cohort. There were no differences seen in
inpatient or 30-day mortality. Multivariable linear regression demonstrated
a patient’s comorbidity profile (Charlson Comorbidity Index (CCI)) and their
date of presentation (pre- or post-protocol), were both associated with
(P<0.01) a patients' time to surgery. Conclusion A standardized preoperative work flow protocol regarding which physician
evaluates and determines which patients require a preoperative TTE allows
for a streamlined perioperative course for hip fracture patients. This
allows for a shortened time to surgery and length of stay with an increase
in home discharges and was associated with a reduced risk of common index
hospitalization complications including UTI and anemia.
Collapse
Affiliation(s)
- Garrett Esper
- Department of Orthopedic Surgery, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| | - Utkarsh Anil
- Department of Orthopedic Surgery, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| | - Sanjit Konda
- Department of Orthopedic Surgery, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| | - David Furgiuele
- Department of Anesthesia, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| | - Jonah Zaretsky
- Department of Medicine, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| | - Kenneth Egol
- Department of Orthopedic Surgery, NYU Langone Health, Grossman School of Medicine, New York, NY, USA
| |
Collapse
|
5
|
Preoperative echocardiogram does not increase time to surgery in hip fracture patients with prior percutaneous coronary intervention. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1013-1022. [PMID: 35279771 DOI: 10.1007/s00590-022-03245-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/28/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The purpose of this study was to (1) assess the effect of preoperative echocardiogram on time to surgery and (2) assess the outcomes of patients with a previous percutaneous coronary intervention (PCI). METHODS Demographic, clinical, quality and cost data were obtained and a validated risk predictive tool (STTGMA) was calculated for each of a consecutive series of hip fracture patients. Comparative analyses of patients who had an echocardiogram prior to surgery or a PCI prior to hospitalization were performed. RESULTS Between 2014 and 2020, 2625 patients presented to our institution with a hip fracture. From this cohort 471 patients underwent a preoperative transthoracic echocardiogram (TTE), 30 who had a history of a PCI, and an additional 26 who had a history of PCI but did not undergo a preoperative TTE. Those undergoing a preoperative TTE had similar time (days) to surgery (1.73 vs 1.77, p = 0.86) and 30-day mortality (4% vs 7%, p = 0.545) regardless of PCI history. PCI patients who underwent a preoperative TTE experienced increased rates of 1-year mortality (27% vs 10%, p = 0.007) and major complications (23% vs 12%, p = 0.08) compared to those without a PCI history. PCI patients undergoing a preoperative TTE had a similar time (days) to surgery (1.77 vs 1.48, .p = 0.397) compared to PCI patients without a preoperative TTE. Patients who underwent a preoperative TTE had higher rates of 90-day readmission (31.0% vs 8.0%, p = 0.047) and 1-year mortality (26.7% vs 3.8%, p = 0.029). CONCLUSIONS Having a preoperative TTE does not affect surgical wait times in hip fracture patients regardless of PCI history, but it may not improve mortality outcomes or reduce postoperative complications in patients with a history of a PCI.
Collapse
|
6
|
Liao CY, Tan TL, Lu YD, Wu CT, Lee MS, Kuo FC. Does preoperative dipyridamole-thallium scanning reduce 90-day cardiac complications and 1-year mortality in patients with femoral neck fractures undergoing hemiarthroplasty? J Orthop Surg Res 2020; 15:385. [PMID: 32894146 PMCID: PMC7487939 DOI: 10.1186/s13018-020-01918-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 08/24/2020] [Indexed: 11/10/2022] Open
Abstract
Background This study aimed to evaluate the effect of dipyridamole-thallium scanning (DTS) on the rates of 90-day cardiac complications and 1-year mortality in patients with a femoral neck fracture treated with hemiarthroplasty. Methods Between 2008 and 2015, 844 consecutive patients who underwent cemented or cementless hemiarthroplasty were identified from the database of a single level-one medical center. One-hundred and thirteen patients (13%) underwent DTS prior to surgery, and 731 patients (87%) did not. Patient characteristics, comorbidities, surgical variables, and length of the delay until surgery were recorded. A propensity score-matched cohort was utilized to reduce recruitment bias in a 1:3 ratio of DTS group to control group, and multivariate logistic regression was performed to control confounding variables. Results The incidence of 90-day cardiac complications was 19.5% in the DTS group and 15.6% in the control group (p = 0.343) among 452 patients after propensity score-matching. The 1-year mortality rate (10.6% vs 13.3%, p = 0.462) was similar in the two groups. In the propensity score-matched patients, utilization of DTS was not associated with a reduction in the rate of 90-day cardiac complications (matched cohort, adjusted odds ratio [aOR] = 1.32; 95% confidence interval [CI] 0.75–2.33, p = 0.332) or the 1-year mortality rate (aOR = 0.62; 95% CI 0.27–1.42, p = 0.259). Risk factors for cardiac complications included an American Society of Anesthesiologists grade ≥ 3 (OR 3.19, 95% CI 1.44–7.08, p = 0.004) and pre-existing cardiac comorbidities (OR 5.56, 95% CI 3.35–9.25, p < 0.001). Risk factors for 1-year mortality were a long time to surgery (aOR 1.15, 95% CI 1.06–1.25, p = 0.001), a greater age (aOR 1.05, 95% CI 1.00 to 1.10, p = 0.040), a low body mass index (BMI; aOR 0.89, 95% CI 0.81–0.98, p = 0.015), and the presence of renal disease (aOR 4.43, 95% CI 1.71–11.46, p = 0.002). Discussion Preoperative DTS was not associated with reductions in the rates of 90-day cardiac complications or 1-year mortality in patients with a femoral neck fracture undergoing hemiarthroplasty. The necessity for DTS should be re-evaluated in elderly patients with femoral neck fractures, given that this increases the length of the delay until surgery. Level of evidence Prognostic level III
Collapse
Affiliation(s)
- Chin-Yi Liao
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan
| | - Timothy L Tan
- Rothman Institute Orthopedic Research Department, Thomas Jefferson University, Rothman Institute Sheridan Building, Suite 1000, 25 S 9th Street, Philadelphia, PA, 19107, USA
| | - Yu-Der Lu
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan
| | - Cheng-Ta Wu
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan
| | - Mel S Lee
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan
| | - Feng-Chih Kuo
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan.
| |
Collapse
|
7
|
Sinvani L, Mendelson DA, Sharma A, Nouryan CN, Fishbein JS, Qiu MG, Zeltser R, Makaryus AN, Wolf-Klein GP. Preoperative Noninvasive Cardiac Testing in Older Adults with Hip Fracture: A Multi-Site Study. J Am Geriatr Soc 2020; 68:1690-1697. [PMID: 32526816 DOI: 10.1111/jgs.16555] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 03/04/2020] [Accepted: 03/11/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES For older adults with acute hip fracture, use of preoperative noninvasive cardiac testing may lead to delays in surgery, thereby contributing to worse outcomes. Our study objective was to evaluate the preoperative use of pharmacologic stress testing and transthoracic echocardiogram (TTE) in older adults hospitalized with hip fracture. DESIGN Retrospective chart review. SETTING Seven hospitals (three tertiary, four community) within a large health system. PARTICIPANTS Patients, aged 65 years and older, hospitalized with hip fracture (n = 1,079; mean age = 84.2 years; 75% female; 82% white; 36% married). MEASUREMENTS Data were extracted from electronic medical records. The study evaluated associations between patient factors as well as clinical outcomes (time to surgery [TTS], length of stay [LOS], and in-hospital mortality) and the use of preoperative noninvasive cardiac testing (pharmacologic stress tests or TTE). Descriptive statistics were calculated. Cox regression was performed for both TTS and LOS (evaluated as time-dependent variable); logistic regression was used for in-hospital mortality. RESULTS Although 34.3% (n = 370) had a preoperative TTE, .7% (n = 8) underwent a nuclear stress test and none had a dobutamine stress echocardiogram. Median TTS was 1.1 days (IQR [interquartile range] = .8-1.8 days), median LOS was 5.3 days (IQR = 4.2-7.2 days), and in-hospital mortality was 3% (n = 32). Patients admitted to the medical service had 3.5 times greater odds of undergoing a TTE compared with those on the orthopedic service (P < .001). Community hospitals had almost three times greater odds of preoperative TTE than tertiary centers (P < .001). In multivariable analysis, preoperative TTE was significantly associated with increased TTS (P < .001). No difference in mortality was found between patients with and without a preoperative TTE. CONCLUSION This study highlights the high rate of TTE in preoperative assessment of older adults with acute hip fracture. Given the association between TTE and longer TTS, further studies must clarify the role of preoperative TTE in this population. J Am Geriatr Soc 68:1690-1697, 2020.
Collapse
Affiliation(s)
- Liron Sinvani
- Division of Hospital Medicine, Northwell Health System, Manhasset, New York, USA.,Department of Medicine, Northwell Health System, Manhasset, New York, USA.,Center for Health Innovations Research, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Daniel A Mendelson
- Department of Medicine, Division of Geriatrics and Aging, University of Rochester, Rochester, New York, USA
| | - Ankita Sharma
- Division of Hospital Medicine, Northwell Health System, Manhasset, New York, USA.,Department of Medicine, Northwell Health System, Manhasset, New York, USA
| | - Christian N Nouryan
- Division of Hospital Medicine, Northwell Health System, Manhasset, New York, USA.,Department of Medicine, Northwell Health System, Manhasset, New York, USA.,Center for Health Innovations Research, Feinstein Institutes for Medical Research, Manhasset, New York, USA.,Zucker School of Medicine at Hofstra/Northwell, Hempstead,, New York, USA
| | - Joanna S Fishbein
- Biostatistics Division, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Michael G Qiu
- Department of Medicine, Northwell Health System, Manhasset, New York, USA
| | - Roman Zeltser
- Department of Medicine, Northwell Health System, Manhasset, New York, USA.,Department of Cardiology, Nassau University Medical Center, East Meadow, New York, USA
| | - Amgad N Makaryus
- Department of Medicine, Northwell Health System, Manhasset, New York, USA.,Department of Cardiology, Nassau University Medical Center, East Meadow, New York, USA
| | - Gisele P Wolf-Klein
- Department of Medicine, Northwell Health System, Manhasset, New York, USA.,Zucker School of Medicine at Hofstra/Northwell, Hempstead,, New York, USA
| |
Collapse
|
8
|
Brink O. Hip fracture clearance: How much optimisation is necessary? Injury 2020; 51 Suppl 2:S111-S117. [PMID: 32081388 DOI: 10.1016/j.injury.2020.02.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/09/2020] [Indexed: 02/02/2023]
Abstract
Patients with hip fractures are typically elderly individuals with several co-morbidities. Upon admission to the hospital, they often present with acute pain, electrolyte disturbances, anaemia, coagulopathy, and delirium. Long waiting times for surgery are associated with increased morbidity and mortality. The balance between the number of clinical tests and optimisation, which may (i.e., fewer complications and better survival) or may not (i.e., more complications and increased mortality due to unnecessary surgical delay) benefit the patient, has been a preoperative challenge. This summary will review existing clinical guidelines and relevant selected studies to evaluate the extent of preoperative optimisation needed prior to hip fracture surgery.
Collapse
Affiliation(s)
- Ole Brink
- Department of Orthopaedic Surgery, Aarhus University Hospital, Palle Juel-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
| |
Collapse
|
9
|
Smeets SJM, van Wunnik BPW, Poeze M, Slooter GD, Verbruggen JPAM. Cardiac overscreening hip fracture patients. Arch Orthop Trauma Surg 2020; 140:33-41. [PMID: 31471640 PMCID: PMC6942037 DOI: 10.1007/s00402-019-03270-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND The aim of this study was to prospectively investigate the adherence to the American College of Cardiology (ACC) and the American Heart Association guidelines for perioperative assessment of patients with hip fracture in daily clinical practice and how this might affect outcome. METHODS This prospective cohort study from Maastricht University Medical Centre included 166 hip fracture patients within a 3-year inclusion period. The preoperative cardiac screening and adherence to the ACC/AHA guideline were analyzed. Cardiac risk was classified as low, intermediate and high risk. Secondary outcome measurements were delay to surgery, perioperative complications and in-hospital, 30-day, 1-year and 2-year mortality. RESULTS According to the ACC/AHA guideline, 87% of patients received correct preoperative cardiac screening. The most important reason for incorrect preoperative cardiac screening was overscreening (> 90%). Multivariate analysis showed that a cardiac consultation (p = 0.003) and overscreening (p = 0.02) as significant predictors for increased delay to surgery, while age, sex, previous cardiac history and preoperative mobility were not. High risk patients had in comparison with low risk patients a significantly higher relative risk ratio for in-hospital mortality (RR 6, 95% CI 2-17). Multivariate analysis showed that a previous cardiac history and increased delay to surgery were predictors for early mortality. High age and previous cardiac history were risk factors for late mortality. CONCLUSION Preoperative cardiac screening for hip fracture patients in adherence to the ACC/AHA guideline is associated with a diminished use of preoperative resources. Overscreening leads to greater delay to surgery, which poses a risk for perioperative complications and early mortality. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- S. J. M. Smeets
- Department of Surgery, Flevoziekenhuis, Hospitaalweg 1, 1315 RA Almere, The Netherlands
| | - B. P. W. van Wunnik
- Department of Surgery, Beatrixziekenhuis, Banneweg 57, 4204 AA Gorinchem, The Netherlands
| | - M. Poeze
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - G. D. Slooter
- Department of Surgery, Máxima Medical Center, De Run 4600, 5504 DB Veldhoven, The Netherlands
| | - J. P. A. M. Verbruggen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| |
Collapse
|
10
|
Butler SA, Salipas A, Rijt A. Comparative study of outcomes for elderly hip fractures presenting directly to a referral hospital versus those transferred from peripheral centres. ANZ J Surg 2019; 89:1314-1318. [DOI: 10.1111/ans.15419] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 07/31/2019] [Accepted: 08/08/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Stephen A. Butler
- Department of OrthopaedicsWagga Wagga Base Hospital Wagga Wagga New South Wales Australia
| | - Andrew Salipas
- Department of OrthopaedicsWagga Wagga Base Hospital Wagga Wagga New South Wales Australia
| | - Adrian Rijt
- Department of OrthopaedicsWagga Wagga Base Hospital Wagga Wagga New South Wales Australia
| |
Collapse
|
11
|
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]
|
12
|
Steinberg EL, Warschawski Y, Elis J, Rotman D, Rachevsky G, Factor S, Salai M, Ben-Tov T. Financial impact and effect on the outcome of preoperative tests for at-risk older hip fracture patients. Geriatr Gerontol Int 2018; 18:937-942. [PMID: 29512305 DOI: 10.1111/ggi.13295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/22/2017] [Accepted: 01/23/2018] [Indexed: 11/28/2022]
Abstract
AIM Older patients with proximal femoral fractures often undergo preoperative tests due to coexisting morbidities. Our aim was to evaluate these tests and their impact on patient outcome and medical expenses. METHODS This retrospective study includes data on head computed tomography, carotid ultrasound, echocardiography and pulmonary functional tests calculated according to the type of surgery (osteosynthesis or hip arthroplasty) carried out on 2798 patients. Time-to-surgery, test repeated postoperatively, American Society of Anesthesiology Physical Status score, additional procedures, hospitalization time, 30-day mortality and associated medical expenses were evaluated. RESULTS A total of 921 preoperative tests were carried out in 780 (28%) patients, and 375 postoperative tests were carried out in 329 (12%) patients (P < 0.001). A total of 23 procedures were carried out after surgery, none related to the originally carried out tests. Significant group differences were found for American Society of Anesthesiology Physical Status score, days to surgery, hospitalization time (days) and mortality rates. The medical expenses of these tests were 1.3% of the average income per case, and 0.6% of the average study group income. CONCLUSIONS Non-routine preoperative tests prolong time-to-surgery, increased hospitalization time and contribute to 30-day mortality. No postoperative procedure was related to preoperative test findings. The financial cost for these tests does not burden the medical expenses per procedure. Geriatr Gerontol Int 2018; 18: 937-942.
Collapse
Affiliation(s)
- Ely L Steinberg
- Orthopedic Division, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yaniv Warschawski
- Orthopedic Division, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jacob Elis
- Orthopedic Division, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dani Rotman
- Orthopedic Division, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gil Rachevsky
- Orthopedic Division, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shai Factor
- Orthopedic Division, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Moshe Salai
- Orthopedic Division, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tomer Ben-Tov
- Orthopedic Division, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| |
Collapse
|
13
|
Kalem M, Kocaoğlu H, Şahin E, Kocaoğlu MH, Başarır K, Kınık H. Impact of echocardiography on one-month and one-year mortality of intertrochanteric fracture patients. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2018; 52:97-100. [PMID: 29305047 PMCID: PMC6136316 DOI: 10.1016/j.aott.2017.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 09/15/2017] [Accepted: 12/18/2017] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The aim of this study was to analyze the effects of preoperative echocardiography on patient survival, timing of surgery in length of hospital stay in patients who will undergo hip nailing for an intertrochanteric fracture. METHODS The clinical records of the patients who were admitted to a tertiary university hospital with an intertrochanteric femur fracture were retrospectively analyzed. The age, gender, American Society of Anesthesiologists (ASA) score, days to surgery, total hospital stay, cardiac drug prescription/modification, cardiac intervention and presence of an echocardiography assessment including detailed findings were reviewed. Mortality data were accessed from the national civil registration system. RESULTS 181 (110 women and 71 men; mean age 81 (44-98)) cases were studied whom 65 underwent pre-operative echocardiography. Time to surgery and total hospital stay was 2 days longer at transthoracic echocardiography (TTE) group (p < 0.001). At one month control group survival rate was 93.1% on contrary it was 75.4% at TTE group. One-year survival rates were 77.3% and 55.1% respectively. Likewise mean expected survival time was 21.6 ± 1.03 months for control group and 15.12 ± 1.64 months for TTE group (p < 0.001). Only increased left ventricular end diastolic diameter (LVEDD) was showed to be associated with increasing one-year mortality with a hazard ratio of 10.78 (2.572-45.19) at multivariate model. CONCLUSION Cardiac findings and requisite for preoperative TTE and increased LVEDD is a strong predictor for mortality. TTE significantly lengthens the time to surgery. Also LVEDD measurement can be easily performed in the bedside which we believe would save time and reduce mortality. LEVEL OF EVIDENCE Level III Diagnostic study.
Collapse
Affiliation(s)
- Mahmut Kalem
- Ankara University Faculty of Medicine, Department of Orthopedics and Traumatology, Ankara, Turkey.
| | - Hakan Kocaoğlu
- Ankara University Faculty of Medicine, Department of Orthopedics and Traumatology, Ankara, Turkey
| | - Ercan Şahin
- Bulent Ecevit University Faculty of Medicine, Department of Orthopedics and Traumatology, Zonguldak, Turkey
| | - Merve H Kocaoğlu
- Ankara University Faculty of Medicine, Department of Anesthesiology and Reanimation, Ankara, Turkey
| | - Kerem Başarır
- Ankara University Faculty of Medicine, Department of Orthopedics and Traumatology, Ankara, Turkey
| | - Hakan Kınık
- Ankara University Faculty of Medicine, Department of Orthopedics and Traumatology, Ankara, Turkey
| |
Collapse
|
14
|
Sawhney C, Trikha V, Janani S, Bajwa SJS, Sharma V, Khanna M. Impact of Preoperative Echocardiography on Perioperative Management in Geriatric Hip Trauma: A Retrospective Observational Study. Int J Appl Basic Med Res 2017; 7:104-107. [PMID: 28584740 PMCID: PMC5441256 DOI: 10.4103/2229-516x.205816] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND AIM Hip fractures are associated with a significant risk of morbidity and mortality in the elderly population. Current guidelines propose that these patients should be operated as early as possible. Preoperative cardiac investigations, especially echocardiography, have been considered to delay surgery with few changes in the patient management. The present study has been conducted to evaluate whether preoperative echocardiography improve or worsen the prognosis in such hip trauma surgery. MATERIALS AND METHODS In this retrospective study, we reviewed the records of elderly patients with hip trauma operated in the tertiary care trauma center of our institute over a period of 1 year. Out of 120 patients, preoperative echocardiography was done in 30 patients. We compared the patients for whom echocardiography was done with the patients who did not undergo echocardiography. Descriptive statistical methods were used to analyze the results and observations. RESULTS We observed that preoperative transthoracic echocardiography led to an escalation in cardiac medication in 53% patients when compared with 23.3% in patients who did not undergo echocardiography. No preoperative cardiac intervention was done in any patient. However, there was a delay of 2.5 days in surgery in the echocardiography group as compared to the patients of nonechocardiography group. Rate of regional anesthesia was comparable in both the groups (54% vs. 56.6%). CONCLUSIONS In the present study, it was observed that echocardiography significantly delays surgery without a significant change in preoperative cardiac medication or anesthesia technique. This may have a potential possible adverse effect on the outcome in geriatric hip trauma which was not observed to a significant limit in the present study as the study was not a longitudinal study. For "fast tracking" of geriatric hip trauma, institutional guidelines should be developed depending on the resources available.
Collapse
Affiliation(s)
- Chhavi Sawhney
- Department of Anaesthesia, JPNATC, AIIMS, New Delhi, India
| | - Vivek Trikha
- Department of Orthopaedics, JPNATC, AIIMS, New Delhi, India
| | - Sai Janani
- Department of Anaesthesia, JPNATC, AIIMS, New Delhi, India
| | - Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Patiala, Punjab, India
| | - Vijay Sharma
- Department of Orthopaedics, JPNATC, AIIMS, New Delhi, India
| | - Menaal Khanna
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Patiala, Punjab, India
| |
Collapse
|
15
|
Heiberg J, El-Ansary D, Canty DJ, Royse AG, Royse CF. Focused echocardiography: a systematic review of diagnostic and clinical decision-making in anaesthesia and critical care. Anaesthesia 2016; 71:1091-100. [DOI: 10.1111/anae.13525] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2016] [Indexed: 01/15/2023]
Affiliation(s)
- J. Heiberg
- Department of Anaesthesia and Pain Management; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - D. El-Ansary
- Department of Physiotherapy; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - D. J. Canty
- Department of Anaesthesia and Pain Management; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - A. G. Royse
- Department of Surgery; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - C. F. Royse
- Department of Anaesthesia and Pain Management; Royal Melbourne Hospital; Melbourne Victoria Australia
| |
Collapse
|
16
|
Strotman P, Lack W, Bernstein M, Stover M, Summers H. Evaluation of Common Fractures of the Hip in the Elderly. CURRENT GERIATRICS REPORTS 2016. [DOI: 10.1007/s13670-016-0161-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
17
|
Abstract
Hip and spine fractures represent just a portion of the burden of osteoporosis; however, these fractures require treatment and often represent a major change in lifestyle for the patient and their family. The orthopedic surgeon plays a crucial role, not only in the treatment of these injuries but also providing guidance in prevention of future osteoporotic fractures. This review provides a brief epidemiology of the fractures, details the surgical techniques, and outlines the current treatment guidelines for orthopedic surgeons.
Collapse
Affiliation(s)
- Lisa K Cannada
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Brian W Hill
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| |
Collapse
|
18
|
Abstract
GOAL Geriatric trauma patients tend to have worse outcomes than their younger counterparts. The American Heart Association (AHA) recommends preoperative cardiac clearance to stratify patients according to perioperative cardiac risk. The utility of this in the trauma setting remains unclear. We sought to identify the role of preoperative echocardiograms (echo) in geriatric trauma patients. METHODS We performed a retrospective review of geriatric trauma patients who required operative intervention over a 1-year period. Patients with echocardiograms performed were compared with those who did not. RESULTS Three-hundred thirty geriatric trauma patients required an operation. A preoperative echo was performed in 25% (82/330). Abnormalities on echocardiogram were identified in 13% (11/82) of patients. One patient had a change in management based on the echo. None of the patients who died in the perioperative period had a management alteration as a result of the echo. Echo patients had a longer LOS and to operative intervention (P<.006). CONCLUSION Echocardiograms had an exceeding low rate of management change in the acutely injured geriatric trauma patient. Further studies to evaluate the need for echocardiogram in this population are warranted.
Collapse
|
19
|
Barber RL, Fletcher SN. A review of echocardiography in anaesthetic and peri-operative practice. Part 1: impact and utility. Anaesthesia 2014; 69:764-76. [DOI: 10.1111/anae.12663] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2014] [Indexed: 12/11/2022]
Affiliation(s)
| | - S. N. Fletcher
- St George's Hospital and Honorary Senior Lecturer; St George's University of London; London UK
| |
Collapse
|
20
|
Kates SL, O'Malley N, Friedman SM, Mendelson DA. Barriers to implementation of an organized geriatric fracture program. Geriatr Orthop Surg Rehabil 2013; 3:8-16. [PMID: 23569692 DOI: 10.1177/2151458512436423] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION There has been a recent increase in interest in implementing organized geriatric fracture programs for care of older adults with fragility fractures in order to improve both the quality and costs of care. Because such programs are relatively new, there are no standardized methods for implementation and no published descriptions of barriers to implementation. MATERIALS AND METHODS An online survey tool was sent to 185 surgeons and physicians practicing in the United States, who are involved with geriatric fracture care. Sixty-eight responses were received and evaluated. RESULTS Barriers identified included lack of medical and surgical leadership, need for a clinical case manager, lack of anesthesia department support, lack of hospital administration support, operating room time availability, and difficulty with cardiac clearance for surgery. Other issues important to implementation included quality improvement, cost reductions, cost to the hospital, infection prevention, readmission prevention, and dealing with competing interest groups and competing projects mandated by the government. Physicians and surgeons felt that a site visit to a functioning program was most important when considering implementing a hip fracture program. CONCLUSIONS This study provides useful insights into barriers to implementing an organized hip fracture program. The authors offer suggestions on ways to mitigate or overcome these barriers.
Collapse
Affiliation(s)
- Stephen L Kates
- Department of Orthopedics and Rehabilitation, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | | | | | | |
Collapse
|
21
|
Canty DJ, Royse CF, Kilpatrick D, Bowyer A, Royse AG. The impact on cardiac diagnosis and mortality of focused transthoracic echocardiography in hip fracture surgery patients with increased risk of cardiac disease: a retrospective cohort study. Anaesthesia 2012; 67:1202-9. [DOI: 10.1111/j.1365-2044.2012.07300.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
22
|
Lonjaret L, Lairez O, Fourcade O, Minville V. [Continuous spinal anesthesia and pulmonary arterial hypertension]. ACTA ACUST UNITED AC 2012; 31:810-2. [PMID: 22925944 DOI: 10.1016/j.annfar.2012.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 07/18/2012] [Indexed: 11/29/2022]
Abstract
We report the use of continuous spinal anesthesia for hip fracture surgery in a patient with pulmonary arterial hypertension. Preoperative evaluation, anesthetic technique and preoperative monitoring are discussed.
Collapse
Affiliation(s)
- L Lonjaret
- Coordination d'anesthésie, université Paul-Sabatier, hôpital Purpan, centre hospitalier universitaire de Toulouse, place du Dr-Baylac, 31059 Toulouse cedex 9, France.
| | | | | | | |
Collapse
|
23
|
Emergency department echocardiography for preoperative patients at high risk of underlying cardiac disease. J Trauma Acute Care Surg 2012; 72:1724-5; author reply 1725. [PMID: 22695450 DOI: 10.1097/ta.0b013e31825159a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
24
|
Lonjaret L, Lairez O, Minville V. Echocardiographic assessment by anaesthetists. Anaesthesia 2012; 67:794; author reply 795-6. [DOI: 10.1111/j.1365-2044.2012.07181.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|