Anaesthesia & The Hip Fracture Patient

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

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

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

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

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: 146-54. 2. 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: 692-7 3. 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);1602-1616 Thursday, 25 July 13

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

More on this later

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

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

Hip Fractures

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

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

Hip Fractures Time Line

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

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

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

Hip Fractures Time Line 1984 Last U.K. study GA v Spinal 1993 Scottish Hip Fracture Audit starts 1997 SIGN 15 1999 BGS/BOA Blue Book appears Thursday, 25 July 13

Hip Fractures Time Line 1984 Last U.K. study GA v Spinal 1993 Scottish Hip Fracture Audit starts 1997 SIGN 15 1999 BGS/BOA Blue Book appears 2001 Cochrane Review Thursday, 25 July 13

Hip Fractures Time Line 1984 Last U.K. study GA v Spinal 1993 Scottish Hip Fracture Audit starts 1997 SIGN 15 1999 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

Hip Fractures Time Line

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

Hip Fractures Time Line 2002 SIGN 56 2006 BGS/BOA Blue Book version 2 (Age Anaesthesia involved) Thursday, 25 July 13

Hip Fractures Time Line 2002 SIGN 56 2006 BGS/BOA Blue Book version 2 (Age Anaesthesia involved) 2007 NHFD Thursday, 25 July 13

Hip Fractures Time Line 2002 SIGN 56 2006 BGS/BOA Blue Book version 2 (Age Anaesthesia involved) 2007 NHFD 2007 Hip Fracture Anaesthesia Network Thursday, 25 July 13

Hip Fractures Time Line 2002 SIGN 56 2006 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

Hip Fractures Time Line 2002 SIGN 56 2006 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

Hip Fractures Time Line

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

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

Hip Fractures Time Line 2010 Hip Fracture Anaesthesia Network becomes Hip Fracture Perioperative network 2011 NICE 124 2012 AAGB&I Guidelines First ever document specifically for anaesthetists Thursday, 25 July 13

Hip Fracture Perioperative Network www.networks.nhs.uk/nhs- networks/hip-fracture- anaesthesia richardgriffiths1@nhs.net Thursday, 25 July 13

Hip Fractures

Hip Fractures

Hip Fractures

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

NHFD 2001-2012 Mortality (30 day) 9.3% to 8.4% return to normal residence (30 day) 40% data on 300,000 patients Thursday, 25 July 13

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

2000

2000 Studies were old Thursday, 25 July 13

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

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

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

2000 to 2011

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

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

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

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

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

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

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

3 Distinct Groups

Group 1

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

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

Group 2

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

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

Group 3

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

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

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

Anesthesiology 2012 117:72-92

SIGNAL emerging from the noise

SIGNAL emerging from the noise

GA v Spinal

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

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

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

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

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

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

GA v Spinal

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

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

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

GA v Spinal Primary hip & knee arthroplasty operations 400 US hospitals 528,495 indentified 2006-2010 Thursday, 25 July 13

GA v Spinal Primary hip & knee arthroplasty operations 400 US hospitals 528,495 indentified 2006-2010 382,236 had anaesthesia information Thursday, 25 July 13

GA v Spinal

GA v Spinal 382,236 Thursday, 25 July 13

GA v Spinal 382,236 11.1 % neuraxial anaesthesia Thursday, 25 July 13

GA v Spinal 382,236 11.1 % neuraxial anaesthesia 14.2 % GA plus neuraxial Thursday, 25 July 13

GA v Spinal 382,236 11.1 % neuraxial anaesthesia 14.2 % GA plus neuraxial 74% GA Thursday, 25 July 13

GA v Spinal 382,236 11.1 % neuraxial anaesthesia 14.2 % GA plus neuraxial 74% GA (no mention of sedation) Thursday, 25 July 13

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

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

Information on 59,000 anaesthetics Thursday, 25 July 13

Information on 59,000 anaesthetics Thursday, 25 July 13

2001

Predictions for Anaesthesia Thursday, 25 July 13

Predictions for Anaesthesia Regional? Thursday, 25 July 13

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

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

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

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

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

GA 53%

GA 53% Spinal 42% Thursday, 25 July 13

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

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

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

36 % mean drop in blood pressure

QMC Nottingham

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

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

19 studies, all RCTs 6,264 pa5ents 3 hip fracture studies 1 elec5ve orthopaedic 1. 120 pa5ents 2. 84 pa5ents 3. 2,016 (FOCUS) 4. 603 (elec5ve) 637 from a PICU study 838 TRICC study Thursday, 25 July 13

? Define high risk groups?

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

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

FOCUS

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

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

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

Hidden Blood Loss

Hidden Blood Loss

Hidden Blood Loss

AFTER

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

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

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