Impact of Preoperative Echocardiography on Perioperative Management in Geriatric Hip Trauma: A Retrospective Observational Study

Standardized Preoperative Pathways Determining Preoperative Echocardiogram Usage Continue to Improve Hip Fracture Quality

Introduction

The purpose of this study was to assess the hospital quality measures and outcomes of operative hip fracture patients before and after implementation of an anesthesiology department protocol assigning decision for a preoperative transthoracic echocardiogram (TTE) to the hospitalist co-managing physician.

Materials and Methods

Demographics, injury details, hospital quality measures, and outcomes were reviewed for a consecutive series of patients presenting to our institution with an operative hip fracture. In May of 2019, a new protocol assigning the responsibility to indicate a patient for preoperative TTE was mandated to the co-managing hospitalist at the institution. Patients were split into pre-protocol and post-protocol cohorts. Linear regression modeling and comparative analyses were conducted with a Bonferroni adjusted alpha as appropriate.

Results

Between September 2015 and June 2021, 1002 patients presented to our institution and were diagnosed with a hip fracture. Patients in the post-protocol cohort were less likely to undergo a preoperative echocardiogram, experienced a shorter time (days) to surgery, shorter length of stay, an increase in amount of home discharges, and lower complication risks for urinary tract infection and acute blood loss anemia as compared to those in the pre-protocol cohort. There were no differences seen in inpatient or 30-day mortality. Multivariable linear regression demonstrated a patient’s comorbidity profile (Charlson Comorbidity Index (CCI)) and their date of presentation (pre- or post-protocol), were both associated with (P<0.01) a patients' time to surgery.

Conclusion

A standardized preoperative work flow protocol regarding which physician evaluates and determines which patients require a preoperative TTE allows for a streamlined perioperative course for hip fracture patients. This allows for a shortened time to surgery and length of stay with an increase in home discharges and was associated with a reduced risk of common index hospitalization complications including UTI and anemia.

Factors associated with delayed surgery in elderly hip fractures in India

Early hip fracture surgery is recommended to decrease the morbidity and mortality. The extent to which such guidelines are being followed in developing countries like India is unknown. About 20% of the patients presented to hospital after 24 hours of injury, and only one-third had surgery within 48 hours of presentation.

INTRODUCTION

Early hip fracture surgery is recommended to decrease the morbidity and mortality following hip fractures. Understanding the factors responsible for delay in surgery is important to improve the quality of hip fracture care. This study was conducted to study the factors causing delay in elderly hip fracture surgery in India.

METHODS

In this prospective study, 272 consecutive hip fracture surgeries at a single hospital were included. Delayed surgery was defined as when the time to surgery (reaching hospital to start of incision) was more than 48 hours. Additionally, the total time to surgery (including time taken for patients to reach hospital after injury) was studied. Factors associated with delayed surgery were assessed using regression models.

RESULTS

Eighty-seven (32%) patients had a surgery within 48 hours of presentation. Majority of the patients had a delay (82%, N = 151/185) due to one or more medical reasons. Fifty-four (20%) patients presented to hospital after 24 hours of injury. The mean total time to surgery was 112 ± 90 hours with time after reaching hospital contributing to 78% of the total time. Multiple comorbidities (odds ratio, OR = 3.47 [1.42-8.45]), fall as mode of injury (OR = 3.54 [1.61-7.80]), requiring an additional investigation (OR = 10.4 [3.4-31.81]), and requiring arthroplasty (OR = 40.57 [7.01-234.97]) were independently associated with delayed surgery.

CONCLUSION

Only about one-third of the patients received surgery within 48 hours of reaching the hospital, and about 20% of the patients presented to hospital after 24 hours of injury. Delayed surgery was primarily due to medical comorbidities. Hospitals should establish protocols to ensure faster optimization of patients.

Does preoperative dipyridamole-thallium scanning reduce 90-day cardiac complications and 1-year mortality in patients with femoral neck fractures undergoing hemiarthroplasty?

Background

This study aimed to evaluate the effect of dipyridamole-thallium scanning (DTS) on the rates of 90-day cardiac complications and 1-year mortality in patients with a femoral neck fracture treated with hemiarthroplasty.

Methods

Between 2008 and 2015, 844 consecutive patients who underwent cemented or cementless hemiarthroplasty were identified from the database of a single level-one medical center. One-hundred and thirteen patients (13%) underwent DTS prior to surgery, and 731 patients (87%) did not. Patient characteristics, comorbidities, surgical variables, and length of the delay until surgery were recorded. A propensity score-matched cohort was utilized to reduce recruitment bias in a 1:3 ratio of DTS group to control group, and multivariate logistic regression was performed to control confounding variables.

Results

The incidence of 90-day cardiac complications was 19.5% in the DTS group and 15.6% in the control group (p = 0.343) among 452 patients after propensity score-matching. The 1-year mortality rate (10.6% vs 13.3%, p = 0.462) was similar in the two groups. In the propensity score-matched patients, utilization of DTS was not associated with a reduction in the rate of 90-day cardiac complications (matched cohort, adjusted odds ratio [aOR] = 1.32; 95% confidence interval [CI] 0.75–2.33, p = 0.332) or the 1-year mortality rate (aOR = 0.62; 95% CI 0.27–1.42, p = 0.259). Risk factors for cardiac complications included an American Society of Anesthesiologists grade ≥ 3 (OR 3.19, 95% CI 1.44–7.08, p = 0.004) and pre-existing cardiac comorbidities (OR 5.56, 95% CI 3.35–9.25, p < 0.001). Risk factors for 1-year mortality were a long time to surgery (aOR 1.15, 95% CI 1.06–1.25, p = 0.001), a greater age (aOR 1.05, 95% CI 1.00 to 1.10, p = 0.040), a low body mass index (BMI; aOR 0.89, 95% CI 0.81–0.98, p = 0.015), and the presence of renal disease (aOR 4.43, 95% CI 1.71–11.46, p = 0.002).

Discussion

Preoperative DTS was not associated with reductions in the rates of 90-day cardiac complications or 1-year mortality in patients with a femoral neck fracture undergoing hemiarthroplasty. The necessity for DTS should be re-evaluated in elderly patients with femoral neck fractures, given that this increases the length of the delay until surgery.

Level of evidence

Prognostic level III

Perioperative Transthoracic Echocardiography Practice By Cardiac Anesthesiologists-Report of a "Start-Up" Experience

OBJECTIVE

In this paper, the authors report their experience of perioperative transthoracic echocardiography (TTE) practice and its impact on perioperative patient management.

DESIGN

Retrospective case series.

SETTING

Single institution, tertiary university hospital.

PARTICIPANTS

A total of 101 adult ASA II-V male and female patients >18 years old who were scheduled for or having surgery were included in this retrospective case series.

INTERVENTIONS

All patients underwent a focused perioperative TTE exam performed by cardiac anesthesiologists with significant TTE experience, and further clinical management was based on echocardiography findings discussed with the anesthesia care team.

MEASUREMENTS

Significant echocardiographic findings and changes in patient management were reported. Step-up management was a new intervention that was executed based on echocardiographic findings (volume infusion, inotropic therapy, cardiology consultation, and other interventions), and step-down management was avoidance of an unnecessary intervention based on echocardiographic findings (proceeding to surgery without cancellation, delay, cardiology consultation, and additional investigations/interventions).

MAIN RESULTS

Fifty-three percent of TTEs were performed in the preoperative setting, 34% were intra-operative, and 13% were postoperative. No significant findings were detected in 38 patients, leading to step-down management in all of them. Among patients with positive findings, left ventricular dysfunction (12.8%), hypovolemia (10.8%), and right ventricular dysfunction (7.9%) were the most common. Step-up therapy included inotropic/vasopressor therapy (24.8%), intensive care admission after surgery for further management (13.8%), volume infusion (12.8%), and other interventions (additional monitoring, surgical delay, cardiology consultation, and modification of surgical technique).

CONCLUSION

Perioperative focused TTE examination is useful in the diagnosis of new cardiac conditions for anesthesia management (intraoperative monitoring and hemodynamic therapy) and postoperative care (intensive care unit admissions). Perioperative TTE performed by anesthesiologists can also help avoid procedural delays and unnecessary consults.

Hip fracture clearance: How much optimisation is necessary?

Patients with hip fractures are typically elderly individuals with several co-morbidities. Upon admission to the hospital, they often present with acute pain, electrolyte disturbances, anaemia, coagulopathy, and delirium. Long waiting times for surgery are associated with increased morbidity and mortality. The balance between the number of clinical tests and optimisation, which may (i.e., fewer complications and better survival) or may not (i.e., more complications and increased mortality due to unnecessary surgical delay) benefit the patient, has been a preoperative challenge. This summary will review existing clinical guidelines and relevant selected studies to evaluate the extent of preoperative optimisation needed prior to hip fracture surgery.

Prediction of Early Postoperative Major Cardiac Events and In-Hospital Mortality in Elderly Hip Fracture Patients: The Role of Different Types of Preoperative Cardiac Abnormalities on Echocardiography Report

INTRODUCTION

Transthoracic echocardiography (TTE) is a common cardiac screening test before hip fracture surgery. However, the general TTE test delays surgery, so it would be meaningful if we could simplify the TTE by only assessing cardiac abnormality specifically. Therefore, we aimed to establish the most clinically relevant abnormality by comparing the predictive value of each major cardiac abnormality in postoperative cardiac complications and mortality in elderly hip fracture patients.

PATIENTS AND METHODS

From January 2014 to January 2019, the medical records of all surgically treated elderly patients (>65 years) with hip fracture were analyzed. The major TTE abnormalities were defined as left ventricular hypertrophy, systolic pulmonary arterial pressure >25 mm Hg, moderate-severe valve abnormality, left ventricular ejection fraction (LVEF) <50%, and pericardial effusion. The outcomes were postoperative cardiac complications and in-hospital mortality.

RESULTS

There were 354 patients involved finally. Postoperative cardiac complications were encountered in 7.6% (n=27) of patients. The mortality rate was 2.8% (n=10). History of coronary artery disease (CAD) (OR: 3.281, 95% CI: 1.332-8.079, p=0.010) and presence of aortic stenosis (AS) (OR:5.656, 95% CI: 1.869-17.117, p=0.002) were independent predictors of postoperative cardiac complications. In addition, age (OR: 1.264, 95% CI: 1.047-1.527, p=0.015), history of CAD (OR: 19.290, 95% CI: 2.002-185.885, p=0.010), presence of AS (OR:7.164, 95% CI: 1.988-51.413, p=0.040) and LVEF <50% (OR:8.803, 95% CI: 1.115-69.472, p=0.039) were independent predictors of mortality. However, the rest of preoperative TTE abnormalities were not associated with postoperative cardiac complications or mortality.

CONCLUSION

Among the TTE abnormalities presented by elderly patients with hip fracture, moderate-severe AS was the predictor of postoperative cardiac complications. Moreover, moderate-severe AS and LVEF <50% were the predictors of in-hospital mortality. Therefore, we could simplify the TTE process by assessing aortic valve and LVEF specifically on focused echocardiography, which could avoid surgery delay.

Preoperative Mild Pericardial Effusion Is Associated With Perioperative Complications In Elderly Patients Following Hip Fracture Surgery

Background: The prevalence and prognostic value of mild pericardial effusion (MPE) has not been examined in patients undergoing non-cardiac surgery. Our study aimed to assess the frequency and prognostic value of MPE in elderly patients undergoing surgery for hip fracture. Methods: This is a single center, and retrospective study including elderly patients who underwent hip fracture surgery. The medical records of all patients, aged ≥65 years with femoral neck, intertrochanteric or subtrochanteric hip fracture undergoing surgery (intramedullary hip screw, sliding compression hip screw, hemiarthroplasty, or total hip arthroplasty) from June 2014 to June 2019 were analyzed. Patients with of multiple trauma and accidents were excluded. The MPE was defined as the presence of <10 mm pericardial effusion. The primary outcomes of the study were perioperative adverse medical events and length of stay in hospital. Results: A total of 462 patients (mean age 75.2 ± 11.7 years, and 53.5% female) were enrolled. MPE was detected in 72 patients (15.6%), and 62 patients (13.4%) experienced perioperative adverse medical events. Patients with MPE were older, had higher prevalence of diabetes, coronary artery disease, and heart failure, and had longer length of stay compared to patients without MPE. Univariate analysis showed a significant association between age, diabetes, coronary artery disease, American Society of Anesthesiologists status, MPE, and perioperative adverse events. After adjustment for age, demographics, and medical history, the presence of MPE remained as significant variable associated with perioperative complications (OR: 2.543, 95% CI: 1.173-3.469, p = 0.003). Conclusion: Our study is the first to demonstrate that the presence of MPE is associated with perioperative adverse events in elderly patients undergoing hip fracture surgery.