Regional Anaesthesia for Hip Surgery should it be the automatic choice

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Regional Anaesthesia for Hip Surgery - should it
be the automatic choice?

• Richard Griffiths MD FRCA
• Peterborough Hospitals

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Fractured Femur Anaesthesia

• Talk will be directed at fractured neck of femur
  patients
• Review the literature
• Any recent developments
• Delaying surgery
• The murmur
• Clopidogrel

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• Demographic Data
• Approx 80,000 per year in UK (65,000 in over
  65s)
• Cost is approximately 1,000,000,000 per year
• Life expectancy increases by 5 hours every week
  in the UK

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UK Census 1981 2001
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Hip Fracture

• Operative risk
• Donati et al BJA 2004 93(3) 393-400
• Looked at approx 4,000 patients to validate data
• Risk for ASA 4, age gt 70 elective surgery is 3.7
• For urgent/emergency is 16.7

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UK Census 2001

• Over-60s outnumbered the under-16s for
• the first time
• Over-85s had increased 5-fold since 1951

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Fractured Femur Anaesthesia

• The Evidence Meta-analysis
• Urwin SC, Parker MJ, Griffiths R. BJA
  200084450-454
• Latest update from Cochrane August 2004 (search
  up to November 2003)
• There is no evidence of substantial differences
  between regional and GA in terms of long term
  mortality

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Fractured Femur Anaesthesia

• Cochrane Review
• 50 studies identified
• 22 published as full papers in peer reviewed
  journals
• 2,567 patients
• ALL studies have methodological flaws

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• Pooled data from 8 studies
• Regional anaesthesia decreased mortality at one
  month
• 56/811 (6.9) V 86/857 (10)
• (Borderline significance
• RR 0.69, 95 CI 0.50 to 0.95)

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• Mortality
• Only 2 studies have mortality data for one year
  post surgery
• 80/354(22.6) V 78/372(21)
• Regional V General
• (RR 1.07, 95 CI 0.82 to 1.41)

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• DVT Reduction
• Regional V General
• 39/129(30) V 61/130(47)
• This is a significant comparison, but the
  selection of individuals for investigations was
  biased in the studies

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• Confusion
• Regional V General
• 11/117(9.4) V 23/120(19.2)
• Significant but very small numbers

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• Looking at retrospective data?
• Can it tell us anything?
• Anesthesiology 200092947-957
• 9,425 patients, 1983-1993, 20 hospitals, no
  differences detected.

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• Last 4,723 hip fracture anaesthetics in
  Peterborough (1989 to 2005)
• Type of anaesthesia
• GA 2,548
• Spinal 1,541
• Local 254
• Paravertebral block 37
• 64 of cases done by one surgeon (MP)

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ASA Grading
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Post-Operative complications
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• No significant difference in mortality between
  types of anaesthesia
• Multivariate analysis that did significantly
  affect mortality were age, gender, ASA score,
  haemoglobin level, mobility score and mental test
  score
• Were spinal patients sicker? (not according to
  ASA score)

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Epidural Analgesia and Hip Fracture

• 1. Improved analgesia, but no significant
  clinical improvement
• Anesthesiology 20051021197-1204, Foss et al
• 60 patients, double blind design
• 2. Reduced cardiac events
• Anesthesiology 200398156-163
• 68 patients
• 7/34 versus 0/34 (p 0.01)

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• Not much new for the Final FRCA candidate
• but, anaesthesia is crucial to the management of
  these patients
• Slightly off the topic of the talk, lets cover
  some other interesting areas

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• Delaying Surgery, does this affect mortality?
• Are we to blame for delays?

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• BMJ 2006332947-950 ((Dr Foster)
• Mortality associated with delay in operation
  after hip fracture
• Only patients from own homes
• (April 2001 to March 2004)
• 130,000 cases, 18,500 deaths in hospital (14.3)

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• BMJ 2006332947-950
• Delay in operation associated with increased risk
  of death in hospital
• 40 of procedures performed gt 1 day after
  admission
• 21 delayed for 2 days
• deleterious effect of delaying operation even
  after adjusting for co-morbidity

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• Delay to surgery and mortality is controversial
• Delay is a problem in Finland
• Sund and Liski, Qual. Saf. Health Care
  200514371-377
• But not so much of an issue in Northern Italy
• Friuli, Venezia, BMJ April 2006

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• This is also shown by Scottish Hip Fracture Audit
• Must distinguish clinical delay from
  organisational delay
• 40 initially medically unfit for surgery
• Compared to patients operated on within 24
  hours, delay to surgery in those initially
  medically unfit was associated with an increased
  mortality

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• Does this mean that delaying a medically unfit
  patient does them any harm?
• I am not sure, but it is likely that the medical
  profession can do nothing about mortality in up
  to 40 of these patients
• Foss Kehlet British Journal of Anaesthesia 94
  (1) 24-29 2005

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• Foss Kehlet British Journal of Anaesthesia 94
  (1) 24-29 2005
• 300 patients, continuous epidural analgesia,
  preop and for 4 days post op
• delay of surgery because of other medical
  optimisation was generally avoided
• Has implications for the design of future studies
  that only look at mortality
• (unchanged for 20 years BMJ 2003327771-775)

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Hip Fracture Time of Surgery

• Time from Admission to Operation
• (Peterborough Data, last 10 years)
• Mean is 28.9 hours
• 2091 /3,139 (67) had received operation within
  24 hours of admission to AE

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• Opioids in spinal solution
• Limited studies
• No benefit so far
• Hypotension in elderly patients undergoing spinal
  anaesthesia for repair of fractured neck of
  femur. A comparison of two different spinal
  solutions. Anaesthesia and Intensive
  Care200129501-505

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Aortic stenosis

• Aortic stenosis
• Echocardiography
• Two questions to ask
• Delay operation until echo performed?
• Is it safe to perform regional anaesthesia in a
  patient with aortic stenosis?

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Aortic Stenosis

• I advocate the following
• If Echo will not delay operation go ahead
• Now able to perform assessment quickly and often
  at bed side
• If in doubt
• Use invasive monitoring
• Draw up vasopressors

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Aortic Stenosis

• Why is spinal anaesthesia a relative
  contraindication in a patient with aortic
  stenosis?
• Extrapolation of potential physiological changes
  that occur with spinal anaesthesia

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Aortic Stenosis

• The Evidence
• Is neuraxial blockade contraindicated in the
  patient with aortic stenosis?
• Regional anesthesia and pain medicine
• Sep/Oct 2004 29, 5496-502
• Susan B McDonald
• Seattle USA

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Aortic Stenosis

• Medline 1951 to 1965, nothing
• Medline 1966 to 2003
• No RCTs or prospective studies identified
• Two retrospective series published, from same
  authors at Mayo Clinic, 1989 and 1998 (mainly
  GAs)

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Aortic Stenosis

• 7 case reports successful use of regional
  anaesthesia in 10 patients from 1993 to 2003
• 2 letters describing use of regional anaesthesia
  for obstetric patients
• 6 obstetric patients
• 3 hip fractures
• 3 ESW lithotripsy

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Aortic Stenosis

• Does the problem of AS stem from Goldmans paper
  in 1977?
• Earliest paper identifying AS as a risk factor
  was in 1964 (Skinner et al, Journal of Chronic
  Diseases 17 57-72)
• 766 patients, 59 with aortic lesions, 10
  mortality, no info on type of anaesthesia or type
  of surgery

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Aortic Stenosis

• So even for GAs
• The wisdom that AS patients are at high risk is
  based on small studies, with poor methodology
• For regional anaesthesia I do not know where the
  original advice came from?

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Aortic Stenosis

• In the literature there are approximately, 23
  successful regional techniques in patients with
  AS, over a 52 year period (1951 to 2003)
• I have collected a series of 5 patients in the
  last month and will continue to collect them,
  hopefully for a series

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• Clopidogrel (plavix)
• Delay or proceed?
• Regional anaesthesia?
• Evidence?

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Clopidogrel

• Discontinue for 7 days prior to elective surgery
  (platelets back to normal after 5 days)
• Regional anesthesia and pain medicine 2003,
  28(3)172-197 regional anesthesia in the
  anticoagulated patient
• (ASRA 2003)
• Actual risk of spinal haematoma with clopidogrel
  is unknown

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Clopidogrel

• French Guidelines 2001
• Spinal/epidural anaesthesia with these agents is
  inadvisable (expert opinion)
• German Society of Anaesthesiology and ICM
• 3 day interval between aspirin application and
  spinal anaesthesia

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Clopidogrel

• Case reports
• BJA 2006 96262-265, combined spinal epidural,
  stopped for 7 days, developed haematoma (was on
  LMWH)
• Anesthesiology 2002 97(3) 740-743, Following
  lumbar sympathectomy, stopped for 3 days, large
  retroperitoneal haematoma.

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Clopidogrel

• 3. Anesthesiology 2004 101(6) 1467-1470
• 81 yrs old. Stopped for 7 days, elective
  fasciotomy, received LMWH, repeated attempts,
  platelet count was 161. Developed epidural
  haematoma. Received 40mg enoxaprin 8 36 hrs
  after LP.
• 4. Anaesthesia 2005 60(1) 85-87
• Patient with coronary stent, waiting for lung
  transplant, decision taken that spinal was safer
  than GA. Given platelet transfusion. Successful
  case. No complications

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Clopidogrel

• Peterborough
• 7 successful outcomes in patients on clopidogrel
  in fractured NOF patients.
• 4 spinal 2 GA 1 LA (Age Anaesthesia Manchester
  May 2007)
• Surgery was not delayed
• (Morbidity from stopping drug?)

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Clopidogrel

• Each case must be judged separately
• Risks of proceeding
• Risks of delaying
• Consultant opinion which must be consistent
• Close co-operation between specialties

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Other Information

• Hospital Process, complex. Lots of individuals
  involved
• Blue book (BOA revision 2007)
• NHS Institute (high volume care 2006/2007)
• Anaesthesia champion in each acute trust

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• Summary
• Spinal probably best (personal view)
• Optimise as soon as enter hospital, the clock is
  ticking!!!
• Consultant responsible for these patients

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• My contact details
• richard_at_wothorpe.com
• 01733 874327
• Edith Cavell Hospital
• Peterborough
• PE3 9GZ

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Aortic Stenosis

• Collard et al, Anesthesia and Analgesia
  199581195-198
• Two case reports merged into one (both CSA)
• 84 yrs removal of infected hip prosthesis, AV
  area lt 0,8cm2, Ef 25
• 84 yrs NOF, gradient 84 mm Hg, EF 50
• Maximum haemodynamic effects only occur after 20
  mins with CSA or epidural

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Aortic Stenosis

• Goldman 1977
• Prospective study, 1,001 patients, 857
  non-cardiac procedures
• Patients with AS, 17 risk of cardiac
  complications and 13 risk of death (1.6 in
  those without AS)
• NB only 23 patients with AS in whole study

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Aortic Stenosis

• I have also found another series with 55 patients
  in a Canadian study, mixed GA and regional
• Second Mayo Clinic Series
• American Journal of Cardiology 1998,
  81(4)448-452
• Mayo Clinic USA

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Aortic Stenosis

• Can J Anaesthesia 199845,9855-859 retrospective
  audit 55 patients
• 32 men, 23 female average age 73
• Mean area 0.9 cm2
• Classify AVA
• Mild 1- 1.6cm2
• Moderate 0.8-0.99 cm2
• Severe lt 0.8cm2

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Aortic Stenosis

• 55 patients, 25 of these had angina
• 24 severe, 13 moderate, 18 mild
• 43 elective ops, 12 emergency, cardiac
  complications only in 5 cases ( 1 Death)
• 10 had regional techniques, 6 combined with GA
• No technique differences