Hip Fracture Is there a best anaesthetic technique

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Hip Fracture Is there a best anaesthetic
technique?
Richard Griffiths MD FRCA
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Hip Fracture

• Simple answer is
• NO
• Quick review of evidence
• New developments

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Hip Fracture

• Demographic Data
• Approx 80,000 per year in UK (65,000 in over
  65s)
• Cost is approximately 1,000,000,000 per year
• Life expectancy increases by 5 hours every week
  in the UK

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Current State(NHS Hospital England alone)
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Hip Fracture

• 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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Hip Fracture

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

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Hip Fracture

• 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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Hip Fracture

• 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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Hip Fracture
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Hip Fracture
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Post-Operative complications
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Hip Fracture

• No significant difference in mortality between
  types of anaesthesia
• Multivariate analysis that did significantly
  affect mortality were
• age, gender, ASA score, haemoglobin level,
  mobility score and mental test score

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Hip Fracture

• Meta-analysis of RCTS
• No difference spinal or GA
• Retrospective data
• No difference spinal or GA
• Other techniques, epidural, opioids in spinals,
  nerve blocks

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Hip Fracture, epidural analgesia

• Improved analgesia, but no significant clinical
  improvement
• Anesthesiology 20051021197-1204, Foss et al
• 60 patients, double blind design

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Hip Fracture, epidural analgesia

• Reduced cardiac events
• Anesthesiology 200398156-163
• 68 patients
• 7/34 versus 0/34 (p 0.01)

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Hip Fracture

• Opioids in spinal solution
• Limited studies
• No benefit so far
• Hypotension in elderly patients undergoing spinal
  anaesthesia for repair of fractured neck of
  femur. A comparison of two different spinal
  solutions. Anaesthesia and Intensive
  Care200129501-505

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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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Hip Fracture

• Many institutions do use their own well tried
  techniques
• The numbers needed to prove an advantage in any
  RCT are enormous
• If it works well in your hospital stick with it
• Ensure good audit and data collection
• Join the Hip Fracture Anaesthesia Network
• (coming to you soon!!!)

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Hip Fracture

• Other interesting data
• Mortality has not really changed for 30 years in
  European series (patients are getting older and
  more frail)
• We may have no influence on at least 40 of the
  mortality
• (Foss Kehlet British Journal of Anaesthesia 94
  (1) 24-29 2005)

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Hip Fracture ITU

• In 11 years as a consultant in a good UK centre
  I have only seen a hip fracture patient admitted
  to ITU twice
• 1.Acquired Von Willebrands secondary to
  undiagnosed hypothyroidism
• 2. Aspiration pneumonitis following LMA GA in
  obese diabetic (transferred from another ITU)
• Kehlet study 11 out of 47 deaths had maximum
  therapy including ITU, no effect on mortality
• This may contrast to practice in the USA

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Hip Fracture

• How else can anaesthesia influence the process?
• 1. Timing of surgery?
• 2. Process changes
• 3. National network of anaesthetists with an
  interest in hip fracture

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Hip Fracture

• Timing of surgery
• A common thread operation cancelled by
  anaesthetist because the sodium was 129
• Is there any evidence that operation delay
  affects outcome?

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Hip Fracture

• BMJ 2006332947-950
• 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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Hip Fracture

• Timing of surgery for a hip fracture a
  systematic review of 46 published studies
  involving 282,829 patients (BTS Poster 2007)
• Outcomes considered were mortality,
  post-operative complications, length of hospital
  stay and return of patients back home.
• Martyn Parker

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Hip fracture

• No RCTs on delaying surgery
• 14 studies of 257,746 patients were retrospective
  reviews of patient records
• 11 reported increased mortality with delayed
  surgery and one reduced mortality with delayed
  surgery

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Hip Fracture

• Six studies of 15,937 patients had the most
  appropriate methodology, which was prospective
  collection of data
• Five of these studies found no effect on
  mortality for any delays in surgery

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Hip fracture

• Post-operative complications
• 11 studies showed reduced complications with
  early surgery and six studies showed no
  difference
• 11 of the 14 studies that reported on hospital
  stay reported a reduced stay with early surgery

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Hip Fracture

• Message is
• Dont delay
• Optimise as soon as hit hospital
• Operate on first available day time
  trauma/emergency list

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UNACCEPTABLE REASONS FOR DELAYING SURGERY (gt24
HOURS FROM ADMISSION)

• 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

• 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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Hip Fracture Time of Surgery

• Time from Admission to Operation
• (Peterborough Data, last 10 years)
• Mean is 28.9 hours
• 2091 /3,139 (67) had received operation within
  24 hours of admission to AE

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Hip Fracture

• Process Changes
• The NHS does not have uniform care
• Vast differences across the UK
• Anaesthesia must engage other disciplines and
  take a lead in the care of these patients
• BOA Blue Book
• NHS Institute

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To ECHO or not

• Hip Fracture Anaesthesia Network
• (First Anaesthesia NHS Network)
• www.networks.nhs.uk/hipfa
• Site links to Age Anaesthesia

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Hip Fracture

• For next Year
• Anaesthetist in each acute trust responsible for
  hip fracture patients
• Consistent Opinion
• Close co-operation between specialties
• richard_at_wothorpe.com