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National Hip Fracture Database
Transcript of National Hip Fracture Database
76 yr old Male.
CVA 10 yrs ago
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
Echo bedside: good LVSF no valvulopathy
ECG: sinus nil else
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)
USS guided Fasciailiaca block
Ephidrine 3 x 9mg boluses
Phenylephrine infusion SBP 75-125.
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 - ?
Na 150 K 5.77 BE -13
Time of death 11.25 am.
Post Op Day 4:
Notes requested from medical records
NHFD + Sprint audit
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
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%,
Type of agent
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
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.
Prospective data collection
1st May 13 to 31st July 13
16,904 cases, aged >60
97.6% underwent anaesthesia and an operation
12 hospital submitted data on every patient
95 hopsitals submitted data on 80% of their patients
70 000 per year
£2 billion a year
-10% 1 month
-33% 12 month
Mean age 83
76% are women
To combat age related decline in pulmonary gas transfer
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
Lowest intraoperative SBP < 100 mmHg
Relative Hypotension >20% drop from preoperative baseline
Although no commonly agreed definition:
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
1. Dual antiplatelets ? why
2. Intraoperative hypotension
6. ?? Apiration
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.