S. M. White

Outcome by mode of anaesthesia for hip fracture surgery. An observational audit of 65 535 patients in a national dataset

Large observational studies of accurate data can provide similar results to more arduous and expensive randomised controlled trials. In 2012, the National Hip Fracture Database extended its dataset to include ‘type of anaesthesia’ data fields. We analysed 65 535 patient record sets to determine differences in outcome. Type of anaesthesia was recorded in 59 191 (90%) patients. Omitting patients who received both general and spinal anaesthesia or in whom an uncertain type of anaesthesia was recorded, there was no significant difference in either cumulative five‐day (2.8% vs 2.8%, p = 0.991) or 30‐day (7.0% vs 7.5%, p = 0.053) mortality between 30 130 patients receiving general anaesthesia and 22 999 patients receiving spinal anaesthesia, even when 30‐day mortality was adjusted for age and ASA physical status (p = 0.226). Mortality within 24 hours after surgery was significantly higher among patients receiving cemented compared with uncemented hemiarthroplasty (1.6% vs 1.2%, p = 0.030), suggesting excess early mortality related to bone cement implantation syndrome. If these data are accurate, then either there is no difference in 30‐day mortality between general and spinal anaesthesia after hip fracture surgery per se, and therefore future research should focus on how to make both types of anaesthesia safer, or there is a difference, but mortality is not the correct outcome to measure after anaesthesia, and therefore future research should focus on differences between general and spinal anaesthesia. These could include more anaesthesia‐sensitive outcomes, such as hypotension, pain, postoperative confusion, respiratory infection and mobilisation.

Anaesthesia for proximal femoral fracture in the UK: first report from the NHS Hip Fracture Anaesthesia Network.

The aim of this audit was to investigate process, personnel and anaesthetic factors in relation to mortality among patients with proximal femoral fractures. A questionnaire was used to record standardised data about 1195 patients with proximal femoral fracture admitted to 22 hospitals contributing to the Hip Fracture Anaesthesia Network over a 2‐month winter period. Patients were demographically similar between hospitals (mean age 81u2003years, 73% female, median ASA grade 3). However, there was wide variation in time from admission to operation (24–108u2003h) and 30‐day postoperative mortality (2–25%). Fifty percent of hospitals had a mean admission to operation time <u200348u2003h. Forty‐two percent of operations were delayed: 51% for organisational; 44% for medical; and 4% for ‘anaesthetic’ reasons. Regional anaesthesia was administered to 49% of patients (by hospital, rangeu2003=u20030–82%), 51% received general anaesthesia and 19% of patients received peripheral nerve blockade. Consultants administered 61% of anaesthetics (17–100%). Wide national variations in current management of patients sustaining proximal femoral fracture reflect a lack of research evidence on which to base best practice guidance. Collaborative audits such as this provide a robust method of collecting such evidence.

Nottingham Hip Fracture Score: longitudinal and multi-centre assessment

BACKGROUNDnThe Nottingham Hip Fracture Score (NHFS) was developed and validated in a single centre in 2007 as a predictor of 30 day mortality. It has subsequently been shown to predict longer term and functional outcomes. We wished to assess the ability of NHFS to predict outcomes in other centres and to investigate the change in outcome after hip fracture over time.nnnMETHODSnThe NHFS was calculated for all patients with data from three UK hip fracture units: Peterborough (1992-2009), Brighton (2008-9), and Nottingham (2000-9) including 4804, 585, and 1901 patients, respectively. The logistic regression was used to recalibrate the NHFS to 30 day mortality across the three units using a random selection of 50% of the data set. Calibration was assessed using the Hosmer-Lemeshow goodness of fit.nnnRESULTSnThe median (inter-quartile range) NHFS values were Peterborough [4.0 (1-6)], Brighton [5.0 (3-7)], and Nottingham [5.0 (3-7)]. There was no correlation between 30 day mortality and time (R(2)=0.05, P=0.115). The proportion of patients with NHFS ≥ 4 showed a weak correlation with time (R(2)=0.2, P=0.003). The original NHFS equation overestimates mortality in the higher-risk groups. A modified equation shows good calibration for all three centres {30 day mortality (%)=100/1+e([(5.012 × (NHFS × 0.481)])}. The hospital was not a predictor of 30 day mortality.nnnCONCLUSIONSnThe NHFS, with an updated equation, is a robust predictor of 30 day mortality after hip fracture repair in geographically distinct UK centres.

Secondary analysis of outcomes after 11,085 hip fracture operations from the prospective UK Anaesthesia Sprint Audit of Practice (ASAP-2)

We re‐analysed prospective data collected by anaesthetists in the Anaesthesia Sprint Audit of Practice (ASAP‐1) to describe associations with linked outcome data. Mortality was 165/11,085 (1.5%) 5 days and 563/11,085 (5.1%) 30 days after surgery and was not associated with anaesthetic technique (general vs. spinal, with or without peripheral nerve blockade). The risk of death increased as blood pressure fell: the odds ratio (95% CI) for mortality within five days after surgery was 0.983 (0.973–0.994) for each 5 mmHg intra‐operative increment in systolic blood pressure, p = 0.0016, and 0.980 (0.967–0.993) for each mmHg increment in mean pressure, p = 0.0039. The equivalent odds ratios (95% CI) for 30‐day mortality were 0.968 (0.951–0.985), p = 0.0003 and 0.976 (0.964–0.988), p = 0.0001, respectively. The lowest systolic blood pressure after intrathecal local anaesthetic relative to before induction was weakly correlated with a higher volume of subarachnoid bupivacaine: r2 −0.10 and −0.16 for hyperbaric and isobaric bupivacaine, respectively. A mean 20% relative fall in systolic blood pressure correlated with an administered volume of 1.44 ml hyperbaric bupivacaine. Future research should focus on refining standardised anaesthesia towards administering lower doses of spinal (and general) anaesthesia and maintaining normotension.

Incidence and estimated annual cost of emergency laparotomy in England: is there a major funding shortfall?.

Significant recent interest has focussed on improving outcomes after emergency laparotomy. This retrospective database analysis estimated the annual incidence and associated inpatient costs of emergency laparotomy in England. Demographic, process and outcome data were collected for all patients undergoing emergency laparotomy in Brighton for two calendar years (2009–2010). Cost analysis assumed £16u2003per minute theatre time, and £282u2003per day ward bed and £1382u2003per day critical care bed costs. National incidence was confirmed from Hospital Episode Statistics and Office of National Statistics mid‐year population data. In total, 768 patients underwent 850 emergency laparotomies. The incidence of emergency laparotomy was estimated as ∼1:1100 population. Thirty‐six percent (276 patients) were admitted for a median (IQR [range]) of 5 (3–11 [1–76]) days of critical care. Postoperative median (IQR [range]) length of stay was 13 (8–24 [1–176]) days. Our estimated annual inpatient cost of emergency laparotomy for Brighton was ∼£5 million, equivalent to ∼£13u2003000 per patient, and for England, an annual estimated cost of ∼£650 million. However, ‘Payment by Results’ reimbursement amounted to a mean (SD) hospital income of just £6905 (2639) per patient, a net financial loss of ∼£6100 per patient, equivalent to a reimbursement shortfall nationally of ∼£300 million. We also found that patients >u200370u2003years (46%) had significantly higher 30‐day postoperative mortality (18% vs 6%, pu2003<u20030.0001), significantly prolonged median (IQR [range]) length of stay (15u2003(10–26 [1–123]) days vs 12u2003(7–22 [1–176]) days, pu2003<u20030.001) and incurred higher costs (median (IQR [range]) £9667 (6620–15u2003732 [1920–103u2003624]) vs £7467 (4975–14u2003251 [1178–118u2003060]), pu2003<u20030.001). Emergency laparotomy is a common procedure associated with considerable cost, particularly among elderly patients. A National Emergency Laparotomy Database will help provide an evidence base on which to improve clinical outcome and cost efficiency.

Anaesthesia for 1131 patients undergoing proximal femoral fracture repair: a retrospective, observational study of effects on blood pressure, fluid administration and perioperative anaemia

Intra‐operative hypotension is a frequent occurrence during anaesthesia for hip fracture surgery in older patients with co‐morbidities. We analysed retrospective data from the Brighton Hip Fracture Database to determine the intra‐operative fall in systolic blood pressure, and the incidence of absolute (lowest systolic blood pressureu2003<u200390u2003mmHg) and relative (>u200320% fall in systolic blood pressure from baseline) hypotension during general or spinal anaesthesia among 1131 non‐consecutive patients with hip fracture. General anaesthesia for 489 patients (43.2%) produced a greater mean (SD) fall in systolic blood pressure than spinal anaesthesia for 578 patients (51.1%): 34.2% (13.0%) vs 29.7% (10.8%), respectively (pu2003<u20030.0001), mean difference 4.5% (95% CI 3.1–5.9%), and was associated with greater mean (SD) intra‐operative fluid administration (1555 (801)u2003ml vs 1375u2003(621) ml, respectively, pu2003<u20030.0001). We observed a correlation between the volume of subarachnoid hyperbaric bupivacaine 0.5% and fall in systolic blood pressure (pu2003= 0.004): compared with patients receiving > 1.5u2003ml (nu2003=u2003463), fewer patients receiving ≤u20031.5u2003ml bupivacaine 0.5% (nu2003=u200397) experienced episodes of absolute (31.1% vs 11.3%, pu2003<u20030.0001) or relative (83.9% vs 26.8%, pu2003<u20030.0001) hypotension. Both mean (SD) intravenous fluid administration (1097u2003ml (439) vs 1431u2003ml (638), pu2003<u20030.0001) and mean peri‐operative fall in haemoglobin concentration (2.1u2003(1.8)u2003g.dl−1 vs 2.6u2003(1.7)u2003g.dl−1 , pu2003=u20030.009) were lower in the low‐dose spinal group. If these data are confirmed by other researchers, intra‐operative hypotension (and consequent haemodilution secondary to reactive fluid administration) in this patient group may be reduced by the simple expedient of administering more cautious general anaesthesia, or reduced volumes of subarachnoid local anaesthetic.

Cost estimates of spinal versus general anaesthesia for fractured neck of femur surgery.

It remains uncertain whether spinal anaesthesia is preferable to general anaesthesia for surgical repair of hip fracture, but one determining factor is the comparative cost. A detailed cost analysis relating to 20 consultants’ intended anaesthetic practice (which provided information of consumables used) and data from the Brighton Hip Fracture Database was performed to quantify any difference in the costs of administering spinal versus general anaesthesia for patients with hip fracture. Although spinal anaesthesia took significantly longer to administer (mean (SD) time 31u2003(15) min vs 27u2003(16) min; pu2003<u20030.0001), the mean (SD) cost of spinal anaesthesia (£193.81 (37.49)) was significantly less than the cost of general anaesthesia (£270.58 (44.68); pu2003<u20030.0001). The mean percentage cost of anaesthesia was 3.8% of hospital income per hip fracture, and personnel contributed approximately 46% of this cost. While such considerations indicate that spinal anaesthesia is financially preferable, it is unknown whether differential clinical outcomes between regional and general anaesthesia may offset this apparent monetary advantage.

Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015: Association of Anaesthetists of Great Britain and Ireland British Orthopaedic Association British Geriatric Society.

Concise guidelines are presented for the preparation and conduct of anaesthesia and surgery in patients undergoing cemented hemiarthroplasty for hip fracture. The Working Party specifically considered recent publications highlighting complications occurring during the peri‐operative period . The advice presented is based on previously published advice and clinical studies.

Type of anaesthesia for hip fracture surgery – the problems of trial design

store.iec.ch/preview/info_iec606012-13%7Bed3.1%7Den.pdf (accessed 18 ⁄ 02 ⁄ 2012). 7. Australian and New Zealand College of Anaesthetists. Minimum Safety Requirements for Anaesthetic Machines for Clinical Practice (2011). http://www. anzca.edu.au/resources/professionaldocuments/documents/technical/pdffiles/T3.pdf (accessed 18 ⁄ 02 ⁄ 2012). 8. Australian And New Zealand College of Anaesthetists. Recommendations on Checking Anaesthesia Delivery Systems – 2003. http://www.anzca.edu.au/resources/ professional-documents/documents/ professional-standards/professionalstandards-31.html (accessed18 ⁄ 02 ⁄ 2012). 9. American Society of Anesthesiologists. Recommendations for Pre-Anesthesia Checkout Procedures. Sub-Committee of ASA Committee on Equipment and Facilities (2008). http://www.asahq.org/ForMembers/Clinical-Information/2008-ASARecommendations-for-PreAnesthesia-Check out.aspx (accessed 18 ⁄ 02 ⁄ 2012). 10. Food and Drug Administration. Anesthesia Apparatus Checkout Recommendations, 1993. http://www.fda.gov/cdrh/ humfac/anesckot.html (accessed 18 ⁄ 02 ⁄ 2012). 11. Amt für Arbeitsschutz, Hamburg. Umgang mit Narkosegasen (2006). http:// www.hamburg.de/contentblob/200118/ data/m09-pdf.pdf (accessed 18 ⁄ 02 ⁄ 2012). 12. Société Française d’Anesthésie et de Réanimation. Recommandations concernant l’appareil d’anesthésie et sa vérification avant utilization (2002). http:// www.sfar.org/article/10/recommandations-concernant-l-appareil-d-anesthesieet-sa-verification-avant-utilisation (accessed 18 ⁄ 02 ⁄ 2012). 13. Merchant R, Chartrand D, Dain S, et al. Guidelines to the Practice of Anesthesia – Revised Edition 2012. Canadian Journal of Anesthesia 2012; 59: 63–102. 14. Association of Anaesthetists of Great Britain and Ireland. Checking Anaesthetic Equipment 2012. Anaesthesia; 67: 660– 8. 15. Association of Anaesthetists of Great Britain and Ireland. Checking Anaesthetic Equipment 3. London: AAGBI, 2004. 16. Medicines and Healthcare products Regulatory Agency MDA ⁄ 2005 ⁄ 062 07 November 2004 http://www.mhra.gov. uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON2022493 (accessed 19 ⁄ 02 ⁄ 2012). 17. Association of Anaesthetists of Great Britain and Ireland. Recommendations for Standards of Monitoring during Anaesthesia and Recovery, 4th edn. London: AAGBI, 2007.

Prediction of 30-day mortality after hip fracture surgery by the Nottingham Hip Fracture Score and the Surgical Outcome Risk Tool

The care of the elderly with hip fractures and their outcomes might be improved with resources targeted by the accurate calculation of risks of mortality and morbidity. We used a multicentre national dataset to evaluate and recalibrate the Nottingham Hip Fracture Score and Surgical Outcome Risk Tool. We split 9,017 hip fracture cases from the Anaesthesia Sprint Audit of Practice into derivation and validation data sets and used logistic regression to derive new model co‐efficients for death at 30 postoperative days. The area (95% CI) under the receiver operator characteristic curve of 0.71 (0.67–0.75) indicated acceptable discrimination by the Nottingham Hip Fracture Score and acceptable calibration fit (Hosmer–Lemeshow test), p = 0.23, with a similar discrimination by the Surgical Outcome Risk Tool, 0.70 (0.66–0.74), which was miscalibrated to the observed data, p = 0.001. We recommend that studies test these scores for patients with hip fractures in other countries. We also recommend these models are compared with case‐mix adjustment tools used in the UK.