Anaesthesia for hip fracture repair

Shelton, Cliff; White, Stuart

doi:10.1016/j.bjae.2020.02.003

Cited by 20 publications

(25 citation statements)

References 22 publications

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“…Alongside optimal clinical care, the organisation and delivery of service matters as much. Despite an abundance of literature discussing the clinical management of hip fractures, 5–7 9 there is a dearth of reports describing how to set up and audit an anaesthesia perioperative service for it. Without a substantial evidence base to guide implementation, we may be blind to how effective our perioperative care is, even when we know it is integral.…”

Section: Discussionmentioning

confidence: 99%

“…Greater involvement, quality control and standardisation of perioperative care by the anaesthetist for hip fracture patients is widely recommended. [5][6][7] Yet, internal analysis of our anaesthesia department's practices revealed the following issues specific to hip fracture care: 1. The race against time to provide early and proactive anaesthesia involvement The hip fracture patient was reviewed by multiple disciplines on admission, with the exception of anaesthesia.…”

Section: Problem Descriptionmentioning

confidence: 99%

“…Greater involvement, quality control and standardisation of perioperative care by the anaesthetist for hip fracture patients is widely recommended. 5–7 Yet, internal analysis of our anaesthesia department’s practices revealed the following issues specific to hip fracture care:…”

Section: Introductionmentioning

confidence: 99%

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Quality improvement initiative: how the setting up of an anaesthesia consultant-led perioperative outreach service addressed anaesthesia-specific issues to improve anaesthesia consult and surgery timings for hip fracture patients

2022

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BackgroundSurgery is recommended within 48 hours of hip fractures for better perioperative outcomes. Yet, such targets still commonly remain a challenge. Our institution is no exception.As part of a hospital-wide initiative, our anaesthesia department focused on improving perioperative processes with aims to reduce the time to first anaesthesia consult and surgery for hip fracture patients. Acknowledging multiple causes for surgical delay, we decided first to address anaesthesia-specific factors—(a) first anaesthetist contact usually happens after surgery is offered which leaves a short runway for preoptimisation, (b) this is compounded by varying degrees of anaesthetist involvement for follow-up thereafter. (c) There is a need to calibrate our perioperative care standards and (d) enforce more consistent auditing in quality assurance. This project was conducted in a 1000-bed hospital serving eastern Singapore.InterventionWe created an integrated anaesthesia consultant-led outreach service for hip fracture patients, based on a perioperative workflow system to provide proactive anaesthetist consults within 24 hours of admission in advance of surgical decision. This was streamlined with a coordinated follow-up system for preoptimisation until surgery.MethodsOur quality improvement project applied the iterative Plan-Do-Study-Act model from pilot to sustainability stage. We collected data at baseline followed by 6-monthly audits from electronic databases.Primary outcomes measured were time to first anaesthesia consult and surgery. Secondary outcomes included rate of critical care reviews and admission, mortality rate, length of stay and time to nerve blocks.ResultsPost implementation, our service reviewed >600 hip fracture patients. Median time to anaesthesia consult reduced significantly from 35.3 hours (2019) to 21.5 hours (2021) (p=0.029). Median time to surgery was reduced from 61.5 hours (2019) to 50 hours (2021) (p=0.897) with a 13.6% increase in patients operated <48 hours. Critical care admissions, 6-monthly and 12-monthly mortality rates and time to nerve block were reduced with a greater percentage of patients discharged within 10 days.ConclusionOur project focused on improving anaesthesia perioperative processes to address surgical delays in hip fracture patients. Our consultant-led anaesthesia service ensured that proactive anaesthesia care was delivered to provide sufficient time for preoptimisation with greater standardisation to follow-up, better communication and quality assurance.

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Section: Discussionmentioning

confidence: 99%

Section: Problem Descriptionmentioning

confidence: 99%

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Quality improvement initiative: how the setting up of an anaesthesia consultant-led perioperative outreach service addressed anaesthesia-specific issues to improve anaesthesia consult and surgery timings for hip fracture patients

2022

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“…On the other side, it was reported more breakthrough pain with bupivacaine doses of 5 mg or less [16]. This tendency to adopt a higher dose approach is likely to be attributable to concerns that duration of spinal anesthesia may not be sufficient for the proposed surgery when bupivacaine < 10mg is used [17].…”

Section: Discussionmentioning

confidence: 99%

Comparative analysis of effects of three different doses of fentanyl and standard dose of bupivacaine on a spinal block in patients with hip endoprosthesis surgery

Jović¹,

Janković

Videnović³

et al. 2021

Srp Arh Celok Lek

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Introduction/Objective. Spinal anesthesia is often used for hip endoprosthesis surgery. Significant surgical stress response consisting of hormonal, metabolic and inflammatory changes can be initiated by the hip replacement surgery. Intrathecal opioids, as adjuvants to local anesthetics, make spinal block sufficient even with lower doses of the local anesthetics, and the incidence of the side effects reduce to minimum. Methods. This study included 162 patients of either sex, ASA 1- 2, scheduled for total hip arthroplasty. The patients had spinal anesthesia with 10mg of 0.5% bupivacaine with 20 ?g (Group I), or 25 ?g (Group II) or 30?g fentanyl intrathecally (Group III). Results. Mean time to achieve maximum motor and sensory blockade was with no significant difference among the groups. Time of motor block duration was shorter in the Group III. Four hours after the operation, patients in the Group I had significantly higher cortisol serum levels. Blood glucose levels were with no significant difference among the groups. Levels of CRP increased remarkably postoperatively in the Group I. Incidence of hypotension, bradycardia, nausea and vomiting was significantly higher in the Group III. Pruritus and shevering were not recorded among the groups. The first time an analgetic was needed postoperatively was the longest in the Group III. Conclusion. The dose of 10mg of bupivacaine combined with 25 ?g fentanyl was the optimal option to achieve hemodynamic stability, sufficient sensory and motor blockade, and reduce the stress response and incidence of the opioids side effects such as vomiting, nausea, pruritus etc.

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“…Second-generation supraglottic devices are a valid alternative to endotracheal intubation and help in reducing the need for hypnotic drugs and neuromuscular blocking agents. In case of general anaesthesia, propofol is preferable to benzodiazepines because of its lower risk of delirium [20,160,161].…”

Section: Anaesthesiologic Indicationsmentioning

confidence: 99%

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

Vincentis

Behr²,

Bellelli

et al. 2021

Aging Clin Exp Res

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Background Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues. Aim To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF. Methods A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra-and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence. Results A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics). Conclusion These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.

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Anaesthesia for hip fracture repair

Cited by 20 publications

References 22 publications

Quality improvement initiative: how the setting up of an anaesthesia consultant-led perioperative outreach service addressed anaesthesia-specific issues to improve anaesthesia consult and surgery timings for hip fracture patients

Quality improvement initiative: how the setting up of an anaesthesia consultant-led perioperative outreach service addressed anaesthesia-specific issues to improve anaesthesia consult and surgery timings for hip fracture patients

Comparative analysis of effects of three different doses of fentanyl and standard dose of bupivacaine on a spinal block in patients with hip endoprosthesis surgery

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

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