Principles for management of hip fracture for older adults taking direct oral anticoagulants: an international consensus statement

Hip fracture is a common serious injury among older adults, yet the management of hip fractures for patients taking direct oral anticoagulants remains inconsistent worldwide. Drawing from a synthesis of available evidence and expert opinion, best practice approaches for managing patients with a hip fracture and who are taking direct oral anticoagulants pre-operatively were considered by a working group of the Fragility Fracture Network Hip Fracture Audit Special Interest Group. The literature and related clinical guidelines were reviewed and a two-round modified Delphi study was conducted with a panel of experts from 16 countries and involved seven clinical specialities. Four consensus statements were achieved: peripheral nerve blocks can reasonably be performed on presentation for patients with hip fracture who are receiving direct oral anticoagulants; hip fracture surgery can reasonably be performed for patients taking direct oral anticoagulants < 36 h from last dose; general anaesthesia could reasonably be administered for patients with hip fracture and who are taking direct oral anticoagulants < 36 h from last dose (assuming eGFR > 60 ml.min-1.1.73 m-2); and it is generally reasonable to consider recommencing direct oral anticoagulants (considering blood loss and haemoglobin) < 48 h after hip fracture surgery. No consensus was achieved regarding timing of spinal anaesthesia. The consensus statements were developed to aid clinicians in their decision-making and to reduce practice variations in the management of patients with hip fracture and who are taking direct oral anticoagulants. Each statement will need to be considered specific to each individual patient's treatment.

Comparing perioperative outcomes between regional anesthesia and general anesthesia in patients undergoing hip fracture surgery: a systematic review and meta-analysis

PURPOSE

Nearly all patients with hip fractures undergo surgical treatment. The use of different anesthesia techniques during surgery may influence the clinical outcomes. The optimal anesthetic technique for patients undergoing hip fracture surgery is still controversial. We performed this updated systematic review and meta-analysis to compare clinical outcomes of patients undergoing hip fracture surgery with different anesthesia techniques.

SOURCE

Articles published from 2000 to May 2023 were included from MEDLINE, Embase, Web of Science, and the Cochrane Library. We included randomized controlled trials and observational studies comparing general anesthesia (GA) with regional anesthesia (RA) for the outcomes of 30-day mortality, 90-day mortality, in-hospital mortality, perioperative complications, length of hospital stay, and length of surgery in patients undergoing hip fracture surgery. Subgroup analyses were performed for the outcomes based on study design (randomized controlled trials or observational studies). We used a random-effects model for all analyses.

PRINCIPAL FINDINGS

In this meta-analysis, we included 12 randomized controlled trials. There was no difference in postoperative 30-day mortality between the two groups (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.44 to 1.74; I2 = 0%). The incidence of intraoperative hypotension was lower in patients who received RA vs GA (OR, 0.52; 95% CI, 0.38 to 0.72; I2 = 0%). No significant differences were observed in 90-day mortality, in-hospital mortality, postoperative delirium, pneumonia, myocardial infarction, venous thromboembolism, length of surgery, and length of hospital stay.

CONCLUSION

In this updated systematic review and meta-analysis, RA did not reduce postoperative 30-day mortality in hip fracture surgery patients compared to GA. Fewer patients receiving RA had intraoperative hypotension than those receiving GA did. Apart from intraoperative hypotension, the data showed no differences in complications between the two anesthetic techniques.

STUDY REGISTRATION

PROSPERO (CRD42023411854); registered 7 April 2023.

A retrospective, observational, single-centre, cohort database analysis of the haemodynamic effects of low-dose spinal anaesthesia for hip fracture surgery

Background

Careful administration of either spinal (intrathecal) or general anaesthesia probably has a greater impact on outcomes after hip fracture surgery than which method is used per se. Intraoperative hypotension is associated with poorer outcomes, but appears less prevalent using lower doses of spinal anaesthesia.

Methods

In this observational single-centre study, intraoperative noninvasive blood pressure data were analysed from 280 patients undergoing unilateral hip fracture surgery after the administration of hyperbaric spinal bupivacaine 0.5%, 1.3 ml (0.65 mg).

Results

Mean cohort mean arterial pressure (MAP) remained within 10% of baseline (spinal injection) MAP for 97/98 (99.0%) subsequent aggregated 1-min recording intervals. The prevalences of lowest MAP <70 mm Hg and <55 mm Hg were significantly lower than historical equivalents (Anaesthesia Sprint Audit of Practice 1 and 2) (52.9% and 10.4% vs 71.9% and 23.8%, respectively, both <0.0001). The proportions of 10 551 MAP readings <70 mm Hg and <55 mm Hg were 6.7% and 0.4%, respectively. Forty-five (16.1%) patients had relatively persistent hypotension (MAP ≤70 mm Hg for five or more intraoperative readings), and were statistically more likely to be frail (Nottingham Hip Fracture Score ≥7/10, 37.8% vs 19.6%, P=0.0109) and be taking alpha-/beta-blockers (44.4% vs 24.3%, P=0.0099) than the remaining 'normotensive' cohort. Surgical anaesthesia remained effective for up to 190 min, with only one patient requiring supplemental local anaesthesia during skin closure.

Conclusions

Low doses of hyperbaric spinal 0.5% bupivacaine (1.3 ml, 6.5 mg) are associated with minimal reductions in blood pressure during surgery and provide adequate duration of surgical anaesthesia. Randomised comparisons of lower vs higher/standard doses of spinal anaesthesia are now required to confirm outcome benefits in this vulnerable patient group.

Clinical trial registration

NCT05799300.

Oral midodrine for prophylaxis against post-spinal anesthesia hypotension during hip arthroplasty in elderly population: a randomized controlled trial

BACKGROUND

We aimed to evaluate the efficacy of midodrine as a prophylaxis against post-spinal hypotension in elderly patients undergoing hip arthroplasty.

METHODS

This randomized controlled trial included elderly patients undergoing hip arthroplasty under spinal anesthesia. Ninety minutes before the procedure, patients were randomized to receive either 5-mg midodrine or placebo (metoclopramide). After spinal anesthesia, mean arterial pressure (MAP) and heart rate were monitored every 2 min for 20 min then every 5 min until the end of the procedure. Post-spinal hypotension (MAP < 80% baseline) was treated with 10 mg ephedrine. The primary outcome was intraoperative ephedrine consumption. Secondary outcomes were the incidence of post-spinal hypotension, bradycardia, and hypertension (MAP increased by > 20% of the baseline reading).

RESULTS

We analyzed 29 patients in the midodrine group and 27 in the control group. The intraoperative ephedrine consumption was lower in the midodrine group than in the control group (median [quartiles]: 10 [0, 30] mg versus 30 [20, 43] mg, respectively, P-value: 0.002); and the incidence of intraoperative hypotension was lower in the midodrine group than that in the control group. The incidence of hypertension and bradycardia were comparable between the two groups.

CONCLUSION

The use of 5 mg oral midodrine decreased the vasopressor requirements and incidence of hypotension after spinal anesthesia for hip surgery in elderly patients.

CLINICAL TRIAL REGISTRATION

This study was registered on September 22, 2022 at clinicaltrials.gov registry, NCT05548985, URL: https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05548985 .

The Analysis of Multiple Outcomes between General and Regional Anesthesia in Hip Fracture Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Surgical interventions in hip fracture have been associated with multiple adverse events, including perioperative hypotension and mortality, making the choice of the anesthetic method for this procedure crucial. There is still no consensus on whether regional (RA) or general (GA) anesthesia should be used to maintain hemodynamic stability and more favorable outcomes. Therefore, this meta-analysis examines the differences between RA and GA groups in the incidence of mortality, intraoperative hypotension, and other intra- and postoperative complications. The comparison is essential given the rising global prevalence of hip fractures and the need to optimize anesthesia strategies for improved patient outcomes, particularly in an aging population. We followed PRISMA guidelines (PROSPERO #CRD42022320413). We conducted the search for studies published in English before March 2022 in PubMed, Google Scholar, and the Cochrane Library. We included RCTs that compared general and regional anesthesia in adult patients having hip fracture surgical interventions. The primary outcome was perioperative mortality. The secondary outcomes were peri- or postoperative complications and duration of hospital stay. We conducted a meta-analysis in RevMan (version 5.4). We examined the quality of the methodology with the Cochrane risk of bias 2 tool, while the quality of evidence was determined with GRADE. Fifteen studies with 4110 patients were included. Our findings revealed no significant difference between general and regional anesthesia in risk of perioperative mortality (RR = 1.42 [0.96, 2.10], p-value = 0.08), intraoperative complications, or duration of hospital length of stay. Our results suggest that regional anesthesia and general anesthesia have comparable safety and can be used as alternatives based on specific patient requirements.

Comparing the Effect of Spinal and General Anesthesia for Hip Fracture Surgery in Older Patients: A Meta-analysis of Randomized Clinical Trials

OBJECTIVE

Hip fractures are the most common fractures among older adults, with most patients undergoing surgery. The debate regarding the type of anesthetic technique for hip fracture surgery is still ongoing. This meta-analysis aimed to compare the intraoperative and postoperative outcomes of spinal and general anesthesia in older patients undergoing hip fracture surgery.

METHODS

Eligible studies that compared the effects of spinal and general anesthesia were systematically searched from PubMed, Embase, and the Cochrane Library until May 27, 2022. The intraoperative and postoperative outcomes of the two anesthesia techniques were compared. Quality assessment, heterogeneity analysis, and publication bias of the studies were also assessed.

RESULTS

Nine articles of methodological quality were included in the meta-analysis. The pooled results revealed that there were significant differences in hypotension (risk ratio [RR] (95% confidence interval [CI]) = 0.81 (0.68, 0.97), p = 0.02) and ephedrine dose (weighted mean difference [WMD] [95%CI] = -20.94 [-37.50, -4.37] mg, p = 0.01) between the spinal and general anesthesia groups. However, no significant differences were observed in the use of ephedrine (RR [95% CI] = 0.77 [0.19, 3.05]), blood loss (WMD [95%CI] = -34.38 [-89.56, 20.80) mL], myocardial infarction (RR [95% CI] = 0.78 [0.31, 1.94] mL), heart failure (RR [95% CI] = 0.87 [0.17, 4.36] mL), stroke (RR [95%CI) = 0.65 [0.22, 1.95] mL), postoperative nausea and vomiting (RR [95% CI] = 0.88 [0.17, 4.35] mL), delirium (RR [95% CI] = 1.08 [0.89, 1.31] mL), and mortality (RR [95% CI] = 1.10 [0.72, 1.68] mL) (all p < 0.05). No publication bias was observed in any of the included studies.

CONCLUSION

Compared to general anesthesia, spinal anesthesia was associated with a lower risk of intraoperative hypotension and lower doses of ephedrine in older patients undergoing hip fracture surgery.

Protective effect of sevoflurane on lung function of elderly chronic obstructive pulmonary disease patients undergoing total hip arthroplasty

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a common respiratory disorder that affects the elderly population and increases the risk of postoperative pulmonary complications (PPCs) after major surgeries. Sevoflurane is a volatile anesthetic that has been shown to have anti-inflammatory and antioxidant properties and attenuate lung injury in animal models.

AIM

To evaluate the protective effect of sevoflurane on the lung function of elderly COPD patients undergoing total hip arthroplasty (THA).

METHODS

In this randomized controlled trial, we randomly assigned 120 elderly patients with COPD, who were scheduled for THA, to receive either sevoflurane (sevoflurane group) or propofol (propofol group) as the maintenance anesthetic. The primary outcome was the incidence of PPCs within seven days after surgery. The secondary outcomes were changes in the lung function parameters, inflammatory markers, oxidative stress markers, and postoperative pain scores.

RESULTS

The results showed that the incidence of PPCs was significantly lower in the sevoflurane group than in the propofol group (10% vs 25%, P = 0.02). Furthermore, the decline in the forced expiratory volume in 1 s, forced vital capacity, and peak expiratory flow was significantly lesser in the sevoflurane group than in the propofol group at 24 h and 48 h after surgery (P < 0.05). The interleukin-6, tumor necrosis factor-alpha, malondialdehyde, and 8-hydroxy-2 α-deoxyguanosine levels were significantly lower in the sevoflurane group than in the propofol group at 24 h after surgery (P < 0.05). The sevoflurane group showed significantly lower postoperative pain scores than the propofol group at 6 h, 12 h, and 24 h after surgery (P < 0.05).

CONCLUSION

Sevoflurane protects the lung function of elderly COPD patients undergoing THA under general anesthesia by reducing the incidence of PPCs, attenuating inflammatory and oxidative stress responses, and alleviating postoperative pain.

The Outcome of Surgically Treated Proximal Femur Fractures Managed by Ortho-anesthetic Geriatric Care Pathway: A Prospective Observational Study with 2-Year Follow-Up

Background

Evaluation of the ortho-anesthetic geriatric care pathway for patients with proximal femur fracture in a tertiary care referral center was done by reporting the peri-operative morbidity and mortality. Clinical and demographic predictors of mortality were also identified in this cohort.

Material and Methods

This prospective observational study was conducted between August 2017 and November 2018. Demographic, anesthetic and surgical characteristics were recorded. Telephonic post-discharge follow-up was done for a period of 2 years. Factors predicting mortality were estimated using multivariate logistic regression.

Results

The cohort was characterized by frailty, high ASA physical status, NYHA class and Charlson co-morbidity index. The delay in presentation to hospital and subsequent surgical fixation was 7 (1-8) and 8 (5-13) days, respectively. The 30, 60, 90-day, 1-year and 2-year mortality was 13.6%, 21.8%, 25.45%, 36.5% and 44%, respectively. Intra-operative blood transfusion was a predictor of 30-day mortality (OR 9.2, 95% CI 1.02-83.17; p = 0.048). Pre-operative respiratory dysfunction predicted 60-day (OR 11.245, 95% CI 1.38-91.58; p = 0.024) and 90-day (OR 11.654, 95% CI 1.91-71.1; p = 0.008) mortality. Post-operative morbidity was reported in 31 (28.1%) patients; incidence of pneumonia (n = 9), sepsis (n = 8), MI (n = 6), PTE (n = 5) and ARF (n = 3) were 8.18%, 7.27%, 5.45%, 4.54% and 2.72%, respectively.

Conclusion

Existing pathway facilitated surgical fixation with median delay of 8 days which should be shortened to 48 h. High mortality in our cohort needs to be decreased by preventing admission delays and aggressively managing co-morbidities. Acceptable benchmark goals for pre-operative optimization of lung disease and decrease in intra-operative blood transfusion need to be incorporated in existing care pathway.

Perioperative outcomes in different anesthesia techniques for patients undergoing hip fracture surgery: a systematic review and meta-analysis

BACKGROUND

Previous studies of the perioperative effects of general and regional anesthesia in adult patients undergoing effects of different anesthesia techniques on patients undergoing hip fracture surgery have not produced consistent results. The aim of this systematic review and meta-analysis was to compare the hip fracture surgery.

METHODS

We performed a systematic review and meta-analysis to compare the effects of general anesthesia with regional anesthesia on in-hospital mortality, 30-day mortality, postoperative pneumonia, and delirium in adult hip fracture patients (≥ 18 years). Between January 1, 2022, and March 31, 2023, a systematic search was performed for retrospective observational and prospective randomized controlled studies in PubMed, Ovid Medline, Cochrane Library, and Scopus.

RESULTS

Twenty-one studies including 363,470 patients showed higher in-hospital mortality in the general anesthesia group compared with regional anesthesia (OR = 1.21; 95% CI 1.13-1.29; P < 0.001, n = 191,511). The 30-day mortality (OR = 1.00; 95% CI 0.96-1.05; P = 0.95, n = 163,811), the incidence of postoperative pneumonia (OR = 0.93; 95% CI 0.82-1.06; P = 0.28, n = 36,743) and the occurrence of postoperative delirium in the two groups (OR = 0.94; 95% CI 0.74-1.20; P = 0.61, n = 2861) had no significant difference.

CONCLUSION

Regional anesthesia is associated with reduced in-hospital mortality. However, the type of anesthesia did not affect the occurrence of 30-day mortality, postoperative pneumonia, and delirium. A large number of randomized studies are needed in the future to examine the relationship between type of anesthesia, postoperative complications, and mortality.

Association of intraoperative hypotension and severe postoperative complications during non-cardiac surgery in adult patients: A systematic review and meta-analysis

Background

Intraoperative hypotension (IOH) is a common side effect of non-cardiac surgery that might induce poor postoperative outcomes. The relationship between the IOH and severe postoperative complications is still unclear. Thus, we summarized the existing literature to evaluate whether IOH contributes to developing severe postoperative complications during non-cardiac surgery.

Methods

We conducted a comprehensive search of PubMed, Embase, Cochrane Library, Web of Science, and the CBM from inception to 15 September 2022. The primary outcomes were 30-day mortality, acute kidney injury (AKI), major adverse cardiac events (myocardial injury or myocardial infarction), postoperative cognitive dysfunction (POCD), and postoperative delirium (POD). Secondary outcomes included surgical-site infection (SSI), stroke, and 1-year mortality.

Results

72 studies (3 randomized; 69 non-randomized) were included in this study. Low-quality evidence showed IOH resulted in an increased risk of 30-day mortality (OR, 1.85; 95% CI, 1.30-2.64; P < .001), AKI (OR, 2.69; 95% CI, 2.15-3.37; P < .001), and stroke (OR, 1.33; 95% CI, 1.21-1.46; P < .001) after non-cardiac surgery than non-IOH. Very low-quality evidence showed IOH was associated with a higher risk of myocardial injury (OR, 2.00; 95% CI, 1.17-3.43; P = .01), myocardial infarction (OR, 2.11; 95% CI, 1.41-3.16; P < .001), and POD (OR, 2.27; 95% CI, 1.53-3.38; P < .001). Very low-quality evidence showed IOH have a similar incidence of POCD (OR, 2.82; 95% CI, 0.83-9.50; P = .10) and 1-year-mortality (OR, 1.66; 95% CI, 0.65-4.20; P = .29) compared with non-IOH in non-cardiac surgery.

Conclusion

Our results suggest IOH was associated with an increased risk of severe postoperative complications after non-cardiac surgery than non-IOH. IOH is a potentially avoidable hazard that should be closely monitored during non-cardiac surgery.

There is (probably) no (meaningful) difference in (most) outcomes between 'spinal' and 'general' anaesthesia for hip fracture surgery: time to move forward

A meta-analysis influenced by two recent large randomised controlled trials (REGAIN and RAGA) concluded that little, if any, difference in commonly measured outcomes exists between patients administered spinal or general anaesthesia for their hip fracture surgery. We explore whether there is genuinely no difference, or what the methodological problems in research might be that prevent any real difference from being observed. We also discuss the need for greater nuance in future research to determine how anaesthetists might deliver perioperative care towards improving postoperative recovery trajectories in patients following hip fracture.

Effect of perioperative ultrasound guided fascia iliaca compartment block in elderly adults with hip fractures undergoing arthroplasty in spinal anesthesia-a randomized controlled trial

BACKGROUND

For elderly adults undergoing hip arthroplasty, fascia iliaca compartment block (FICB) is often used before spinal anesthesia to reduce the pain of posture placement. However, the impact of FICB within 48 h needs further study.

METHODS

89 elderly adults scheduled to undergo arthroplasty for hip fracture were enrolled and randomized into the FICB group (n = 45) and the control group (n = 44). The fascia iliaca on the operated side was located using ultrasound, and a puncture needle was placed under the fascia iliaca. The FICB group was injected with 40 ml of 0.5% ropivacaine, and the control group was injected with 40 ml of normal saline. Spinal anesthesia was performed after 20 min. Our primary outcome measures were: duration of analgesia, muscle strength, and Quality of Recovery (QoR).

RESULTS

The duration of analgesia in the FICB group was 403.5 ± 39.6 min, which was longer than that (357.5 ± 35.9 min) of the control group (P = 0.012). There were 19 (42.2%) patients with muscle strength of grade 4 in the FICB group and 36 (81.8%) patients with muscle strength of grade 4 in the control group. FICB group was lower (P < 0.001). QoR-15 at 24 h after surgery was 114.1 ± 8.3 in the FICB group and 104.6 ± 8.4 in the control group (P < 0.001). QoR-15 at 48 h after surgery was 122.7 ± 8.4 in the FICB group and 120.5 ± 9.5 in the control group (P = 0.232).

CONCLUSIONS

For elderly adults with hip fractures, FICB provided longer analgesia and improved 24-h QoR, but reduced postoperative muscle strength.

TRAIL REGISTRATION

Chinese Clinical Registry Center, ChiCTR2200056937, 23/02/2022.

Operative room time comparison between general and spinal anesthesia in total hip arthroplasty: an institutional study

PURPOSE

A relatively high expense with any procedure is total operative time; two components being the time spent anesthetizing the patient and time spent transferring the patient out of the operating room (OR). Both times can be affected by the anesthetic method used. This study compares different operative time intervals for both spinal anesthesia (SA) and general anesthesia (GA), in patients undergoing a primary total hip arthroplasty (THA), to identify the most appropriate and cost-effective anesthetic method.

METHODS

A retrospective chart review was performed at a single institution for primary total hip arthroplasty procedures performed in the year 2019. Primary THAs without complications performed by three orthopedic surgeons were selected. Anesthesia records for 200 patients were used to compare perioperative time intervals; 100 consecutive patients that received SA and 100 consecutive patients that received GA.

RESULTS

The time spent transferring the patient out of the operating room was 8 min for GA and 5 min for SA (p < 0.001). Total operative time for GA was 90 min and 87 min for SA (p = 0.3330). Total pre-operative time averaged 26 min in SA compared to 25 min in GA (p = 0.5874). Non-operative total time (all time components of patient interaction excluding surgery start to surgery finish) was significantly shorter in SA with an average of 52 compared to 56 in GA (p = 0.0151).

CONCLUSION

Time to transfer patient out of the OR and total non-operative time was significantly shorter in patients who received spinal anesthesia. These results and the complications of both general and spinal anesthesia should be taken into consideration when anesthetizing patients undergoing primary THA.

LEVEL OF EVIDENCE

III.

A retrospective observational study on the types of anaesthesia in hip fracture surgery

BACKGROUND

There is no specific recommendation regarding the type of anaesthesia in hip fracture surgery.

OBJECTIVES

This study sought to examine the current local anaesthetic practice (general anaesthesia versus regional anaesthesia (RA)) in hip fracture surgery and to analyse their associations with perioperative outcomes.

METHODOLOGY

A retrospective observational study of hip fracture patients from April to December 2017 was undertaken. Patient characteristics and perioperative outcomes were analysed against the types of anaesthesia using multiple logistic regression.

RESULTS

One hundred and twelve out of 154 patients (72.7%) had a general anaesthesia. Patients from residential care facilities were more likely to receive general anaesthesia (OR = 2.9, 95% CI: 1.1, 7.4; P = 0.03). There was no significant association between type of anaesthesia and specific postoperative outcomes; however, patients with postoperative delirium and hypotension were more likely to have received general anaesthesia [OR = 1.7, 95% CI: 0.68, 4.38; P = 0.25] and [OR = 1.6, 95% CI: 0.67, 4.04; P = 0.27] respectively). Subgroup analysis showed increased length of stay with patients who underwent general anaesthesia (OR = 1.26, 95% CI:1.04, 1.54; P = 0.02).

CONCLUSION

Regional anaesthesia may be considered in patients without contraindications in view of increased risk of postoperative delirium and hypotension, and longer length of stay with general anaesthesia. A larger prospective study is needed to confirm these findings.

The efficacy and safety of pre-emptive methoxamine infusion in preventing hypotension by in elderly patients receiving spinal anesthesia: A PRISMA-compliant protocol for systematic review and meta-analysis

BACKGROUND

Hypotension is frequent after spinal anesthesia, especially in elderly patients. Whether pre-emptive methoxamine infusion is effective and safe to prevent spinal anesthesia-induced hypotension is still a controversial issue, to dress this knowledge lack, we performed a systemic review and meta-analysis to evaluated it.

PARTICIPANTS

Elderly patients undergoing spinal anesthesia.

INTERVENTIONS

Administration of methoxamine prior to spinal anesthesia.

METHODS

We searched PUBMED, Cochrane Library, EMBASE, China National Knowledge Infrastructure, Wanfang Database, and VIP Database, Chinese BioMedical Literature & Retrieval System from January 1st 1978 to February 28th 2022. Primary outcomes of interests included hemodynamic parameters, such as systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate. Secondary outcomes of interests included the incidence of intraoperative hypotension, bradycardia, nausea and vomiting, vasopressors requirement, intraoperative blood loss. For continuous or dichotomous variables, treatment effects were calculated as weighted mean difference or odds ratio, respectively.

RESULTS

Our search yielded 8 randomized controlled trials including 480 patients, and 240 patients were allocated into methoxamine group and 240 into control group. Meta-analysis demonstrated that pre-emptive methoxamine infusion in preventing hypotension by in elderly patients receiving spinal anesthesia had higher blood pressures, lower heart rates. Compared with the control group, the incidence of perioperative hypotension in elderly patients was lower, and elderly patients had less requirement for vasopressor in methoxamine group.

CONCLUSION

This meta-analysis demonstrated that pre-emptive methoxamine infusion in elderly patients receiving spinal anesthesia can improve blood pressure, slow down heart rate, reduce the incidence of hypotension and requirement for vasopressor. However, these findings should be interpreted rigorously. Further well-conducted trials are required to confirm this.

Pressure response to fluid challenge administration in hypotensive surgical patients: a post-hoc pharmacodynamic analysis of five datasets

In this study we evaluated the effect of fluid challenge (FC) administration in elective surgical patients with low or normal blood pressure. Secondarily, we appraised the pharmacodynamic effect of FC in normotensive and hypotensive patients. We assessed five merged datasets of patients with a baseline mean arterial pressure (MAP) above or below 65 mmHg and assessed the changes of systolic, diastolic, mean and dicrotic arterial pressures, dynamic indexes of fluid responsiveness and arterial elastance over a 10-min infusion. The hemodynamic effect was assessed by considering the net area under the curve (AUC), the maximal percentage difference from baseline (d_max), the time when the maximal value was observed (t_max) and change from baseline at 5-min (d₅) after FC end. A stroke volume index increase > 10% with respect to the baseline value after FC administration indicated fluid response. Two hundred-seventeen patients were analysed [102 (47.0%) fluid responders]. On average, FC restored a MAP [Formula: see text] 65 mmHg after 5 min. The AUCs and the d_max of pressure variables and arterial elastance of hypotensive patients were all significantly greater than normotensive patients. Pressure variables and arterial elastance changes in the hypotensive group were all significantly higher at d₅ as compared to the normotensive group. In hypotensive patients, FC restores a MAP [Formula: see text] 65 mmHg after 5 min from infusion start. The hemodynamic profile of FC in hypotensive and normotensive patients is different; both the magnitude of pressure augmentation and duration is greater in the hypotensive group.

The influence of mode of anaesthesia on perioperative outcomes in people with hip fracture: a prospective cohort study from the National Hip Fracture Database for England, Wales and Northern Ireland

BACKGROUND

Delirium is common after hip fracture surgery, affecting up to 50% of patients. The incidence of delirium may be influenced by mode and conduct of anaesthesia. We examined the effect of spinal anaesthesia (with and without sedation) compared with general anaesthesia on early outcomes following hip fracture surgery, including delirium.

METHODS

We used prospective data on 107,028 patients (2018 to 2019) from the National Hip Fracture Database, which records all hip fractures in patients aged 60 years and over in England, Wales and Northern Ireland. Patients were grouped by anaesthesia: general (58,727; 55%), spinal without sedation (31,484; 29%), and spinal with sedation (16,817; 16%). Outcomes (4AT score on post-operative delirium screening; mobilisation day one post-operatively; length of hospital stay; discharge destination; 30-day mortality) were compared between anaesthetic groups using multivariable logistic and linear regression models.

RESULTS

Compared with general anaesthesia, spinal anaesthesia without sedation (but not spinal with sedation) was associated with a significantly reduced risk of delirium (odds ratio (OR)=0.95, 95% confidence interval (CI)=0.92-0.98), increased likelihood of day one mobilisation (OR=1.06, CI=1.02-1.10) and return to original residence (OR=1.04, CI=1.00-1.07). Spinal without sedation (p<0.001) and spinal with sedation (p=0.001) were both associated with shorter hospital stays compared with general anaesthesia. No differences in mortality were observed between anaesthetic groups.

CONCLUSIONS

Spinal and general anaesthesia achieve similar outcomes for patients with hip fracture. However, this equivalence appears to reflect improved perioperative outcomes (including a reduced risk of delirium, increased likelihood of mobilisation day one post-operatively, shorter length of hospital stay and improved likelihood of returning to previous residence on discharge) among the sub-set of patients who received spinal anaesthesia without sedation. The role and effect of sedation should be studied in future trials of hip fracture patients undergoing spinal anaesthesia.

The impact of regional versus general anesthesia on postoperative neurocognitive outcomes in elderly patients undergoing hip fracture surgery: A systematic review and meta-analysis

BACKGROUND

Randomized trials have shown conflicting results regarding differences in outcomes according to anesthesia type on the prevalence of postoperative delirium (POD) or postoperative cognitive dysfunction (POCD) in hip surgery patients. The aim of this Meta analysis is to compare the effect of general and regional anesthesia in older patients undergoing hip fracture surgery.

METHODS

A literature search for meta-analysis was performed using Pubmed, The Cochrane Library, Embase and Web of Science citation index for randomized controlled trials (RCTs) to compare the regional anesthesia (RA) to general anesthesia (GA) for postoperative outcomes in elderly undergoing hip fracture surgery till June 2022. The primary outcomes were the incidence of POD or POCD at 24 h, 3 days and 7 days postoperatively. The secondary outcomes were 30 days mortality rate and other adverse events. The risk of bias was assessed using the Cochrane methodology.

RESULTS

Eight studies including 3555 elderly patients over 65 years old showed that there was no significant difference in the prevalence of POD or POCD between RA and GA at 24 h [OR 0.73; 95% coincidence interval (CI) 0.19, 2.71, I2 = 53%; n = 452; P = 0.63], at 3 days [OR 1.03; 95% CI 0.79, 1.35, I2 = 0%; n = 1362; P = 0.82], at 7 days [OR 0.79; 95% CI 0.41, 1.52, I2 = 51%; n = 1336; P = 0.47], respectively. No significant differences were observed in the incidence of other adverse events.

CONCLUSIONS

No significant difference was found in the incidence of cognitive dysfunction after either general or regional anesthesia in elderly patients. Our finding of similar outcomes at 24 h, 3 days and 7 days postoperatively with either technique suggests that anesthesia choices for hip-fracture surgery may be based on the individual characteristics of each patient rather than on anticipated differences in clinical outcomes.

A systematic review and meta-analysis of anesthesia type on hip fracture post-surgery outcomes

Objective

To compare technical, clinical, and safety outcomes among hip fracture patients treated with procedures supplemented by general anesthesia (GA) or spinal/regional anesthesia (S/R).

Data sources

We searched for original studies on PubMed, Ovid MEDLINE, Ovid Embase, and Cochrane databases.

Study selection

Studies that reported clinical outcomes in patients that underwent hip fracture surgery, had available data on type of anesthesia administered, and clinical follow-up data were selected for data extraction.

Data extraction

The primary outcomes of interest were odds of mortality, including in-hospital, 30-day, 90-day, and 1-year mortality. Various adverse events (AEs) were also compared.

Data synthesis

Twenty-eight studies met our selection criteria, including 190,394 patients. A total of 107,314 (56.4%) patients were treated with procedures involving GA while 83,080 (43.6%) were treated with procedures involving S/R. There was no difference in 30-day or >1-year mortality rates between the GA and SR groups; however, compared to S/R group, the GA group had a significantly higher odds of in-hospital (P = .004) and 90-day mortality (P = .004). There was no difference in odds of adverse events between the GA and the S/R group.

Conclusions

Patients administered S/R for hip fracture procedures demonstrate lower risk of in-hospital mortality and 90-day mortality compared to patients administered GA.

Level of evidence

Therapeutic level III.

Hypotension following hip fracture surgery in patients aged 80 years or older: A prospective cohort study

Background

Hip fractures occurring in older patients often result in significant anemia, even hemodynamic disorders and hypoperfusion. The present study aims to investigate the general characteristics of hypotension following hip fracture surgery (HFHFS) and its effect on clinical outcomes.

Methods

A total of 168 patients aged ≥80 years who underwent hip fracture surgery at a tertiary orthopaedic hospital from January 1, 2020 to August 31, 2020 were enrolled and followed up for one year. Patients were divided into HFHFS and non-HFHFS cohorts according to blood pressure within 24 h after surgery. General difference comparison, univariate and multivariate regression, and survival analysis were applied to investigate the association between HSHSF and in-hospital and one-year clinical outcomes.

Results

The incidence of HFHFS was 23.8% (40/168), with a median time to onset of 8.0 (5.0-12.0) hours after surgery. The HFHFS group had more chronic heart disease before injury and experienced more positive fluid balance on the day of surgery (P values were 0.032 and 0.028, respectively). After adjustment for potential confounders, HFHFS was associated with prolonged length of hospital stay (B 2.66, 95% CI 0.22, 5.10; P = 0.033), postoperative cardiac dysfunction (OR 2.92, 95% CI 1.05, 8.11; P = 0.039), and postoperative brain dysfunction (OR 3.51, 95% CI 1.50, 8.23; P = 0.004). HFHFS had no effect on one-year modified Rankin Scale (mRS) (B 0.28, 95% CI -0.28, 0.84; P = 0.322) and one-year mortality (HR 1.07, 95% CI 0.29, 3.96; P = 0.917).

Conclusion

Many older patients develop hypotension several hours after hip fracture surgery, which may be related with preexisting decline in cardiac reserve in addition to postoperative hidden blood loss. Patients who experienced HFHFS were more likely to have postoperative cardiac and brain dysfunction and longer hospital stay. However, HFHFS had no significant effect on mRS and mortality at one year.

Hip fracture specialists facilitate low-dose spinal anaesthesia in fractured neck of femur surgery

Fractured neck of femur is a common but potentially devastating complication of frailty. In other surgical specialities, there is an inverse relationship between surgical experience and duration of surgery; however, this has not been quantified in hip trauma. In perioperative hip fracture care, prolonged surgery may be associated with increased morbidity and significantly impacts on the conduct of anaesthesia. Specifically, low-dose spinal anaesthesia, which is associated with improved haemodynamic stability, cannot be used if surgery is likely to be prolonged. We studied the duration of hip fracture surgery undertaken in our institution and compared this to surgical expertise. We retrospectively explored our theatre database to identify patients who underwent hip fracture surgery in our hospital over a 62-month period, recording duration of surgery and primary operating surgeon. Surgeons were classified into one of 3 groups: Consultant hip surgeon (specialist interest in hip surgery), Consultant orthopaedic surgeon but non-hip specialist, or Non-consultant (trainee or non-training grade). We identified 1426 hip fracture procedures. Consultant hip surgeons performed all types of hip fracture surgery faster, and with reduced variation in surgical duration, than did either non-hip specialist consultants or non-consultant grades. Consultant hip surgeons consistently performed hip fracture surgery in under 60 minutes. Specialist consultant hip surgeons make low-dose spinal anaesthesia (with shorter block duration but increased haemodynamic stability) feasible. Our data supports the development of dedicated hip fracture trauma lists where patients should be operated on by specialist hip surgeons or trainees directly under their supervision.

Spinal anesthesia and hypotensive events in hip fracture surgical repair in elderly patients: a meta-analysis

BACKGROUND

Spinal anesthesia (SA) is widely used for anesthetic management of patients undergoing hip surgery, and hypotension is the most common cardiovascular side effect of SA. This paper aims to assess the lowest effective dose of SA that reduces the occurrence of intraoperative hypotension in elderly patients scheduled for major lower limb orthopedic surgery.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs) performed in elderly patients scheduled for surgical hip repair and a meta-analysis with meta-regression on the occurrence of hypotensive episodes at different effective doses of anesthetics. We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials registered.

RESULTS

Our search retrieved 2085 titles, and after screening, 6 were finally included in both the qualitative and quantitative analysis, including 344 patients [15% (10-28) males], with a median (25th to 75th interquartile) age of 82 (80-85). The risk of bias assessment reported "low risk" for 5 (83.3%) and "some concerns" for 1 (16.7%) of the included RCTs. The low dose of SA of [mean 6.5 mg (1.9)] anesthetic was associated with a lower incidence of hypotension [OR = 0.09 (95%CI 0.04-0.21); p = 0.04; I² = 56.9%], as compared to the high-dose of anesthetic [mean 10.5 mg (2.4)].

CONCLUSIONS

In the included studies of this meta-analysis, a mean dose of 6.5 mg of SA was effective in producing intraoperative comfort and motor block and associated with a lower incidence of hypotension as compared to a mean dose of 10.5 mg.

TRIAL REGISTRATION

CRD42020193627.

A Comparison of Two Peripheral Nerve Blocks Combined With General Anesthesia in Elderly Patients Undergoing Arthroplasty for Hip Fractures: A Pilot Randomized Controlled Trial

Background

Combined anesthesia can be a promising option for hip surgery when neuraxial anesthesia is contraindicated. Lumbar and sacral plexus blocks, and femoral nerve and lateral femoral cutaneous (LFC) nerve blocks in combination with general anesthesia (GA) are commonly used in elderly patients undergoing arthroplasty for hip fracture surgery. However, no study has compared these two anesthetic strategies in the perioperative period.

Methods

A total of 41 elderly patients scheduled for arthroplasty for hip fracture surgery were randomized into group A (n = 20) and group B (n = 21). Group A received femoral nerve block, LFC nerve blocks, and GA, and group B received lumbar plexus block, sacral plexus block, and GA. Primary outcomes were incidences of hemodynamic events and changes in blood pressure (BP) and heart rate (HR). Secondary outcomes included time and drug consumption, infusion and bleeding volume, eyes opening time after surgery, and postoperative quality recovery rate.

Results

Compared with group B, group A showed a lower incidence of intraoperative hypotension (p < 0.001), higher BP [including mean arterial pressure (MAP), systolic BP (SBP), and diastolic BP (DBP)] following induction (IN), and higher HR from mid-surgery. Time required for nerve blockade (p < 0.001) and ephedrine consumption was significantly shorter in group A (p < 0.001), while sufentanil consumption was higher as compared to group B (p = 0.002). No significant differences in other intraoperative parameters and postoperative quality recovery rate were reported during the observation.

Conclusion

Our pilot data indicate that compared with lumbar and sacral plexus blocks, femoral nerve and LFC nerve blocks may provide more stable intraoperative hemodynamics and a comparable postoperative recovery for elderly patients undergoing arthroplasty for hip fracture under GA. Further studies with a larger sample size are needed to derive stronger evidence.

Association Between Frailty and Clinical Outcomes and Quality of Life in Older Adults Following Hip Fracture Surgery: A Retrospective Cohort Study

BACKGROUND

Hip fracture is a serious event in the older population and is associated with morbidity, mortality, and disability among those who survive. Emerging evidence suggests that frailty is pertinent to the clinical outcomes of older patients with hip fracture.

METHODS

We conducted a retrospective cohort study on older patients (aged ≥65 years) who underwent orthopedic repair with hip fracture under spinal or general anesthesia between June 1, 2019 and May 31, 2020. Demographic, surgical, and anesthetic features; chart-derived frailty index (CFI); occurrence of complications; and length of stay were retrospectively collected by reviewing patients' anesthesia records and medical charts. Patients were divided into 2 groups according to their CFI: high CFI group (CFI, 3-5) and low CFI group (CFI, 0-2). The CFI was calculated as the addition of the patient's conditions, including age >70 years, preoperative body mass index <18.5 kg/m2, hematocrit <35%, albumin <34 g/L, and serum creatinine >176.8 mol/L (2.0 mg/dL). The EuroQol 5-dimensional questionnaire (EQ-5D) was obtained through telephone interviews 12 months after surgery to assess mortality and long-term quality of life.

RESULTS

During the study period, 381 patients met the inclusion criteria. Patients in the high CFI group had an increased incidence of delirium by 13.80% (95% confidence interval [CI], 6.31-21.29) (17 [16.6%] vs 8 [2.8%]; P < .001) compared to patients in the low CFI group. More patients in the high CFI group had pneumonia with an increased incidence of 17.71% (95% CI, 7.08-23.34) (40 [39.2%] vs 60 [21.5%]; P < .001) than patients in the low CFI group. Postoperative hospital stay was significantly longer in the high CFI group (8 [6-12] vs 7 [5-10] days; P = .0222) than in the low CFI group. More patients died in the high CFI group 1 year after surgery with an increased mortality of 19.33% (95% CI, 9.47-29.18) (26.4% [23/87] vs 7.1% [16/225]; P < .001) than patients in the low CFI group. A total of 64 patients in the high CFI group and 209 patients in the low CFI group completed the EQ-5D survey 1 year after surgery. The EQ-5D score in the high CFI group was significantly lower than that in the low CFI group (0.63 ± 0.22 vs 0.72 ± 0.22; P = .002).

CONCLUSIONS

Frailty status is associated with adverse postoperative outcomes, mortality, and low quality of life 12 months after hip fracture surgery in older patients.

Impact and Outcomes of Regional Anesthesia Techniques in Elderly Patients With Fracture of Proximal Femur: A Retrospective Study

Background Although subarachnoid block (SAB) is the most popular regional anesthesia (RA) technique for fixation of femur fractures, continuous lumbar epidural (CLE) anesthesia, and lumbosacral plexus blocks (LSPB) are also employed in specific situations. The choice of RA technique depends on either the choice of the anesthesiologist or based on the underlying comorbidities. At our institute, we anesthetize elderly patients who come for fixation of femur fracture with multiple comorbidities using RA techniques as mentioned based on comorbidities and overall general condition.  Methods In a cohort of 184 elderly patients, we analyzed RA techniques employed over a period of five years in elderly patients admitted with fractures of the proximal femur, its hemodynamic implications and thus attempted to find the suitable RA technique with minimal adverse events after ethics committee approval. We also compared the length of stay in the hospital in relation to RA techniques. Results The demographic data was comparable with no significant difference in administering the three RA techniques. SAB, CLE and LSPB was implemented at 33.33%, 35.96%, and 30.7% respectively. Perioperative noradrenaline infusion was a feature in patients who received SAB (p<0/001). The higher number of CLE and LSPB patients had a length of stay of fewer than 48 hours whereas most SAB patients had a length of stay of more than 48 hrs (p<0.001). Conclusion Elderly patients with multiple comorbidities should be offered CLE instead of SAB so as to maintain stable hemodynamics. RA technique in an elderly patient with multiple comorbidities should be standardized so as to provide uneventful surgical anesthesia.

Psoas compartment block efficacy and safety for perioperative analgesia in the elderly with proximal femur fractures: a randomized controlled study

Background

Proximal femur fractures are most common fractures in the elderly and associated with significant mortality and morbidity, with high economic and social impact. Perioperative pain management influence outcomes and mortality after surgery with early mobilization being possible. The goal of the study was to compare the efficacy and safety of the psoas compartment block (PCB) with spinal and general anesthesia.

Methods

We included 90 patients in this randomized controlled study and divided them into three groups. For patients in group 1 ultrasound-guided PCB with bupivacaine 0.125% 6–8 ml / h was performed. Intraoperative anesthesia was provided with PCB and a sciatic nerve block. Postoperative analgesia include prolonged CPB with bupivacaine 0.125% 6–8 ml / h. In group 2 intraoperative spinal anaesthesia were performed. Group 3 patients underwent general sevoflurane inhalation anaesthesia with fentanyl infusion for analgesia. All patients received paracetamol 3 g/day and dexketoprofen 75 mg/day during hospitalization. On-demand, nalbuphine 5 mg SC was used for analgesia. Efficacy outcomes were the ICU length of stay and the total duration of hospitalization, number of patients who had severe pain after surgery, incidence of on-demand analgesia, sleep quality, postoperative mobilization time. Safety outcomes include complication incidence.

Results

There were no differences in the duration of ICU stay - gr.1 72 [70–75], gr.2 74 [72–76], gr.3 72 [70–75] hours respectively (p = 0.29), and the total duration of hospitalization - gr.1144 [170–184], gr.2170 [148–188], gr.3178 [144–200] hours respectively. Patients in gr.1 had significantly lower nalbuphine consumption in the first 24 h after surgery and total during hospitalization (0 [0–5] mg versus 15 [10–20] and 20 [15–25] mg in the first 24 h in groups 2 and 3, respectively (p < 0.001). Gr. 1 had lower number of patients with severe pain (10% vs. 47 and 60% in groups 2 and 3, respectively, p < 0.05), lower number of on demand analgesia (0 [0–1] vs. 3 [2–4] and 4 [3, 4] in groups 2 and 3, respectively), better sleep quality (8 [7–9] vs. 6 [5–7] and 4 [3, 4] in groups 2 and 3, respectively, p < 0.001), significantly faster mobilization after surgery – sitting in bed and getting to his feet. MINS was diagnosed significantly more often in gr. 2 and 3 compared with gr. 1 (OR 9 95 CI 1,01–77, p = 0,048 for gr. 2 and OR 11 95 CI 1,2–91, p = 0, 03 for gr. 3). However, none of the patients had symptoms of myocardial ischemia and was not diagnosed with myocardial infarction. There were no difference in the incidence of nosocomial pneumonia and delirium.

Conclusion

Perioperative PCB in elderly patients with a proximal femur fracture could be an effective analgesia technique, as it decrease the number of patients with severe pain, need for on demand analgesia and opioid consumption. PCB also decrease the incidence of opioid-associated nausea and vomiting, comparing to general anesthesia, and increase the number of patients, who was mobilized in the 1st day (sitting) and 2nd day (getting up) after surgery. PCB may reduce the incidence of MINS, although to assess this outcome more studies are needed.

Trial registration

Clinicaltrials.gov: NCT04648332, first registration date 1/12/2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01473-9.

The effect of intra-operative hypotension on acute kidney injury, postoperative mortality and length of stay following emergency hip fracture surgery

The association between intra-operative hypotension and postoperative acute kidney injury, mortality and length of stay has not been comprehensively evaluated in a large single-centre hip fracture population. We analysed electronic anaesthesia records of 1063 patients undergoing unilateral hip fracture surgery, collected from 2015 to 2018. Acute kidney injury, 3-, 30- and 365-day mortality and length of stay were evaluated to assess the relationship between intra-operative hypotension absolute values (≤ 55, 60, 65, 70 and 75 mmHg) and duration of hypotension. The rate of acute kidney injury was 23.7%, mortality at 3-, 30- and 365 days was 3.7%, 8.0% and 25.3%, respectively, and median (IQR [range]) length of stay 8 (6-12 [0-99]) days. Median (IQR [range]) time ≤ MAP 55, 60, 65, 70 and 75 mmHg was 0 (0-0.5[0-72.1]); 0 (0-4.4 [0-104.9]); 2.2 (0-8.7 [0-144.2]); 6.6 (2.2-19.7 [0-198.8]); 17.5 (6.6-37.1 [0-216.3]) minutes, and percentage of surgery time below these thresholds was 1%, 2.5%, 7.9%, 12% and 21% respectively. There were some univariate associations between hypotension and mortality; however, these were no longer evident in multivariable analysis. Multivariable analysis found no association between hypotension and acute kidney injury. Acute kidney injury was associated with male sex, antihypertensive medications and cardiac/renal comorbidities. Three-day mortality was associated with delay to surgery ? 48 hours, whilst 30-day and 365-day mortality was associated with delay to surgery ≥ 48 hours, impaired cognition and cardiac/renal comorbidities. While the rate of acute kidney injury was similar to other studies, use of vasopressors and fluids to reduce the time spent at hypotensive levels failed to reduce this complication. Intra-operative hypotension at the levels observed in this cohort may not be an important determinant of acute kidney injury, postoperative mortality and length of stay.

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

BACKGROUND

Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues.

AIM

To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF.

METHODS

A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence.

RESULTS

A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics).

CONCLUSION

These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.

Heterogeneous impact of hypotension on organ perfusion and outcomes: a narrative review

Arterial blood pressure is the driving force for organ perfusion. Although hypotension is common in acute care, there is a lack of accepted criteria for its definition. Most practitioners regard hypotension as undesirable even in situations that pose no immediate threat to life, but hypotension does not always lead to unfavourable outcomes based on experience and evidence. Thus efforts are needed to better understand the causes, consequences, and treatments of hypotension. This narrative review focuses on the heterogeneous underlying pathophysiological bases of hypotension and their impact on organ perfusion and patient outcomes. We propose the iso-pressure curve with hypotension and hypertension zones as a way to visualize changes in blood pressure. We also propose a haemodynamic pyramid and a pressure-output-resistance triangle to facilitate understanding of why hypotension can have different pathophysiological mechanisms and end-organ effects. We emphasise that hypotension does not always lead to organ hypoperfusion; to the contrary, hypotension may preserve or even increase organ perfusion depending on the relative changes in perfusion pressure and regional vascular resistance and the status of blood pressure autoregulation. Evidence from RCTs does not support the notion that a higher arterial blood pressure target always leads to improved outcomes. Management of blood pressure is not about maintaining a prespecified value, but rather involves ensuring organ perfusion without undue stress on the cardiovascular system.

Low-dose spinal and opioid-free anesthesia in patient with Severe Aortic Stenosis and SARS-CoV-2 infection: Case report

The best anesthesiologic approach to severe AS patient has not been adequately studied in literature. Although the current guidelines have a cautious attitude in this regard, Combined Spinal-Epidural Anesthesia (CSEA) has proved to be a safe technique. Therefore, we would like to provide our experience with a severe AS and COVID-19 patient.

Machine Learning Algorithm Using Electronic Chart-Derived Data to Predict Delirium After Elderly Hip Fracture Surgeries: A Retrospective Case-Control Study

Background: Elderly patients undergoing hip fracture repair surgery are at increased risk of delirium due to aging, comorbidities, and frailty. But current methods for identifying the high risk of delirium among hospitalized patients have moderate accuracy and require extra questionnaires. Artificial intelligence makes it possible to establish machine learning models that predict incident delirium risk based on electronic health data.

Methods: We conducted a retrospective case-control study on elderly patients (≥65 years of age) who received orthopedic repair with hip fracture under spinal or general anesthesia between June 1, 2018, and May 31, 2019. Anesthesia records and medical charts were reviewed to collect demographic, surgical, anesthetic features, and frailty index to explore potential risk factors for postoperative delirium. Delirium was assessed by trained nurses using the Confusion Assessment Method (CAM) every 12 h during the hospital stay. Four machine learning risk models were constructed to predict the incidence of postoperative delirium: random forest, eXtreme Gradient Boosting (XGBoosting), support vector machine (SVM), and multilayer perception (MLP). K-fold cross-validation was deployed to accomplish internal validation and performance evaluation.

Results: About 245 patients were included and postoperative delirium affected 12.2% (30/245) of the patients. Multiple logistic regression revealed that dementia/history of stroke [OR 3.063, 95% CI (1.231, 7.624)], blood transfusion [OR 2.631, 95% CI (1.055, 6.559)], and preparation time [OR 1.476, 95% CI (1.170, 1.862)] were associated with postoperative delirium, achieving an area under receiver operating curve (AUC) of 0.779, 95% CI (0.703, 0.856).

The accuracy of machine learning models for predicting the occurrence of postoperative delirium ranged from 83.67 to 87.75%. Machine learning methods detected 16 risk factors contributing to the development of delirium. Preparation time, frailty index uses of vasopressors during the surgery, dementia/history of stroke, duration of surgery, and anesthesia were the six most important risk factors of delirium.

Conclusion: Electronic chart-derived machine learning models could generate hospital-specific delirium prediction models and calculate the contribution of risk factors to the occurrence of delirium. Further research is needed to evaluate the significance and applicability of electronic chart-derived machine learning models for the detection risk of delirium in elderly patients undergoing hip fracture repair surgeries.

Treatment threshold for intra-operative hypotension in clinical practice-a prospective cohort study in older patients in the UK

Intra-operative hypotension frequently complicates anaesthesia in older patients and is implicated in peri-operative organ hypoperfusion and injury. The prevalence and corresponding treatment thresholds of hypotension are incompletely described in the UK. This study aimed to identify prevalence of intra-operative hypotension and its treatment thresholds in UK practice. Patients aged ≥ 65 years were studied prospectively from 196 UK hospitals within a 48-hour timeframe. The primary outcome was the incidence of hypotension (mean arterial pressure <65 mmHg; systolic blood pressure reduction >20%; systolic blood pressure <100 mmHg). Secondary outcomes included the treatment blood pressure threshold for vasopressors; incidence of acute kidney injury; myocardial injury; stroke; and in-hospital mortality. Additionally, anaesthetists providing care for included patients were asked to complete a survey assessing their intended treatment thresholds for hypotension. Data were collected from 4750 patients. Hypotension affected 61.0% of patients when defined as mean arterial pressure <65 mmHg, 91.3% of patients had >20% reduction in systolic blood pressure from baseline and 77.5% systolic blood pressure <100 mmHg. The mean (SD) blood pressure triggering vasopressor therapy was mean arterial pressure 64.2 (11.6) mmHg and the mean (SD) stated intended treatment threshold from the survey was mean arterial pressure 60.6 (9.7) mmHg. A composite adverse outcome of myocardial injury, kidney injury, stroke or death affected 345 patients (7.3%). In this representative sample of UK peri-operative practice, the majority of older patients experienced intra-operative hypotension and treatment was delivered below suggested thresholds. This highlights both potential for intra-operative organ injury and substantial opportunity for improving treatment of intra-operative hypotension.

Impact of multiple nerves blocks anaesthesia on intraoperative hypotension and mortality in hip fracture surgery intermediate-risk elderly patients: A propensity score-matched comparison with spinal and general anaesthesia

BACKGROUND

A Hip fracture in the intermediate-risk elderly patient is common and associated with a high rate of postoperative morbidity and mortality. There is a lack of consensus on the optimal anaesthetic technique but there is a clear association between intraoperative hypotension and postoperative morbidity and mortality. We aimed to compare the haemodynamic stability of three anaesthesia techniques: general anaesthesia (GA), continuous spinal anaesthesia (CSA), and multiple nerve blocks (MNB).

METHODS

The primary outcome was the occurrence of intraoperative hypotension defined by a 30% decrease in mean arterial pressure (MAP) from baseline. Secondary outcomes included incidence of hypotension under 50 mmHg of MAP, time spent below MAP 50 mmHg, use of vasopressors, in-hospital and 30-day mortality. A propensity score-matched analysis was performed.

RESULTS

After screening and application of the exclusion criteria, 593 patients undergoing hip fracture surgery between the 1^st of January 2015 and the 31^st of December 2016 were included. The propensity score match analysis selected 43 patients in each group. The incidence of hypotension was significantly higher in the GA group than in the MNB and CSA groups: 39 (90%), 22 (51%), and 23 (53.5%), respectively; p < 0.0001. The incidence of MAP < 50 mmHg (59.5%, 23.3%, and 16.3%; p < 0.0001) and the use of vasopressors (93%, 39.5%, and 25.6%; p < 0.0001) were increased significantly in the GA group. With the GA group as a reference, odds ratios were reported in the MNB group at 0.08 [0.022-0.30] (p = 0.0002) for hypotension episodes; 0.17 [0.04-0.66] (p = 0.01) for hypotension < 50 mmHg for more than 3 min and 0.049 [0.013-0.018] (p < 0.0001) for use of vasopressors. The duration of hospital stay, postoperative complications, in-hospital and 30-day mortality rates did not differ significantly between the groups.

CONCLUSION

CSA and MNB provide better haemodynamic stability than GA. However, whatever the anaesthesia technique used, the mortality rates do not change even if MNB leads to less hypotension. IRB contact information: CERAR IRB 00010254-2016-118. Clinical Trial Number: ClinicalTrials.gov. ID: NCT03356704.

Patient, surgical and hospital factors associated with the presence of a consultant surgeon during hip fracture surgery. Do we know the answer?

BACKGROUND

Provision of quality care can help to reduce adverse health outcomes following hip fracture. While surgical management by either a consultant or junior surgeon has shown inconclusive differences in patient outcomes, consultant presence is often recommended, yet little is known about the factors that influence whether a consultant surgeon is present during hip fracture surgery. The aim of this study is to examine patient, surgical and hospital factors associated with having a consultant surgeon present during hip fracture surgery.

METHODS

An examination of hip fracture surgeries of adults aged ≥ 50 years admitted to hospitals in Australia and New Zealand between 1 January 2015 and 31 December 2018 using data from the Australia and New Zealand Hip Fracture Registry was conducted. Multivariable logistic regression was used to examine factors associated with the presence of a consultant surgeon during hip fracture surgery.

RESULTS

There were 29 530 hip fracture surgeries 58.1% had a consultant surgeon present (range 8.5-100% by hospital). Patients were more likely to have a consultant surgeon present during surgery if they had private health insurance, were operated on after hours, required total hip replacements or were operated on in hospitals that conducted ≤150 surgeries per year.

CONCLUSION

There is variation in the presence of consultant surgeons within Australia and New Zealand during hip fracture surgery, potentially associated with the complexity of surgery and hospital factors. However, further research is needed to determine the optimum level of supervision required based on patient factors and surgical complexity.

The National Hip Fracture Database is only as good as the data we feed it - significant inaccuracy demonstrated and how to improve it

INTRODUCTION

The National Hip Fracture Database of England, Wales and Northern Ireland (NHFD) is the largest such database in the world. Data errors in within the NHFD lead to spurious evidence which ultimately informs Orthopaedic, Anaesthetic and Orthogeriatric clinical practice.

MATERIALS AND METHODS

This multi-centre quality improvement study investigated, and sought to improve data inaccuracy within the NHFD. Hip arthroplasty episodes recorded between 2011-2020 were analysed for errors in operation, implant polarity and cementation.

RESULTS

Inaccuracies were observed in 20.5% of 3972 data entries. Following the introduction of a hip fracture clinical data administrator in each centre, inaccuracies reduced four-fold (5.2% of 559 data entries).

CONCLUSION

We advise caution when utilising NHFD data for research and audit purposes. In order to build a robust, accurate database for future research, we recommend the incorporation of specialist data administrators into the hip fracture multidisciplinary team.

Determination of the initial minimum effective dose of 0.5% bupivacaine with 20 μg of fentanyl for an operative fixation of fractured neck of femur: a prospective, observational trial

BACKGROUND

Fractured neck of femur (FNF) is a common cause of morbidity and mortality in elderly. Spinal catheter allows fractionation of local anesthetic dose which combined with intrathecal opioid leads to a dose reduction and better hemodynamic stability. The primary objective of this paper was to investigate the initial minimum local anesthetic dose (iMLAD) of 0.5% isobaric bupivacaine with 20 μg of fentanyl administered via spinal catheter in order to commence the operative fixation of FNF.

METHODS

A prospective, single-blinded, adaptive clinical trial with patients undergoing dynamic hip screw implantation (DHS) or hemiarthroplasty (HEMI) due to FNF. The Dixon and Massey's up and down method was used to determine the ED50 of intrathecal bupivacaine. This figure was confirmed with Probit analysis, in addition to the ED95.

RESULTS

Using the Dixon and Massey's approach, the iMLADED50 for DHS was 0.29 mL (1.45 mg) and the iMLADED50 for HEMI was 0.33 mL (1.65 mg) of 0.5% isobaric bupivacaine. The Probit analyses demonstrated that the iMLADED95 for DHS and HEMI were 0.32 mL (1.6 mg) and 0.34 mL (1.7 mg) respectively. The mean cumulative dose of 0.5% bupivacaine for the whole surgery was 0.67 mL (3.35 mg) and 0.87 mL (4.35 mg) in the DHS and HEMI groups, respectively.

CONCLUSIONS

This study demonstrates that the placement of a spinal catheter allows for careful titration of local anesthetic, enabling a reduction of the initial intrathecal dose of 0.5% isobaric bupivacaine below 0.4 mL (2 mg) and leading to a significant reduction of a dose required for the whole surgery when combined with an intrathecal opioid.

Hip fracture care and mortality among patients treated in dedicated COVID-19 and non-COVID-19 circuits

Aim

What were the effects of the COVID-19 pandemic and patient cohorting on the mortality and care provided for patients with hip fractures?

Findings

Mortality due to COVID-19 infection was higher before patient cohorting, and no nosocomial infections were detected after cohorting. Survival of patients treated in the COVID-19 circuit was similar to non-COVID-19 controls, in spite of longer surgical delay and length of stay.

Message

Separate circuits for COVID-19 and non-COVID-19 patients allows adequate hip fracture care, without observing increased mortality when delaying surgery until stabilization among patients with severe respiratory illness.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00455-x.

Introduction

To analyze the effect of the COVID-19 pandemic on the provision of fragility hip fracture care, comparing patients treated before cohorting and in separate COVID-19 and non-COVID-19 circuits with the corresponding months in 2018 and 2019.

Materials and methods

Retrospective single-center cohort study including 64 patients with fragility hip fractures treated during the COVID-19 pandemic (March 1st–May 1st, 2020), compared to 172 patients treated in 2018 and 2019. Dedicated COVID-19 and non-COVID-19 circuits were established on March 14th. Patients treated before cohorting (17 patients), in COVID-19 (14 patients) and non-COVID-19 circuits (33 patients) were included.

Results

Baseline characteristics were similar for 2018–19 and 2020. Patients in 2020 had a lower median surgical delay (50.5 vs. 91.3 h) and length of stay (9.0 vs. 14.0 days), while those with COVID-19, had longer surgical delays and length of stay (87.7 h and 15.0 days, respectively). Thirty-days mortality was higher among patients before cohorting, but similar in Covid-19 and non-Covid-19 pathways compared to 2018–19 (7.1% and 3.0% vs 5.2%, respectively). 23.5% of patients treated before circuiting suffered coronavirus infectious disease-19 disease after discharge. Following separation, no secondary cases of coronavirus infectious disease-19 were observed.

Conclusions

Separate circuits for patients with and without coronavirus infectious disease-19 provided adequate hip fracture care. We did not observe increased mortality rates among hip fracture patients with preoperatively confirmed or suspected coronavirus infectious disease-19, compared to negative cases and 2018–19. Delaying surgery among patients with severe respiratory illness until a favourable trend could be observed did not lead to increased mortality.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00455-x.

[Hip fracture in elderly and COVID-19 infection. Report of 3 cases]

Since its first description in china in January 2020, COVID-19 pandemia outbreak has affected health organization and conventional care in all settings as wards, intensive care and surgery. Hip fracture patients usually are older and have a lot of comorbidities. This type of patientes benefit from early surgery. However, surgery in COVID-19 patients with active infection is associate with bad outcomes and mortality. We present three patients with COVID infection undergoing hip fracture surgery. Surgery was performed tree weeks after admission. Despite have risk factor (old age, arterial hypertension, elevated inflammatory parameters) the outcome was good and were discharged from hospital without events.

Defining success in regional anaesthesia

Utilisation of regional anaesthesia is increasing globally; however, it remains challenging to determine the overall benefit of individual regional anaesthesia procedures. Like any peri-operative intervention, the benefit to the patient and healthcare system must outweigh any patient risk or resource implications. This review aims to identify markers of success in regional anaesthesia, categorise these into an objective framework and rationalise suggestions on how measuring outcomes in regional anaesthesia can be used to develop the widespread performance of this evolving subspecialty. This framework of measuring success of regional anaesthesia contains four pillars: patient-centred, population-centred, healthcare-centred and training-centred outcomes. Each pillar of success contains several outcomes which provide a structure for the measurement and development of regional anaesthesia success on a global scale.

Association of intraoperative hypotension with postoperative morbidity and mortality: systematic review and meta-analysis

Background

Intraoperative hypotension, with varying definitions in literature, may be associated with postoperative complications. The aim of this meta-analysis was to assess the association of intraoperative hypotension with postoperative morbidity and mortality.

Methods

MEDLINE, Embase and Cochrane databases were searched for studies published between January 1990 and August 2018. The primary endpoints were postoperative overall morbidity and mortality. Secondary endpoints were postoperative cardiac outcomes, acute kidney injury, stroke, delirium, surgical outcomes and combined outcomes. Subgroup analyses, sensitivity analyses and a meta-regression were performed to test the robustness of the results and to explore heterogeneity.

Results

The search identified 2931 studies, of which 29 were included in the meta-analysis, consisting of 130 862 patients. Intraoperative hypotension was associated with an increased risk of morbidity (odds ratio (OR) 2.08, 95 per cent confidence interval 1.56 to 2.77) and mortality (OR 1.94, 1.32 to 2.84). In the secondary analyses, intraoperative hypotension was associated with cardiac complications (OR 2.44, 1.52 to 3.93) and acute kidney injury (OR 2.69, 1.31 to 5.55). Overall heterogeneity was high, with an I² value of 88 per cent. When hypotension severity, outcome severity and study population variables were added to the meta-regression, heterogeneity was reduced to 50 per cent.

Conclusion

Intraoperative hypotension during non-cardiac surgery is associated with postoperative cardiac and renal morbidity, and mortality. A universally accepted standard definition of hypotension would facilitate further research into this topic.

Analysis of factors among 30-day and 1-year mortality rates in patients with borderline stable-unstable intertrochanteric hip fracture

OBJECTIVE

This study aimed to evaluate the possible effects of surgical procedures on mortality and to identify the possible risk factors for mortality in the management of geriatric hip fractures.

METHODS

A total of 191 patients (105 women and 86 men; mean age 82.26±9.681 [60-108] years) with AO/OTA 31A2.2 intertrochanteric fractures and treated with sliding hip screw, proximal femoral nail, or hemiarthroplasty were included in this retrospective cohort study. The treatment type was decided by the responsible surgeon according to the patients' pre-injury activity level, bone quality, and features of the fracture. Age, sex, type of fracture, type of surgery performed, American society of anesthesiology (ASA) grade, type of anesthesia, time to surgery, type of physical therapy, length of hospital stay, and number of comorbidities were documented. We evaluated the 30-day and 1-year mortality of patients treated with sliding hip screw (SHS), proximal femoral nail antirotation (PFN-A), or hemiarthroplasty and identified the possible risk factors for mortality.

RESULTS

A total of 49 patients underwent SHS, 58 underwent PFN-A, and 84 underwent hemiarthroplasty. Of these, 2 patients with SHS, 2 with PFN-A, and 11 with hemiarthroplasty died within 30 days after surgery, whereas 7 patients with SHS, 15 with PFN-A, and 23 with hemiarthroplasty died 1 year after surgery. The 30-day and 1-year overall mortality rates were 7.9% and 23.6%, respectively. Both the 30-day and 1-year mortality risks were higher in patients undergoing hemiarthroplasty than in patients undergoing SHS (p=0.068 versus 0.058). The 30-day mortality was higher in patients receiving general anesthesia than in those receiving combined spinal and epidural anesthesia (p=0.009). The 1-year mortality risk was higher in patients with ASA grade 4 than in those with grade 1 and 2 (p=0.045). Advanced age (p=0.022) and male sex (p=0.007) were also found to be the risk factors for 1-year mortality.

CONCLUSION

We demonstrated that higher ASA grade, male sex, general anesthesia, and hemiarthroplasty procedures are associated with higher mortality rates in elderly patients with hip fractures. Thus, we highly recommend orthopedic surgeons to consider all these factors in the management of intertrochanteric hip fractures in the geriatric population.

LEVEL OF EVIDENCE

Level IV, Prognostic Study.

Guideline for the management of hip fractures 2020: Guideline by the Association of Anaesthetists

We convened a multidisciplinary Working Party on behalf of the Association of Anaesthetists to update the 2011 guidance on the peri-operative management of people with hip fracture. Importantly, these guidelines describe the core aims and principles of peri-operative management, recommending greater standardisation of anaesthetic practice as a component of multidisciplinary care. Although much of the 2011 guidance remains applicable to contemporary practice, new evidence and consensus inform the additional recommendations made in this document. Specific changes to the 2011 guidance relate to analgesia, medicolegal practice, risk assessment, bone cement implantation syndrome and regional review networks. Areas of controversy remain, and we discuss these in further detail, relating to the mode of anaesthesia, surgical delay, blood management and transfusion thresholds, echocardiography, anticoagulant and antiplatelet management and postoperative discharge destination. Finally, these guidelines provide links to supplemental online material that can be used at readers' institutions, key references and UK national guidance about the peri-operative care of people with hip and periprosthetic fractures during the COVID-19 pandemic.

Ultra-low-dose spinal anaesthesia for elective hip arthroplasty in a patient with severe pulmonary hypertension

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.