Anaesthesia & The Hip Fracture Patient

Transcription

1 Anaesthesia & The Hip Fracture Patient Richard Griffiths MD FRCA Peterborough & Stamford Hospitals Thursday, 25 July 13

2 Declarations of Interest Honorary Secretary of the Association of Anaesthetists of Great Britain & Ireland Trustee Wothorpe Towers Preservation Trust Thursday, 25 July 13

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8 Time to Surgery Even in 1996 pa5ents were only wai5ng one day in Sweden Median length of stay is also good at 9 days Thursday, 25 July 13

9 Time to Surgery Probably reduces morbidity and mortality if opera5on done early The evidence? Thursday, 25 July 13

10 Time to Surgery 1. Shiga T, Wajima Z, Ohe Y. Is opera5ve delay associated with increased mortality of hip fracture pa5ents? Systema5c review, meta- analysis and meta- regression. Canadian Journal of Anaesthesia 2008; 55: Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: A systema5c review of 52 published studies involving 291, 413 pa5ents. Injury 2009; 40: Nicole Simunovic, P. J. Devereaux, Sheila Sprague, Gordon H. Guya], Emil Schemitsch, Jus5n Debeer, Mohit Bhandari. Effect of early surgery a4er hip fracture on mortality and complica5ons: systema5c review and meta- analysis. Canadian Medical Associa.on Journal, 2010, 182 (15); Thursday, 25 July 13

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15 Pilot Study Acute management of fractured femurs Immediate repair Ontario and Cleveland Clinic Thursday, 25 July 13

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21 More on this later

22 Dilemmas Type of Anaesthesia Clopidogrel Blood transfusion trigger Heart murmur Thursday, 25 July 13

23 Hip Fractures Started talking about hip fracture anaesthesia in 2001 The Cochrane Review of anaesthesia for hip fracture The Cochrane Review of nerve block and hip fracture Thursday, 25 July 13

24 Hip Fractures

25 Hip Fractures Mayday Hospital in Croydon Orthogeriatrics was a new specialty Only database in England was in Peterborough Scotland was ahead of the game Thursday, 25 July 13

26 Hip Fractures Mayday Hospital in Croydon Orthogeriatrics was a new specialty Only database in England was in Peterborough Scotland was ahead of the game Thursday, 25 July 13

27 Hip Fractures Time Line

28 Hip Fractures Time Line 1984 Last U.K. study GA v Spinal Thursday, 25 July 13

29 Hip Fractures Time Line 1984 Last U.K. study GA v Spinal 1993 Scottish Hip Fracture Audit starts Thursday, 25 July 13

30 Hip Fractures Time Line 1984 Last U.K. study GA v Spinal 1993 Scottish Hip Fracture Audit starts 1997 SIGN 15 Thursday, 25 July 13

31 Hip Fractures Time Line 1984 Last U.K. study GA v Spinal 1993 Scottish Hip Fracture Audit starts 1997 SIGN BGS/BOA Blue Book appears Thursday, 25 July 13

32 Hip Fractures Time Line 1984 Last U.K. study GA v Spinal 1993 Scottish Hip Fracture Audit starts 1997 SIGN BGS/BOA Blue Book appears 2001 Cochrane Review Thursday, 25 July 13

33 Hip Fractures Time Line 1984 Last U.K. study GA v Spinal 1993 Scottish Hip Fracture Audit starts 1997 SIGN BGS/BOA Blue Book appears 2001 Cochrane Review 2001 CEPD article Jandziol AK, Griffiths R. The anaesthetic management of patients with hip fractures. BJA CEPD Reviews 2001; 1: 52 5 Thursday, 25 July 13

34 Hip Fractures Time Line

35 Hip Fractures Time Line 2002 SIGN 56 Thursday, 25 July 13

36 Hip Fractures Time Line 2002 SIGN BGS/BOA Blue Book version 2 (Age Anaesthesia involved) Thursday, 25 July 13

37 Hip Fractures Time Line 2002 SIGN BGS/BOA Blue Book version 2 (Age Anaesthesia involved) 2007 NHFD Thursday, 25 July 13

38 Hip Fractures Time Line 2002 SIGN BGS/BOA Blue Book version 2 (Age Anaesthesia involved) 2007 NHFD 2007 Hip Fracture Anaesthesia Network Thursday, 25 July 13

39 Hip Fractures Time Line 2002 SIGN BGS/BOA Blue Book version 2 (Age Anaesthesia involved) 2007 NHFD 2007 Hip Fracture Anaesthesia Network 2008 Scottish Hip Fracture Audit ends Thursday, 25 July 13

40 Hip Fractures Time Line 2002 SIGN BGS/BOA Blue Book version 2 (Age Anaesthesia involved) 2007 NHFD 2007 Hip Fracture Anaesthesia Network 2008 Scottish Hip Fracture Audit ends 2009 SIGN 111 Thursday, 25 July 13

41 Hip Fractures Time Line

42 Hip Fractures Time Line 2010 Hip Fracture Anaesthesia Network becomes Hip Fracture Perioperative network Thursday, 25 July 13

43 Hip Fractures Time Line 2010 Hip Fracture Anaesthesia Network becomes Hip Fracture Perioperative network 2011 NICE 124 Thursday, 25 July 13

44 Hip Fractures Time Line 2010 Hip Fracture Anaesthesia Network becomes Hip Fracture Perioperative network 2011 NICE AAGB&I Guidelines First ever document specifically for anaesthetists Thursday, 25 July 13

45 Hip Fracture Perioperative Network networks/hip-fracture- anaesthesia Thursday, 25 July 13

46 Hip Fractures

47 Hip Fractures

48 Hip Fractures

49 Hip Fractures National Audit Linked to tariff (England, N. Ireland, not Wales) Lots of data Anaesthesia? Thursday, 25 July 13

50 NHFD Mortality (30 day) 9.3% to 8.4% return to normal residence (30 day) 40% data on 300,000 patients Thursday, 25 July 13

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53 We conclude that there are marginal advantages for regional anaesthesia compared to general anaesthesia for hip fracture patients in terms of early mortality and risk of DVT Thursday, 25 July 13

54 2000

55 2000 Studies were old Thursday, 25 July 13

56 2000 Studies were old Was there DVT prophylaxis in 1980 s? Thursday, 25 July 13

57 2000 Studies were old Was there DVT prophylaxis in 1980 s? Confusion greater in GA group, but numbers very small Thursday, 25 July 13

58 2000 Studies were old Was there DVT prophylaxis in 1980 s? Confusion greater in GA group, but numbers very small N.B. There has never been a study using spinal anaesthesia with no sedation Thursday, 25 July 13

59 2000 to 2011

60 2000 to 2011 No new RCT s Thursday, 25 July 13

61 2000 to 2011 No new RCT s But do they give the correct answer? Thursday, 25 July 13

62 2000 to 2011 No new RCT s But do they give the correct answer? Observational studies? Thursday, 25 July 13

63 2000 to 2011 No new RCT s But do they give the correct answer? Observational studies? Audit data? Thursday, 25 July 13

64 2000 to 2011 No new RCT s But do they give the correct answer? Observational studies? Audit data? What has appeared since 2000? Thursday, 25 July 13

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68 Hip Fracture Anaesthesia Regional Anaesthesia 49% General Anaesthesia 51% nerve block to 19% Thursday, 25 July 13

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70 For hip fracture surgery, the choice of anaesthesia (general or neuroaxial) is made by the anaesthesiologist and is based on the patient s preference, comorbidities, potential general postoperative complications and the clinical experience Thursday, 25 July 13

71 3 Distinct Groups

72 Group 1

73 Group 1 Those who are relatively fit and have fallen outside (17%) Thursday, 25 July 13

74 Group 1 Those who are relatively fit and have fallen outside (17%) Thursday, 25 July 13

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76 Group 2 Frail community dwellers who have fallen inside (59%) Thursday, 25 July 13

77 Group 2 Frail community dwellers who have fallen inside (59%) Thursday, 25 July 13

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79 Group 3 Patients from long term care institutions (24%) Thursday, 25 July 13

80 Group 3 Patients from long term care institutions (24%) Thursday, 25 July 13

81 3 Distinct Groups Often those in the last 2 groups have some cognitive impairment and are excluded from any randomised controlled studies However, they can be included in large observational studies Thursday, 25 July 13

82 Anesthesiology :72-92

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86 SIGNAL emerging from the noise

87 SIGNAL emerging from the noise

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89 GA v Spinal

90 GA v Spinal Studies done have been: Thursday, 25 July 13

91 GA v Spinal Studies done have been: single centre Thursday, 25 July 13

92 GA v Spinal Studies done have been: single centre OLD Thursday, 25 July 13

93 GA v Spinal Studies done have been: single centre OLD small Thursday, 25 July 13

94 GA v Spinal Studies done have been: single centre OLD small badly designed Thursday, 25 July 13

95 GA v Spinal Studies done have been: single centre OLD small badly designed never been a pure spinal v GA comparison Thursday, 25 July 13

96 GA v Spinal

97 GA v Spinal Primary hip & knee arthroplasty operations Thursday, 25 July 13

98 GA v Spinal Primary hip & knee arthroplasty operations 400 US hospitals Thursday, 25 July 13

99 GA v Spinal Primary hip & knee arthroplasty operations 400 US hospitals 528,495 indentified Thursday, 25 July 13

100 GA v Spinal Primary hip & knee arthroplasty operations 400 US hospitals 528,495 indentified Thursday, 25 July 13

101 GA v Spinal Primary hip & knee arthroplasty operations 400 US hospitals 528,495 indentified ,236 had anaesthesia information Thursday, 25 July 13

102 GA v Spinal

103 GA v Spinal 382,236 Thursday, 25 July 13

104 GA v Spinal 382, % neuraxial anaesthesia Thursday, 25 July 13

105 GA v Spinal 382, % neuraxial anaesthesia 14.2 % GA plus neuraxial Thursday, 25 July 13

106 GA v Spinal 382, % neuraxial anaesthesia 14.2 % GA plus neuraxial 74% GA Thursday, 25 July 13

107 GA v Spinal 382, % neuraxial anaesthesia 14.2 % GA plus neuraxial 74% GA (no mention of sedation) Thursday, 25 July 13

108 GA v Spinal All types of anaesthesia 50% of the patients were covered by Medicare Outcomes were 30 day mortality and complications Thursday, 25 July 13

109 GA v Spinal Results 30 day mortality was lower in neuraxial group, GA + neuraxial compared with just GA 0.10% v 0.10% v 0.18% Thursday, 25 July 13

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124 Information on 59,000 anaesthetics Thursday, 25 July 13

125 Information on 59,000 anaesthetics Thursday, 25 July 13

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132 2001

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140 Predictions for Anaesthesia Thursday, 25 July 13

141 Predictions for Anaesthesia Regional? Thursday, 25 July 13

142 Predictions for Anaesthesia Regional? 70% Thursday, 25 July 13

143 Predictions for Anaesthesia Regional? 70% Nerve blocks? Thursday, 25 July 13

144 Predictions for Anaesthesia Regional? 70% Nerve blocks? 60% Thursday, 25 July 13

145 Predictions for Anaesthesia Regional? 70% Nerve blocks? 60% reduced use of benzodiazepines Thursday, 25 July 13

146 Predictions for Anaesthesia Regional? 70% Nerve blocks? 60% reduced use of benzodiazepines reduce acute delirium Thursday, 25 July 13

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150 GA 53%

151 GA 53% Spinal 42% Thursday, 25 July 13

152 GA 53% Spinal 42% Nerve Block 29% Thursday, 25 July 13

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154 ASAP Anaesthesia Technique Hypotension Bone cement implantation syndrome Nottingham Hip Fracture Score Thursday, 25 July 13

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157 ASAP Data collection underway at present 140 hospitals Hope to get data on over 10,000 patients in three months There have been some teething troubles Thursday, 25 July 13

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160 36 % mean drop in blood pressure

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163 QMC Nottingham

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166 Clean hit rate from anaesthesia, 1 in 250,000 but morbidity and later mortality likely to be much higher Thursday, 25 July 13

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170 Spinal and GA We are deluding ourselves that we are conducting sympathetic anaesthesia to these patients I now have data on over 400 cases I will soon have data on 10,000 Protocols Thursday, 25 July 13

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176 19 studies, all RCTs 6,264 pa5ents 3 hip fracture studies 1 elec5ve orthopaedic pa5ents pa5ents 3. 2,016 (FOCUS) (elec5ve) 637 from a PICU study 838 TRICC study Thursday, 25 July 13

177 ? Define high risk groups?

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180 FOCUS It is a study in the rehabilita5on period and not within the preopera5ve or periopera5ve period However, it is a large study which must have been very hard to conduct There are some posi5ve elements that come form it Thursday, 25 July 13

181 Now, is that a 2.5gm.dl drop in haemoglobin in both groups?

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183 FOCUS Does that suggest that there may be hidden blood loss in hip fracture? Thursday, 25 July 13

184 FOCUS Does that suggest that there may be hidden blood loss in hip fracture? So, even if the blood loss at surgery is only 200ml, the Hb s5ll goes down? Thursday, 25 July 13

185 FOCUS Does that suggest that there may be hidden blood loss in hip fracture? So, even if the blood loss at surgery is only 200ml, the Hb s5ll goes down? What a surprise!!!!!! Thursday, 25 July 13

186 Hidden Blood Loss

187 Hidden Blood Loss

188 Hidden Blood Loss

189 AFTER

190 Constant Vigilance Measure frequently Blood loss is usually 2.5gm/ dl Many are anaemic before they fracture their hip Thursday, 25 July 13

191 Constant Vigilance Measure frequently Blood loss is usually 2.5gm/ dl Many are anaemic before they fracture their hip Thursday, 25 July 13

192 Summary Important area for anaesthesia Specialist area Protocols may help Audit data is important UK database may yield information Thursday, 25 July 13