Mitigating the stress response to improve outcomes for older patients undergoing emergency surgery with the addition of beta-adrenergic blockade

Trauma Surg Acute Care Open

Cao

Ekestubbe

et al. 2022

Self Cite

ObjectivesFrailty is common among patients with hip fracture and may, in part, contribute to the increased risk of mortality and morbidity after hip fracture surgery. This study aimed to develop a novel frailty score for patients with traumatic hip fracture that could be used to predict postoperative mortality as well as facilitate further research into the role of frailty in patients with hip fracture.MethodsThe Orthopedic Hip Frailty Score (OFS) was developed using a national dataset, retrieved from the Swedish National Quality Registry for Hip Fractures, that contained all adult patients who underwent surgery for a traumatic hip fracture in Sweden between January 1, 2008 and December 31, 2017. Candidate variables were selected from the Nottingham Hip Fracture Score, Sernbo Score, Charlson Comorbidity Index, 5-factor modified Frailty Index, as well as the Revised Cardiac Risk Index and ranked based on their permutation importance, with the top 5 variables being selected for the score. The OFS was then validated on a local dataset that only included patients from Orebro County, Sweden.ResultsThe national dataset consisted of 126,065 patients. 2365 patients were present in the local dataset. The most important variables for predicting 30-day mortality were congestive heart failure, institutionalization, non-independent functional status, an age ≥85, and a history of malignancy. In the local dataset, the OFS achieved an area under the receiver-operating characteristic curve (95% CI) of 0.77 (0.74 to 0.80) and 0.76 (0.74 to 0.78) when predicting 30-day and 90-day postoperative mortality, respectively.ConclusionsThe OFS is a significant predictor of short-term postoperative mortality in patients with hip fracture that outperforms, or performs on par with, all other investigated indices.Level of evidenceLevel III, Prognostic and Epidemiological.

Section: Discussionmentioning

confidence: 99%

Developing and validating a scoring system for measuring frailty in patients with hip fracture: a novel model for predicting short-term postoperative mortality

Trauma Surg Acute Care Open

Cao

Ekestubbe

et al. 2022

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“… 1–6 31 34–38 These comorbidities, along with the acute injury, have a negative impact on the cardiovascular system as well as other organ systems, which may affect the postoperative risk of adverse events. 7–9 14 Furthermore, studies have shown that several other factors could increase the risk of postoperative adverse events after hip fracture surgery, such as surgical duration, out-of-hours surgery, and dementia. 5 19–22 24 25 31 However, these variables have not been taken into account in the previous studies on this topic.…”

Section: Discussionmentioning

confidence: 99%

“… 14 Hip fracture patients are often frail and suffer several insults in a short period: the insult from the trauma causing the fracture, the insults from fasting and preparing for surgery, the insult from anesthesia, as well as the insult from the hip fracture surgery. 7–9 14 Recently, Neuman et al published a prospective randomised trial where 1600 patients were included in the New England Journal of Medicine . They investigated the effects of spinal anesthesia compared with general anesthesia on the functional outcome and demonstrated no differences in the relative risk (RR) of recovered ambulation (RR (95% CI): 1.06 (0.82 to 1.36)), delirium (RR (95% CI): 1.04 (0.84 to 1.30)), or survival (RR (95% CI): 0.97 (0.59 to 1.57)).…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4][5][6] These comorbidities along with the acute physiological insult, present additional perioperative, including anesthetic, concerns. [7][8][9] Unlike elective surgery, the opportunity for preoperative optimization is limited in patients undergoing emergency surgery for hip fractures. Additionally, increased vigilance is required when assessing medication use such as anticoagulants, the potential for postoperative delirium, and the impact of respiratory compromise.…”

Section: Introductionmentioning

confidence: 99%

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Mode of anesthesia is not associated with outcomes following emergency hip fracture surgery: a population-level cohort study

Ismail

Trauma Surg Acute Care Open

Bass

et al. 2022

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Background Hip fractures often occur in frail patients with several comorbidities. In those undergoing emergency surgery, determining the optimal anesthesia modality may be challenging, with equipoise concerning outcomes following either spinal or general anesthesia. In this study, we investigated the association between mode of anesthesia and postoperative morbidity and mortality with subgroup analyses. Methods This is a retrospective study using all consecutive adult patients who underwent emergency hip fracture surgery in Orebro County, Sweden, between 2013 and 2017. Patients were extracted from the Swedish National Hip Fracture Registry, and their electronic medical records were reviewed. The association between the type of anesthesia and 30-day and 90-day postoperative mortality, as well as in-hospital severe complications (Clavien-Dindo classification ≥3a), was analyzed using Poisson regression models with robust SEs, while the association with 1-year mortality was analyzed using Cox proportional hazards models. All analyses were adjusted for potential confounders. Results A total of 2437 hip fracture cases were included in the study, of whom 60% received spinal anesthesia. There was no statistically significant difference in the risk of 30-day postoperative mortality (adjusted incident rate ratio (IRR) (95% CI): 0.99 (0.72 to 1.36), p=0.952), 90-day postoperative mortality (adjusted IRR (95% CI): 0.88 (0.70 to 1.11), p=0.281), 1-year postoperative mortality (adjusted HR (95% CI): 0.98 (0.83 to 1.15), p=0.773), or in-hospital severe complications (adjusted IRR (95% CI): 1.24 (0.85 to 1.82), p=0.273), when comparing general and spinal anesthesia. Conclusions Mode of anesthesia during emergency hip fracture surgery was not associated with an increased risk of postoperative mortality or in-hospital severe complications in the study population or any of the investigated subgroups. Level of evidence: Therapeutic/Care Management, level III

“…These TBI patients should reasonably be expected to require a different management strategy compared to their healthier counterparts. Using the RCRI, these high risk patients may be identified early on which could allow for a more efficient allocation of expertise and resources [46]. It could also enable the quantification of risk for patients and family members to aid them in participating in the decision making process around critical care, operative interventions, and even goals-of-care [47,48].…”

Section: Discussionmentioning

confidence: 99%

Mortality risk stratification in isolated severe traumatic brain injury using the revised cardiac risk index

Eur J Trauma Emerg Surg

Bass

Scheufler

et al. 2021

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Purpose Traumatic brain injury (TBI) continues to be a significant cause of mortality and morbidity worldwide. As cardiovascular events are among the most common extracranial causes of death after a severe TBI, the Revised Cardiac Risk Index (RCRI) could potentially aid in the risk stratification of this patient population. This investigation aimed to determine the association between the RCRI and in-hospital deaths among isolated severe TBI patients. Methods All adult patients registered in the TQIP database between 2013 and 2017 who suffered an isolated severe TBI, defined as a head AIS ≥ 3 with an AIS ≤ 1 in all other body regions, were included. Patients were excluded if they had a head AIS of 6. The association between different RCRI scores (0, 1, 2, 3, ≥ 4) and in-hospital mortality was analyzed using a Poisson regression model with robust standard errors while adjusting for potential confounders, with RCRI 0 as the reference. Results 259,399 patients met the study’s inclusion criteria. RCRI 2 was associated with a 6% increase in mortality risk [adjusted IRR (95% CI) 1.06 (1.01–1.12), p = 0.027], RCRI 3 was associated with a 17% increased risk of mortality [adjusted IRR (95% CI) 1.17 (1.05–1.31), p = 0.004], and RCRI ≥ 4 was associated with a 46% increased risk of in-hospital mortality [adjusted IRR(95% CI) 1.46 (1.11–1.90), p = 0.006], compared to RCRI 0. Conclusion An elevated RCRI ≥ 2 is significantly associated with an increased risk of in-hospital mortality among patients with an isolated severe traumatic brain injury. The simplicity and bedside applicability of the index makes it an attractive choice for risk stratification in this patient population.