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

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.

Higher intraoperative mean arterial blood pressure does not reduce postoperative delirium in elderly patients following gastrointestinal surgery: A prospective randomized controlled trial

BACKGROUND

This study aimed to describe the relationship between the different levels of intraoperative mean arterial blood pressure (MAP) and postoperative delirium in elderly patients undergoing gastrointestinal laparoscopic surgery.

MATERIALS AND METHODS

This prospective controlled clinical trial enrolled 116 patients aged 65 to 85 years who underwent gastrointestinal laparoscopic surgery. These patients were randomized 1:1 to a MAP goal of 65 to 85 mmHg (L group) or an 86 to 100 mmHg (H group). The primary endpoint was the incidence of postoperative delirium, assessed twice daily with the Confusion Assessment Method (CAM) and Richmond Agitation-Sedation Scale (RASS) during the first five postoperative days. Delirium severity was evaluated with the Delirium-O-Meter (D-O-M).

RESULTS

108 patients (L group n = 55, H group n = 53) were eventually included in intention-to-treat analyses. Postoperative delirium occurred in 18 (32.7%) of 55 cases of L group and in 15 (28.3%) of 53 cases of H group. The incidence of delirium subtypes between the two groups: hypoactive delirium 14.5% (8/55) vs 11.3% (6/53); hyperactive delirium 7.3% (4/55) vs 3.8% (2/53); mixed delirium 10.9% (6/55) vs 13.2% (7/53). However, the L group showed higher D-O-M scores of the first episode of delirium: 14.5 (Q1 = 12, Q3 = 18.5) vs 12 (Q1 = 10, Q3 = 14), which means the delirium is more severe.

CONCLUSIONS

Compared with 65 to 85 mmHg, maintaining intraoperative MAP at 86-100 mmHg did not reduce the incidence of postoperative delirium in elderly patients undergoing gastrointestinal laparoscopic surgery. However, the severity of delirium could be reduced and blood loss is a risk factor for postoperative delirium.

Fluid-responsiveness, blood volume and perfusion in preoperative haemodynamic optimisation of hip fracture patients; a prospective observational study

BACKGROUND

Preoperative resuscitation strategies in patients with hip fracture (HF) are lacking. We aimed to investigate fluid-responsiveness, peripheral perfusion index (PPI) and blood volume (BV)-status in patients with HF undergoing resuscitation in the preoperative phase.

METHODS

In a prospective observational study, we evaluated preoperative fluid-responsiveness, indices of perfusion and BV before and after lumbar epidural analgesia in 50 patients with HF shortly after admittance.

RESULTS

Initially, 18 (36%) patients were fluid-responsive (≥10% increased SV in response to 250 ml fluid bolus) and 13 (26%) presented hypovolaemia (deviation of measured BV from estimated BV ≤ 0.9). According to fluid-responsiveness, no difference in absolute values of cardiac index (CI) (2.7 L [2.1-3.3] vs. 2.8 L [2.3-3.4], p = .5) was seen, but cardiac output (CO) rose significantly in the hypovolaemic patients: 9% [5-18] vs. 1% [-3-7], p = .004. After epidural analgesia, 26 (52%) patients were again fluid-responsive and 15 (30%) were hypovolaemic. CI was now significantly lower in fluid-responsive patients (2.2 L [1.7-2.7] vs. 2.9 L [2.3-3.5], p = .001). Prior to epidural analgesia, no significant trend towards hypovolaemic patients having lower indices of perfusion was seen. After epidural analgesia, more patients with hypovolaemia presented with PPI≤1.5 (8 (53%) vs. 3 (9%), p = .001) and absolute values of PPI were also significantly lower if IBV was low (1.4 [0.9-3.2] vs. 3.2 [2.4-4.8], p = .01). PPI correlated with hypovolaemia after epidural analgesia (rho 0.4 [0.1-0.7], p = .007).

CONCLUSIONS

Preoperative fluid-responsivity in HF patients might be attributable to elements of hypovolaemia and sympathetic compensatory ability conjointly, confounding the use of SV-guided resuscitation. PPI could be associated with BV, which may support clinicians during perioperative haemodynamic optimisation.

Unsupervised Data Mining and Effect of Fast Rehabilitation Nursing Intervention in Fracture Surgery

At present, the most commonly used surgical treatment for fractures caused by external force injury is clinical, and unsupervised data mining is more advantageous in the face of the unknown format of perioperative network data. Therefore, this research aims to explore the application effect of unsupervised data mining in the concept of rapid rehabilitation nursing intervention after fracture surgery. 80 patients who underwent fracture surgery in the Department of Orthopedics of XXX Hospital were determined as the subjects, who were rolled into a research group (group R, 40 cases) and a control group (group C, 40 cases) by drawing lots. An unsupervised data mining algorithm based on unsupervised data mining for support vector machines (VDMSVMs) was proposed and applied to two groups of patients undergoing perioperative fracture surgery with the rapid rehabilitation nursing intervention and basic routine nursing. The results showed that the number of important features selected by the VDMSVM algorithm (5) was obviously more than that of the compressed edge fragment sampling (CEFS) algorithm (1) and the multicorrelation forward searching (MCFS) algorithm (2) (P < 0.05). The number of noise features screened by the VDMSVM algorithm (3) was much less in contrast to that of the CEFS algorithm and the MCFS algorithm, which was 8 and 10, respectively (P < 0.05). The Visual Analogue Scale (VAS) scores of the fracture site at the 4th, 8th, 12th, and 16th hour after surgery in group R were all lower than the scores in group C (P < 0.05). The length of hospital stay (LoHS) in group R was greatly shorter than that in group C (P < 0.05). After different nursing methods, the World Health Organization Quality of Life (WHOQOL-BREF) score of patients in group R (89.64 points) was greatly higher than the score in group C (61.45 points) (P < 0.05). The nursing satisfaction score of group R was 92.35 ± 3.65 points, and that in group C was 2.14 ± 1.25 points, respectively (P < 0.05). The test results verified the effectiveness of the feature selection of the VDMSVM algorithm. The rapid rehabilitation nursing intervention was conductive to reducing the postoperative pain of fracture patients, shortening the LoHS of patients, improving the quality of life (QOL) of fracture surgery patients, and increasing the patient's satisfaction with nursing.

Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients

BACKGROUND

Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention.  OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU).

SEARCH METHODS

We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium.  DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium.

MAIN RESULTS

We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies.  Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain.  Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I² = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias).  There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I² = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision).  No studies of multicomponent interventions reported data on new diagnoses of dementia.  Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I² = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I²=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I²=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited.  Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm.  Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial.  Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I² = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias).  Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention.  AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.

Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients

BACKGROUND

Delirium is an acute neuropsychological disorder that is common in hospitalised patients. It can be distressing to patients and carers and it is associated with serious adverse outcomes. Treatment options for established delirium are limited and so prevention of delirium is desirable. Non-pharmacological interventions are thought to be important in delirium prevention.  OBJECTIVES: To assess the effectiveness of non-pharmacological interventions designed to prevent delirium in hospitalised patients outside intensive care units (ICU).

SEARCH METHODS

We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP to 16 September 2020. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of single and multicomponent non-pharmacological interventions for preventing delirium in hospitalised adults cared for outside intensive care or high dependency settings. We only included non-pharmacological interventions which were designed and implemented to prevent delirium.  DATA COLLECTION AND ANALYSIS: Two review authors independently examined titles and abstracts identified by the search for eligibility and extracted data from full-text articles. Any disagreements on eligibility and inclusion were resolved by consensus. We used standard Cochrane methodological procedures. The primary outcomes were: incidence of delirium; inpatient and later mortality; and new diagnosis of dementia. We included secondary and adverse outcomes as pre-specified in the review protocol. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes and between-group mean differences for continuous outcomes. The certainty of the evidence was assessed using GRADE. A complementary exploratory analysis was undertaker using a Bayesian component network meta-analysis fixed-effect model to evaluate the comparative effectiveness of the individual components of multicomponent interventions and describe which components were most strongly associated with reducing the incidence of delirium.

MAIN RESULTS

We included 22 RCTs that recruited a total of 5718 adult participants. Fourteen trials compared a multicomponent delirium prevention intervention with usual care. Two trials compared liberal and restrictive blood transfusion thresholds. The remaining six trials each investigated a different non-pharmacological intervention. Incidence of delirium was reported in all studies.  Using the Cochrane risk of bias tool, we identified risks of bias in all included trials. All were at high risk of performance bias as participants and personnel were not blinded to the interventions. Nine trials were at high risk of detection bias due to lack of blinding of outcome assessors and three more were at unclear risk in this domain.  Pooled data showed that multi-component non-pharmacological interventions probably reduce the incidence of delirium compared to usual care (10.5% incidence in the intervention group, compared to 18.4% in the control group, risk ratio (RR) 0.57, 95% confidence interval (CI) 0.46 to 0.71, I2 = 39%; 14 studies; 3693 participants; moderate-certainty evidence, downgraded due to risk of bias).  There may be little or no effect of multicomponent interventions on inpatient mortality compared to usual care (5.2% in the intervention group, compared to 4.5% in the control group, RR 1.17, 95% CI 0.79 to 1.74, I2 = 15%; 10 studies; 2640 participants; low-certainty evidence downgraded due to inconsistency and imprecision).  No studies of multicomponent interventions reported data on new diagnoses of dementia.  Multicomponent interventions may result in a small reduction of around a day in the duration of a delirium episode (mean difference (MD) -0.93, 95% CI -2.01 to 0.14 days, I2 = 65%; 351 participants; low-certainty evidence downgraded due to risk of bias and imprecision). The evidence is very uncertain about the effect of multicomponent interventions on delirium severity (standardised mean difference (SMD) -0.49, 95% CI -1.13 to 0.14, I2=64%; 147 participants; very low-certainty evidence downgraded due to risk of bias and serious imprecision). Multicomponent interventions may result in a reduction in hospital length of stay compared to usual care (MD -1.30 days, 95% CI -2.56 to -0.04 days, I2=91%; 3351 participants; low-certainty evidence downgraded due to risk of bias and inconsistency), but little to no difference in new care home admission at the time of hospital discharge (RR 0.77, 95% CI 0.55 to 1.07; 536 participants; low-certainty evidence downgraded due to risk of bias and imprecision). Reporting of other adverse outcomes was limited.  Our exploratory component network meta-analysis found that re-orientation (including use of familiar objects), cognitive stimulation and sleep hygiene were associated with reduced risk of incident delirium. Attention to nutrition and hydration, oxygenation, medication review, assessment of mood and bowel and bladder care were probably associated with a reduction in incident delirium but estimates included the possibility of no benefit or harm.  Reducing sensory deprivation, identification of infection, mobilisation and pain control all had summary estimates that suggested potential increases in delirium incidence, but the uncertainty in the estimates was substantial.  Evidence from two trials suggests that use of a liberal transfusion threshold over a restrictive transfusion threshold probably results in little to no difference in incident delirium (RR 0.92, 95% CI 0.62 to 1.36; I2 = 9%; 294 participants; moderate-certainty evidence downgraded due to risk of bias).  Six other interventions were examined, but evidence for each was limited to single studies and we identified no evidence of delirium prevention.  AUTHORS' CONCLUSIONS: There is moderate-certainty evidence regarding the benefit of multicomponent non-pharmacological interventions for the prevention of delirium in hospitalised adults, estimated to reduce incidence by 43% compared to usual care. We found no evidence of an effect on mortality. There is emerging evidence that these interventions may reduce hospital length of stay, with a trend towards reduced delirium duration, although the effect on delirium severity remains uncertain. Further research should focus on implementation and detailed analysis of the components of the interventions to support more effective, tailored practice recommendations.

Impact of Frailty and Malnutrition on Outcomes After Surgical Fixation of Lower Extremity Fractures in Young Patients

OBJECTIVES

Evaluate the relationship of nutrition parameters and the modified frailty index (mFI) on postsurgical complications within a young patient population sustaining lower extremity orthopaedic trauma.

DESIGN

Retrospective observational cohort study.

SETTING

Urban, American College of Surgeons-Verified, Level-1, Trauma Center.

PATIENTS/PARTICIPANTS

Seventeen-thousand one hundred nine adult patients under the age of 65 sustaining lower extremity fractures undergoing operative intervention from 2006 to 2018.

MAIN OUTCOME MEASURES

On admission, mFI and albumin levels were obtained, as well as complication data. Statistical analysis was used to analyze the association between frailty, malnutrition, and postoperative complications. Patients were stratified, healthy (mFI ≤1, albumin ≥3.5 g/dL), malnourished (mFI ≤1, albumin <3.5 g/dL), frail (mFI ≥2, albumin ≥3.5 g/dL), and frail and malnourished (mFI ≥2, albumin <3.5 g/dL).

RESULTS

60.4% of patients were healthy, 18.8% were malnourished, 11.7% were frail, and 9.0% were frail and malnourished. Frailty and/or malnourishment on admission predicted significantly higher odds of postoperative complications and mortality when compared with healthy patients. Frailty and malnourishment in conjunction predicted a significantly higher odds ratio of 1.46 (1.22-1.75) for developing postoperative complications when compared with the only malnourished. This was also observed when compared with the only frail (odd ratio: 1.61, P < 0.001); however, there was also a 2.72 (P < 0.001) increased odds of mortality.

CONCLUSIONS

Frailty and malnutrition in conjunction predicts a subset of patients with a higher risk of postoperative complications beyond that of frailty or malnutrition in isolation. Identification of these physiological states on admission allows for interventional opportunities during hospitalization.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Hypotension during hip fracture surgery and postoperative morbidity

Background

Hip fracture is a growing healthcare challenge, with 6–8% 30-day mortality and 20–30% of patients incurring major morbidity, including impaired mobilisation and ability to live independently. While observational studies have shown no benefit of general versus spinal anaesthesia on 30-day mortality, intraoperative hypotension during hip fracture surgery is associated with increased 30-day mortality regardless of anaesthetic technique. Although a recent trial on younger patients demonstrated reduced postoperative complications by maintaining intraoperative arterial blood pressure close to preoperative baseline, there are no data correlating intraoperative hypotension during hip fracture surgery with postoperative morbidity.

Objective

We evaluated the hypothesis that duration and severity of intraoperative hypotension during hip fracture surgery is associated with increased postoperative morbidity.

Methods

A retrospective analysis was carried out on n = 52 patients undergoing hip fracture surgery between January and June 2017. Measurements of patients’ intraoperative systolic arterial pressure (SAP) and mean arterial pressure (MAP) during anaesthesia, logged electronically through an anaesthesia information management system, were reviewed. We calculated the total duration of time where SAP or MAP were below pre-defined thresholds for hypotension (MAP < 75 mmHg, MAP < 55 mmHg, SAP ≤ 80% admission baseline or SAP ≤ 80% pre-induction baseline). Univariate and bivariate descriptive statistics were generated for all relevant variables. With multivariable regression models containing known predictors, cumulative duration of hypotension was correlated with postoperative comorbidities as quantified by the Clavien-Dindo and Comprehensive Complication Indices.

Results

Mean age (± SD) was 78 ± 13 years, 75% were female, 87% were ASA II or III and 60% underwent spinal anaesthesia. Mean Comprehensive Complication Index was 20.4 ± 19.2. Lowest absolute SAP and MAP values were 82 ± 18 mmHg and 55 ± 12 mmHg respectively. Cumulative time of SAP < 80% pre-induction value adjusted to gender, age and the Charlson Comorbidity Index was associated with progression to a higher Clavien-Dindo classification (odds ratio 1.020 per additional minute; 95% CI 1.008–1.035; P = 0.003).

Conclusions

In this exploratory retrospective analysis, the cumulative time of hypotension during hip fracture surgery correlated with extensive postoperative morbidity when adjusting to other known predictors. Intraoperative cumulative time of hypotension may be a good candidate for larger prediction studies as a predictor of postoperative complications. A randomised controlled trial evaluating the effect of actively minimising intraoperative hypotension on postoperative morbidity in hip fracture patients seems warranted.

Perioperative multi-system optimization protocol in elderly hip fracture patients: a randomized-controlled trial

PURPOSE

Hip fractures in elderly patients are associated with increased postoperative morbidity and mortality. We evaluated whether a perioperative multi-system optimization protocol can reduce postoperative complications in these patients.

METHODS

Immediately after diagnosis of hip fracture, patients ≥ 60 yr were randomized to an intervention or control group. Patients in the intervention group were admitted to our postanesthesia care unit where they were treated with goal-directed hemodynamic management, optimized pain therapy, oxygen therapy, and optimized nutrition. Patients in the control group were managed according to our usual standard of care on a regular ward. Postoperative complications during hospital stay included pre-determined cardiovascular, respiratory, neurologic, renal, or surgical events.

RESULTS

The incidence of at least one postoperative complication (primary outcome) was seen in 32 of 65 (49%) controls compared with 24 of 62 (39%) in the intervention group (relative risk [RR], 0.79; 95% confidence interval [CI], 0.53 to 1.17; P = 0.23). The secondary unadjusted outcomes showed that patients in the intervention group received more Ringer's acetate compared with controls (median difference, 1.3 L; 95% CI, 0.6 to 2.1 L; P < 0.001), had more frequently a mean arterial pressure > 70 mmHg (57% control vs 75% intervention; median percentage difference, 16%; 95% CI, 7 to 25%; P = 0.001), better pain control (numeric rating scale < 4 at all postoperative measurements; 25% control vs 81% intervention; RR, 0.26; 95% CI, 0.15 to 0.43; P < 0.001), and possibly a lower incidence of acute renal failure (RR, 0.37; 95% CI, 0.14 to 0.98; P = 0.04).

CONCLUSIONS

The implementation of a perioperative multi-system optimization protocol algorithm did not significantly reduce the risk of postoperative complications. Nevertheless, we likely over-estimated the potential treatment effect in our study design and thus were under-powered to show an effect.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT01673776). Registered 23 August, 2012.

General versus spinal anesthesia for the elderly hip fractured patient

PURPOSE OF REVIEW

There is an urge to improve care for patients with hip fracture. The present review will compare the efficacy of spinal versus general anesthesia for patients requiring hip fracture surgery.

RECENT FINDINGS

The present review gives an overview with particular emphasis on literature published during the past 24 months.

SUMMARY

So far, no clear evidence form randomized trials exists to identify the best anesthesia technique for hip fracture surgery. However, several large-scale pragmatic trials are ongoing and will provide future guidance.

Frailty predicts mortality and complications in chronologically young patients with traumatic orthopaedic injuries

BACKGROUND

As morbidity and mortality from traumatic orthopaedic injuries continues to rise, increased research is being conducted on how to best predict complications in at risk patients. Recently, frailty indices have been validated in a variety of surgical subspecialties as predictors of morbidity and mortality. However, the vast majority of research has been conducted on geriatric patient populations, with little evidence on patients who are chronologically young. The purpose of this study was to evaluate the role of a modified frailty index (mFI) in predicting mortality and complications after pelvis, acetabulum, and lower extremity trauma in patients of all ages.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2014 for all patients who underwent surgery for pelvis, acetabulum, and lower extremity trauma. The sample size was divided into geriatric (age ≥ 60) and young (age < 60) cohorts. The mFI score was calculated for each patient. Bivariate analysis was performed using logistic regression and a chi-square test to determine the relationship between mFI and both primary and secondary outcomes while adjusting for age. Univariate analysis and multivariate analyses were performed. All analyses were done using SAS 9.4 (Cary, NC) and a p < 0.05 was considered significant.

RESULTS

56,241 patients were identified to have undergone surgery for pelvis, acetabulum, or lower extremity trauma. 28% of patients were identified under the age of 60. In the young cohort, mFI was a strong predictor of thirty-day mortality (OR 11.02, 95% CI 6.26-19.39, p < 0.001). With regards to Clavien-Dindo grade IV complications, MFI is also a strong predictor in the young cohort (OR 28.82, 95% CI 16.05-51.77, p < 0.001).

CONCLUSION AND RELEVANCE

The mFI score was a significant predictor of morbidity and mortality in chronologically young orthopaedic trauma patients. The use of the mFI score can provide an individualized risk assessment to interdisciplinary teams for perioperative counseling and to improve outcomes.

Acute hip fracture surgery anaesthetic technique and 30-day mortality in Sweden 2016 and 2017: A retrospective register study

Background: Hip fractures affect 1.6 million patients yearly worldwide, often elderly with complex comorbidity. Mortality following surgery for acute hip fracture is high and multifactorial; high age, comorbidities and complication/deterioration in health following surgery. Whether the anaesthesia technique affects the 30-day mortality rate has been studied widely without reaching a consensus. The primary aim of this study was to determine anaesthetic techniques used in Sweden and their impact on the 30-day mortality rate in elderly undergoing acute hip fracture surgery. Other aims were to study the impact of age, gender, ASA class, fracture type and delay in surgery on the 30-day mortality rate. Methods: Data from 13,649 patients ≥50 years old who had undergone acute hip fracture surgery and been reported to Swedish perioperative register (SPOR) between 2016 and 2017 were analysed.     Results: The most commonly used anaesthetic technique was neuraxial anaesthesia (NA; 11,257, 82%), followed by general anaesthesia (GA; 2,190, 16%) and combined general and neuraxial anaesthesia (CA; 202, 1.5%) out of the 13,649 studied. The 30-day mortality rate was 7.7% for the entire cohort; GA 7.8%, NA 7.7% and CA 7.4%. Mortality was higher in elderly patients, those with a high ASA class, pertrochanteric fracture and males.     Conclusions: The present study showed that NA is by far the most common anaesthetic technique for acute hip fracture surgery in Sweden. However, the anaesthetic technique used during this type of surgery had no impact on the 30-day mortality rate in patients. Increasing age, ASA class and male gender increased the 30-day mortality.

Acute hip fracture surgery anaesthetic technique and 30-day mortality in Sweden 2016 and 2017: A retrospective register study

Background: Hip fractures affect 1.6 million patients yearly worldwide, often elderly with complex comorbidity. Mortality following surgery for acute hip fracture is high and multifactorial; high age, comorbidities and complication/deterioration in health following surgery. Whether the anaesthesia technique affects the 30-day mortality rate has been studied widely without reaching a consensus. The primary aim of this study was to determine anaesthetic techniques used in Sweden and their impact on the 30-day mortality rate in elderly undergoing acute hip fracture surgery. Other aims were to study the impact of age, gender, ASA class, fracture type and delay in surgery on the 30-day mortality rate.

Methods: Data from 13,649 patients ≥50 years old who had undergone acute hip fracture surgery and been reported to Swedish perioperative register (SPOR) between 2016 and 2017 were analysed.    

Results: The most commonly used anaesthetic technique was neuraxial anaesthesia (NA; 11,257, 82%), followed by general anaesthesia (GA; 2,190, 16%) and combined general and neuraxial anaesthesia (CA; 202, 1.5%) out of the 13,649 studied. The 30-day mortality rate was 7.7% for the entire cohort; GA 7.8%, NA 7.7% and CA 7.4%. Mortality was higher in elderly patients, those with a high ASA class, pertrochanteric fracture and males.    

Conclusions: The present study showed that NA is by far the most common anaesthetic technique for acute hip fracture surgery in Sweden. However, the anaesthetic technique used during this type of surgery had no impact on the 30-day mortality rate in patients. Increasing age, ASA class and male gender increased the 30-day mortality.