Richard Griffiths md frca peterborough & Stamford Hospitals nhs trust


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ASAP Pilot Study 

Findings


Richard Griffiths MD FRCA

Peterborough & Stamford Hospitals NHS Trust

Wednesday, 13 March 13


Declarations of Interest

Honorary Secretary of the Association of 



Anaesthetists of Great Britain & Ireland

Any speaker fees earned have been 



donated to Lifebox

Wednesday, 13 March 13



ASAP Results

I can only present the results from 



Peterborough to start with

Background information



nerve blocks

results


ASAP study

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Hip Fractures

National Audit



Linked to tariff (England, 

N. Ireland, not Wales)

Lots of data



Anaesthesia?

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Hip Fractures

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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

Wednesday, 13 March 13


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

Wednesday, 13 March 13



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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Editorial  Anaesthesia  November  

2008

“Gambling  with  ethics?  A  sta3s3cal  

note  on  the  Poisson  distribu3on”  

JJ  Pandit

The  inescapable  conclusion  is  

that,  for  perhaps  the  majority  of  

anaesthe>c  ques>ons  of  import,  

the  only  way  to  make  useful  

progress  is  through  

collabora>ve,  mul>-­‐centre  

studies

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Hip Fracture Anaesthesia

Regional Anaesthesia 49%



General Anaesthesia 51%

nerve block to 19%



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Wednesday, 13 March 13

Anesthesiology 2012 117:72-92

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SIGNAL emerging from the “noise”

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Information on 

59,000 anaesthetics

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2001

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Predictions for 

Anaesthesia

Regional must be in the order of 70%



Nerve blocks in over 60%

reduced use of benzodiazepines



reduced use of opioids?

reduce acute delirium



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Wednesday, 13 March 13

GA 53%

Spinal 42%

Nerve Block 

29%

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This is 

worrying, may 

be surgical 

reasons for this

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Electronic Pilot

10 trusts in England & Wales



three week period data put into NHFD

data input by RG (very easy)



Captured 30/32 patients

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Peterborough Results

20 GA (two had a GA 



following a failed spinal)

14 Spinal 



62 % GA


38 % spinal

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Peterborough Results

5 spinals no sedation



Rest a mixture of 

propofol, midazolam, 

ketamine, opioids

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Peterborough Results

Blocks



15/32 received some 

kind of nerve block

SIGN 111, NICE 124 or 



the AAGB&I guidelines

Ignored



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36 % mean drop in blood pressure

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2nd in Poster Competition at WSM London 2013

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Blood Pressure

GA 40% mean drop



Spinal 28% mean drop

but


Low dose spinal/fentanyl





13% drop

General anaesthesia has the 

advantages of having a lower incidence 

of hypotension and a tendency towards 

fewer cerebrovascular accidents 

compared to neuroaxial anaesthesia

.

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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 

100



I will soon have data on 



10,000

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Protocol Driven

These are only suggestions



Audit will continue for evermore

Outcome of ASAP will be interesting



May lead to focused studies

Peterborough Protocol is being introduced



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Hip Fracture 

Perioperative 

Network

www.networks.nhs.uk/nhs-



networks/hip-fracture-

anaesthesia

richardgriffiths1@nhs.net

Wednesday, 13 March 13



Wednesday, 13 March 13

Hip Fracture 

Anaesthesia

We will soon know what we actually do



Team work

Protocol driven anaesthesia may hold the 



key

Research can only follow the large 



observational study

Wednesday, 13 March 13



richardgriffiths1@ nhs.net

Wednesday, 13 March 13





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