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ERAHF Grand Rounds
- 1. “ERAHF”: designing a pathway for Enhanced Recovery After Hip Fracture Garrett Barry PGY2 @garrettsbarry Dept. of Anesthesia, Pain Management & Perioperative Care 13/03/2019
- 2. Disclosures • No conflicts of interest.
- 4. Outline 1. Review epidemiology of hip fractures 2. Review Evidence for Optimal Analgesic / Anesthetic Management • Pre-op • Intra-op • Post-op 3. Designing A Hip Fracture “Pathway” For Enhanced Periop Care
- 5. Hip Fracture Epidemiology • Incidence • Comorbidities • Length of stay • Delirium • Mortality
- 6. Hip Fracture Epidemiology • Incidence • Comorbidities • Length of stay • Delirium • Mortality Annual Mean: 414 per 100,000 (men) Annual Mean: 957 per 100,000 (women)
- 7. Hip Fracture Epidemiology • Incidence • Comorbidities • Length of stay • Delirium • Mortality
- 8. Hip Fracture Epidemiology • Incidence • Comorbidities • Length of stay • Delirium • Mortality
- 9. Hip Fracture Epidemiology • Incidence • Comorbidities • Length of stay • Delirium • Mortality Delirium = $8286 per patient!
- 10. Hip Fracture Epidemiology • Incidence • Comorbidities • Length of stay • Delirium • Mortality
- 11. Towards an “ERAHF” Pathway Pre-op Intra-op Post-op
- 19. Delay vs. Proceed? Minimize delays for stable patients with chronic comorbidities and reversing anticoagulation Delay to OR reasonable in unstable conditions: • Active ACS • Decompensated CHF • Unstable arrhythmia • AECOPD • Sepsis / pneumosepsis • (Known mod/severe AS or MS with no ECHO in last 12 months)
- 20. Pre-operative Peripheral Nerve Blocks (PNBs)
- 22. Anterior Approaches to Lumbar Plexus • Fascia Iliaca Compartment Block • “3-in-1” Block • Femoral Nerve Block (FNB) • Supra-inguinal Block • Pericapsular Nerve Group Block
- 23. Decreased pain during movement at 2-hours compared to opioids
- 24. Lower pre-operative opioid consumption with FICB
- 25. Longer time interval until first analgesic request
- 26. • FICB had a protective effect for delirium • Mouzopolous et al (2009): RR 0.45, lower delirium severity score (DRSR-98) and shorter duration (5.22 vs. 11 days) • Godoy-Monzon et al (2010): incidence 0% in FICB vs. 6.45% in control (NSAIDs)
- 28. Methods Included 31 trials - 1760 patients. Patients included were aged 59-88 years old and had a range of ASA classes between 1.75– 2.87 Included blocks: • femoral nerve block • 3-in-1 • FNB + local infiltration • FICB • LCFN block • LCFN + obturator block • psoas compartment block Both single shot injection and perineural catheter studies were included.
- 29. Results • Lower pain on movement within 30 minutes post block
- 30. Pain within 30 min of Block Placement
- 32. • Lower pain on movement within 30 minutes post block (-3.4 on a 10pt VAS) • Lower post-op pain at rest at 6-8h and 24h Results
- 33. PNBs for Post-op Pain at 24h
- 34. • Lower pain on movement within 30 minutes post block (-3.4 on a 10pt VAS) • Lower post-op pain at rest at 6-8h and 24h • Lower opioid requirements up to 24 hours post-op Results
- 36. • Lower pain on movement within 30 minutes post block (-3.4 on a 10pt VAS) • Lower post-op pain at rest at 6-8h and 24h • Lower opioid requirements up to 24 hours post-op • Greater patient satisfaction • Lower risk of pneumonia (RR 0.4) • Earlier post-op mobilization (mean time to mobilize 11.25 hours sooner) Results
- 38. Not significant: • Acute confusional state • Myocardial infarction • Mortality • But ALL trend towards favouring PNB Results
- 39. Nie et al: 1. Small study 2. Did not control for or report pre-operative dementia 3. More ASA 3 patients in the FIB group Delirium
- 40. - Retrospective cohort study at two academic hospitals - 668 patients aged ≥65 - 181 (27.1%) patients developed delirium within 72 hours of ED arrival
- 41. • Single UK hospital based study on FICB performed by junior doctors, ED nurse practitioners, and anesthetic nurse practitioners • Hip fracture pts receiving FICB went up from 37% to 68% over 4-6mo period
- 42. • Novel U/S guided block of articular branches of FN, AON, and (maybe) ON • Theoretically motor sparing; targets sensory branches to ant. hip joint • 5 patients only, all had significant static and dynamic pain score reduction • No appreciable quad weakness
- 43. Summary: Pre-op PNBs • Reduced pre-op pain with movement, post-op pain and opioid requirements • Better patient satisfaction • Reduced rate of pneumonia, may reduce delirium • Faster / less painful positioning for spinal anesthesia • Earlier post-op mobilization • Easy to learn and perform by HCPs other than just anesthesiologists PNBs should be used for all new hip fracture admissions (where not contraindicated).
- 44. Pre-op: Early anesthesia assessment Avoid delays in stable comorbid patients Good analgesia (Nerve Blocks) Intra-op Post-op
- 45. Pre-op: Early anesthesia assessment Avoid delays in stable comorbid patients Good analgesia (Nerve Blocks) Intra-op Post-op
- 46. Age Old Question: Spinal Vs. GA? How does anesthetic technique impact outcomes such as… Mortality Complications Length of stay
- 49. • Neuraxial anesthesia • Reduced in-hospital mortality [OR 0.85] • Reduced LOS [MD -0.26] • Reduced MI [OR 0.90] • Reduced respiratory failure [OR 0.50] • No significant difference in 30-day mortality, pneumonia, or PE
- 55. Summary: Spinal vs. GA • Spinals are associated with a reduction in • In-hospital mortality • Cardio-pulmonary complications • ICU admission • Hospital length of stay • *Likely* Infection and Transfusion rates Spinal is superior to GA when possible Sedation depth does not impact delirium risk Lighter sedation may have mortality benefit in highly comorbid patients
- 56. Pre-op: Early anesthesia assessment Avoid delays in stable comorbid patients Good analgesia (Nerve Blocks) Intra-op: Spinal superior to GA Sedation does not increase delirium risk Deep sedation may increase mortality in highly comorbid pts Post-op
- 57. Pre-op: Early anesthesia assessment Avoid delays in stable comorbid patients Good analgesia (Nerve Blocks) I Intra-op: Spinal superior to GA Sedation does not increase delirium risk Deep sedation may increase mortality in highly comorbid pts Post-op:
- 59. Post-operative Multimodal Analgesia • Pre-op single shot and continuous nerve blocks • Pain management protocols • Neurostimulation • Relaxation • Stretching / strengthening • Acupressure No significant difference: • Intrathecal opioids • Skin traction
- 60. • Delirium-friendly PPOs for post-op hip fractures • Optimizing post-op treatment of pain, nausea, constipation, sleep • Removal of urinary catheters • Labs to detect signs of dehydration • Optimized treatment of agitation • Led to lower risk of delirium • Whole group ARR 18% • Pre-existing dementia ARR 37% • Trend towards lower risk of death
- 61. • Patients >65yo getting a hip fracture repair • Intervention: randomized to geriatrics consultation preoperatively or within 24 hours post-op
- 66. Goals include: 1. ED administered FICB and oral analgesics 2. Delirious patients get geriatrics / IM consult 3. Time to OR within 24 hours 4. Only delay unstable conditions 5. Neuraxial anesthesia strongly preferred (INR ≤ 1.3)
- 67. Integrated Hip Fracture Program Goals (Yale): 1. U/S guided FNB a) within 45 mins during work hours 0700 - 1900 b) FNB within 4 hours during off hours 1900 - 0700 2. Medically cleared hip fracture patients go for surgery within 24 hours
- 68. Towards an “ERAFH” Pathway Pre-op: Early anesthesia assessment Avoid delays in stable comorbid patients Good analgesia (Nerve Blocks) Intra-op: Spinal superior to GA Sedation does not increase delirium risk Deep sedation may increase mortality in highly comorbid pts Post-op: Multimodal pain control Delirium prevention strategies Multidisciplinary follow up care
- 69. Thank you! Dr. Kwesi Kwofie Dr. Jennifer Szerb Dr. Vishal Uppal Dr. Andrew Jarvie Dr. Andrew Milne Paul Brouseau
- 70. Questions?
Editor's Notes
- Good morning. My name is Garrett Barry if you haven’t met me yet, I’m one of the 2nd year anesthesia residents. Today I’ll be presenting on what I am calling “ERAHF”: designing a pathway for enhanced recovery after hip fracture. Thank you for coming today.
- I have no conflicts of interest to disclose.
- First I want to start with why this topic is of interest to me. We all care for a population that is aging, living longer with chronic illness and frailty. I’m sure we all have had relatives in old age. My grandfather passed away in 2013 after suffering a hip fracture at the age of 96. He was a kind, generous, no-BS kind of man who I looked up to a lot. He developed a delirium and passed away in hospital after his fracture. Hip fractures are a very common cause of morbidity and mortality in the growing frail and elderly population. There are times when these patients are so comorbid and frail that it makes one wonder if our choices as anesthesiologists make a meaningful difference. Looking through the literature, I believe that our choices do matter and have a significant ability to improve the outcomes for these patients.
- So my goal is to inspire you all that we can improve patient outcomes by designing an enhanced recovery pathway for hip fracture patients that leads to consistent, evidence-based care. First I want to quickly review the epidemiology of hip fractures, which will help us see why enhancing perioperative care is so important for this high risk population. Next, we will talk about how we as anesthesiologists can make a meaningful difference in outcomes from pre-op all the way to post-op periods. Lastly, I want to present the idea of a hip fracture pathway to enhance peri-operative care for this high risk population and some examples where this is taking place. This is already in the early stages of development locally.
- Hip fracture patients are at high risk of mortality, morbidity, and indeed some may even be having palliative surgery, so they require the careful attention of their anesthesiologist. Let’s start by looking at some of the epidemiology of hip fractures that show why they can be so devastating.
- Hip fractures are very common, one of the most common traumatic injuries in those over 65. Epidemiologic studies (such as this one from JAMA) that the incidence of hip fracture ranges from an annual mean of approx. 400 to 950 per 100,000, so about 0.5-1% of the population. The risk appears to be 2 to 3-fold higher in those above 85, reaching rates of 1.5-2.5%.
- These patients have high rates of comorbid conditions as well. Some of the most common conditions are COPD (25-35%), Congestive Heart Failure (25-30%), and Diabetes (20-25%). Other particularly worrisome conditions such as Stroke, Dementia, and Myocardial infarction are in the realm of 10%.
- Not surprisingly, with a frail elderly population like this, length of stay in hospital is significantly long. Only a very small percentage of patients (darkest blue) leave hospital after only 4 days. Many patients require longer hospital stays, with most spending more than 8 days in hospital.
- I already mentioned that dementia is a common problem almost reaching 10% prevalence. As you would expect, delirium is also alarmingly common, with studies showing incidences ranging between 30-60% of hospitalized hip fracture patients. The outcomes of patients who develop delirium are much worse than those who do not, with a negative impact on functional recovery and mortality. At a societal level, the economic impact of delirium is significant, with added costs of over $8000 attributable to delirium per patient. In this study of 242 patients of which 116 developed delirium, the total cost attributable to delirium was close to $1M dollars.
- Hip fracture carries a high risk of mortality as well. Rates of 30 day mortality ranges from about 5-10% and up to one third of patients will die within the first year. I will acknowledge that for some patients a hip fracture surgery is becomes a palliative procedure to reduce suffering and pain. These patients deserve the same high quality perioperative care as any other patient, deserving dignity and respect at the end of life.
- What I’d like to do as we go through the talk, is generate some ideas on how to work towards an “ERAHF” pathway from the pre-op phase all the way through to post-op.
- What I’d like to do as we go through the talk, is generate some ideas on how to work towards an “ERAHF” pathway from the pre-op phase all the way through to post-op.
- The 2014 American Academy of Orthopedic Surgeons guidelines proposes recommendations about several perioperative medicine topics that are actionable by us as anesthesiologists. These guidelines are supported by a large number of organizations crossing several disciplinary lines.
- One of these guidelines pertains to surgical timing. Based on several studies, the AAOS has a guideline that states that moderate evidence supports that hip fracture surgery within 48 hours is associated with a better outcome. These guidelines do acknowledge that there is a confounding effect by patient comorbidities: patients with a higher illness burden are often delayed more than their healthier counterparts, so the question becomes is it the delay itself, or what the patient brings to the table, to cause a difference in outcomes?
- One of these older studies of 4600 hip Fx patients, by Novack et al. 2007, showed that there is a significant increase in 1-year mortality the longer patients are delayed for surgery. So for a delay of 2-4 days, there is a 20% increase in the mortality rate, and beyond 4 days, a 50% increase in mortality rate. 1-year mortality (Table 3) adjusted for comorbidity, age and gender shows that the length of operation delay has a gradual effect on increasing mortality.
- So the study by Novack would suggest it’s the delay itself. However a large cohort study in Annals of Internal Medicine in 2011 showed that when controlling for age, dementia, chronic comorbid conditions, and functional status, only delays longer than 5 days remained significantly associated with an increased mortality. A similar result exists for in-hospital major morbidity as well (delirium, pneumonia, heart failure, UTI, pressure sore). Interestingly, up to 60% of the surgical delays were due to lack of operating room availability as opposed to an acute medical reason. (2250 elderly patients with hip fracture)
- Next let’s finish this part of the discussion with this population-based, retrospective cohort study of adults undergoing hip fracture surgery at 72 hospitals in Ontario, Canada, including 41,000 patients. These models are adjusted for many factors including age, gender, frailty status, diabetes, heart failure, COPD, MI, HTN, etc. We can see in this adjusted model, there is a slight decrease in mortality at the 24 hours mark, after which mortality continues to increase with longer delay. (Probabilities (95% CIs) models used restricted cubic splines adjusting for age, sex, calendar year, income quintile, rurality, transfer from any health care institution, Deyo-Charlson score, history of frailty, diabetes, heart failure, chronic obstructive pulmonary disease, myocardial infarction, or hypertension, fracture and surgery type, Injury Severity Score, surgeon volume and experience, hospital volume and type, and surgery duration.)
- Adjusted models showed similar trends in outcomes such as pneumonia, MI, DVT and PE, with a trend that delay longer than 24 hours significantly increased risk of these negative outcomes.
- Does a delay in and of itself increase morbidity / mortality, or is it due to the bias of acute medical illness? Probably both are true to some extent, but based on the literature we have to date, it looks like delaying surgery has an independent negative impact on mortality and complications. My take-aways are to minimize delaying patients which are stable but have a high level of chronic comorbidity that will not be possible to fix in the short period before surgery. It makes more sense to delay only patients with unstable conditions, a few of which I listed here. These are reasons to delay surgery based on a UCSF hip fracture protocol that I will show you later.
- Let’s talk about regional analgesia for hip fracture patients. Peripheral nerve blocks have been studied extensively in this population.
- The 2014 AAOS guidelines strongly support preoperative regional analgesia based on a number of high strength studies. If you look into some of the guidelines out of the UK such as NICE and SIGN, you can also find that preoperative regional techniques are suggested as effective analgesic methods in these patients.
- I’m going to focus on studies that analysed anterior approaches to block lumbar plexus nerves. Posterior approaches certainly exist and are effective for hip fracture pain, but come at the cost of higher risk of complications and decreased motor strength.
- A recent systematic review of FICB in the BJA in 2018 was done and they looked at studies comparing FICB with other analgesics given for hip fracture pain at various time points. The review analyzed 11 studies that met their inclusion criteria, which included both single shot and continuous catheters, although all studies were single shot FICB and done by LOR technique. While there was not a significant difference in pain scores at rest at 30 minutes after block placement compared to systemic opioids, there was significant reductions in pain with movement at 120 minutes. I think this would imply that systemic opioids can probably effectively reduce pain at rest preoperatively, however there is a lack of improvement in dynamic pain scores which are important for re-positioning patients and positioning for spinal anesthesia. I’ll come back to this.
- FICB also led to reduced pre-operative opioid consumption compared to opioids alone. Two of the studies reported that patients in the FIC group often required no additional IV morphine while the opioid group received 5-6mg, one study indicated FIC group patients needed a mean of 4mg while the IV opioid group required 7.4mg. Overall there was a significant reduction in preoperative opioid requirements.
- There was also an increased time to first analgesic request with FICB compared to opioids alone.
- While there were not enough studies to perform a meta-analysis for perioperative delirium, two included studies did show a significant protective effect for the development of delirium when patients had a pre-op regional block. Mouzopolous et al. (2009, RCT with 200 patients) looked at the effect of FICB on perioperative delirium outcomes. They showed a risk ratio of 0.45, lower delirium severity, and a shorter duration of delirium. Interestingly the Mouzopolous study studied the difference in effect for patients high-risk for delirium and the effect of FICB was no longer significant but it was most highly significant for intermediate risk patients (RR=0.13). High risk patients 3+/4 risk factors: illness severity, cog. Impairment, dehydration, visual impairement. Godoy-Monzon et al was a double blind RCT in a tertiary ED comparing FIB to systemic NSAIDs in hip fracture patients over 65. They included 154 patients. They showed a significant difference in the incidence of delirium. The incidence was 0% in the FICB group and 6.45% in the NSAID group despite similar pain levels.
- This Cochrane review on peripheral nerve blocks for hip fractures from 2017. They included only RCTs comparing nerve blocks for hip fracture with control. Primary outcomes were pain after block placement and post-operatively at a number of time-points, acute confusional state, and myocardial infarction. Secondary outcomes included pneumonia, mortality, time to first mobilization, opioid consumption, participant satisfaction, and costs.
- This meta-analysis analyzed 31 trials including 1760 patients. Patients included were aged 59-88 years old and had a range of ASA classes between 1.75– 2.87 Included blocks are: femoral nerve block / 3-in-1 / FNB + local infiltration / FICB / LCFN block / LCFN + obturator block / psoas compartment block. Both single shot injection and perineural catheter studies are included.
- You can see from this forest plot that almost all studies included showed a decrease in pain within 30 minutes compared to opioid only treatment. I want to point out the study by Diakomi 2014…
- This study showed that nerve blocks aid in improving positioning for spinal anesthesia. In this 41 patient RCT in 2014, patients were randomized to to either bolus IV fentanyl 1.5mcg/kg vs. FICB 40ml ropi 0.5% 20min before spinal. The FICB group had significantly reduced pain scores before, during, and after positioning for spinal. There was a significantly shorter time to perform the spinals, higher quality of positioning and patient satisfaction levels.
- Back to the Cochrane review, patients also had lower post-op pain at 6-8 hours and this effect persisted as long as 24 hours post op.
- Both single shot blocks and continuous catheters showed this effect in most studies.
- Patients had lower opioid requirements up to 24 hours post-op
- Looking at the studies that reported on acute confusional state AKA delirium, the two larger studies by Godoy and Mouzopolous did show a significant reduction in delirium in the PNB groups. An small, older study by White showed no significant difference but I think it’s hard to justify that this relates to current practice. The more recent study by Nie et al was a relatively small RCT comparing continuous fascia iliaca block vs. PCA. They did find that the FIB group had lower pain scores at all post-operative time points but oddly there were more patients who became delirious in the nerve block group. However, they did not control for or report pre-operative dementia, which we know to be a major risk factor, and they also had more ASA 3 patients in the FIB group.
- A recent retrospective study in the Canadian Journal of Emergency Medicine (2018) looked to identify risk factors for acute delirium developing within 72hrs of ED arrival. Of 668 patients reviewed over one year at two hospitals in Toronto, 27% developed delirium. The independent risk factors identified were no ED analgesia, age > 75 years old, and a history of neurodegenerative disease or signs of dementia. We can’t modify age, and we can’t modify history of dementia, but we can certainly modify pain. I believe this is the most important factor we can act upon in the pre-op period to improve outcomes for these patients.
- And nerve blocks for hip fracture don’t need to be reserved to be performed by anesthesiologists only. In fact, many emergency physicians perform these blocks in other centres around the world. There is even this study in an orthopedic nursing journal in 2018 showing that in a single UK hospital, FICB performed by trained junior doctors and nurse practitioners were able to learn and perform nerve blocks for hip fracture patients. Implementing this training led to a significant rise in the number of patients receiving nerve blocks for hip fracture pain. I’d like to suggest there may be a solution locally where we can take a multidisciplinary approach to getting our hip fractures access to effective pre-operative pain control including blocks performed by residents and staff across ED and anesthesia departments.
- The novel PENG block, paper published Nov 2018, has been generating a lot of buzz lately, being touted as a motor sparing nerve block for hip surgery. These are between the anterior inferior iliac spine and iliopubic eminence
- In summary, Pre-op peripheral nerve blocks are effective in reducing pain with movement pre-operatively, post op pain, and opioid requirements. They lead to better patient satisfaction, reduced rates of complications like pneumonia and delirium They allow for faster and better positioning for spinal anesthesia. Patients mobilize more quickly post-operatively And finally these are simple blocks that don’t require direct supervision by a staff anesthesiologist once the practitioner is adequately trained in performing these blocks.
- What I’d like to do as we go through the talk, is generate some ideas on how to work towards an “ERAHF” pathway from the pre-op phase all the way through to post-op.
- What I’d like to do as we go through the talk, is generate some ideas on how to work towards an “ERAHF” pathway from the pre-op phase all the way through to post-op.
- Of course how could I talk about hip fractures without asking the long debated spinal vs. GA question? As we’ll see in the literature, there is a significant difference in mortality, complications, and length of stay.
- This meta-analysis in 2017 in BMC Anesthesiology included 23 studies, 20 observational retrospective studies and 3 randomized control trials. 413,999 patients were included in the meta-analysis. You will notice the largest of these is Chu et al. which is from Taiwan's 1997-2011 in-patient claims database and includes over 100,000 patients. You can see that neuraxial anesthesia led to an odds ratio of 0.85 for in-hospital mortality compared to general anesthesia.
- Hospital length of stay was also reduced for patients receiving a neuraxial technique compared to general anesthesia.
- In addition to the reduction in in-hospital mortality and length of stay, patients had becreased rates of myocardial infarction and respiratory failure. 30-day mortality however was not significantly reduced, as was pneumonia and PE. So neuraxial has a mortality benefit in the perioperative period that does not seem to persist past hospitalization.
- With respect to how the patient’s age and comorbidity status impact whether there are better outcomes from neuraxial vs. general anesthesia, we can look into the THA and TKA literature as a surrogate to get an idea of this. Memtsoudis et al. performed a very large Retrospective cohort study including 872,000 records (2006-2012) from almost 500 hospitals across the US. They categorized patients by age groups and by cardiopulmonary disease status (including MI, CHF, COPD and pulm HTN). GA was used in 60-65% of the cases. They performed a multivariable analysis adjusting for demographic and procedure variables to compare neuraxial (N) vs. GA (G). Spinal was almost always associated with a lower odds of cardio-pulmonary complications, reduced length of stay, and less ICU utilization across age groups and in those with baseline cardiopulmonary disease.
- Again looking at THA/TKA data, this retrospective observational meta analysis including a total of 13 studies (N=362,000) looked at type of anesthesia effect on surgical site infections. Most studies demonstrate a significant association with fewer SSIs when spinal is used instead of GA.
- In this retrospective study querying the NSQIP THA dataset from 2005-2012, neuraxial anesthesia technique had an association with a lower risk of transfusion, with an OR of 0.82. This was another large study including over 17,000 pts in the GA group and over 11,000 in the neuraxial group.
- Now that we’ve seen some data showing spinal is better than general, how does level of sedation during spinal affect outcomes? There are relatively few studies specifically on this in hip fracture patients, but this study by Brown et al (2015) led by Frederick Sieber, looked at the effect of light vs. deep sedation on one year mortality in hip fracture patients receiving a spinal. This study was based on a prior double blind RCT at John’s Hopkins including 114 patients. Patients were randomized to receive sedation to accomplish a BIS=50 vs BIS=80, and groups were balanced except that the deep sedation group received higher doses of Propofol. The deep sedation group did have a significantly higher 1-year mortality, seen on the left two Kaplan Meier curves. This result was only significant in patients with a high comorbidity index score, the Charlson comorbidity index. The right two curves show overall mortality. This index is scored based on age and a number of comorbidities such as heart, vascular, pulmonary, cerebrovascular disease as well as others. A score of 4 would indicate a 50% estimated 10-year mortality.
- Looking at effect of sedation on delirium in older patients undergoing hip fracture repair, This study again by Frederick Sieber in 2018 was another double blind RCT with 200 patients >65yo receiving non-elective hip fracture repair. They randomized patients to light vs deep sedation as guided by both BIS and clinical examination (modified observers assessment of alertness/sedation). Heavier sedation has a larger impact on the risk of delirium in patients who have no comorbidity compared with those with a comorbidity score greater than zero, as seen on the right in panel A. There was no significant HR for delirium, with 95% CI bars crossing 1, in those with a charlson score greater than zero. In panel B, we see the risk estimates in percentage of developing post-operative delirium across comorbidity index and sedation levels. The overall risk of delirium was 36.5% (the dotted line), and there was no significant increase in delirium with heavier vs. lighter sedation across comorbidity scores So ultimately, this says if you have a patient with any level of major comorbidity, the level of sedation you give seems to have a minimal impact on risk of post-operative delirium. The risk of death is a serious worry, however, so in very highly cormorbid patients, ie. With a Charlson score of 4+, it may be best to lighten sedation as much as you can.
- In summary.
- What I’d like to do as we go through the talk, is generate some ideas on how to work towards an “ERAHF” pathway from the pre-op phase all the way through to post-op.
- What I’d like to do as we go through the talk, is generate some ideas on how to work towards an “ERAHF” pathway from the pre-op phase all the way through to post-op.
- Now I want to just quickly touch on the post-operative phase. The AAOS gives several guidelines on improving care for hip fracture patients. First they have a strong recommendation for post-operative multimodal analgesia for reduction in pain, improved satisfaction and function, lower complication rates, reduced N/V, reduced delirium, and less opioid use. Second, they strongly support the implementation of interdisciplinary care programs for patients with mild-moderate dementia to improve functional outcomes after hip fracture.
- In terms of post-operative analgesia, we already talked about pre-operative nerve blocks, including continuous catheters, to improve pain and delirium outcomes post-op. Another review in the annals of internal medicine (2011) looked at a number of other techniques to improve pain control, and showed there is evidence to support TENS, relaxation, stretching/strengthening and acupressure. There was no significant benefits from intrathecal opioids or skin traction as means of analgesia.
- This local study by Dr Ken Rockwood and Michael Dunbar was published in the journal of American geriatrics society. They performed a pragmatic controlled single-blind quality improvement trial implementing delirium-friendly PPOs in the post-op period. N = 283 admitted hip fracture patients aged >65 The goals of these PPOs were to optimize treatment of pain, nausea, constipation, and sleep. They had routine orders for removal of urinary catheters, lab work for dehydration screening, and treatment of agitation. These PPOs led to a significant reduction in delirium, especially in those patients with pre-existing dementia. There was a non-significant trend toward a lower risk of death as well.
- In this RCT, patients >65yo with hip fracture repairs were randomized to perioperative geriatrics consultation vs. usual care. Geratrics consultation had a structured review with recommendations regarding oxygen delivery / hemodynamic treatments, fluid/electrolyte balance, nutritional support, treatment of pain, elimination of unnecessary or deliriogenic medications, bowel/bladder care, early mobilization, delirium prevention strategies and treatment of agitation, and detection/treatment of early complications. The intervention group had a significant reduction of in-hospital delirium, and a lower risk of severe delirium.
- What could this ERAFH pathway look like practically speaking? Examples out of the UK show chart based bundles that keep record of recommended assessments and interventions to improve outcomes, such as this one out of Dumfries and Galloway.
- An example out of UCSF is the Hip Fracture Protocol, which is an online and paper based protocol based on all the of principals in this talk. They have a very accessible and well organized website to allow providers to focus in on their component of patient care.
- Each topic has recommended tests and treatments throughout the patient’s stay. I find that this would be a very useful resource in a multidisciplinary team where not each team member knows all the guidelines for the other specialties. So ED can easily see recommended pain management strategies, ortho can get an idea of when an anesthesia consult is warranted, and anesthesia can see the guidelines for anticoagulation management, for example. These are helpful in a place where there are a lot of learners, as a way to unify management across many fields.
- Ultimately, with all of the research going on for hip fracture patients, I think we should all start to consider working towards a clinical pathway or protocol to optimize care for these patients. There are many interventions that we as anesthesiologists can provide that the literature shows is beneficial to these at-risk patients. In the pre-op phase we should work towards having a standardized selection criteria for patients who should receive early anesthesia assessment, avoid delays for stable comorbid patients while only delaying those with unstable conditions. Importantly, providing effective analgesia, best met with regional techniques, is an important intervention to reduce pre- and post-op pain, opioid consumption, delirium, and improve satisfaction and patient functional outcomes. Intraoperatively, the data consistently shows that spinal anesthesia is preferable to GA. However, spinals are not always possible in patients is absolute contraindications, so there is sometimes a conflict between delay to surgery and optimal anesthetic technique. While more information will be coming in the future, I think it is best to use spinal anesthesia when at all possible but avoid long delays such as when patients are on antiplatelet therapy. The literature also shows some evidence that minimizing sedation may reduce mortality particularly in highly comorbid patients, but the depth of sedation does not have much impact on delirium in these patients. Post-operatively, we can work towards improving multimodal pain control, perhaps through regional blocks/catheters as well as optimizing order sets, and improving standardized delirium prevention strategies and access to follow up care after our time with them is over.