Perioperative outcomes in the context of mode of anaesthesia for patients undergoing hip fracture surgery: systematic review and meta-analysis

Background

Previous meta-analyses on the anaesthetic management of patients undergoing surgery for hip fracture have focused on randomized trials. Furthermore, heterogeneity in outcome reporting across the studies has made it difficult to inform best practice guidelines for patient care.

综合护理干预预防老年髋部骨折患者术后谵妄

目的探讨综合护理干预对老年髋部骨折术后谵妄的预防效果。方法将186例髋部骨折手术老年患者分为对照组94例、观察组92例。对照组行常规护理;观察组实施针对性综合护理干预措施,包括心理干预、疼痛管理、氧疗、视听觉及谵妄前兆的观察、睡眠管理,渐进式功能锻炼。结果观察组谵妄发生率及住院时间显著低于/短于对照组,患者满意率显著高于对照组(P0.05,P0.01)。结论对老年髋部骨折手术患者实施针对性综合护理干预能有效降低术后谵妄发生率,缩短住院时间,从而提高患者满意度。     

Emergence and early cognitive function in the elderly after xenon or desflurane anaesthesia: a double-blinded randomized controlled trial

Background: Postoperative cognitive impairment after general anaesthesia,especially in the elderly, is a well-recognized problem. Xenon,known to be an N-methyl-D-aspartate antagonist, may be advantageous.In this study, the early cognitive function in the elderly aftergeneral anaesthesia with xenon was compared with that afterdesflurane. Methods: After approval by the local ethical committee and after obtainingwritten informed consent, patients were enrolled in this randomized,double-blinded, controlled study. Thirty-eight patients (65–75yr old, ASA status I–III) undergoing an elective surgerywith a planned duration of 60–180 min were allocated toeither the xenon (n = 18) or the desflurane (n = 20) anaesthesiagroup. The primary outcome was the cognitive Test for AttentionalPerformance (TAP) with its subtests Alertness, Divided Attention,and Working Memory. After baseline assessment 12–24 hbefore operation, patients were followed-up 6–12 and 66–72h after operation. Secondary outcomes were emergence times fromanaesthesia and the modified Aldrete score. Results: No difference was found between the groups in the TAP at 6–12and 66–72 h after operation. In the xenon group, emergencetime was significantly faster for the following parameters:time to open eyes (P = 0.001), to react on demand (P = 0.001),to extubation (P = 0.001), and for time and spatial orientation(P = 0.007). The modified Aldrete score was significantly higherafter 30, 45 and 60 min in the xenon group. Conclusions: There was no difference in the postoperative cognitive testingat 6–12 and 66–72 h. Xenon was associated in theelderly with a faster emergence from general anaesthesia thandesflurane.     

应用小剂量右美托咪定预防老年髋骨折患者术后谵妄的前瞻性随机对照研究

目的 探讨应用小剂量右美托咪定预防老年髋骨折患者术后谵妄的有效性与安全性.方法 采用前瞻性随机对照研究方法.纳入2019年7月至2020年9月北京大学第四临床医学院北京积水潭医院重症医学科(ICU)收治的老年髋骨折术后患者127例,中位年龄86(83,89)岁.患者接受手术方式包括全髋关节置换术19例(15.0％),半...     

The effect of a multidisciplinary care bundle on the incidence of delirium after hip fracture surgery: a quality improvement study

Delirium is a common complication following hip fracture surgery. We introduced a peri-operative care bundle that standardised management in the emergency department, operating theatre and ward. This incorporated: use of fascia iliaca blocks; rationalisation of analgesia; avoidance of drugs known to trigger delirium; a regular education program for staff; and continuous auditing of compliance. The study was conducted between June 2017 and December 2018. We recruited 150 patients before (control group) and 150 patients after (care bundle group) the introduction of the care bundle. In patients having surgery for a hip fracture, there was a lower incidence of delirium on the third postoperative day in the care bundle group compared with the control group (33 patients (22%) vs. 49 patients (33%)), respectively; p = 0.04). Patients in the care bundle group had an adjusted OR of 2.2 (95%CI 1.1–4.4) (p = 0.03) for the avoidance of delirium on the third postoperative day. There was no difference between groups for the secondary outcome measures (measured at 30 days postoperatively) including: all-cause mortality; composite morbidity; institutionalisation; and walking status. During the study period, compliance with elements of the care bundle improved in the emergency department (49 patients (33%) compared with 85 patients (59%); p < 0.001) and anaesthetic department (40 patients (27%) compared with 104 patients (69%); p < 0.001), while orthogeriatrics maintained a high level of compliance (140 patients (93%) compared with 143 patients (95%); p = 0.45). There was a clinically and statistically significant reduction in the incidence of delirium following hip fracture surgery in patients treated with a multidisciplinary care bundle.     

Steroids to reduce the impact on delirium (STRIDE): a double-blind,randomised, placebo-controlled feasibility trial of pre-operative dexamethasone in people with hip fracture

Neuro-inflammation may be important in the pathogenesis of postoperative delirium following hip fracture surgery. Studies have suggested a potential role for steroids in reducing postoperative delirium; however, the potential efficacy and safety of pre-operative high-dose dexamethasone in this specific population is largely unknown. Conducting such a study could be challenging, considering the multidisciplinary team involvement and the emergency nature of the surgery. The aim of this study was to assess feasibility and effectiveness of dexamethasone given as early as possible following hospital admission for hip fracture, to inform whether a full-scale trial is warranted. This single-centre, randomised, double-blind, placebo-controlled study randomly allocated 79 participants undergoing hip fracture surgery to dexamethasone 20 mg or placebo pre-operatively. Eligibility and recruitment rates, timing of the intervention and adverse events were recorded. Incidence and severity of postoperative delirium were assessed using the 4AT delirium screening tool and the Memorial Delirium Assessment Scale. Postoperative pain, length of stay and mortality were also assessed. The eligibility rate for inclusion was 178/527 (34%), and 57/178 (32%) of eligible patients presented to hospital when no researcher was available (e.g. after-hours, weekends, public holidays). Recruitment was limited mainly by ethical limitations (not including patients with impaired cognition) and lack of weekend staffing. Median (IQR [range]) time from emergency department admission to drug administration was 13.3 (5.9–17.6 [1.8–139.6]) hours. There was a significant difference in delirium severity scores, favouring the dexamethasone group: median (IQR [range]) 5 (3–6 [3–7]) vs. 9 (6–13 [5–14]) in the placebo group, with the probability of superiority effect size being 0.89, p = 0.010. Delirium incidence did not differ between groups: 6/40 (15%) in the dexamethasone group vs. 9/39 (23%) in the placebo group, relative risk (95%CI) 0.65 (0.22–1.65), p = 0.360). A larger randomised controlled trial is feasible and ideally this should include people with existing cognitive impairment, seven days-a-week cover and a multicentre design.     

Spinal or general anaesthesia for surgical repair of hip fracture and subsequent risk of mortality and morbidity: a database analysis using propensity score-matching

Around 76,000 people fracture their hip annually in the UK at a considerable personal, social and financial cost. Despite longstanding debate, the optimal mode of anaesthesia (general or spinal) remains unclear. Our aim was to assess whether there is a significant difference in mortality and morbidity between patients undergoing spinal anaesthesia compared with general anaesthesia during hip fracture surgery. A secondary analysis examined whether a difference exists in mortality for patients with pre-existing cardiovascular disease or chronic obstructive pulmonary disease. This was a clinical database analysis of patients treated for hip fracture in Nottingham, UK between 2004 and 2015. Propensity score-matching was used to generate matched pairs of patients, one of whom underwent each mode of anaesthesia. Data were analysed using conditional logistic regression, with 7164 patients successfully matched. There was no difference in 30- or 90-day mortality in patients who had spinal rather than general anaesthesia (OR [95%CI] 0.97 [0.8–1.15]; p = 0.764 and 0.93 [0.82–1.05]; p = 0.247 respectively). Patients who had a spinal anaesthetic had a lower-risk of blood transfusion (OR [95%CI] 0.84 [0.75–0.94]; p = 0.003) and urinary tract infection (OR [95%CI] 0.72 [0.61–0.84]; p < 0.001), but were more likely to develop a chest infection (OR [95%CI] 1.23 [1.07–1.42]; p = 0.004), deep vein thrombosis (OR [95%CI] 2.18 [1.07–4.45]; p = 0.032) or pulmonary embolism (OR [95%CI] 2.23 [1.16–4.29]; p = 0.016). The mode of anaesthesia for hip fracture surgery resulted in no significant difference in mortality, but there was a significant difference in several measures of postoperative morbidity.     

Sufentanil anaesthesia for major surgery: the multicentre Canadian clinical trial

One hundred and fortyone investigators from 45 institutions across Canada participated in the phase 4 clinical trial of sufentanil citrate involving 616 patients. All patients were ASA physical status class I, II, or III, undergoing elective, noncardiac, major surgical procedures. The average duration of surgery was 1.98 hr and mean dosage of sufentanil was 1.24 μg·kg^{? 1}· hr^{? 1}. Supplemental inhalational anaesthesia was administered to 266 patients (43 per cent). Eightysix patients required naloxone in the immediate postoperative period. Eighty per cent of these patients had received in excess of 1.0 μg· kg^{? 1}·hr^{? 1} of sufentanil. One hundred and twentynine adverse reactions were reported as disturbing and possibly drugrelated. Profound bradycardia or sinus arrest was reported in four cases and disturbing hypotension in 37. None of these events required termination of the procedure. The induction, maintenance and recovery phases were rated as good or satisfactory by the participating investigators in 94, 92 and 93 per cent of cases respectively.     

Spinal anaesthesia versus general anaesthesia (SAGA) on recovery after hip and knee arthroplasty: A study protocol for three randomized,single-blinded,multi-centre,clinical trials

Mobilisation difficulties, due to muscle weakness, and urinary retention are common reasons for prolonged admission following hip and knee arthroplasty procedures. Whether spinal anaesthesia is detrimental to early mobilisation is controversial. Previous studies have reported differences in post-operative recovery between spinal anaesthesia and general anaesthesia; however, up-to-date comparisons in fast-track setups are needed. Our randomized, single-blinded, multi-centre, clinical trials aim to compare the post-operative recovery after total hip (THA), total knee (TKA), and unicompartmental knee arthroplasties (UKA) respectively when using either spinal anaesthesia (SA) or general anaesthesia (GA) in a fast-track setup. Included patients (74 THA, 74 TKA, and 74 UKA patients) are randomized (1:1) to receive either SA (2 mL 0.5% Bupivacaine) or GA (Induction: Propofol 1.0–2.0 mg/kg iv with Remifentanil 3–5 mcg/kg iv. Infusion: Propofol 3–5 mg/kg/h and Remifentanil 0.5 mcg/kg/min iv). Patients undergo standard primary unilateral hip and knee arthroplasty procedures in an optimized fast-track setup with intraoperative local infiltrative analgesia in TKA and UKA, post-operative multimodal opioid sparing analgesia, immediate mobilisation with full weightbearing, no drains and in-hospital only thromboprophylaxis. Data will be collected on the day of surgery and until patients are discharged. The primary outcome is the ability to be safely mobilised during a 5-m walking test within 6 h of surgery. Secondary outcomes include fulfilment of discharge criteria, post-operative pain, dizziness, and nausea as well as patient reported recovery and opioid related side effects. Data will also be gathered on all hospital contacts within 30-days of surgery. This study will offer insights into advantages and disadvantages of anaesthetic methods used in fast-track arthroplasty surgery.     

Changes in body heat during hip fracture surgery: a comparison of spinal analgesia and general anaesthesia

Postoperative hypothermia initiates an increased oxygen demand in the postoperative period and may endanger patients with restricted cardiopulmonary reserves. In order to compare net heat losses and gains, we studied 28 women undergoing hip fracture surgery, using either general anaesthesia or spinal analgesia. The superficial and central temperatures were followed in the per- and postoperative period. Total body heat was calculated from temperature measurements. Temperature changes were unrelated to the type of anaesthesia. Large net heat losses occurred on transfer to the recovery room.     

Impact of length of red blood cells transfusion on postoperative delirium in elderly patients undergoing hip fracture surgery: A cohort study

PurposeThe purpose of the present study was to test whether older red blood cells (RBCs) transfusion results in an increased risk of postoperative delirium (POD) and various in-hospital postoperative complications in elderly patients undergoing hip fracture surgery.Materials and methodsPatients (≥65 years) who underwent hip fracture surgery were enrolled, 179 patients were divided into two groups according to the storage time of the RBCs. The shorter storage time of RBCs transfusion group comprised patients who received RBCs ≤14 days old and the longer storage time of RBCs transfusion group comprised patients who received RBCs >14 days old. The blood samples were collected before anaesthesia induction, 4 and 24 h after RBCs transfusion for the determination of proinflammatory mediators, malondialdehyde, and superoxide dismutase activity.ResultsThere was no difference in the baseline characteristics, the incidence of POD, and the in-hospital postoperative complications between the shorter storage time of RBCs transfusion group and the longer storage time of RBCs transfusion groups (P > 0.05). Compared with the shorter storage time of RBCs transfusion group, the longer storage time of RBCs transfusion caused significantly longer duration of POD (P < 0.05). There were significantly increased plasma levels of IL-8 and malondialdehyde at 24 h and IL-1β at 4 h after RBCs transfusion in the POD group compared with the non-POD group (P < 0.05).ConclusionTransfusion of the longer storage RBCs is not associated with a higher incidence of POD or in-hospital postoperative complications, but with longer duration of POD in elderly patients undergoing hip fracture surgery.     

Comparison of xenon with propofol for supplementary general anaesthesia for knee replacement: a randomized study

Background. Xenon anaesthesia is associated with rapid recoveryand may also offer protection against neuronal damage. The aimof this study was to compare xenon with propofol for supplementarygeneral anaesthesia in patients undergoing knee replacementin spinal anaesthesia. Methods. In total, 39 patients aged 60 or over were randomizedto xenon 50–70% or propofol 3–5 mg kg^–1 h^–1.Vital signs and emergence time were recorded and cognitive functionwas assessed before operation, at discharge between the thirdand the fifth day and at 3 months using four neuropsychologicaltests. Results. Propofol supplementation was necessary in six xenonpatients (29%) because of detectable movement of the upper body.Emergence time was significantly shorter with xenon (260 s forxenon and 590 s for propofol, P=0.001). There was no significantdifference between the groups in blood pressure, heart rate,ventilatory frequency or end-tidal carbon dioxide concentration.No difference could be detected in cognitive function, whichmay be attributed to insufficient sample-size rather than theabsence of a true difference. Conclusions. Xenon was well tolerated for supplementary generalanaesthesia in elderly spontaneously breathing patients butsupplementation may be necessary. Compared with propofol, emergencewas faster with xenon. A larger sample-size is needed if cognitivefunction is to be addressed.     

Use of conventional ECG electrodes for depth of anaesthesia monitoring using the cerebral state index: a clinical study in day surgery

Background: The cost–benefit relationship for depth of anaesthesiamonitors is complicated by the high cost of specially designedEEG electrodes. The cerebral state index (CSI) monitor willaccept regular ECG electrodes with snap connectors. The purposeof this study was to determine if generic ECG electrodes couldreplace the more expensive proprietary EEG electrodes for theCSI monitor. Methods: Two identical cerebral state monitors were used simultaneouslyduring sevoflurane anaesthesia for knee arthroscopy in 14 ASAI–II patients. One monitor used proprietary (Danmeter)EEG electrodes and the other used ECG electrodes (3M^TM Red Dot^TMDiagnostic ECG Electrodes). Paired CSI values were recordedevery other minute. Anaesthetic depth was titrated clinically.Sedation depth was scored according to the Observer's Assessmentof Alertness/Sedation (OAAS) scale. Results: The agreement between the two measures was found to be high,mean difference – 0.23, and the overall repeatabilitymean bias was 6.6 and 153/163 pairs (94%) were located withinthe 95% limits of agreement. No major difference was noted inimpedance, noise, or artifacts. A large overlap in CSI was notedfor each level of the OAAS scale; patients with CSI values aslow as 40–50 responded whereas patients not respondingto surgical stimulation had CSI values as high as 75. The directcost of disposables decreased from 4 to 0.50 per patient byusing ordinary ECG electrodes. Conclusions: Switching from proprietary EEG electrodes to ordinary genericECG electrodes maintains the same accuracy at about a 10th ofthe cost when measuring CSI during day surgery with sevofluraneanaesthesia.     

Preoperative saline versus gelatin for hip fracture patients; a randomized trial of 396 patients

Background. The aim of this study was to determine if the preoperativeadministration of 500 ml of a gelatin colloid solution intravenouslybefore hip fracture surgery improves outcome, compared witha conventional i.v. fluid regime with a crystalloid solution. Methods. Randomized, double blind, controlled trial of i.v.saline vs colloid for 396 patients having hip fracture surgeryadmitted to a district general hospital. Patients were followedup for 1 yr. Results. There was no statistically significant difference betweengroups for mortality (30-day mortality 9/198 for saline groupvs 19/198 for colloid group, 95% confidence intervals 0.21–1.02),length of hospital stay (22.5 days vs 17.3 days, 95% CI –10.78to 0.38), or occurrence of postoperative complications. Conclusions. The inclusion of 500 ml of colloid solution tothe i.v. fluid regime before hip fracture surgery does not improveoutcome. Br J Anaesth 2004; 92: 67–70     

Association of electroencephalogram trajectories during emergence from anaesthesia with delirium in the postanaesthesia care unit: an early sign of postoperative complications

Background

Postoperative delirium is associated with an increased risk of morbidity and mortality, especially in the elderly. Delirium in the postanaesthesia care unit (PACU) could predict adverse clinical outcomes.

Development of a Core Outcome Set for studies evaluating the effects of anaesthesia on perioperative morbidity and mortality following hip fracture surgery

Background

Perioperative studies of patients following hip fracture have large heterogeneity within their reported outcomes. This study aimed to develop a core outcome set for use in perioperative studies comparing the types of anaesthesia for hip fracture surgery.

Impact of intraoperative blood pressure,blood pressure fluctuation,and pulse pressure on postoperative delirium in elderly patients with hip fracture: A prospective cohort study

AimPostoperative delirium (PD) is a frequent complication of hip fracture surgery, but its pathophysiology remains poorly understood. We investigated the impact of a single episode of intraoperative hyper/hypotension, blood pressure (BP) fluctuation (ΔMAP), and pulse pressure (PP) on hyper/hypoactive PD in elderly patients undergoing surgery for hip fracture. We also assessed the effect of PD on clinical outcomes.MethodsThis was a prospective 1-year follow-up study of patients over 60 years of age with a primary diagnosis of acute low-energy hip fracture. Perioperative delirium was assessed using the Confusion Assessment Method (CAM); the development of PD and the type, hyperactive or hypoactive PD, were recorded. Cognitive assessment was evaluated using the Short Portable Mental Status Questionnaire (SPMSQ). The lowest and highest BP values were extracted from the patients’ anaesthesia charts. Postoperative complications, reinterventions and 1-month mortality were recorded.ResultsPD occurred in 148 (53%) patients during the first postoperative week, with 75% of the cases diagnosed as hypoactive PD. Patients developing PD of any type were older, had a lower body mass index, higher SPMSQ and Charlson scores, more severe systemic diseases, a lower lowest intraoperative BP, a higher ΔMAP, a lower PP, and a higher postoperative pain score. They also took more drugs and received more blood transfusion intraoperatively. Multivariate logistic regression analyses showed that a higher MAP min had a protective effect on the occurrence of any type of PD, as well as hypoactive and hyperactive. PD had negative effect on outcomes.ConclusionOur results provide evidence of an association between maximal hypotension, the lowest intraoperative mean blood pressure (MAP), ΔMAP, PP, and PD. A progressive decrease in MAP during surgery was associated with the increased odds of developing either type of PD.     

Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised,observer-masked,controlled trial

The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that aims to provide hip analgesia with preservation of motor function, although evidence is currently lacking. In this single-centre, observer-masked, randomised controlled trial, patients undergoing total hip arthroplasty received pericapsular nerve group block or no block (control group). Primary outcome measure was maximum pain scores (0–10 numeric rating scale) measured in the first 48 h after surgery. Secondary outcomes included postoperative opioid consumption; patient mobilisation assessments; and length of hospital stay. Sixty patients were randomly allocated equally between groups. The maximum pain score of patients receiving the pericapsular nerve group block was significantly lower than in the control group at all time-points, with a median (IQR [range]) of 2.5 (2.0–3.7 [0–7]) vs. 5.5 (5.0–7.0 [2–8]) at 12 h; 3 (2.0–4.0 [0–7]) vs. 6 (5.0–6.0 [2–8]) at 24 h; and 2.0 (2.0–4.0 [0–5]) vs. 3.0 (2.0–4.7 [0–6]) at 48 h; all p < 0.001. Moreover, the pericapsular nerve group showed a significant reduction in opioid consumption, better range of hip motion and shorter time to ambulation. Although no significant difference in hospital length of stay was detected, our results suggest improved postoperative functional recovery following total hip arthroplasty in patients who received pericapsular nerve group block.     

大头金对金全髋关节置换治疗老年人股骨颈骨折近期疗效

目的 探讨大头金对金全髋关节置换术治疗老年人股骨颈骨折的近期疗效.方法 55例老年股骨颈骨折患者(55髋)中,26髋采用大头金对金全髋关节置换(观察组),29髋采用常规小头金属对聚乙烯全髋关节置换(对照组),比较两组的临床疗效,对并发症进行分析.结果 55例门诊随访12~23(18.3±5.4)个月.术后对照组发生脱位1例2次;观察组无脱位发生.观察组术后6、12周的髋关节活动范围和术后12个月的Harris评分优秀率均优于对照组,差异有统计学意义(P<0.05).结论 大头金对金全髋关节置换术治疗老年股骨颈骨折,具有术后脱位率低、关节活动范围大等优点,近期临床疗效满意.