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Best Evidence in Hip Fracture Anaesthesia: Enhancing Patient Outcomes

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36 diapositives · 542 Views · Nov 07, 2019

Discover the latest evidence on hip fracture anaesthesia interventions, outcomes, pain management, and blood management strategies to improve patient care and surgical outcomes. Stay informed on best practices and the impact of different approaches to hip fracture surgery.

#best evidence in hip fracture anaesthesia: enhancing patient outcomes #best evidence in hip fracture anaesthesia: enhancing patient outcomes ppt #powerpoint #presentation
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Best Evidence in Hip Fracture Anaesthesia: Enhancing Patient Outcomes
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  1. Best evidence in hip fracture anaesthesia Iain Moppett @IainMoppett

  2. Declarations Hip fracture Peer reviews National Hip Fracture Database Guidelines NICE Quality Standards Committee AAGBI Guideline working groups: Fragility Fracture Network Research AAGBI, BJA, Sir Jules Thorn Trust, NIHR

  3. Declarations These are my opinions – based on my interpretation of the evidence • You are welcome to disagree • I am almost certainly wrong

  4. Best Evidence in Hip Fracture What do we know? What would we like to know? What matters?

  5. What do we know? Associations with worse outcomes • Not operating • Waiting • Anaemia • Hypotension • Pain • Poor nutrition

  6. What do we know? Interventions associated with better outcomes …

  7. What do we know? Interventions associated with better outcomes Geriatricians Possibly feeding assistance

  8. GA Spinal

  9. No compelling evidence (yet) for mode of anaesthesia

  10. Not operating 50% 30-day mortality 85% one-year mortality Painful… blocks might help but why not operate? Rashidifard et al. Geriatr Orth Surg Rehab 2019 Johansen et al. Anaesthesia 2017

  11. Risk aversion Johansen et al. Anaesthesia 2017

  12. Risk aversion Johansen et al. Anaesthesia 2017

  13. Hip fracture surgery should (almost) always be offered

  14. When to operate? Association vs causation? HipAttack 6 hours Finished recruiting Humanitarian imperatives

  15. Pain management Do blocks work? Probably better temporary analgesia No convincing benefit on other outcomes Small reduction in LOS? Hamilton et al. Anesthesiology 2019

  16. Pain management Which one? Suprainguinal Fascia Iliaca? Beware the seduction of ultrasound

  17. The point of a regional block is to benefit the patient not the anaesthetist

  18. Hip fracture patient blood management Transfusion thresholds No difference in mortality with restrictive Higher CVS rates Pick one and use it Trials practice ≠ real world

  19. Hip fracture patient blood management Tranexamic acid • No evidence of harm • Neurotoxic (spinals) • Impact on transfusion rates

  20. Hip fracture patient blood management Intravenous iron • Functional +/- absolute iron deficiency • Stimulates erythropoiesis • ?Benefit later

  21. Intravenous iron Moppett et al. Age Ageing 2019

  22. DOACs 5-6% hip fracture patients on DOACs • No RCTs • Few case series Pragmatic approach Have a plan Balance of benefit vs risk of delay Don’t forget to restart

  23. Dabigatran Apixaban / Rivaroxaban / Edoxaban General principles List for 24 hours after last dose taken unless: List for afternoon theatre slot day after admission Record drug / dose / time last taken Coagulation tests not required on admission except for patients on warfarin Thrombin time 8AM day of planned surgery • eGFR < 30ml/min: • d/w haematology about anti-Xa assay • Ensure anaesthetist aware of outcomes of discussion and results Normal TT Prolonged TT Check eGFR General anaesthesia unless strong indication for spinal Proceed with surgery in afternoon d/w Haematology Consultant about Praxbind Specific additional bleeding risks Praxbind given in anaesthetic room by anaesthetist Consider TXA intraoperatively • Discuss with HAEMATOLOGY if: • eGFR < 30 ml/min • TT prolonged on morning of surgery (dabigatran) • Patient specific concerns • Intraoperative bleeding problems Modified from Welsh FFN

  24. Hypotension BP and death Spinal dose and BP White et al. Anaesthesia 2016

  25. Hypotension Association vs causation • No good evidence of benefits of intervention • Prevention • Minimally invasive anaesthesia

  26. Prevention probably better than cure

  27. Outcomes that matter Functional Delirium Early mobility

  28. Delirium Ward environment Attention to detail Silver bullets still wanted • Methylprednisolone • Lidocaine • Dexmedetomidine

  29. Early mobility Impacted by perioperative care • Transfusions • Hypotension • Pain • Confusion • Fatigue • Nausea

  30. Good outcomes aren’t measured at the recovery room door

  31. Hip fracture anaesthesia Evidence for interventions is pretty weak The system matters Focus on outcomes important to the person

  32. Best evidence in hip fracture anaesthesia Iain Moppett @IainMoppett