Can the anaesthetist influence morbidity and mortality

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Can the anaesthetist influence morbidity and
mortality?

• Richard Griffiths MD FRCA
• Peterborough Stamford Hospitals NHS Trust

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Hip Fracture

• I hope that the answer is yes
• I am certain that we can contribute to morbidity
  and mortality
• Complex question that may not yield a straight
  answer ?

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Hip Fracture

• Areas to cover
• Anaesthetic technique
• Resuscitation
• Analgesia
• Timing of surgery
• Medical co-morbidity

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1. Anaesthetic Technique

• The Evidence Meta-analysis
• Urwin SC, Parker MJ, Griffiths R. BJA
  200084450-454
• Latest update from Cochrane August 2004 (search
  up to November 2003)
• There is no evidence of substantial differences
  between regional and GA in terms of long term
  mortality

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1. Anaesthetic Technique

• Confusion
• Regional V General
• 11/117(9.4) V 23/120(19.2)
• Significant but very small numbers

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1. Anaesthetic Technique

• Looking at retrospective data?
• Can it tell us anything?
• Anesthesiology 200092947-957
• 9,425 patients, 1983-1993, 20 hospitals, no
  differences detected.

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1. Anaesthetic Technique

• Last 4,723 hip fracture anaesthetics in
  Peterborough (1989 to 2005)
• Type of anaesthesia
• GA 2,548
• Spinal 1,541
• Local 254
• Paravertebral block 37
• 64 of cases done by one surgeon (MP)

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Post-Operative complications
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2. Hip Fracture - resuscitation

• Fluid resuscitation is the subject of a Cochrane
  Review
• Perioperative fluid optimization following
  proximal femoral fracture (review)
• Price JD , Sear JW, Venn RM
• 2004, issue 1.
• Only 2 studies in review!

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2. Hip Fracture - resuscitation

• Sinclair et al BMJ 1997315909-912
• Improved outcome with Doppler guided
  intra-operative fluid resuscitation, shorter
  hospital stay
• Basic Message is
• IV fluids as soon as hit front door, optimize
  immediately, then operate

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3. Analgesia Hip Fracture

• Epidural Analgesia
• 1. Improved analgesia, but no significant
  clinical improvement
• Anesthesiology 20051021197-1204, Foss et al
• 60 patients, double blind design
• 2. Reduced cardiac events
• Anesthesiology 200398156-163
• 68 patients
• 7/34 versus 0/34 (p 0.01)

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3. Analgesia Hip Fracture

• Nerve blocks
• No benefit from limited number of studies in
  Cochrane
• Foss et al Anesthesiology 2007106773-778
• Improved analgesia with fascia iliaca block
  versus morphine (24 patients in each group)

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3. Analgesia Hip Fracture

• Fascia Iliaca block is popular in many
  institutions
• Simple to teach and learn
• Nurses and other medical workers can learn
  technique
• N.B. Failure rate may be high
• Luton Dunstable nurse led programme

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3. Analgesia Hip fracture

• Analgesia continued
• Fracture fixation is best form of analgesia
• IV paracetamol very good in elderly
• Continuous epidural analgesia used in Denmark
• (not a starter in Peterborough!!)

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4. Hip Fracture, timing of surgery

• Japanese meta-analysis
• Is Operative Delay Associated with Increased
  Mortality of hip fracture patients?
• Shiga et al Toho University Tokyo Japan
• ASA San Francisco September 2007

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4. Hip Fracture, timing of surgery

• Surgical repair within 24 hours recommended (RCP)
• 15 studies , observational, 252,336 patients
• Mean age 81 yrs
• Female 77.4
• Cut off of 24-72 hrs (mean 48) to define delay

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4. Hip Fracture, timing of surgery

• Shiga et al continued
• Delayed surgery increased 30 day all cause
  mortality significantly, by 44
• 1 year all cause mortality increased by 33

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4. Hip Fracture, timing of surgery

• Shiga et al
• For every 1,000 patients who undergo delayed
  surgery instead of early surgery there would be
  29 more deaths after 30 days
• And 52 more deaths after a year

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4. Hip Fracture, timing of surgery

• Problem appears again
• Early surgery versus optimisation for surgery?
• Which route do we take?
• Is there any British Evidence?

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4. Hip Fracture, timing of surgery

• Bottle A, Aylin P. BMJ 2006332947-950
• Mortality associated with delay in operation
  after hip fracture observational study
• Study period April 2001 to March 2004
• Delay in operation associated with increased risk
  of death in hospital
• 40 of procedures performed gt 1 day after
  admission
• 21 delayed for 2 days
• deleterious effect of delaying operation even
  after adjusting for co-morbidity

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4. Hip Fracture, timing of surgery

• (Bottle A, Aylin P. BMJ 2006332947-950)
• Delay in operation is associated with an
  increased risk of death but not readmission after
  fractured neck of femur

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4. Hip Fracture, timing of surgery

• Again
• The message, delay is bad, but what is the place
  for optimisation or should I say
• CANCELLATION?

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5. Hip Fracture co-morbidity

• Medical Co-morbidity
• The dilemma, optimise patient if significant
  cardiovascular or respiratory compromise but this
  will inevitably lead to surgical delay

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5. Hip Fracture co-morbidity

• Which route to take?
• Delay or optimise?
• Is there any evidence for optimisation?
• Is there any evidence that delay can do harm?

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5. Hip Fracture co-morbidity

• McLaughlin et al Preoperative Status and Risk of
  Complications in Patients with Hip Fracture
• Journal of General Internal Medicine
  200621(3)219-225
• Attempt to investigate of presence of
  pre-operative abnormalities caused post-operative
  complications
• Complex paper, I will try and review it

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5. Hip Fracture co-morbidity

• Hip fracture patients from 4 New York Hospitals
• Looked at hospital records
• 571 identified, 554 had surgery
• 12 from nursing homes
• 23 had dementia
• 14 had COPD
• (Journal of General Internal Medicine
  200621(3)219-225)

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5. Hip Fracture co-morbidity

• Definition of Major Abnormality
• Blood Pressure
• Systolic lt 90 mm HG
• Heart Rate and Rhythm
• AF or SVT gt 121, VT, 3rd degree block or HR lt 45
• Infection/Pneumonia
• Temperature lt 35 C or gt 38.5 C, infiltrate on CXR
• Chest Pain
• Any new MI or chest pain with abnormal ECG
• CCF
• Pulmonary oedema on CXR, significant clinical
  signs
• (Journal of General Internal Medicine
  200621(3)219-225)

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5. Hip Fracture co-morbidity

• Major Abnormalities continued
• INR
• 1.6
• Electrolytes
• Na lt 125, K lt 2.5 or gt 6.0, HCO3 lt 18 or gt36
• Glucose
• 33 mmol/litre
• Renal Function
• BUN gt 18 mmol/litre or creatinine gt 230
  micromol/litre
• Anaemia
• Hb lt 7.5 gm/dl
• (Journal of General Internal Medicine
  200621(3)219-225

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UNACCEPTABLE REASONS FOR DELAYING SURGERY (gt24
HOURS FROM ADMISSION) Peterborough

• MEDICAL ASSESSMENT
• UNNECESSARY INVESTIGATIONS E.G ECHO
  CARDIOGRAM
• MINOR ELECTROLYTE ABNORMALITIES
• CONSENT
• HIGH INR
• ASPIRIN, CLOPIDOGREL
• LACK FACILITIES

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ACCEPTABLE REASONS FOR DELAYING SURGERY
Peterborough

• ANAEMIA (Hb LESS THAN ABOUT 90G/L)
• DEHYDRATION OR ACUTE URAEMIA
• SEVERE ELECTROLYTE IMBALANCE (Na lt 120 or gt
  150 k lt 2.8 or gt 6.0 mmol/l)
• UNCONTROLLED DIABETES
• UNCONTROLLED HEART FAILURE
• CORRECTABLE CARDIAC ARRHYTHMIA
• ? ACUTE CHEST INFECTION OR EXACERBATION OF
  CHRONIC CHEST

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5. Hip Fracture co-morbidity

• 23 of patients had one or more major
  complication on admission
• Most frequent major abnormalities respiratory
  failure (7)
• Coagulopathy (6.5)
• 15 had surgery without correction for major
  abnormality
• 50 had abnormality corrected, most common were
  for electrolyte and renal dysfunction,
  coagulopathy, heart failure and respiratory
  failure

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5. Hip Fracture co-morbidity

• Results
• Presence or gt one major abnormality that was not
  corrected before surgery independently associated
  with postoperative complications
• Odds for cardiopulmonary complications
• Major abnormality on admission, none prior to
  surgery 1.57 (0.41 to 6.01)
• Major abnormality not corrected 4.22 (1.68 to
  10.63)

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5. Hip Fracture co-morbidity

• Small numbers
• Only 15 in uncorrected group
• No data on timing of surgery, type of
  anaesthesia, length of surgery
• However, does open a debate that probably occurs
  in your own institution

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5. Hip Fracture co-morbidity

• Delay
• Or
• Operate?

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5. Hip Fracture co-morbidity

• Scottish Hip Fracture Audit 2007
• Fitness for theatre assessments
• Took McLaughlin et al 2006 and looked at reasons
  for postponement
• 23 of hip fracture patients deemed medically
  unfit causing delay

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5. Hip Fracture co-morbidity

• Scottish Hip Fracture Audit 2007
• Anaesthetists carried out 88 of all
  known-specialty assessments
• 11 performed by orthopaedic doctors
• Orthopaedic postponement rate was 89
• Anaesthetic postponement rate was 14
• (earlier recognition of significant co-morbidity)

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5. Hip Fracture co-morbidity

• My conclusion from this is,
• Senior anaesthetists should be involved early in
  the process
• Suggest a treatment plan, optimize and get on
  with fixing the fracture

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5. Hip Fracture co-morbidity

• Scottish Hip Fracture Audit 2007
• 2938 patients
• 519 (18) had one or more major abnormality
• 57 of these postponed for theatre at first
  assessment
• More chance of postponement if had increasing
  numbers of abnormalities

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Hip Fracture

• Need to quickly look at INR
• Scottish Hip Fracture Audit 2007
• One of McLaughlins major criteria is INR gt1.6
• 95 of 109 patients with this abnormality had
  surgery postponed
• 71 of these did not get an operation for gt48 hrs
• INR should be corrected quickly and is not an
  indication for postponement

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Hip Fracture

• It is likely that the medical profession can do
  nothing about mortality in up to 40 of these
  patients
• Foss Kehlet British Journal of Anaesthesia 94
  (1) 24-29 2005

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Hip Fracture

• Foss Kehlet British Journal of Anaesthesia 94
  (1) 24-29 2005
• 300 patients, continuous epidural analgesia,
  preop and for 4 days post op
• delay of surgery because of other medical
  optimisation was generally avoided

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Hip Fracture

• So what do anaesthetists do?
• Get Involved
• Hip Fracture Anaesthesia Network
• (First Anaesthesia NHS Network)
• www.networks.nhs.uk/hipfa

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Hip Fracture

• 2. Optimisation as soon as patient hits hospital
• Resuscitation and analgesia start immediately

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Hip Fracture

• 3. Become part of a multi-disciplinary team
• Consistent opinion
• Consultant (or experienced SAS) involvement
• Not the place for decisions to be made by
  trainees (surgeons or anaesthetists)

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Hip Fracture

• Anaesthetists have a pivotal role in hip fracture
  management
• Get involved!!!!!!!
• www.networks.nhs.uk/hipfa