Cost estimates of spinal versus general anaesthesia for fractured neck of femur surgery

It remains uncertain whether spinal anaesthesia is preferable to general anaesthesia for surgical repair of hip fracture, but one determining factor is the comparative cost. A detailed cost analysis relating to 20 consultants’ intended anaesthetic practice (which provided information of consumables used) and data from the Brighton Hip Fracture Database was performed to quantify any difference in the costs of administering spinal versus general anaesthesia for patients with hip fracture. Although spinal anaesthesia took significantly longer to administer (mean (SD) time 31 (15) min vs 27 (16) min; p < 0.0001), the mean (SD) cost of spinal anaesthesia (£193.81 (37.49)) was significantly less than the cost of general anaesthesia (£270.58 (44.68); p < 0.0001). The mean percentage cost of anaesthesia was 3.8% of hospital income per hip fracture, and personnel contributed approximately 46% of this cost. While such considerations indicate that spinal anaesthesia is financially preferable, it is unknown whether differential clinical outcomes between regional and general anaesthesia may offset this apparent monetary advantage.     

Hypoxaemia in elderly patients suffering from fractured neck of femur.

The purpose of this study was to assess the degree and frequency of hypoxaemia in elderly patients with fractured neck of femur and to note the effect of manipulation and internal fixation on these measurements. Twenty-seven patients aged between 44 and 93 were studied for 5 days after the fracture and for 5 days after surgery. The fractures were treated by internal fixation under either general anaesthesia or spinal analgesia. The arterial oxygen tension following the fracture but before surgery was low relative to the ages of the patients, and the arterial carbon dioxide tension was low in twenty-five out of twenty-seven patients. There was also a significant increase in the dead space/tidal volume ratio (VD/VT) and the alveolar-arterial oxygen tension difference, (A--a)DO2 in eight out of nine patients in the first 5 days following the fracture. The mean arterial oxygen tension was still reduced up to 5 days postoperatively. The VD/VT ratio returned to normal postoperatively although the (A-a)DO2 remained elevated. The haemoglobin and platelet levels following the fracture and before surgery were low, although not remarkably so, and there was no significant change post-operatively. There were no significant changes in the electrocardiograph or the chest radiographs. These results and their implications are discussed.     

Perioperative multimodal optimisation in patients undergoing surgery for fractured neck of femur

IntroductionEnhanced Recovery after Surgery protocols are associated with reduced length of stay and morbidity in patients undergoing major surgery. The aim of this audit was to assess the impact of a multimodal optimisation protocol in patients admitted with fractured neck of femur.Patients and methodsA multimodal optimisation protocol was introduced for the care of patients with proximal femoral fractures. The short-term effects of the optimised perioperative care programme was assessed and compared with the conventional perioperative care before the intervention.ResultsA total of 232 patients were included in this audit, 117 optimised care and 115 conventional care. Patients were similar with regards to age, gender, domicile, mental status and the type of operation. The optimised group suffered from fewer post-operative complications (36 out of 117 vs 48 out of 115, P = 0.04, Chi square test). There was no significant difference between two groups with regards to the length of hospital stay and 30-day mortality.ConclusionMultimodal optimisation may be associated with a decline in post-operative morbidity in patients with proximal hip fracture. It does not have any significant impact on the length of hospital stay and 30-day mortality.     

Randomized comparison between sevoflurane anaesthesia and unilateral spinal anaesthesia in elderly patients undergoing orthopaedic surgery

BACKGROUND AND OBJECTIVE: This prospective, randomized study was conducted to compare unilateral spinal block using small doses of hyperbaric bupivacaine and single-agent anaesthesia with sevoflurane in elderly patients undergoing hip surgery. METHODS: Thirty patients (> 65 yr) undergoing hip fracture repair were randomly allocated to receive unilateral spinal anaesthesia with hyperbaric bupivacaine 7.5 mg 0.5% (Group Spinal, n = 15) or volatile induction and maintenance anaesthesia with sevoflurane (Group SEVO, n = 15). General anaesthesia was induced by increasing the inspired concentration to 5%. A laryngeal mask airway was placed without muscle relaxants, and the end-tidal concentrations of sevoflurane were adjusted to maintain cardiovascular stability. Hypotension (decrease in systolic arterial pressure > 20% from baseline), hypertension or bradycardia (heart rate < 50 beats min(-1)) requiring treatment, and the length of stay in the postanaesthesia care unit was recorded. Cognitive functions were evaluated the previous day, and 1 and 7 days after surgery with the Mini Mental State Examination test. RESULTS: Hypotension occurred in seven patients of Group Spinal (46%) and in 12 patients of Group SEVO (80%) (P = 0.05). Phenylephrine was required to control hypotension in three spinal patients (21%) and four SEVO patients (26%) (n.s.). SEVO patients had lower heart rates than spinal patients from 15 to 60 min after anaesthesia induction (P = 0.01). Bradycardia was observed in three SEVO patients (22%). Discharge from the postanaesthesia care unit required 15 (range 5-30) min in Group Spinal and 55 (15-80) min in Group SEVO (P = 0.0005). Eight patients in Group Spinal (53%) and nine patients in Group SEVO (60%) showed cognitive decline (Mini Mental State Examination test decreased > or = 2 points from baseline) 24 h after surgery (n.s.). Seven days after surgery, confusion was still present in one patient of Group Spinal (6%) and in three patients of Group SEVO (20%) (n.s.). CONCLUSIONS: In elderly patients undergoing hemiarthroplasty of the hip, induction and maintenance with sevoflurane provide a rapid emergence from anaesthesia without more depression of postoperative cognitive function compared with unilateral spinal anaesthesia. This technique represents an attractive option when patient refusal, lack of adequate co-operation or concomitant anticoagulant therapy contraindicate the use of spinal anaesthesia.     

Thompson prosthesis for fractured neck of femur. A comparison of surgical approaches.

The records of 243 patients with Thompson prostheses for displaced femoral neck fractures have been studied. One hundred and seven prostheses were inserted through an anterior approach and 136 by a posterior approach. The short-term results and complications in these otherwise comparable groups are discussed. The infection rate of 18.5 percent in the group operated upon by the posterior approach was thrice that after operations by the anterior route (6.5 per cent infected). Drained wounds had significantly less infection (6.3 per cent) compared with the undrained group (28 per cent infected). Other factors influencing the infection rate are discussed. The anterior approach offered greater stability. Of the twenty dislocations in the series, nineteen followed operations by the posterior approach. The mortality rate six weeks after operation was 6.5 per cent after the anterior approach and 20.6 per cent after the posterior approach. Statistical analysis significantly favours the anterior approach.     

POSSUM scoring for patients with fractured neck of femur

Background. POSSUM scoring is validated as an audit tool ingeneral and orthopaedic surgery. It is also used for preoperativetriage to assess perioperative risk. However its ability topredict mortality in specific surgical subgroups, such as patientswith fractured neck of the femur, has not been studied. Thisstudy assessed the predictive capability of POSSUM for 30-daymortality after surgery for fractured neck of femur. Methods. A cohort study was conducted in Queen's Medical Centre,Nottingham over a period of nearly 2 yr. Complete data from1164 patients were analysed to compare the mortality predictedby POSSUM and the observed mortality. POSSUM risk of death wascalculated using the original POSSUM equation, with modificationsto the operative score appropriate for orthopaedic surgery. Results. POSSUM predicted 181 (15.6%) deaths and the observedmortality was 119 (10.2%). The area under the receiver operatingcharacteristic curve was 0.62, indicating poor performance bythe POSSUM equation. Conclusion. POSSUM overpredicts mortality in hip fracture patients.It should be used with caution whether as an audit tool or forpreoperative triage. An abstract of part of the study was presented at the AnaestheticResearch Society meeting, Aberdeen, April 2004 and publishedin British Journal of Anaesthesia 2004; 93: 161.     

Anaesthesia for fractured neck of femur

Fracture of the femoral neck is a common injury in the elderly and many patients have significant comorbidities. Effective management requires a multidisciplinary approach including anaesthetists, geriatricians and orthopaedic surgeons. Strict adherence to clinical practice guidelines such as the American College of Cardiology and American Heart Association (ACC/AHA) may reduce unnecessary cardiac consultations. Although early surgery within 24–48 hours is beneficial, there may be medical conditions that need prior optimization. Both general and neuraxial anaesthesia can be used. Overall, there is no significant difference between them in terms of mortality and most complications including pneumonia and pulmonary embolism, although neuraxial anaesthesia is associated with reduced deep vein thrombosis. Pain management should begin preoperatively and a multimodal approach should be used. Peripheral nerve blocks can provide effective analgesia.     

Anaesthesia for fractured neck of femur

Fracture of the femoral neck is a common injury in the elderly, and many patients have significant co-morbidities. Effective management requires a multidisciplinary approach involving anaesthetists, medical physicians and orthopaedic surgeons. Although early surgery within 24–48 hours is beneficial, there may be medical conditions that need prior optimization. Both general anaesthesia and regional neuroaxial anaesthesia can be used, although it appears regional anaesthesia is preferred by most anaesthetists as it is associated with reduced early postoperative mortality, less deep vein thrombosis, less fatal pulmonary embolism, and fewer pulmonary complications.     

Anaesthesia for fractured neck of femur

In the UK, 70,000 patients per year fracture their hips and the annual incidence is rising. There is an inevitable hospital mortality rate of 4–6% associated primarily with carcinomatosis. The 30% mortality rate at 1 year has not improved significantly over 25 years. The evidence base for best practice is weak and leads to conflicting conclusions. Many aspects of care advocated in guidelines are determined by consensus opinion. Early anaesthesia and surgery are championed but should not be rigidly offered at the expense of neglecting investigations such as echocardiography to identify significant aortic stenosis or the acute treatment of hypovolaemia, dysrhythmias, hypertension, cardiac ischaemia, cardiac failure, pulmonary insufficiency and poorly controlled diabetes. Anaesthesia should be tailored to each individual patient’s needs. Regional anaesthesia has only marginal advantages compared with general anaesthesia and is contraindicated if coagulation is abnormal. The closer involvement of anaesthetists in the management of resuscitation, perioperative fluid balance, postoperative pain relief and postoperative nutrition may improve outcome. Mortality rates vary between hospitals and within hospitals year by year. Regular departmental audit is advised to identify local areas of good or deficient practice.     

Anaesthesia for fractured neck of femur

Femoral neck fractures are painful, debilitating and associated with significant morbidity and mortality. Early surgery is important to facilitate recovery and restoration of mobility. A multidisciplinary team of anaesthetists, orthopaedic surgeons, orthogeriatricians, nurses and allied health staff can provide comprehensive assessment and care for these high-risk patients. Preoperative evaluation emphasizes risk stratification and medical optimization. Multimodal analgesia, including systemic analgesics and peripheral nerve blocks, plays an integral part. Other specific issues include cardiac complications, venous thromboembolism, bone cement implantation syndrome and postoperative cognitive dysfunction. Postoperative rehabilitation should start as early as possible and structured clinical care pathways can be implemented to facilitate integrated management and smooth recovery for these patients.     

Anaesthetic techniques for surgical correction of fractured neck of femur

Fifty-five patients presenting with fractured neck of femur were randomly allocated to either a standard general anaesthetic or spinal block in the lateral position combined with light sedation. The comparability of the two groups was established. There was little difference in the intra-operative course of postoperative morbidity in the two groups. There was a statistically significant difference in post-operative mortality between two groups, the general anaesthetic group showing a much higher mortality than the spinal group.