Effect of Prophylactic Fibrinogen Concentrate In Scoliosis Surgery (EFISS): a study protocol of two-arm, randomised trial

INTRODUCTION

Fibrinogen is one of the essential coagulation factors. Preoperative lower plasma fibrinogen level has been associated with higher blood loss. Scoliosis surgery presents a challenge for the anaesthetic team, one of the reasons being blood loss and transfusion management. Recently, the prophylactic fibrinogen administration has been a debated topic in various indications. It has been described for example, in urological or cardiovascular surgery, as well as in paediatrics. This pilot study is focused on verifying the feasibility of potential large randomised trial and verifying the safety of prophylactic fibrinogen administration in paediatric scoliosis surgery.

METHODS AND ANALYSIS

A total of 32 paediatric patients indicated for scoliosis surgery will be recruited. Participants will be randomised into study groups in a 1:1 allocation ratio. Patients in the intervention group will receive prophylactic single dose of fibrinogen, in addition to standard of care. Patients in the control group will receive standard of care without study medication prior to skin incision. The primary aim is to assess the safety of prophylactic fibrinogen administration during scoliosis surgery in children, the incidence of any adverse events (AEs) and reactions will be monitored during participation in the study. The secondary objective is to investigate the additional safety information, feasibility and efficacy of a prophylactic fibrinogen administration. The incidence of AEs and reactions according to selected adverse events of special interest will be monitored. All collected data will be subjected to statistical analysis according to a separate statistical analysis plan.

ETHICS AND DISSEMINATION

This trial follows the applicable legislation and requirements for good clinical practice according to the International Conference on Harmonisation E6(R2). All essential trial documents were approved by the relevant ethics committee and national regulatory authority (State Institute for Drug Control) and their potential amendments will be submitted for approval.

TRIAL REGISTRATION NUMBER

NCT05391412.

Risk factors for emergence agitation during the awakening period in elderly patients after total joint arthroplasty: a retrospective cohort study

OBJECTIVES

This study aimed to explore the incidence and risk factors for emergence agitation (EA) in elderly patients who underwent total joint arthroplasty (TJA) under general anaesthesia, and to assess their predictive values.

DESIGN

Single-centre retrospective cohort study.

SETTING

A 1600-bed general tertiary hospital in China.

PARTICIPANTS

This study enrolled 421 elderly patients scheduled for elective primary TJA under general anaesthesia.

PRIMARY AND SECONDARY OUTCOME MEASURES

EA was assessed using the Richmond Agitation Sedation Scale during the awakening period after surgery in the post-anaesthesia care unit. Risk factors for EA were identified using univariate and multivariable logistic analyses. The receiver operating characteristic (ROC) curve was used to assess the predictive values of the risk factors for EA.

RESULTS

The incidence of EA in elderly patients who underwent TJA was 37.6%. According to the multivariable logistic analysis, postoperative pain (95% CI: 1.951 to 3.196), male sex (95% CI: 1.781 to 6.435), catheter-related bladder discomfort (CRBD) (95% CI: 4.001 to 15.392) and longer fasting times for solids (95% CI: 1.260 to 2.301) and fluids (95% CI: 1.263 to 2.365) were independent risk factors for EA. As shown by the ROC analysis, postoperative pain and fasting times for solids and fluids had good predictive values, with areas under the ROC curve equalling 0.769, 0.753 and 0.768, respectively.

CONCLUSIONS

EA is a common complication after TJA in elderly patients. Some risk factors, including postoperative pain, male sex, CRBD and longer fasting times, can increase the incidence of EA. These risk factors may contribute to identifying high-risk patients, which facilitates the development of effective strategies to prevent and treat EA.

TRIAL REGISTRATION NUMBER

ChiCTR1800020193.

Randomised controlled trial comparing intraoperative cell salvage and autotransfusion with standard care in the treatment of hip fractures: a protocol for the WHITE 9 study

INTRODUCTION

People who sustain a hip fracture are typically elderly, frail and require urgent surgery. Hip fracture and the urgent surgery is associated with acute blood loss, compounding patients' pre-existing comorbidities including anaemia. Approximately 30% of patients require a donor blood transfusion in the perioperative period. Donor blood transfusions are associated with increased rates of infections, allergic reactions and longer lengths of stay. Furthermore, there is a substantial cost associated with the use of donor blood. Cell salvage and autotransfusion is a technique that recovers, washes and transfuses blood lost during surgery back to the patient. The objective of this study is to determine the clinical and cost effectiveness of intraoperative cell salvage, compared with standard care, in improving health related quality-of-life of patients undergoing hip fracture surgery.

METHODS AND ANALYSIS

Multicentre, parallel group, two-arm, randomised controlled trial. Patients aged 60 years and older with a hip fracture treated with surgery are eligible. Participants will be randomly allocated on a 1:1 basis to either undergo cell salvage and autotransfusion or they will follow the standard care pathway. Otherwise, all care will be in accordance with the National Institute for Health and Care Excellence guidance. A minimum of 1128 patients will be recruited to obtain 90% power to detect a 0.075-point difference in the primary endpoint: EuroQol-5D-5L HRQoL at 4 months post injury. Secondary outcomes will include complications, postoperative delirium, residential status, mobility, allogenic blood use, mortality and resource use.

ETHICS AND DISSEMINATION

NHS ethical approval was provided on 14 August 2019 (19/WA/0197) and the trial registered (ISRCTN15945622). After the conclusion of this trial, a manuscript will be prepared for peer-review publication. Results will be disseminated in lay form to participants and the public.

TRIAL REGISTRATION NUMBER

ISRCTN15945622.

Regional haemodynamic variables and perfusion index in the evaluation of sciatic nerve block: a prospective observational trial

OBJECTIVE

We determined whether regional haemodynamics and perfusion index (PI) could be reliable indicators of a successful sciatic nerve block (SNB).

DESIGN

Prospective observational trial.

SETTING

A tertiary teaching hospital in China from April 2020 to August 2020.

PARTICIPANTS

We assessed 79 patients for eligibility to participate in this study. Nine patients were excluded for not meeting our inclusion criteria, and three patients were excluded due to missing measurements at all time points.

INTERVENTIONS

The patients underwent SNB. Pulsed-wave Doppler and PI measurements were performed.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was the diagnostic power of regional haemodynamic change and PI to predict successful SNB. The secondary outcome measure was the effect of SNB on the regional haemodynamics and PI in the lower extremity.

RESULTS

We assessed 79 patients in this study and 67 patients available for the final analysis. The SNB was successful in 59 patients and failed in eight patients. There were no significant differences in demographic characteristics between the patients with successful and failed SNB. Starting from 10 min after SNB, the peak systolic velocity (PSV), end-diastolic velocity, time-averaged maximum velocity and time-averaged mean velocity of the anterior tibial artery and posterior tibial artery of patients in the successful SNB group were significantly higher than those in the failed SNB group (p<0.05). The PSV percentage increase at 10 min after SNB has great potential to predict the block success. The area under the receiver operating characteristic curve (AUC) values were 0.893 (95% CI 0.7809 to 1.000) and 0.880 (95% CI 0.7901 to 0.9699). The corresponding cut-off values were 19.22 and 35.88, respectively. The PI increased during 5-45 min intervals in patients with successful SNB. The AUC for the PI percentage increases at 10 min after SNB was 0.853 (95% CI 0.7035 to 1.000), with a cut-off value of 93.09.

CONCLUSION

The regional haemodynamic variables, PSV and PI in particular, can be used as alternative indicators for clinicians to evaluate the success of SNB objectively and early.

TRIAL REGISTRATION NUMBER

ChiCTR2000030772.

Effects of pericapsular nerve group (PENG) block on postoperative recovery in elderly patients with hip fracture: study protocol for a randomised, parallel controlled, double-blind trial

INTRODUCTION

Hip fracture is a common and serious emergency in the elderly, and it is associated with severe pain, significant morbidity and mortality. The use of peripheral nerve block can relieve pain effectively and reduce opioid requirements, which may accelerate patient's recovery. The pericapsular nerve group (PENG) block has been found to provide an effective blockade to the hip joint with a potential motor-sparing effect, so we hypothesised that the PENG block may be an effective tool to enhance the recovery in elderly patients after hip fracture surgery.

METHODS AND ANALYSIS

This study is a single-centred, randomised, parallel controlled, double-blind trial. A total of 92 elderly patients scheduled for hip fracture surgery will be divided into two groups at random to receive either ultrasound-guided femoral nerve block or ultrasound-guided PENG block. The primary outcome will be to compare the Quality of Recovery-15 scores at 24 hours postoperatively between the two groups. The secondary outcomes will include measuring and comparing the strength of the quadriceps, the visual analogue scale at rest and on movement, the total morphine consumption, the rescue analgesic, the first time of postoperative out-of-bed mobilisation and complications.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board of the Ethics Committee of The First Affiliated Hospital of Guangzhou University of Chinese Medicine on 15 December 2020 (reference K2020-110). The results of this study will be published in peer-reviewed international journals.

TRIAL REGISTRATION NUMBER

ChiCTR2100042341.

Randomised comparative effectiveness trial of Pulmonary Embolism Prevention after hiP and kneE Replacement (PEPPER): the PEPPER trial protocol

INTRODUCTION

More than 1 million elective total hip and knee replacements are performed annually in the USA with 2% risk of clinical pulmonary embolism (PE), 0.1%-0.5% fatal PE, and over 1000 deaths. Antithrombotic prophylaxis is standard of care but evidence is limited and conflicting. We will compare effectiveness of three commonly used chemoprophylaxis agents to prevent all-cause mortality (ACM) and clinical venous thromboembolism (VTE) while avoiding bleeding complications.

METHODS AND ANALYSIS

Pulmonary Embolism Prevention after HiP and KneE Replacement is a large randomised pragmatic comparative effectiveness trial with non-inferiority design and target enrolment of 20 000 patients comparing aspirin (81 mg two times a day), low-intensity warfarin (INR (International Normalized Ratio) target 1.7-2.2) and rivaroxaban (10 mg/day). The primary effectiveness outcome is aggregate of VTE and ACM, primary safety outcome is clinical bleeding complications, and patient-reported outcomes are determined at 1, 3 and 6 months. Primary data analysis is per protocol, as preferred for non-inferiority trials, with secondary analyses adherent to intention-to-treat principles. All non-fatal outcomes are captured from patient and clinical reports with independent blinded adjudication. Study design and oversight are by a multidisciplinary stakeholder team including a 10-patient advisory board.

ETHICS AND DISSEMINATION

The Institutional Review Board of the Medical University of South Carolina provides central regulatory oversight. Patients aged 21 or older undergoing primary or revision hip or knee replacement are block randomised by site and procedure; those on chronic anticoagulation are excluded. Recruitment commenced at 30 North American centres in December 2016. Enrolment currently exceeds 13 500 patients, representing 33% of those eligible at participating sites, and is projected to conclude in July 2024; COVID-19 may force an extension. Results will inform antithrombotic choice by patients and other stakeholders for various risk cohorts, and will be disseminated through academic publications, meeting presentations and communications to advocacy groups and patient participants.

TRIAL REGISTRATION

NCT02810704.

Melatonin for prevention of postoperative delirium after lower limb fracture surgery in elderly patients (DELIRLESS): study protocol for a multicentre randomised controlled trial

INTRODUCTION

Postoperative delirium (POD) is one of the most frequent complication after surgery in elderly patients, and is associated with increased morbidity and mortality, prolonged length of stay, cognitive and functional decline leading to loss of autonomy, and important additional healthcare costs. Perioperative inflammatory stress is a key element in POD genesis. Melatonin exhibits antioxidative and immune-modulatory proprieties that are promising concerning delirium prevention, but in perioperative context literature are scarce and conflicting. We hypothesise that perioperative melatonin can reduce the incidence of POD.

METHODS AND ANALYSIS

The DELIRLESS trial is a prospective, national multicentric, phase III, superiority, comparative randomised (1:1) double-blind clinical trial. Among patients aged 70 or older, hospitalised and scheduled for surgery of a severe fracture of a lower limb, 718 will be randomly allocated to receive either melatonin 4 mg per os or placebo, every night from anaesthesiologist preoperative consultation and up to 5 days after surgery. The primary outcome is POD incidence measured by either the French validated translation of the Confusion Assessment Method (CAM) score for patients hospitalised in surgery, or CAM-ICU score for patients hospitalised in ICU (Intensive Care Unit). Daily delirium assessment will take place during 10 days after surgery, or until the end of hospital stay if it is shorter. POD cumulative incidence function will be compared at day 10 between the two randomised arms in a competing risks framework, using the Fine and Grey model with death as a competing risk of delirium.

ETHICS AND DISSEMINATION

The DELIRLESS trial has been approved by an independent ethics committee the Comité de Protection des Personnes (CPP) Sud-Est (ref CPP2020-18-99 2019-003210-14) for all study centres. Participant recruitment begins in December 2020. Results will be published in international peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

NCT04335968, first posted 7 April 2020.

PROTOCOL VERSION IDENTIFIER

N°3-0, 3 May 2021.

Evaluation of the insertion parameters and complications of the i-gel Plus airway device for maintaining patent airway during planned procedures under general anaesthesia: a protocol for a prospective multicentre cohort study

INTRODUCTION

Supraglottic airway devices represent a less invasive method of airway management than tracheal intubation during general anaesthesia. Their continued development is focused mainly on improvements in the insertion success rate and minimalisation of perioperative and postoperative complications. The i-gel Plus is a novel, anatomically preshaped supraglottic airway device which achieves a perilaryngeal seal due to a non-inflatable cuff made of a soft thermoplastic elastomer. The purpose of this cohort study is to assess the success rate of the i-gel Plus use during elective procedures under general anaesthesia, its intraoperative performance, and the degree of postoperative complications.

METHODS AND ANALYSIS

This is a multicentre, prospective, interventional cohort study. The enrolment will take place in seven centres in four European countries. We plan to enrol 2000 adult patients in total, who are scheduled for elective surgery under general anaesthesia, and with an indication for use of a supraglottic airway device for management of their airway. The study is projected to run over a period of 18 months. The primary outcome of the study is the total success rate of the i-gel Plus insertion in terms of successful ventilation and oxygenation through the device. Secondary outcomes include perioperative parameters, such as insertion time, seal/leak pressures, number of insertion attempts and postoperative adverse events and complications. Postoperative follow-up will be performed at 1 hour, 24 hours in all patients, and for selected patients at 3 and 6 months.

ETHICS AND DISSEMINATION

The cohort study has received the following ethical approvals: General University Hospital Prague, University Hospital Olomouc, University Military Hospital Prague, University Hospital Barcelona, University Hospital Lodz, Antrim Area Hospital, Craigavon Area Hospital, Office for Research Ethics Committees Northern Ireland. The results will be published in peer-reviewed journals and presented at relevant anaesthesia conferences.

TRIAL REGISTRATION NUMBER

ISRCTN86233693;Pre-results.

Association between tissue oxygenation and myocardial injury in patients undergoing major spine surgery: a prospective cohort study

OBJECTIVE

To describe the association between intraoperative tissue oxygenation and postoperative troponin elevation in patients undergoing major spine surgery. We hypothesised that a decrease in intraoperative skeletal muscle tissue oxygenation (SmO₂) was associated with the peak postoperative cardiac troponin value.

DESIGN

This is a prospective cohort study.

SETTING

Single-centre, University of California San Francisco Medical Center.

PARTICIPANTS

Seventy adult patients undergoing major elective spine surgery.

PRIMARY AND SECONDARY OUTCOME MEASURES

High-sensitivity troponin T (hsTnT) was measured in plasma preoperatively and on the first and second day after surgery to assess the primary outcome of peak postoperative hsTnT. Secondary outcomes included MINS and intensive care unit (ICU) admission within 30 days. Skeletal cerebral tissue oxygenation and SmO₂ was measured continuously with near-infrared spectroscopy during surgery. The primary exposure variable was time-weighted area under the curve (TW AUC) for SmO₂.

RESULTS

Mean age was 65 (33-85) years and 59% were female. No significant association was found between TW AUC for SmO₂ and peak hsTnT (Spearman's correlation, r_s=0.17, p=0.16). A total of 28 (40%) patients had MINS. ICU admission occurred in 14 (40%) in lower vs 25 (71%) in upper half of patients based on TW AUC for SmO₂, p=0.008.

CONCLUSIONS

Decrease in SmO₂ was not a statistically significant predictor for peak troponin value following major spine surgery but is a potential predictor for other postoperative complications.

TRIAL REGISTRATION NUMBER

NCT03518372.

Point-of-care ultrasound-guided regional anaesthesia in older ED patients with hip fractures: a study to test the feasibility of a training programme and time needed to complete nerve blocks by ED physicians after training

OBJECTIVES

Point-of-care ultrasound-guided regional anaesthesia (POCUS-GRA) provides safe, rapid analgesia for older people with hip fractures but is rarely performed in the emergency department (ED). Self-perceived inadequate training and time to perform POCUS-GRA are the two most important barriers. Our objective is to assess the feasibility of a proposed multicentre, stepped-wedge cluster randomised clinical trial (RCT) to assess the impact of a knowledge-to-practice (KTP) intervention on delirium.

DESIGN

Open-label feasibility study.

SETTING

An academic tertiary care Canadian ED (annual visits 60 000).

PARTICIPANTS

Emergency physicians working at least one ED shift per week, excluding those already performing POCUS-GRA more than four times per year.

INTERVENTION

A KTP intervention, including 2-hour structured training sessions with procedure bundle and email reminders.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary feasibility outcome is the proportion of eligible physicians that completed training and subsequently performed POCUS-GRA. Secondary outcome is the time needed to complete POCUS-GRA. We also test the feasibility of the enrolment, consent and randomisation processes for the future stepped-wedge cluster RCT (NCT02892968).

RESULTS

Of 36 emergency physicians, 4 (12%) were excluded or declined participation. All remaining 32 emergency physicians completed training and 31 subsequently treated at least one eligible patient. Collectively, 27/31 (87.1%) performed 102 POCUS-GRA blocks (range 1-20 blocks per physician). The median (IQR) time to perform blocks was 15 (10-20) min, and reduction in pain was 6/10 (3-7) following POCUS-GRA. There were no reported complications.

CONCLUSION

Our KTP intervention, consent process and randomisation were feasible. The time to perform POCUS-GRA rarely exceeded 30 min, Our findings reinforce the existing data on the safety and effectiveness of POCUS-GRA, mitigate perceived barriers to more widespread adoption and demonstrate the feasibility of trialling this intervention for the proposed stepped-wedge cluster RCT.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov #02892968.

Effects of general versus regional anaesthesia on circadian melatonin rhythm and its association with postoperative delirium in elderly patients undergoing hip fracture surgery: study protocol for a prospective cohort clinical trial

INTRODUCTION

Postoperative delirium (POD) is a common neurological complication after hip fracture surgery and is associated with high morbidity and mortality in elderly patients. Although the specific mechanism of POD remains unclear, circadian rhythm disruptions have recently drawn increased attention. To date, only limited postoperative time points of plasma melatonin level measurements were recorded in previous studies, and such data cannot represent a comprehensive melatonin rhythm. The process of anaesthesia (either general anaesthesia (GA) or regional anaesthesia (RA)) is known to influence the melatonin rhythm. However, how these two anaesthesia methods differently affect the postoperative melatonin rhythm is still unknown. Therefore, we hypothesise that RA may attenuate the disruption of the melatonin rhythm, which might decrease the incidence of POD in elderly patients undergoing hip surgery.

METHODS AND ANALYSIS

In this prospective cohort clinical trial, 138 patients scheduled for hip fracture surgery will be divided into two groups to receive either GA or RA. The primary aim is to compare the circadian rhythm of melatonin secretion between the two groups and explore its association with the incidence of POD.

ETHICS AND DISSEMINATION

The study has been approved by the Medical Science Research Ethics Committees of Beijing Jishuitan Hospital (JLKS201901-04). The results of the study will be published in peer-reviewed international journals.

TRIAL REGISTRATION NUMBER

ChiCTR1900027393.

How should we manage hip fracture patients on direct oral anticoagulants?

OBJECTIVE

Currently, there are no national protocols in place for managing hip fracture patients on direct oral anticoagulants (DOACs). Hence, various local management protocols exist. We compared three different local protocols and a control group to assess blood loss and time delay to theatre.

METHODS

Sequential data were collected for 120 hip fracture patients in four groups; wait 24 hours from last dose, wait 48 hours, perform DOAC levels and control.

RESULTS

DOAC use in our hip fracture patients was 14%. Median haemoglobin (Hb) drop between the three protocol groups showed no significant difference (13.5, 21.5 and 16.0 g/L) (Kruskal-Wallis, p=0.9). Median Hb drop in the control group was 16.0 g/L versus 17.5 g/L in the protocol groups combined (Mann Whitney-U, p=0.7). Average Hb drop in the control group was 19.2 g/L and in the protocol groups was 22.1 g/L; a 15% greater blood loss with DOACs. The frequency distribution of blood loss was different between the control and protocol groups, but not between the protocol groups. The highest Hb drop in the control group was 3.4 g/L, while in the protocol groups, it was 7.8 g/L. Median Hb on arrival to hospital was higher in the control group (124 g/L) compared with the three protocol groups (87 g/L) (t-test p<0.0001). Transfusion rates of up to 40% were observed within the DOAC groups compared with zero in the control group.Median time to theatre between the three protocol groups was significantly different at 17.5, 53.3 and 22.5 hours, respectively (Kruskal-Wallis, p<0.0001).

CONCLUSION

DOACs caused increased bleeding and delays to theatre in hip fracture patients, however the largest Hb difference was already apparent on arrival. Subsequent blood loss was minimal on average; a few patients bled heavily. Prolonged waiting made no significant difference to blood loss, but caused delay to theatre leading to financial losses from best practice tariff.

Perioperative intravenous lignocaine infusion for postoperative pain control in patients undergoing surgery of the spine: protocol for a systematic review and meta-analysis

INTRODUCTION

Intravenous lignocaine is an amide local anaesthetic known for its analgesic, antihyperalgesic and anti-inflammatory properties. Administration of intravenous lignocaine has been shown to enhance perioperative recovery parameters. This is the protocol for a systematic review which intends to summarise the evidence base for perioperative intravenous lignocaine administration in patients undergoing spinal surgery.

METHODS AND ANALYSIS

Our primary outcomes include: postoperative pain scores at rest and movement at predefined early, intermediate and late time points and adverse events. Other outcomes of interest include perioperative opioid consumption, composite morbidity, surgical complications and hospital length of stay. We will include randomised controlled trials, which compared intravenous lignocaine infusion vs standard treatment for perioperative analgesia. We will search electronic databases from inception to present; MEDLINE, EMBASE and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two team members will independently screen all citations, full-text articles and abstract data. The individual study risk of bias will be appraised using the Cochrane risk of bias tool. We will obtain a risk ratio or mean difference (MD) from the intervention and control group event rates based on the nature of data. We will correct for the variable measurement tools by using the standardised MD (SMD). We will use a random-effects model to synthesise data. We will conduct five subgroup analysis: major versus minor surgery, emergency versus elective surgery, patients with chronic pain conditions versus patients without, duration of lignocaine infusion and adult versus paediatric. Confidence in cumulative evidence for will be classified according to the Grading of Recommendations, Assessment, Development and Evaluation system. We will construct summary of findings tables supported detailed evidence profile tables for predefined outcomes.

ETHICS AND DISSEMINATION

Formal ethical approval is not required as primary data will not be collected. The results will be disseminated through a peer-reviewed publication.

PROSPERO REGISTRATION NUMBER

CRD420201963314.

Comparative efficacy and safety of intra-articular analgesics after knee arthroscopy: a Bayesian network meta-analysis protocol

INTRODUCTION

Most of the patients who received arthroscopic knee surgery will suffer moderate to severe pain, which can delay the rehabilitation process and increase the risk of postoperative complications. Therefore, seeking a safe and effective postoperative analgesia is necessary for promoting the application of arthroscopic surgery. This protocol aims to detail a planned systematic review and meta-analysis on the comparative efficacy and safety of single-dose intra-articular injection of analgesics for pain relief after knee arthroscopy.

METHOD AND ANALYSIS

PubMed, Embase, Web of Science and Cochrane Library will be searched from inception to 1 June 2020 to retrieve randomised controlled trials (RCTs) that compared the commonly used single-dose intra-articular analgesics (ie, morphine; bupivacaine (including levobupivacaine); ropivacaine and magnesium alone or in combination) with placebo or between each other for postoperative pain relief among patients who had received knee arthroscopy. The primary outcome is pain intensity at 2-hour and 24-hour postoperatively; the secondary outcomes include side effects (eg, knee effusion, nausea, vomiting and flushing), the number of patients requiring supplementary analgesia and the time to first analgesic request. The methodological quality of the included RCTs will be assessed based on the Cochrane risk of bias table. The Bayesian network meta-analysis will be conducted using WinBUGS V.1.4.3.

ETHICS AND DISSEMINATION

Since no private or confidential patient data will be contained in the reporting, approval from an ethics committee is not required. Our study raises no ethical issue, and the results will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019130876.

Improve hip fracture outcome in the elderly patient (iHOPE): a study protocol for a pragmatic, multicentre randomised controlled trial to test the efficacy of spinal versus general anaesthesia

INTRODUCTION

Hip fracture surgery is associated with high in-hospital and 30-day mortality rates and serious adverse patient outcomes. Evidence from randomised controlled trials regarding effectiveness of spinal versus general anaesthesia on patient-centred outcomes after hip fracture surgery is sparse.

METHODS AND ANALYSIS

The iHOPE study is a pragmatic national, multicentre, randomised controlled, open-label clinical trial with a two-arm parallel group design. In total, 1032 patients with hip fracture (>65 years) will be randomised in an intended 1:1 allocation ratio to receive spinal anaesthesia (n=516) or general anaesthesia (n=516). Outcome assessment will occur in a blinded manner after hospital discharge and inhospital. The primary endpoint will be assessed by telephone interview and comprises the time to the first occurring event of the binary composite outcome of all-cause mortality or new-onset serious cardiac and pulmonary complications within 30 postoperative days. In-hospital secondary endpoints, assessed via in-person interviews and medical record review, include mortality, perioperative adverse events, delirium, satisfaction, walking independently, length of hospital stay and discharge destination. Telephone interviews will be performed for long-term endpoints (all-cause mortality, independence in walking, chronic pain, ability to return home cognitive function and overall health and disability) at postoperative day 30±3, 180±45 and 365±60. ETHICS AND DISSEMINATION: iHOPE has been approved by the leading Ethics Committee of the Medical Faculty of the RWTH Aachen University on 14 March 2018 (EK 022/18). Approval from all other involved local Ethical Committees was subsequently requested and obtained. Study started in April 2018 with a total recruitment period of 24 months. iHOPE will be disseminated via presentations at national and international scientific meetings or conferences and publication in peer-reviewed international scientific journals.

TRIAL REGISTRATION NUMBER

DRKS00013644; Pre-results.