Perioperative fluid volume optimization following proximal femoral fracture

Cardiac output monitoring: Technology and choice

The accurate quantification of cardiac output (CO) is given vital importance in modern medical practice, especially in high-risk surgical and critically ill patients. CO monitoring together with perioperative protocols to guide intravenous fluid therapy and inotropic support with the aim of improving CO and oxygen delivery has shown to improve perioperative outcomes in high-risk surgical patients. Understanding of the underlying principles of CO measuring devices helps in knowing the limitations of their use and allows more effective and safer utilization. At present, no single CO monitoring device can meet all the clinical requirements considering the limitations of diverse CO monitoring techniques. The evidence for the minimally invasive CO monitoring is conflicting; however, different CO monitoring devices may be used during the clinical course of patients as an integrated approach based on their invasiveness and the need for additional hemodynamic data. These devices add numerical trend information for anesthesiologists and intensivists to use in determining the most appropriate management of their patients and at present, do not completely prohibit but do increasingly limit the use of the pulmonary artery catheter.

Resuscitation in hip fractures: The practicality and clinical effectiveness of pre-operative resuscitation of patients with hip fracture using blood products

Introduction

This study aimed to determine the practicality and estimate the effect of administering pre-operative blood product resuscitation to a consecutive, prospectively recruited cohort of 100 patients admitted to a single centre with a hip fracture with all other treatment unchanged.

Method

100 patients aged 65 years or over admitted acutely to our unit with unilateral fractured femoral neck during the study period were included in this study, regardless of cognitive function. Patients were excluded only if there were relevant medical comorbidities or consent was declined. Each patient was resuscitated with a single unit of packed red cells in the immediate perioperative period in addition to standard care. The primary outcome was to establish the feasibility of the study protocol employed in using blood products to resuscitate eligible patients and recording reasons for any failures to include eligible patients. Additional data regarding mortality at 30 days following injury, subsequent blood product use, any transfusion related adverse reactions and total blood product use was measured.

Results

We were able to show that it is safe and practicable to deliver blood as an early resuscitative strategy in the frail elderly hip fracture population. The mortality rate of the study cohort was 3%. No adverse reaction was observed in any of the 99 patients given blood as a result of the resuscitation strategy and no morbidity was seen that could be attributed to the effect of giving blood. The total amount of blood received by comparable cohorts in the study period and the two preceding years were similar.

Conclusions

The study suggests that in the hip fracture population it is both practical and beneficial to move away from reactive transfusion regimens, and instead centre efforts instead on optimal resuscitation at the initial presentation.

Feasibility of using administrative data for identifying medical reasons to delay hip fracture surgery: a Canadian database study

PURPOSE

Failure to account for medically necessary delays may lead to an underestimation of early surgery benefits. This study investigated the feasibility of using administrative data to identify the National Institute for Health and Care Excellence (NICE) 124 guideline list of conditions that appropriately delay hip fracture surgery.

METHODS

We assembled a list of diagnosis and procedure codes to reflect the NICE 124 conditions. The list was reviewed and updated by an advanced clinical coder. The list was refined by five clinical experts. We then screened Canadian Institute for Health Information discharge abstracts for 153 918 patients surgically treated for a non-pathological first hip fracture between 1 January 2004 and 31 December 2012 for diagnosis codes present on admission and procedure codes that antedated hip fracture surgery. We classified abstracts as having medical reasons for delaying surgery based on the presence of these codes.

RESULTS

In total, 10 237 (6.7%; 95% CI 6.5% to 6.8%) patients had diagnostic and procedure codes indicating medical reasons for delay. The most common reasons for medical delay were exacerbation of a chronic chest condition (35.9%) and acute chest infection (23.2%). The proportion of patients with reasons for medical delays increased with time from admission to surgery: 3.9% (95% CI 3.6% to 4.1%) for same day surgery; 4.7% (95% CI 4.5% to 4.8%) for surgery 1 day after admission; 7.1% (95% CI 6.9% to 7.4%) for surgery 2 days after admission; and 15.5% (95% CI 15.1% to 16.0%) for surgery more than 2 days after admission. The trend was seen for admissions on weekday working hours, weekday after hours and on weekends.

CONCLUSION

Administrative data can be considered to identify conditions that appropriately delay hip fracture surgery. Accounting for medically necessary delays can improve estimates of the effectiveness of early surgery.

Resuscitation in hip fractures: a systematic review

To evaluate the evidence for the resuscitation of patients with hip fracture in the preoperative or perioperative phase of their treatment and its impact on mortality.

DESIGN

We searched MEDLINE, EMBASE, CENTRAL and PROSPERO databases using a systematic search strategy for randomised trials and observational studies investigating the fluid resuscitation of any patient with hip fracture. No language limits were applied to the search, which was complemented by manually screening the reference lists of appropriate studies.

OUTCOME MEASURES

Mortality at 1 week, 30 days and 1 year following surgery.

RESULTS

Two hundred and ninety-eight citations were identified, and 12 full manuscripts were reviewed; no studies satisfied the inclusion criteria. The background literature showed that the mortality for these patients at 30 days is approximately 8.5% and that bone cement implantation syndrome is insufficient to explain this. The literature was explored to define the need for an interventional investigation into the preoperative resuscitation of patients with hip fracture.

CONCLUSIONS

Patients with hip fracture show similar physiological disturbance to major trauma patients. Nineteen per cent of patients presenting with hip fracture are hypoperfused and 50% show preoperative anaemia suggesting that under resuscitation is a common problem that has not been investigated. A properly conducted interventional trial could improve the outcome of these vulnerable patients.

Perioperative fluid volume optimization following proximal femoral fracture

BACKGROUND

Proximal femoral fracture (PFF) is a common orthopaedic emergency that affects mainly elderly people at high risk of complications. Advanced methods for managing fluid therapy during treatment for PFF are available, but their role in reducing risk is unclear.

OBJECTIVES

To compare the safety and effectiveness of the following methods of perioperative fluid optimization in adult participants undergoing surgical repair of hip fracture: advanced invasive haemodynamic monitoring, such as transoesophageal Doppler and pulse contour analysis; a protocol using standard measures, such as blood pressure, urine output and central venous pressure; and usual care.Comparisons of fluid types (e.g. crystalloid vs colloid) and other methods of optimizing oxygen delivery, such as blood product therapies and pharmacological treatment with inotropes and vasoactive drugs, are considered in other reviews.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 9); MEDLINE (October 2012 to September 2015); and EMBASE (October 2012 to September 2015) without language restrictions. We ran forward and backward citation searches on identified trials. We searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform for unpublished trials. This is an updated version of a review published originally in 2004 and updated first in 2013 and again in 2015. Original searches were performed in October 2003 and October 2012.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in adult participants undergoing surgical treatment for PFF that compared any two of advanced haemodynamic monitoring, protocols using standard measures or usual care, irrespective of blinding, language or publication status.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the impact of fluid optimization interventions on outcomes of mortality, length of hospital stay, time to medical fitness, whether participants were able to return to pre-fracture accommodation at six months, participant mobility at six months and adverse events in-hospital. We pooled data using risk ratio (RR) or mean difference (MD) for dichotomous or continuous data, respectively, on the basis of random-effects models.

MAIN RESULTS

We included in this updated review five RCTs with a total of 403 participants, and we added two new trials identified during the 2015 search. One of the included studies was found to have a high risk of bias; no trial featured all pre-specified outcomes. We found two trials for which data are awaited for classification and one ongoing trial.Three studies compared advanced haemodynamic monitoring with a protocol using standard measures; three compared advanced haemodynamic monitoring with usual care; and one compared a protocol using standard measures with usual care. Meta-analyses for the two advanced haemodynamic monitoring comparisons are consistent with both increased and decreased risk of mortality (RR Mantel-Haenszel (M-H) random-effects 0.41, 95% confidence interval (CI) 0.14 to 1.20; 280 participants; RR M-H random-effects 0.45, 95% CI 0.07 to 2.95; 213 participants, respectively). The study comparing a protocol with usual care found no difference between groups for this outcome.Three studies comparing advanced haemodynamic monitoring with usual care reported data for length of stay and time to medical fitness. There was no statistically significant difference between groups for these outcomes in the two studies that we were able to combine (MD IV fixed 0.63, 95% CI -1.70 to 2.96); MD IV fixed 0.01, 95% CI -1.74 to 1.71, respectively) and no statistically significant difference in the third study. One study reported reduced time to medical fitness when comparing advanced haemodynamic monitoring with a protocol, and when comparing protocol monitoring with usual care.The number of participants with one or more complications showed no statistically significant differences in each of the two advanced haemodynamic monitoring comparisons (RR M-H random-effects 0.83, 95% CI 0.59 to 1.17; 280 participants; RR M-H random-effects 0.72, 95% CI 0.40 to 1.31; 173 participants, respectively), nor any differences in the protocol and usual care comparison.Only one study reported the number of participants able to return to normal accommodation after discharge with no statistically significant difference between groups.There were few studies with a small number of participants, and by using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) approach, we judged the quality of the outcome evidence as low. We had included one study with a high risk of bias, but upon applying GRADE, we downgraded the quality of this outcome evidence to very low.

AUTHORS' CONCLUSIONS

Five studies including a total of 403 participants provided no evidence that fluid optimization strategies improve outcomes for participants undergoing surgery for PFF. Further research powered to test some of these outcomes is ongoing.

Technological advances in perioperative monitoring: Current concepts and clinical perspectives

Minimal mandatory monitoring in the perioperative period recommended by Association of Anesthetists of Great Britain and Ireland and American Society of Anesthesiologists are universally acknowledged and has become an integral part of the anesthesia practice. The technologies in perioperative monitoring have advanced, and the availability and clinical applications have multiplied exponentially. Newer monitoring techniques include depth of anesthesia monitoring, goal-directed fluid therapy, transesophageal echocardiography, advanced neurological monitoring, improved alarm system and technological advancement in objective pain assessment. Various factors that need to be considered with the use of improved monitoring techniques are their validation data, patient outcome, safety profile, cost-effectiveness, awareness of the possible adverse events, knowledge of technical principle and ability of the convenient routine handling. In this review, we will discuss the new monitoring techniques in anesthesia, their advantages, deficiencies, limitations, their comparison to the conventional methods and their effect on patient outcome, if any.

Perioperative fluid volume optimization following proximal femoral fracture

BACKGROUND

Proximal femoral fracture (PFF) is a common orthopaedic emergency, affecting mainly elderly people at high risk of complications. Advanced methods for managing fluid therapy during treatment for PFF are available, but their role in reducing risk is unclear.

OBJECTIVES

To compare the safety and effectiveness of different methods of perioperative fluid optimization in adult participants undergoing surgical repair of hip fracture. We considered the following methods: advanced invasive haemodynamic monitoring, such as transoesophageal Doppler and pulse contour analysis; a protocol using standard measures, such as blood pressure, urine output and central venous pressure; and usual care.Comparisons of fluid types (e.g. crystalloid vs colloid) and other methods of optimizing oxygen delivery, such as blood product therapies and pharmacological treatment with inotropes and vasoactive drugs, are considered elsewhere.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 9); MEDLINE (1966 to October 2012); and EMBASE (1980 to October 2012) without language restrictions. We ran forward and backward citation searches on identified trials. We contacted authors and searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform for unpublished trials. This is an updated version of a review published in 2004. The original search was performed in October 2003.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in adult participants undergoing surgical treatment for PFF, which compared any two of advanced haemodynamic monitoring, protocols using standard measures or usual care, irrespective of blinding, language or publication status.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the impact of fluid optimization interventions on outcomes of mortality, length of hospital stay, return of participant to pre-fracture accommodation and mobility at six months and adverse events in hospital. We pooled data using risk ratio or mean difference for dichotomous or continuous data, respectively, based on random-effects models.

MAIN RESULTS

We included three RCTs with a total of 200 participants. One of these included studies was found to have a high risk of bias; no trial featured all pre-specified outcomes. We found one trial for which data are awaited for classification and two ongoing trials. One included study with low risk of bias found that compared with usual care, time to medical fitness for discharge was shorter with the use of advanced haemodynamic monitoring (mean reduction 6.20 days, 95% CI 2.3 to 10.1 days; 59 participants, one trial) and with the use of protocols that apply standard measures (mean reduction 3.9 days, 95% CI 0.75 to 7.05; 57 participants, one trial). Our results are consistent with both increased and decreased risk of mortality and adverse events in participants receiving the intervention. No data for other outcomes were available. Our results are limited by the quantity of available data.

AUTHORS' CONCLUSIONS

Three studies considering a total of 200 participants reveal an absence of evidence that fluid optimization strategies improve outcomes for participants undergoing surgery for PFF. Length of hospital stay may be improved, but lack of good quality data leaves uncertainty. Further research powered to test some of these outcomes is ongoing.

Management of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain and Ireland

There should be protocol-driven, fast-track admission of patients with hip fractures through the emergency department. Patients with hip fractures require multidisciplinary care, led by orthogeriatricians. Surgery is the best analgesic for hip fractures. Surgical repair of hip fractures should occur within 48 hours of hospital admission. Surgery and anaesthesia must be undertaken by appropriately experienced surgeons and anaesthetists. There must be high-quality communication between clinicians and allied health professionals. Early mobilisation is a key part of the management of patients with hip fractures. Pre-operative management should include consideration of planning for discharge from hospital. Measures should be taken to prevent secondary falls. 10. Continuous audit and targeted research is required in order to inform and improve the management of patients with hip fracture.

The use of LiDCO based fluid management in patients undergoing hip fracture surgery under spinal anaesthesia: neck of femur optimisation therapy - targeted stroke volume (NOTTS): study protocol for a randomized controlled trial

BACKGROUND

Approximately 70,000 patients/year undergo surgery for repair of a fractured hip in the United Kingdom. This is associated with 30-day mortality of 9% and survivors have a considerable length of acute hospital stay postoperatively (median 26 days). Use of oesophageal Doppler monitoring to guide intra-operative fluid administration in hip fracture repair has previously been associated with a reduction in hospital stay of 4-5 days. Most hip fracture surgery is now performed under spinal anaesthesia. Oesophageal Doppler monitoring may be unreliable in the presence of spinal anaesthesia and most patients would not tolerate the probes. An alternative method of guiding fluid administration (minimally-invasive arterial pulse contour analysis) has been shown to reduce length of stay in high-risk surgical patients but has never been studied in hip fracture surgery.

METHODS

Single-centre randomised controlled parallel group trial. Randomisation by website using computer generated concealed tables.

SETTING

University hospital in UK.

PARTICIPANTS

128 patients with acute primary hip fracture listed for operative repair under spinal anaesthesia and aged > 65 years.

INTERVENTION

Stroke volume guided intra-operative fluid management. Continuous measurement of SV recorded by a calibrated cardiac output monitor (LiDCOplus). Maintenance fluid and 250 ml colloid boluses given to achieve sustained 10% increases in stroke volume.

CONTROL GROUP

fluid administration at the responsible (blinded) anaesthetist's discretion. The intervention terminates at the end of the surgical procedure and post-operative fluid management is at the responsible anaesthetist's discretion.

PRIMARY OUTCOME

length of acute hospital stay is determined by a blinded team of clinicians. Secondary outcomes include number of complications and total cost of care. Funding NIHR/RfPB: PB-PG-0407-13073.

TRIAL REGISTRATION NUMBER

TRIAL REGISTRATION

Current Controlled Trials ISRCTN88284896.

Providing perioperative care for patients with hip fractures

Providing perioperative care for patients with hip fractures can present major challenges for the anaesthesiologist. These patients often have multiple comorbidities, the deterioration of any one of which may have precipitated the fall. A careful balance has to be achieved between minimising the time before operation and spending time to optimise their medical status. This review will present insights into preoperative patient assessment and optimization in this group of patients from the anaesthesiologists' perspective. In particular, it will highlight important medical issues of concern that may alter anaesthetic risks and management. With a greater understanding of what these issues are, potentially a more prompt and integrated approach to managing these patients may be made. Hopefully, this would result in minimising last minute cancellations due to medical reasons for these patients.

Hip fracture post-operation dysnatremia and Na+-courses in different cognitive and functional patient groups

The aim of the study was to investigate Na(+)-course of hip fracture patients in relation to demographic and clinical parameters. Data on 155 older hip fracture patients were analyzed retrospectively. Clinical parameters and serum Na(+) on admission (Na1), during 24h pre-op. (Na2), during 24h post-op. (Na3), and pre-discharge (Na4) were recorded. Hyponatremia and hypernatremia rates pre- and post-operation were 26.5%, 2.6%, 24.5% and 5.8%. Higher Na3 (138.76 ± 4.4 mEq/l) vs. Na1 (137.69 ± 4.5 mEq/l) (p = 0.004) and correlation between age and Na3 (p = 0.021) was found. Mean serum Na(+) of impaired mental status (IMS) vs. normal patients and of partially/independent vs. dependent patients were higher (p < 0.05). More complications occurred in IMS patients tending to higher Na3 in patients with complications. No differences in Na(+)-courses were found according to sex or co-morbidities. Dysnatremia is highly prevalent in older hip fracture patients. A distinct post-operative increase in serum Na(+) was found, higher in the cognitively and functionally impaired patients. It seems that the Na(+) increase characterizes more IMS patients who suffer more complications, but does not necessarily indicate complications. We recommend surveillance of serum Na(+), particularly in cognitively and functionally impaired older patients in whom the risk of hypernatremia and complications is higher.

Fast track colorectal surgery

A "fast track" colon surgery program is the global package of perioperative care encompassing preoperative, operative, and postoperative techniques, which in aggregate result in fewer complications, a reduction in cost, less postoperative pain, a reduction in the hospital length of stay, and quicker return to work and normal activities. Results of fast track programs have shown significant advantages; however, strong evidence is forthcoming. Implementation of a fast track program requires a significant commitment and a multidisciplinary approach. Fast track principles may also be applied to anorectal surgery with good results.

[Perioperative fluid management: an analysis of the present situation]

Optimal perioperative fluid management is still controversial. Besides well known perioperative hypovolaemia, hypervolaemia has an influence on perioperative morbidity and mortality, particularly with regard to the patient's medical history, a reduced cardiac and pulmonal function and the operation itself. The concepts of preoperative, intraoperative and postoperative fluid administration are neither adequately validated, nor sufficiently integrated into a perioperative concept. At the present, moderate fluid administration to improve preoperative and postoperative outcome is safe in minor or medium surgical procedures. High-risk surgical patients benefit from a time-oriented or/and goal-oriented monitored fluid therapy. In the past only little attention has been concentrated on postoperative fluid management, but may be stimulated by the new concepts of fast track surgery.

Understanding clinical dehydration and its treatment

Dehydration in clinical practice, as opposed to a physiological definition, refers to the loss of body water, with or without salt, at a rate greater than the body can replace it. We argue that the clinical definition for dehydration, ie, loss of total body water, addresses the medical needs of the patient most effectively. There are 2 types of dehydration, namely water loss dehydration (hyperosmolar, due either to increased sodium or glucose) and salt and water loss dehydration (hyponatremia). The diagnosis requires an appraisal of the patient and laboratory testing, clinical assessment, and knowledge of the patient's history. Long-term care facilities are reluctant to have practitioners make a diagnosis, in part because dehydration is a sentinel event thought to reflect poor care. Facilities should have an interdisciplinary educational focus on the prevention of dehydration in view of the poor outcomes associated with its development. We also argue that dehydration is rarely due to neglect from formal or informal caregivers, but rather results from a combination of physiological and disease processes. With the availability of recombinant hyaluronidase, subcutaneous infusion of fluids (hypodermoclysis) provides a better opportunity to treat mild to moderate dehydration in the nursing home and at home.

Introducing a clinical pathway in fluid management

Following the publication of the National Confidential Enquiry into Perioperative Death's (NCEPOD) report, Extremes of Age (NCEPOD 1999), several recommendations were made relating to the management of patients admitted via Accident and Emergency (A&E) with fractured necks of femur (NOF). An audit was carried out relating fluid management in the elderly. A multidisciplinary clinical pathway for patients with fractured NOF was produced. The audit was repeated in 2002, 2003 and 2005 to obtain data as to whether the pathway had improved the management of patients admitted with fractured NOF Comparing audit data between 2000 and 2005 there were significant reductions in the incidence of perioperative hypotension and an increase in the percentage of patients who were prescribed and received intravenous fluids (p<0.05). A protocol-based pathway produced as a result of a recommendation from NCEPOD has greatly improved the fluid management of patients admitted to a general hospital with fractures.

Clinical trials of monitoring in anaesthesia, critical care and acute ward care: a review

During anaesthesia monitoring is used as part of a complex feedback-control system to keep the patient in a safe physiological 'envelope' and so is central to the conduct of a modern anaesthetic. The utility of basic monitoring is universally acknowledged and will never be assessed using randomized controlled trials. However, each time a new monitoring device is introduced, it can be assessed to see if it adds to the safety and effectiveness of anaesthetics. This review highlights some of the studies that have assessed new monitors in anaesthesia, critical care, and other areas of acute care.

Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study

OBJECTIVES

To evaluate postoperative medical complications and the association between these complications and mortality at 30 days and one year after surgery for hip fracture and to examine the association between preoperative comorbidity and the risk of postoperative complications and mortality.

DESIGN

Prospective observational cohort study.

SETTING

University teaching hospital.

PARTICIPANTS

2448 consecutive patients admitted with an acute hip fracture over a four year period. We excluded 358 patients: all those aged < 60; those with periprosthetic fractures, pathological fractures, and fractures treated without surgery; and patients who died before surgery.

INTERVENTIONS

Routine care for hip fractures.

MAIN OUTCOME MEASURES

Postoperative complications and mortality at 30 days and one year.

RESULTS

Mortality was 9.6% at 30 days and 33% at one year. The most common postoperative complications were chest infection (9%) and heart failure (5%). In patients who developed postoperative heart failure mortality was 65% at 30 days (hazard ratio 16.1, 95% confidence interval 12.2 to 21.3). Of these patients, 92% were dead by one year (11.3, 9.1 to 14.0). In patients who developed a postoperative chest infection mortality at 30 days was 43% (8.5, 6.6 to 11.1). Significant preoperative variables for increased mortality at 30 days included the presence of three or more comorbidities (2.5, 1.6 to 3.9), respiratory disease (1.8, 1.3 to 2.5), and malignancy (1.5, 1.01 to 2.3).

CONCLUSIONS

In elderly people with hip fracture, the presence of three or more comorbidities is the strongest preoperative risk factor. Chest infection and heart failure are the most common postoperative complications and lead to increased mortality. These groups offer a clear target for specialist medical assessment.