Anaesthesia & The Hip Fracture Patient


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Anaesthesia & The Hip 
Fracture Patient
Richard Griffiths MD FRCA
Peterborough & Stamford Hospitals
Thursday, 25 July 13

Declarations of Interest

Honorary Secretary of 
the Association of 
Anaesthetists of Great 
Britain & Ireland

Trustee Wothorpe 
Towers Preservation 
Trust
Thursday, 25 July 13

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Time  to  Surgery
Even  in  1996  pa5ents  were  
only  wai5ng  one  day  in  
Sweden
Median  length  of  stay  is  also  
good  at  9  days
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Time  to  Surgery
Probably  reduces  morbidity  and  mortality  if  
opera5on  done  early
The  evidence?
Thursday, 25 July 13

Time  to  Surgery
1.  Shiga  T,  Wajima  Z,  Ohe  Y.  Is  opera5ve  delay  associated  with  increased  
mortality  of  hip  fracture  pa5ents?  Systema5c  review,  meta-­‐analysis  and  
meta-­‐regression.  Canadian  Journal  of  Anaesthesia  2008;  55:  146-­‐54.
2.  Khan  SK,  Kalra  S,  Khanna  A,  Thiruvengada  MM,  Parker  MJ.  Timing  of  surgery  
for  hip  fractures:  A  systema5c  review  of  52  published  studies  involving  291,  
413  pa5ents.  Injury  2009;  40:  692-­‐7
3.    Nicole  Simunovic,  P.  J.  Devereaux,  Sheila  Sprague,  Gordon  H.  Guya],  Emil  
Schemitsch,  Jus5n  Debeer,  Mohit  Bhandari.  Effect  of  early  surgery  a4er  hip  
fracture  on  mortality  and  complica5ons:  systema5c  review  and  meta-­‐
analysis.  Canadian  Medical  Associa.on  Journal,  2010,  182  (15);1602-­‐1616
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Pilot Study

Acute management of fractured femurs

Immediate repair

Ontario and Cleveland Clinic
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More on this later
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Dilemmas

Type of Anaesthesia

Clopidogrel

Blood transfusion trigger

Heart murmur
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Hip Fractures

Started talking about hip 
fracture anaesthesia in 
2001

The Cochrane Review of 
anaesthesia for hip 
fracture

The Cochrane Review of 
nerve block and hip 
fracture
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Hip Fractures
Thursday, 25 July 13

Hip Fractures

Mayday Hospital in 
Croydon

Orthogeriatrics was a 
new specialty

Only database in England 
was in Peterborough

Scotland was ahead of 
the game
Thursday, 25 July 13

Hip Fractures

Mayday Hospital in 
Croydon

Orthogeriatrics was a 
new specialty

Only database in England 
was in Peterborough

Scotland was ahead of 
the game
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Hip Fractures Time Line
Thursday, 25 July 13

Hip Fractures Time Line

1984 Last U.K. study GA v Spinal
Thursday, 25 July 13

Hip Fractures Time Line

1984 Last U.K. study GA v Spinal

1993 Scottish Hip Fracture Audit starts
Thursday, 25 July 13

Hip Fractures Time Line

1984 Last U.K. study GA v Spinal

1993 Scottish Hip Fracture Audit starts

1997 SIGN 15
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Hip Fractures Time Line

1984 Last U.K. study GA v Spinal

1993 Scottish Hip Fracture Audit starts

1997 SIGN 15

1999 BGS/BOA Blue Book appears
Thursday, 25 July 13

Hip Fractures Time Line

1984 Last U.K. study GA v Spinal

1993 Scottish Hip Fracture Audit starts

1997 SIGN 15

1999 BGS/BOA Blue Book appears

2001 Cochrane Review
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Hip Fractures Time Line

1984 Last U.K. study GA v Spinal

1993 Scottish Hip Fracture Audit starts

1997 SIGN 15

1999 BGS/BOA Blue Book appears

2001 Cochrane Review

2001 CEPD article 
Jandziol AK, Griffiths R. The anaesthetic management of patients with 
hip fractures. BJA CEPD Reviews 2001; 1: 52–5
Thursday, 25 July 13

Hip Fractures Time Line
Thursday, 25 July 13

Hip Fractures Time Line

2002 SIGN 56
Thursday, 25 July 13

Hip Fractures Time Line

2002 SIGN 56

2006 BGS/BOA Blue Book version 2 (Age 
Anaesthesia involved)
Thursday, 25 July 13

Hip Fractures Time Line

2002 SIGN 56

2006 BGS/BOA Blue Book version 2 (Age 
Anaesthesia involved)

2007 NHFD 
Thursday, 25 July 13

Hip Fractures Time Line

2002 SIGN 56

2006 BGS/BOA Blue Book version 2 (Age 
Anaesthesia involved)

2007 NHFD 

2007 Hip Fracture Anaesthesia Network
Thursday, 25 July 13

Hip Fractures Time Line

2002 SIGN 56

2006 BGS/BOA Blue Book version 2 (Age 
Anaesthesia involved)

2007 NHFD 

2007 Hip Fracture Anaesthesia Network

2008 Scottish Hip Fracture Audit ends
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Hip Fractures Time Line

2002 SIGN 56

2006 BGS/BOA Blue Book version 2 (Age 
Anaesthesia involved)

2007 NHFD 

2007 Hip Fracture Anaesthesia Network

2008 Scottish Hip Fracture Audit ends

2009 SIGN 111
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Hip Fractures Time Line
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Hip Fractures Time Line

2010 Hip Fracture Anaesthesia Network 
becomes Hip Fracture Perioperative 
network
Thursday, 25 July 13

Hip Fractures Time Line

2010 Hip Fracture Anaesthesia Network 
becomes Hip Fracture Perioperative 
network

2011 NICE 124
Thursday, 25 July 13

Hip Fractures Time Line

2010 Hip Fracture Anaesthesia Network 
becomes Hip Fracture Perioperative 
network

2011 NICE 124

2012 AAGB&I Guidelines First ever 
document specifically for anaesthetists
Thursday, 25 July 13

Hip Fracture 
Perioperative 
Network
www.networks.nhs.uk/nhs-
networks/hip-fracture-
anaesthesia
richardgriffiths1@nhs.net
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Hip Fractures
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Hip Fractures
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Hip Fractures
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Hip Fractures

National Audit

Linked to tariff (England, 
N. Ireland, not Wales)

Lots of data

Anaesthesia?
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NHFD 2001-2012

Mortality (30 day) 

9.3% to 8.4%

return to normal 
residence (30 day) 40%

data on 300,000 patients
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We conclude that there are marginal advantages for 
regional anaesthesia compared to general anaesthesia 
for hip fracture patients in terms of early mortality and 
risk of DVT
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2000
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2000

Studies were old
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2000

Studies were old

Was there DVT prophylaxis in 1980’s?
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2000

Studies were old

Was there DVT prophylaxis in 1980’s?

Confusion greater in GA group, but 
numbers very small
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2000

Studies were old

Was there DVT prophylaxis in 1980’s?

Confusion greater in GA group, but 
numbers very small

N.B. There has never been a study using 
spinal anaesthesia with no sedation
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2000 to 2011
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2000 to 2011

No new RCT’s
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2000 to 2011

No new RCT’s

But do they give the correct answer?
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2000 to 2011

No new RCT’s

But do they give the correct answer?

Observational studies?
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2000 to 2011

No new RCT’s

But do they give the correct answer?

Observational studies?

Audit data?
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2000 to 2011

No new RCT’s

But do they give the correct answer?

Observational studies?

Audit data?

What has appeared since 2000?
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Hip Fracture Anaesthesia

Regional Anaesthesia 49%

General Anaesthesia 51%

nerve block to 19%
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For hip fracture surgery, the choice of 
anaesthesia (general or neuroaxial) is made by 
the anaesthesiologist and is based on the 
patient’s preference, comorbidities, potential 
general postoperative complications and the 
clinical experience
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3 Distinct Groups
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Group 1
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Group 1

Those who are relatively 
fit and have fallen 
outside 
(17%)
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Group 1

Those who are relatively 
fit and have fallen 
outside 
(17%)
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Group 2
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Group 2

Frail community 
dwellers who have fallen 
inside 
(59%)
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Group 2

Frail community 
dwellers who have fallen 
inside 
(59%)
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Group 3
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Group 3

Patients from long term 
care institutions 
(24%)
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Group 3

Patients from long term 
care institutions 
(24%)
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3 Distinct Groups

Often those in the last 2 groups have some 
cognitive impairment and are excluded from any 
randomised controlled studies

However, they can be included in large 
observational studies
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Anesthesiology 2012 117:72-92
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SIGNAL emerging from the “noise”
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SIGNAL emerging from the “noise”
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GA v Spinal
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GA v Spinal

Studies done have been:
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GA v Spinal

Studies done have been:

single centre
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GA v Spinal

Studies done have been:

single centre

OLD
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GA v Spinal

Studies done have been:

single centre

OLD

small
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GA v Spinal

Studies done have been:

single centre

OLD

small

badly designed
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GA v Spinal

Studies done have been:

single centre

OLD

small

badly designed

never been a pure spinal v GA comparison
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GA v Spinal
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GA v Spinal

Primary hip & knee arthroplasty operations
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GA v Spinal

Primary hip & knee arthroplasty operations

400 US hospitals
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GA v Spinal

Primary hip & knee arthroplasty operations

400 US hospitals

528,495 indentified
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GA v Spinal

Primary hip & knee arthroplasty operations

400 US hospitals

528,495 indentified

2006-2010
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GA v Spinal

Primary hip & knee arthroplasty operations

400 US hospitals

528,495 indentified

2006-2010

382,236 had anaesthesia information
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GA v Spinal
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GA v Spinal

382,236
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GA v Spinal

382,236

11.1 % neuraxial anaesthesia
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GA v Spinal

382,236

11.1 % neuraxial anaesthesia

14.2 % GA plus neuraxial
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GA v Spinal

382,236

11.1 % neuraxial anaesthesia

14.2 % GA plus neuraxial

74% GA
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GA v Spinal

382,236

11.1 % neuraxial anaesthesia

14.2 % GA plus neuraxial

74% GA

(no mention of sedation)
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GA v Spinal

All types of anaesthesia

50% of the patients were covered by 
Medicare

Outcomes were 30 day mortality and 
complications
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GA v Spinal

Results

30 day mortality was lower in neuraxial 
group, GA + neuraxial compared with just 
GA

0.10% v 0.10% v 0.18%
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Information on 
59,000 anaesthetics
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Information on 
59,000 anaesthetics
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2001
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Predictions for 
Anaesthesia
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Predictions for 
Anaesthesia

Regional ?
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Predictions for 
Anaesthesia

Regional ?

70%
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Predictions for 
Anaesthesia

Regional ?

70%

Nerve blocks?
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Predictions for 
Anaesthesia

Regional ?

70%

Nerve blocks?

 60%
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Predictions for 
Anaesthesia

Regional ?

70%

Nerve blocks?

 60%

reduced use of benzodiazepines
Thursday, 25 July 13

Predictions for 
Anaesthesia

Regional ?

70%

Nerve blocks?

 60%

reduced use of benzodiazepines

reduce acute delirium
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GA 53%
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GA 53%
Spinal 42%
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GA 53%
Spinal 42%
Nerve Block 
29%
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ASAP

Anaesthesia Technique

Hypotension

Bone cement implantation syndrome

Nottingham Hip Fracture Score
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ASAP

Data collection underway at present

140 hospitals

Hope to get data on over 10,000 patients 
in three months

There have been some teething troubles
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36 % mean drop in blood pressure
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QMC Nottingham
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Clean hit rate from anaesthesia, 1 
in 250,000
but
morbidity and later mortality likely 
to be much higher
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Spinal and GA 
Protocols

We are deluding 
ourselves that we are 
conducting ‘sympathetic 
anaesthesia” to these 
patients

I now have data on over 
400 cases

I will soon have data on 
10,000
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19  studies,  all  RCTs
6,264  pa5ents
3  hip  fracture  studies  
1  elec5ve  orthopaedic
1.  120  pa5ents
2.  84  pa5ents
3.  2,016  (FOCUS)
4.  603  (elec5ve)
637  from  a  PICU  study
838  TRICC  study
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?  Define  high  risk  groups?
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FOCUS
It  is  a  study  in  the  rehabilita5on  period  and  not  
within  the  preopera5ve  or  periopera5ve    period
However,  it  is  a  large  study  which  must  have  been  
very  hard  to  conduct
There  are  some  posi5ve  elements  that  come  form  
it
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Now,  is  that  a  2.5gm.dl  drop  in  haemoglobin  in  both  groups?
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FOCUS
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FOCUS

Does  that  suggest  that  there  may  be  hidden  
blood  loss  in  hip  fracture?
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FOCUS

Does  that  suggest  that  there  may  be  hidden  
blood  loss  in  hip  fracture?

So,  even  if  the  blood  loss  at  surgery  is  only  
200ml,  the  Hb  s5ll  goes  down?
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FOCUS

Does  that  suggest  that  there  may  be  hidden  
blood  loss  in  hip  fracture?

So,  even  if  the  blood  loss  at  surgery  is  only  
200ml,  the  Hb  s5ll  goes  down?

What  a  surprise!!!!!!
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Hidden  Blood  Loss
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Hidden  Blood  Loss
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Hidden  Blood  Loss
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AFTER
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Constant  Vigilance
Measure  frequently
Blood  loss  is  usually  2.5gm/
dl
Many  are  anaemic  before  
they  fracture  their  hip
Thursday, 25 July 13

Constant  Vigilance
Measure  frequently
Blood  loss  is  usually  2.5gm/
dl
Many  are  anaemic  before  
they  fracture  their  hip
Thursday, 25 July 13

Summary

Important area for anaesthesia

Specialist area

Protocols may help

Audit data is important

UK database may yield information
Thursday, 25 July 13


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