Best evidence in hip fracture anaesthesia

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

3. 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

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

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

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

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

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

10. GA Spinal

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

12. 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

13. Risk aversion Johansen et al. Anaesthesia 2017

14. Risk aversion Johansen et al. Anaesthesia 2017

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

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

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

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

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

21. 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

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

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

24. Intravenous iron Moppett et al. Age Ageing 2019

25. 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

26. 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

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

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

29. Prevention probably better than cure

30. Outcomes that matter Functional Delirium Early mobility

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

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

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

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

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