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National Hip Fracture Database

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by

Tim Knowles

on 3 November 2014

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Transcript of National Hip Fracture Database

Recurrent Faller: Left NOF
76 yr old Male.
Sheltered accommodation
“severe” COPD
CVA 10 yrs ago
HTN
Prev ETOH excess
“Cognitive impairment” admission AMTS 10/10
Weight loss over last 1 yr
The National Hip Fracture Database Anaesthetic Sprint Audit of Practice 2014
Hb 10.4
Plts 234
PT 11
Na+ 141
K+ 4
Creat 76
Echo bedside: good LVSF no valvulopathy
ECG: sinus nil else

Investigations:
Medications

Aspirin
Clopidogrel
Atorvastatin
Aminophylline
Thiamine
Citalopram
Adcal D3
Codeine / Paracetamol
Fall (details not clear) 20/10/14 A&E 3 am
DHS 20/10/14 11:30 – 13:30
Periop – 1 pool platelets (Haematology advice)
GA (Induction: Midazolam 1, Ketamine 30 + 10, Propofol 75, Sevo maintenance)
LMA (AMBU 5)
Rocuronium 10
USS guided Fasciailiaca block
Ephidrine 3 x 9mg boluses
Phenylephrine infusion SBP 75-125.
Timeline:
3 hours post op:
EBL 300-400 mls
Recovery Haemocue 6.3
Poor urine output (convene)
Catheterised in recovery.
2 unit transfusion

Found unreponsive by Ortho F1
Cardiac arrest call
4 cycles PEA
Intubated - ?
Gastric contents
aspirated
No ROSC
VBG: Hb
9.0
Na 150 K 5.77 BE -13
Time of death 11.25 am.
Coroner Informed

Post Op Day 4:
Learning Points:
Notes requested from medical records
AAGBI
NHFD + Sprint audit
Literature review

Standard 1: Patients should be anaesthetised by consultant or specialist with similar clinical experience
Considerable national variation in recording the the seniority of surgeons and anaesthetists
Not recorded in 24%
Where both recorded only 0.4% were unsupervised trainees.
? recording bias

Standard 2: Spinal/epidural anaesthesia should be considered for all patients
White SM, Moppett IK, Griffiths R.
Outcome by mode of anaesthesia for hip fracture surgery. An observational audit of 65 535 patients in a national dataset.
Anaesthesia. 2014 Mar;69(3):224–30.


Standard 3: Spinal anaesthetics should be administered using hyperbaric bupivicaine, less than 10mg with the patient positioned laterally, bad hip down.

Standard 4: Coadministration of intrathecal opioids should be restricted to fentanyl

68.2% successfully administered spinals in which opioid coadministration was recorded

Fentanyl 31.9%
Diamorphine 49.7%
Morphine 3.9%

Standard 5: If sedation is required it should be midazolam or propofol n=5638

Sedation was co-administered to 74% having spinal anaesthesia

Number of agents
one = 74%,
Two =40.7%
Three 5.4%

Type of agent
benzo 33%,
propofol in 29%
ketamine in 22%.

Standard 6: Supplemental oxygen should always be provided

Standard 7: Inhalation agents should be considered for the induction of general anaesthesia

54% of patients received general anaesthesia
AAGBI Perioperative Care of the Elderly 2014
Lerou nomogram

Standard 8: Spontaneous ventilation should be used in preference to mechanical ventilation

Standard 9: Consider intraoperative nerve blocks for all patients undergoing surgery

Standard 10: Neuroaxial and general approaches should not be combined


Standard 11: Hypotension should be avoided

Conclusions and Questions:

Nottingham Hip Score
n = 7290
NHFD is the largest database of proximal femoral fractures
Collaboration between the NHS Hip Perioperative Network (HipPeN) and the NHFD
Additional perioperative data ( e.g. type of anaesthesia, hypotension and bone cement implantation syndrome
RCTs very challenging.
Evidence suggests: Large scale short time "Sprint Audits" may be a powerful tool.
Standards based on the AAGBI Management of proximal femoral fractures 2011.

Background:
Prospective data collection
1st May 13 to 31st July 13
16,904 cases, aged >60
97.6% underwent anaesthesia and an operation
182 hospitals
12 hospital submitted data on every patient
95 hopsitals submitted data on 80% of their patients

Methods:
70 000 per year
£2 billion a year
High mortality
-10% 1 month
-33% 12 month
Mean age 83
76% are women

NICE 2012

To combat age related decline in pulmonary gas transfer
Weak evidence
Administered to71% of patients having spinal anaesthesia.
44% of patients breathed spontaneously under GA
Evidence for IPPV vs SV specific to hip fracture is very limited

Reduce acute and perioperative pain and reduce opiod requirements.
Nerve blocks were administered to 56% of patients
56% were fascia iliaca blocks (commonest single NB)
USS guided in 26.4% of cases
15% were established prior to anaesthesia

Only reported in 3.4% of cases
? related to conversion to GA after failure of regional block
Absolute Hypotension:
Lowest intraoperative SBP < 100 mmHg
Relative Hypotension >20% drop from preoperative baseline

Although no commonly agreed definition:

Poor compliance:

90% of patients had relative hypotension
77% absolute hypotension.

Mean fall in BP for GA 38% and 34% for SA
Moppett IK, Parker M, Griffiths R, Bowers T, White SM, Moran CG.
Nottingham Hip Fracture Score: longitudinal and multi-centre assessment
. Br. J. Anaesth. 2012 Jun 22;aes187.

Total score = 5
30 day predicted mortality = 6.9 %
Dr Tim Knowles CT2
Case Specific:

1. Dual antiplatelets ? why
2. Intraoperative hypotension
3. Catheter
4. Haemocue
5. HDU
6. ?? Apiration

General Points:

Sprint audit methodology is a promising tool for improving anaesthetic technique for NOF patients
The evidence base for the 2011 AAGBI guideline is relatively weak.
The sprint audit provides an overview of current practice.
Further expansion of the NHFB data fields may provide valuable mortality insights e.g to include the Nottingham Hip Score.

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