1
|
White SM, Tedore T, Shelton CL. There is (probably) no (meaningful) difference in (most) outcomes between 'spinal' and 'general' anaesthesia for hip fracture surgery: time to move forward. Br J Anaesth 2023; 130:385-389. [PMID: 36801101 DOI: 10.1016/j.bja.2023.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/12/2023] [Accepted: 01/14/2023] [Indexed: 02/18/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Stuart M White
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK.
| | - Tiffany Tedore
- Weill Cornell Medical College, NewYork-Presbyterian Hospital/Weill Cornell, New York, NY, USA
| | - Clifford L Shelton
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK; Lancaster Medical School, Lancaster University, Lancaster, UK
| |
Collapse
|
2
|
Leibold C, Falbo R, Gupta A, Miller R, Pederson JM, Malpe M. A systematic review and meta-analysis of anesthesia type on hip fracture post-surgery outcomes. OTA Int 2022; 5:e204. [PMID: 36425088 PMCID: PMC9580260 DOI: 10.1097/oi9.0000000000000204] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 03/15/2022] [Indexed: 11/30/2022]
Abstract
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.
Collapse
Affiliation(s)
| | - Ryan Falbo
- Department of Orthopedic Surgery, Mercy Health St. Vincent Medical Center
| | | | - Richard Miller
- Department of Orthopedic Surgery, Mercy Health St. Vincent Medical Center
| | | | | |
Collapse
|
3
|
Brooks DE, Ritchie-McLean SN, Chevannes W, Parker MJ, Griffiths R. Hip fracture specialists facilitate low-dose spinal anaesthesia in fractured neck of femur surgery. Acta Orthop Belg 2022; 88:311-317. [DOI: 10.52628/88.2.8978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
Collapse
|
4
|
McGlennan CM, Christmas TR. "You test because you cannot afford to make assumptions". Anaesthesia 2022; 77:861-864. [PMID: 35587999 DOI: 10.1111/anae.15759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2022] [Indexed: 11/30/2022]
Affiliation(s)
- C M McGlennan
- Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - T R Christmas
- Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| |
Collapse
|
5
|
Moppett I. Individualised care or anaesthetist preference: an uncomfortable question. Br J Anaesth 2021; 128:408-410. [PMID: 34980471 DOI: 10.1016/j.bja.2021.11.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/16/2021] [Accepted: 11/29/2021] [Indexed: 11/02/2022] Open
Abstract
There is widespread variation in how anaesthesia is provided to individual patients even for the same types of surgery. This variation exists within departments, between hospitals, and between countries. Patient and surgical factors are often cited as a justification for variation. Local and national norms, guidance, and standards, and the positive or negative roles of key opinion leaders likely all play a part. Although clinicians may disagree where the line falls between warranted and unwarranted variations, at least some of this variation is down to anaesthetist preference, not individualised patient care.
Collapse
Affiliation(s)
- Iain Moppett
- Anaesthesia and Critical Care Section, Academic Unit of Injury, Inflammation and Repair, University of Nottingham, Nottingham, UK; Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| |
Collapse
|
6
|
McGinn R, Talarico R, Hamiltoon GM, Ramlogan R, Wijeysundra DN, McCartney CJL, McIsaac DI. Hospital-, anaesthetist-, and patient-level variation in peripheral nerve block utilisation for hip fracture surgery: a population-based cross-sectional study. Br J Anaesth 2021; 128:198-206. [PMID: 34794768 DOI: 10.1016/j.bja.2021.10.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/06/2021] [Accepted: 10/08/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Despite high-certainty evidence of benefit, a minority of hip fracture surgery patients receive a peripheral nerve block. Our objective was to estimate variation in peripheral nerve block use at the hospital, anaesthetist, and patient levels, while identifying predictors of peripheral nerve block use in hip fracture patients. METHODS After protocol registration (https://osf.io/48bvp/), we conducted a population-based cross-sectional study using linked administrative data in Ontario, Canada. We included adults >65 yr of age having emergency hip fracture surgery from April 1, 2012 to March 31, 2018. Logistic mixed models were used to estimate the variation in peripheral nerve block use attributable to hospital-, anaesthetist-, and patient-level factors with use of peripheral nerve block, quantified using the variance partition coefficient and median odds ratio. Predictors of peripheral nerve block use were estimated and temporally validated. RESULTS Of 50 950 patients, 9144 (18.5%) received a peripheral nerve block within 1 day of surgery. Patient-level factors accounted for 14% of variation, whereas 42% and 44% were attributable to the hospital and anaesthetist providing care, respectively. The median odds ratio for receiving a peripheral nerve block was 5.73 at the hospital level and 5.97 at the anaesthetist level. No patient factors had large associations with receipt of a peripheral nerve block (odds ratios significant at the 5% level ranged from 0.86 to 1.35). CONCLUSIONS Patient factors explain the minimal variation in peripheral nerve block use for hip fracture surgery. Interventions to increase uptake of peripheral nerve blocks for hip fracture patients will likely need to focus on structures and processes at the hospital and anaesthetist levels.
Collapse
Affiliation(s)
- Ryan McGinn
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Gavin M Hamiltoon
- ICES, Toronto, ON, Canada; Department of Anesthesiology, Queensway Carleton Hospital, Ottawa, ON, Canada
| | - Reva Ramlogan
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, Ottawa Hospital, Ottawa, ON, Canada
| | - Duminda N Wijeysundra
- ICES, Toronto, ON, Canada; Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Colin J L McCartney
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, Ottawa Hospital, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; ICES, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, Ottawa Hospital, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| |
Collapse
|
7
|
Griffiths R, Babu S, Dixon P, Freeman N, Hurford D, Kelleher E, Moppett I, Ray D, Sahota O, Shields M, White S. Guideline for the management of hip fractures 2020: Guideline by the Association of Anaesthetists. Anaesthesia 2020; 76:225-237. [PMID: 33289066 DOI: 10.1111/anae.15291] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2020] [Indexed: 12/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- R Griffiths
- Department of Anaesthesia, Peterborough and Stamford Hospitals NHS Trust Peterborough, UK and Chair, Working Party, Association of Anaesthetists, UK
| | - S Babu
- Department of Anaesthesia, Warrington and Halton Hospitals NHS Trust, Warrington, UK
| | - P Dixon
- Department of Trauma and Orthopaedics, South Tyneside and Sunderland NHS Trust, Sunderland, UK and British Orthopaedic Association, Orthopaedic Trauma Society, UK
| | - N Freeman
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Hurford
- Department of Anaesthesia, Cwm Taf Morgannwg University Health Board and Chair, Welsh Frailty Fracture Network, UK, UK
| | - E Kelleher
- Department of Anaesthesia, University of Galway, Galway, Ireland
| | - I Moppett
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, UK.,Department of Anaesthesia, Nottingham University Hospitals, Nottingham, UK
| | - D Ray
- Department of Anaesthesia, Royal Infirmary Edinburgh and Honorary Clinical Senior Lecturer, University of Edinburgh, Edinburgh, UK
| | - O Sahota
- Department of Healthcare of Older People, Nottingham University Hospitals, Nottingham, UK and British Geriatrics Society, UK
| | - M Shields
- Department of Anaesthesia, Royal Hospitals, Belfast, UK
| | - S White
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| |
Collapse
|
8
|
Shelton C, White S. Anaesthesia for hip fracture repair. BJA Educ 2020; 20:142-149. [PMID: 33456943 PMCID: PMC7808106 DOI: 10.1016/j.bjae.2020.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 01/24/2020] [Accepted: 02/04/2020] [Indexed: 01/13/2023] Open
Affiliation(s)
- C. Shelton
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Lancaster Medical School, Lancaster University, Lancaster, UK
| | - S. White
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| |
Collapse
|
9
|
Morgan L, McKeever TM, Nightingale J, Deakin DE, Moppett IK. Spinal or general anaesthesia for surgical repair of hip fracture and subsequent risk of mortality and morbidity: a database analysis using propensity score-matching. Anaesthesia 2020; 75:1173-1179. [PMID: 32337715 DOI: 10.1111/anae.15042] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2020] [Indexed: 11/30/2022]
Abstract
Around 76,000 people fracture their hip annually in the UK at a considerable personal, social and financial cost. Despite longstanding debate, the optimal mode of anaesthesia (general or spinal) remains unclear. Our aim was to assess whether there is a significant difference in mortality and morbidity between patients undergoing spinal anaesthesia compared with general anaesthesia during hip fracture surgery. A secondary analysis examined whether a difference exists in mortality for patients with pre-existing cardiovascular disease or chronic obstructive pulmonary disease. This was a clinical database analysis of patients treated for hip fracture in Nottingham, UK between 2004 and 2015. Propensity score-matching was used to generate matched pairs of patients, one of whom underwent each mode of anaesthesia. Data were analysed using conditional logistic regression, with 7164 patients successfully matched. There was no difference in 30- or 90-day mortality in patients who had spinal rather than general anaesthesia (OR [95%CI] 0.97 [0.8-1.15]; p = 0.764 and 0.93 [0.82-1.05]; p = 0.247 respectively). Patients who had a spinal anaesthetic had a lower-risk of blood transfusion (OR [95%CI] 0.84 [0.75-0.94]; p = 0.003) and urinary tract infection (OR [95%CI] 0.72 [0.61-0.84]; p < 0.001), but were more likely to develop a chest infection (OR [95%CI] 1.23 [1.07-1.42]; p = 0.004), deep vein thrombosis (OR [95%CI] 2.18 [1.07-4.45]; p = 0.032) or pulmonary embolism (OR [95%CI] 2.23 [1.16-4.29]; p = 0.016). The mode of anaesthesia for hip fracture surgery resulted in no significant difference in mortality, but there was a significant difference in several measures of postoperative morbidity.
Collapse
Affiliation(s)
- L Morgan
- Division of Epidemiology and Public Health, University of Nottingham, UK
| | - T M McKeever
- Division of Epidemiology and Public Health, University of Nottingham, UK
| | - J Nightingale
- Department of Trauma and Orthopaedics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - D E Deakin
- Department of Trauma and Orthopaedics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - I K Moppett
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, University of Nottingham, UK
| |
Collapse
|
10
|
Geisler A, Dahl JB, Thybo KH, Pedersen TH, Jørgensen ML, Hansen D, Schulze LK, Persson EI, Mathiesen O. Pain management after total hip arthroplasty at five different Danish hospitals: A prospective, observational cohort study of 501 patients. Acta Anaesthesiol Scand 2019; 63:923-930. [PMID: 30883668 DOI: 10.1111/aas.13349] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 01/05/2019] [Accepted: 01/08/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The available literature does not present a "gold standard" for post-operative pain treatment after total hip arthroplasty (THA). The aim of this prospective observational study was to explore and document post-operative pain treatment, including outcomes, in a large cohort of patients undergoing THA at five different Danish hospitals. METHODS This prospective, multicentre, observational cohort study of 501 THA patients was performed at five different hospitals in the Capital Region and at the Region Zealand in Denmark, from April 2014 to April 2016. The study had two co-primary outcomes: Pain during mobilisation at 6 hours post-operatively (numeric rating scale [NRS] [0-10]) and morphine consumption 0-24 hours post-operatively. RESULTS A large variety of analgesic treatments were used at the included hospitals and none of the hospitals used the same non-opioid basic analgesic regimen. For all patients at all hospitals, the NRS-pain level during mobilisation at 6 hours was 5 (3-6), (median [interquartile range]) and the 24-hour intravenous morphine (eqv) consumption was 25 mg (18-35). Although some statistically significant differences between hospitals were found for morphine use, no non-opioid analgesic regimen demonstrated consistent clinically relevant superior efficacy. In general, pain levels at rest were low to moderate and pain during mobilisation was moderate. CONCLUSIONS Analgesic treatment routines differed between hospitals. Pain levels, however, did not differ substantially and were in general low at rest and moderate during mobilisation. No non-opioid analgesic treatment demonstrated consistent analgesic superiority.
Collapse
Affiliation(s)
- Anja Geisler
- Department of Anaesthesiology Zealand University Hospital Køge Denmark
- Department of Health Sciences, Faculty of Medicine Lund University Lund Sweden
- Department of Anaesthesiology, Centre of Head and Orthopaedics Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Jørgen B. Dahl
- Department of Anaesthesiology Bispebjerg and Frederiksberg University Hospital Copenhagen Denmark
| | - Kasper H. Thybo
- Department of Anaesthesiology Næstved Hospital Næstved Denmark
| | - Tim H. Pedersen
- Department of Orthopedics Bispebjerg and Frederiksberg University Hospital Copenhagen Denmark
| | | | - Dina Hansen
- Department of Orthopedics Nykøbing Falster Hospital Nykøbing Falster Denmark
| | | | - Eva I. Persson
- Department of Health Sciences, Faculty of Medicine Lund University Lund Sweden
| | - Ole Mathiesen
- Department of Anaesthesiology Zealand University Hospital Køge Denmark
| |
Collapse
|
11
|
Smith AF, Plunkett E. People, systems and safety: resilience and excellence in healthcare practice. Anaesthesia 2019; 74:508-517. [PMID: 30585298 PMCID: PMC6766951 DOI: 10.1111/anae.14519] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2018] [Indexed: 11/28/2022]
Abstract
This article outlines recent developments in safety science. It describes the progression of three 'ages' of safety, namely the 'age of technology', the 'age of human factors' and the 'age of safety management'. Safety science outside healthcare is moving from an approach focused on the analysis and management of error ('Safety-1') to one which also aims to understand the inherent properties of safety systems that usually prevent accidents from occurring ('Safety-2'). A key factor in the understanding of safety within organisations relates to the distinction between 'work as imagined' and 'work as done'. 'Work as imagined' assumes that if the correct standard procedures are followed, safety will follow as a matter of course. However, staff at the 'sharp end' of organisations know that to create safety in their work, variability is not only desirable but essential. This positive adaptability within systems that allows good outcomes in the presence of both favourable and adverse conditions is termed resilience. We argue that clinical and organisational work can be made safer, not only by addressing negative outcomes, but also by fostering excellence and promoting resilience. We outline conceptual and investigative approaches for achieving this that include 'appreciative inquiry', 'positive deviance' and excellence reporting.
Collapse
Affiliation(s)
| | - E. Plunkett
- University Hospitals Birmingham NHS Foundation TrustBirminghamUK
| |
Collapse
|
12
|
Hospital-, Anesthesiologist-, and Patient-level Variation in Primary Anesthesia Type for Hip Fracture Surgery. Anesthesiology 2018; 129:1121-1131. [DOI: 10.1097/aln.0000000000002453] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Manuscript Tells Us That Is New
Background
Substantial variation in primary anesthesia type for hip fracture surgery exists. Previous work has demonstrated that patients cared for at hospitals using less than 20 to 25% neuraxial anesthesia have decreased survival. Therefore, the authors aimed to identify sources of variation in anesthesia type, considering patient-, anesthesiologist-, and hospital-level variables.
Methods
Following protocol registration (NCT02787031), the authors conducted a cross-sectional analysis of a population-based cohort using linked administrative data in Ontario, Canada. The authors identified all people greater than 65 yr of age who had emergency hip fracture surgery from April 2002 to March 2014. Generalized linear mixed models were used to account for hierarchal data and measure the adjusted association of hospital-, anesthesiologist-, and patient-level factors with neuraxial anesthesia use. The proportion of variation attributable to each level was estimated using variance partition coefficients and the median odds ratio for receipt of neuraxial anesthesia.
Results
Of 107,317 patients, 57,080 (53.2%) had a neuraxial anesthetic. The median odds ratio for receiving neuraxial anesthesia was 2.36 between randomly selected hospitals and 2.36 between randomly selected anesthesiologists. The majority (60.1%) of variation in neuraxial anesthesia use was explained by patient factors; 19.9% was attributable to the anesthesiologist providing care and 20.0% to the hospital where surgery occurred. The strongest patient-level predictors were absence of preoperative anticoagulant or antiplatelet agents, absence of obesity, and presence of pulmonary disease.
Conclusions
While patient factors explain most of the variation in neuraxial anesthesia use for hip fracture surgery, 40% of variation is attributable to anesthesiologist and hospital-level practice. Efforts to change practice patterns will need to consider hospital-level processes and anesthesiologists’ intentions and behaviors.
Collapse
|
13
|
Moppett IK, White SM, Griffiths R. Standards for hip fracture anaesthesia - a reply. Anaesthesia 2018; 72:407-408. [PMID: 28176310 DOI: 10.1111/anae.13822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- I K Moppett
- University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - S M White
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | |
Collapse
|
14
|
Kowark A, Adam C, Ahrens J, Bajbouj M, Bollheimer C, Borowski M, Dodel R, Dolch M, Hachenberg T, Henzler D, Hildebrand F, Hilgers RD, Hoeft A, Isfort S, Kienbaum P, Knobe M, Knuefermann P, Kranke P, Laufenberg-Feldmann R, Nau C, Neuman MD, Olotu C, Rex C, Rossaint R, Sanders RD, Schmidt R, Schneider F, Siebert H, Skorning M, Spies C, Vicent O, Wappler F, Wirtz DC, Wittmann M, Zacharowski K, Zarbock A, Coburn M. Improve hip fracture outcome in the elderly patient (iHOPE): a study protocol for a pragmatic, multicentre randomised controlled trial to test the efficacy of spinal versus general anaesthesia. BMJ Open 2018; 8:e023609. [PMID: 30341135 PMCID: PMC6196806 DOI: 10.1136/bmjopen-2018-023609] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/24/2018] [Accepted: 09/12/2018] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Hip fracture surgery is associated with high in-hospital and 30-day mortality rates and serious adverse patient outcomes. Evidence from randomised controlled trials regarding effectiveness of spinal versus general anaesthesia on patient-centred outcomes after hip fracture surgery is sparse. METHODS AND ANALYSIS The iHOPE study is a pragmatic national, multicentre, randomised controlled, open-label clinical trial with a two-arm parallel group design. In total, 1032 patients with hip fracture (>65 years) will be randomised in an intended 1:1 allocation ratio to receive spinal anaesthesia (n=516) or general anaesthesia (n=516). Outcome assessment will occur in a blinded manner after hospital discharge and inhospital. The primary endpoint will be assessed by telephone interview and comprises the time to the first occurring event of the binary composite outcome of all-cause mortality or new-onset serious cardiac and pulmonary complications within 30 postoperative days. In-hospital secondary endpoints, assessed via in-person interviews and medical record review, include mortality, perioperative adverse events, delirium, satisfaction, walking independently, length of hospital stay and discharge destination. Telephone interviews will be performed for long-term endpoints (all-cause mortality, independence in walking, chronic pain, ability to return home cognitive function and overall health and disability) at postoperative day 30±3, 180±45 and 365±60. ETHICS AND DISSEMINATION: iHOPE has been approved by the leading Ethics Committee of the Medical Faculty of the RWTH Aachen University on 14 March 2018 (EK 022/18). Approval from all other involved local Ethical Committees was subsequently requested and obtained. Study started in April 2018 with a total recruitment period of 24 months. iHOPE will be disseminated via presentations at national and international scientific meetings or conferences and publication in peer-reviewed international scientific journals. TRIAL REGISTRATION NUMBER DRKS00013644; Pre-results.
Collapse
Affiliation(s)
- Ana Kowark
- Department of Anaesthesiology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Christian Adam
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Klinikverbund St. Antonius und St. Josef GmbH, Wuppertal, Germany
| | - Jörg Ahrens
- Department of Anaesthesiology and Intensive Care, Medical University Hannover, Hannover, Germany
| | - Malek Bajbouj
- Psychiatry and Affective Neurosciences, Campus Benjamin Franklin, Charité Center Neurology, Neurosurgery and Psychiatry, Berlin, Germany
| | - Cornelius Bollheimer
- Department of Geriatric Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Matthias Borowski
- Institute of Biostatistics and Clinical Research, University of Muenster, Münster, Germany
| | - Richard Dodel
- Department of Geriatrics, University Hospital Essen, Essen, Germany
| | - Michael Dolch
- Department of Anaesthesiology, Ludwig-Maximilian University (LMU) Munich, Munich, Germany
| | - Thomas Hachenberg
- Department of Anaesthesiology and Intensive Care, University Hospital Magdeburg, Magdeburg, Germany
| | - Dietrich Henzler
- Department of Anaesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr-University Bochum, Klinikum Herford, Herford, Germany
| | - Frank Hildebrand
- Department of Orthopaedic Trauma Surgery, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Ralf-Dieter Hilgers
- Department of Medical Statistics, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Andreas Hoeft
- Department of Anaesthesiology and Operative Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Susanne Isfort
- Center for Translational & Clinical Research Aachen (CTC-A), Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Peter Kienbaum
- Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Mathias Knobe
- Department of Orthopaedic Trauma Surgery, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Pascal Knuefermann
- Department of Anaesthesiology, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - Peter Kranke
- Department of Anaesthesiology, University Hospital Würzburg, Würzburg, Germany
| | - Rita Laufenberg-Feldmann
- Department of Anaesthesiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Carla Nau
- Department of Anaesthesiology and Intensive Care, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Mark D Neuman
- Department of Anaesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cynthia Olotu
- Department of the Geriatric Anaesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christopher Rex
- Department of Anaesthesiology and Intensive Care, Reutlingen Hospital GMBH, Reutlingen, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Robert D Sanders
- Department of Anesthesiology, University of Wisconsin – Madison, Madison, Wisconsin, USA
| | - Rene Schmidt
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty RWTH Aachen University, Stuttgart, Germany
| | - Frank Schneider
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty RWTH Aachen University, Aachen, Germany
- Institute for Neuroscience and Medicine (INM-10), Research Centre Jülich, Jülich, Germany
| | | | - Max Skorning
- Section Patient Safety, Medical Advisory Service of Social Health Insurance, Essen, Germany
| | - Claudia Spies
- Department of Anaesthesiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Vicent
- Department of Anaesthesiology and Intensive Care, University Hospital Dresden, Dresden, Germany
| | - Frank Wappler
- Department of Anaesthesiology and Operative Intensive Care, University Witten/Herdecke, Witten/Herdecke, Germany
| | | | - Maria Wittmann
- Department of Anaesthesiology and Operative Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Mark Coburn
- Department of Anaesthesiology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | | |
Collapse
|
15
|
White SM, Foss NB, Griffiths R. Anaesthetic aspects in the treatment of fragility fracture patients. Injury 2018; 49:1403-1408. [PMID: 29958684 DOI: 10.1016/j.injury.2018.06.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 06/21/2018] [Indexed: 02/02/2023]
Abstract
As longevity increases globally, the number of older, frailer, comorbid patients requiring fragility fracture surgery will increase. Fundamentally, anaesthesia should aim to maintain these patients' pre-fracture cognitive and physiological trajectories and facilitate early (ie day 1) postoperative recovery. This review describes the 10 general principles of anaesthesia for fragility fracture surgery that best achieve these aims: multidisciplinary care, 'getting it right first time', timely surgery, standardisation, sympathetic anaesthesia, avoiding ischaemia, sympathetic analgesia, re-enablement, data collection and training.
Collapse
Affiliation(s)
- S M White
- FRCA, Brighton and Sussex University Hospitals NHS Trust, Eastern Road, Brighton, East Sussex, BN2 5BE, United Kingdom.
| | - N B Foss
- Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegård Allé 30, Hvidovre, Denmark
| | - R Griffiths
- North West Anglia Hospitals NHS FT, Bretton Gate, Peterborough, PE3 9GZ, United Kingdom
| |
Collapse
|
16
|
Vasu BK, Ramamurthi KP, Rajan S, George M. Geriatric Patients with Hip Fracture: Frailty and Other Risk Factors Affecting the Outcome. Anesth Essays Res 2018; 12:546-551. [PMID: 29962632 PMCID: PMC6020579 DOI: 10.4103/aer.aer_61_18] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Hip fracture is a devastating health-care problem in a geriatric patient, leading to high mortality and morbidity. Preoperative risk assessment in the geriatric patient is often inexact because of the difficulty in measuring their poor physiologic reserves. AIMS The primary objective was to find the association of modified frailty index (MFI) with 90-day mortality in geriatric patients who received anesthesia for fractured hip. Secondary objectives were to assess the association of preoperative waiting time with the 90-day mortality and the correlation of preexisting medical conditions with poor functional outcome among the survivors. SETTINGS AND DESIGNS This prospective, observational study was conducted at a tertiary care institution. SUBJECTS AND METHODS In this prospective observational study, done over a period of 1 year, 60 geriatric patients aged ≥65 years who received anesthesia for fractured hip and fulfilled selection criteria were recruited. The association of MFI with 90-day mortality and the correlation of preexisting comorbidities with poor functional outcome among the survivors were assessed. STATISTICAL ANALYSIS USED Independent sample t-test, Mann-Whitney test, and odds ratio were used as applicable. RESULTS Total 60 patients were available for analysis as two patients dropped off from final 62 on follow up, fifty three patients survived after 90 days. MFI and 90-day mortality showed a significant direct correlation with P < 0.0001. However, no association was found between the preoperative waiting time and 90-day mortality. Preexisting medical conditions showed a significant association of dementia with total dependence afterward with a P = 0.02. CONCLUSION There is significant statistical correlation of MFI with the 90-day mortality in the geriatric hip-fractured patients undergoing surgery.
Collapse
Affiliation(s)
- Bindu K. Vasu
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Kruthika P. Ramamurthi
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Sunil Rajan
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Mathew George
- Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| |
Collapse
|
17
|
Smirk AJ, Nicholson JJ, Console YL, Hunt NJ, Herschtal A, Nguyen MNHH, Riedel B. The enhanced recovery after surgery (ERAS) Greenie Board: a Navy-inspired quality improvement tool. Anaesthesia 2018; 73:692-702. [DOI: 10.1111/anae.14157] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2017] [Indexed: 12/21/2022]
Affiliation(s)
| | - J. J. Nicholson
- The Alfred Hospital; Melbourne Vic. Australia
- Monash University; Melbourne Vic. Australia
| | - Y. L. Console
- Peter MacCallum Cancer Centre; Melbourne Vic. Australia
| | - N. J. Hunt
- NW Training Scheme; Melbourne Vic. Australia
| | - A. Herschtal
- Centre for Biostatistics and Clinical Trials; Peter MacCallum Cancer Centre; Melbourne Vic. Australia
| | | | - B. Riedel
- Department of Anaesthetics; Perioperative and Pain Medicine; Peter MacCallum Cancer Centre; Melbourne Vic. Australia
- Melbourne University; Melbourne Vic. Australia
| |
Collapse
|
18
|
White SM, Altermatt F, Barry J, Ben-David B, Coburn M, Coluzzi F, Degoli M, Dillane D, Foss NB, Gelmanas A, Griffiths R, Karpetas G, Kim JH, Kluger M, Lau PW, Matot I, McBrien M, McManus S, Montoya-Pelaez LF, Moppett IK, Parker M, Porrill O, Sanders RD, Shelton C, Sieber F, Trikha A, Xuebing X. International Fragility Fracture Network Delphi consensus statement on the principles of anaesthesia for patients with hip fracture. Anaesthesia 2018; 73:863-874. [DOI: 10.1111/anae.14225] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2018] [Indexed: 01/16/2023]
Affiliation(s)
- S. M. White
- Brighton and Sussex University Hospitals NHS Trust; Brighton East Sussex UK
| | - F. Altermatt
- División de Anestesiología; Escuela de Medicina; Pontificia Universidad Católica de Chile; Santiago Chile
| | - J. Barry
- Cairns Hospital; Queensland Australia
| | - B. Ben-David
- University of Pittsburgh Medical Centre; Pittsburgh PA USA
| | - M. Coburn
- Medical Faculty; RWTH Aachen University; Aachen Germany
| | - F. Coluzzi
- Department Medical and Surgical Sciences and Biotechnologies; Sapienza University of Rome; Latina Italy
| | - M. Degoli
- Ospedale Civile di Baggiovara; Azienda Ospedaliero Universitaria di Modena; Modena Italy
| | - D. Dillane
- Anesthesiology and Pain Medicine; University of Alberta; Canada
| | - N. B. Foss
- Department of Anaesthesiology and Intensive Care Medicine; Hvidovre University Hospital; Hvidovre Denmark
| | - A. Gelmanas
- Hospital of Lithuanian University of Health Sciences Kauno klinikos; Lithuania
| | - R. Griffiths
- Peterborough and Stamford Hospitals NHS Trust; Peterborough UK
| | - G. Karpetas
- General University Hospital of Patras; Rio Greece
| | - J.-H. Kim
- Korea University College of Medicine; Seoul South Korea
| | | | - P.-W. Lau
- University of Hong Kong; Hong Kong China
| | - I. Matot
- Critical Care and Pain; Tel Aviv Medical Center; Sackeler School of Medicine; Tel Aviv Israel
| | | | | | - L. F. Montoya-Pelaez
- Department of Anaesthesia and Perioperative Medicine; Groote Schuur Hospital; University of Cape Town; Cape Town South Africa
| | - I. K. Moppett
- Anaesthesia and Critical Care Section; Division of Clinical Neuroscience; Queen's Medical Centre Campus; Nottingham University Hospitals NHS Trust; University of Nottingham; Nottingham UK
| | - M. Parker
- Peterborough and Stamford Hospitals NHS Trust; Peterborough UK
| | - O. Porrill
- New Somerset Hospital; University of Cape Town; South Africa
| | | | - C. Shelton
- Lancaster Medical School and Wythenshawe Hospital; Manchester UK
| | - F. Sieber
- Johns Hopkins Bayview Medical Center; Baltimore MD USA
| | - A. Trikha
- All India Institute of Medical Sciences; New Delhi India
| | - X. Xuebing
- University of Hong Kong-Shenzhen Hospital; Shenzhen China
| |
Collapse
|
19
|
Association of Hospital-level Neuraxial Anesthesia Use for Hip Fracture Surgery with Outcomes. Anesthesiology 2018; 128:480-491. [DOI: 10.1097/aln.0000000000001899] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background
There is consistent and significant variation in neuraxial anesthesia use for hip fracture surgery across jurisdictions. We measured the association of hospital-level utilization of neuraxial anesthesia, independent of patient-level use, with 30-day survival (primary outcome) and length of stay and costs (secondary outcomes).
Methods
We conducted a population-based cohort study using linked administrative data in Ontario, Canada. We identified all hip fracture patients more than 65 yr of age from 2002 to 2014. For each patient, we measured the proportion of hip fracture patients at their hospital who received neuraxial anesthesia in the year before their surgery. Multilevel, multivariable regression was used to measure the association of log-transformed hospital-level neuraxial anesthetic-use proportion with outcomes, controlling for patient-level anesthesia type and confounders.
Results
Of 107,317 patients, 57,080 (53.2%) had a neuraxial anesthetic; utilization varied from 0 to 100% between hospitals. In total, 9,122 (8.5%) of patients died within 30 days of surgery. Survival independently improved as hospital-level neuraxial use increased (P = 0.009). Primary and sensitivity analyses demonstrated that most of the survival benefit was realized with increase in hospital-level neuraxial use above 20 to 25%; there did not appear to be a substantial increase in survival above this point. No significant associations between hospital neuraxial anesthesia-use and other outcomes existed.
Conclusions
Hip fracture surgery patients at hospitals that use more than 20 to 25% neuraxial anesthesia have improved survival independent of patient-level anesthesia type and other confounders. The underlying causal mechanism for this association requires a prospective study to guide improvements in perioperative care and outcomes of hip fracture patients.
Collapse
|
20
|
Gardner JW, Boyer KK, Ward PT. Achieving Time-Sensitive Organizational Performance Through Mindful Use of Technologies and Routines. ORGANIZATION SCIENCE 2017. [DOI: 10.1287/orsc.2017.1159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- John W. Gardner
- Marriott School of Business, Brigham Young University, Provo, Utah 84602
| | - Kenneth K. Boyer
- Max M. Fisher College of Business, The Ohio State University, Columbus, Ohio 43210
| | - Peter T. Ward
- Max M. Fisher College of Business, The Ohio State University, Columbus, Ohio 43210
| |
Collapse
|
21
|
Scott L. Don't quote me on this, but…. Anaesthesia 2017; 72:1567-1568. [DOI: 10.1111/anae.14112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- L. Scott
- Bristol Royal Infirmary; Bristol UK
| |
Collapse
|
22
|
Moppett IK, White S, Griffiths R, Buggy D. Tight intra-operative blood pressure control versus standard care for patients undergoing hip fracture repair - Hip Fracture Intervention Study for Prevention of Hypotension (HIP-HOP) trial: study protocol for a randomised controlled trial. Trials 2017; 18:350. [PMID: 28743315 PMCID: PMC5526232 DOI: 10.1186/s13063-017-2066-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 06/24/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypotension during anaesthesia for hip fracture surgery is common. Recent data suggest that there is an association between the lowest intra-operative blood pressure and mortality, even when adjusted for co-morbidities. This is consistent with data derived from the wider surgical population, where magnitude and duration of hypotension are associated with mortality and peri-operative complications. However, there are no trial to data to support more aggressive blood pressure control. METHODS/DESIGN We are conducting a three-centre, randomised, double-blinded pilot study in three hospitals in the United Kingdom. The sample size will be 75 patients (25 from each centre). Randomisation will be done using computer-generated concealed tables. Both participants and investigators will be blinded to group allocation. Participants will be aged >70 years, cognitively intact (Abbreviated Mental Test Score 7 or greater), able to give informed consent and admitted directly through the emergency department with a fractured neck of the femur requiring operative repair. Patients randomised to tight blood pressure control or avoidance of intra-operative hypotension will receive active treatment as required to maintain both of the following: systolic arterial blood pressure >80% of baseline pre-operative value and mean arterial pressure >75 mmHg throughout. All participants will receive standard hospital care, including spinal or general anaesthesia, at the discretion of the clinical team. The primary outcome is a composite of the presence or absence of defined cardiovascular, renal and delirium morbidity within 7 days of surgery (myocardial injury, stroke, acute kidney injury, delirium). Secondary endpoints will include the defined individual morbidities, mortality, early mobility and discharge to usual residence. DISCUSSION This is a small-scale pilot study investigating the feasibility of a trial of tight intra-operative blood pressure control in a frail elderly patient group with known high morbidity and mortality. Positive findings will provide the basis for a larger-scale study. TRIAL REGISTRATION ISRCTN Registry identifier: ISRCTN89812075 . Registered on 30 August 2016.
Collapse
Affiliation(s)
- Iain Keith Moppett
- Anaesthesia and Critical Care Section, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Stuart White
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Richard Griffiths
- Department of Anaesthesia, Peterborough & Stamford Hospitals NHS Trust, Peterborough, UK
| | - Donal Buggy
- School of Medicine, Mater Hospital, Eccles Street, Dublin 7, Ireland
| |
Collapse
|
23
|
Affiliation(s)
- D. Murray
- James Cook University Hospital; Middlesbrough UK
| |
Collapse
|
24
|
Sivasubramaniam S. Standardising anaesthesia for hip fracture surgery. Anaesthesia 2017; 72:544-545. [PMID: 28297114 DOI: 10.1111/anae.13857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
25
|
Skinner A. Standards for hip fracture anaesthesia. Anaesthesia 2017; 72:406-407. [DOI: 10.1111/anae.13805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|