Objectives: To obtain reliable estimates of the effects of neuraxial blockade with epidural or spinal anaesthesia on postoperative morbidity and mortality. Design: Systematic review of all trials with randomisation to intraoperative neuraxial blockade or not. Studies: 141 trials including 9559 patients for which data were available before 1 January 1997. Trials were eligible irrespective of their primary aims, concomitant use of general anaesthesia, publication status, or language. Trials were identified by extensive search methods, and substantial amounts of data were obtained or confirmed by correspondence with trialists. Main outcome measures: All cause mortality, deep vein thrombosis, pulmonary embolism, myocardial infarction, transfusion requirements, pneumonia, other infections, respiratory depression, and renal failure. Results: Overall mortality was reduced by about a third in patients allocated to neuraxial blockade (103 deaths/4871 patients versus 144/4688 patients, odds ratio=0.70, 95% confidence interval 0.54 to 0.90, P=0.006). Neuraxial blockade reduced the odds of deep vein thrombosis by 44%, pulmonary embolism by 55%, transfusion requirements by 50%, pneumonia by 39%, and respiratory depression by 59% (all P Conclusions: Neuraxial blockade reduces postoperative mortality and other serious complications. The size of some of these benefits remains uncertain, and further research is required to determine whether these effects are due solely to benefits of neuraxial blockade or partly to avoidance of general anaesthesia. Nevertheless, these findings support more widespread use of neuraxial blockade.

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Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials.

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

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The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

So far I have attempted to provide a broad framework within which to consider the importance of managerial and organisational integration. Inevitably in so doing I have found it necessary to raise wider educational and training issues which influence not only conceptual skills but also attitude. Indeed I have, on occasion, moved my argument or perspective to even wider considerations; issues pertaining to national culture. Culture, education policy or structure, industrial organisation, all interact in subtle and perhaps devious forms. Thus a cultural framework which is “overly status or class conscious” reflects this in its educational system. Most likely it is more predisposed to segment its secondary and tertiary education systems according to similar principles. It may well encourage separation of the university and technical college or polytechnic system to a degree that is industrially and commercially counterproductive — and integratively devisive. Such an educational system will no doubt require “preselection and filtering” which relies upon early, too early, subject specialisation; it may, subsequently, influence adversely the need for individuals and subgroups to communicate more intimately and to organise themselves more closely. In fact it may ensure the continuance of barriers, hierarchies, and polarised attitudes of class, structure and function all the way across and through commerce and industry.

A National Survey

BACKGROUND:Regional anesthesia (RA) provides excellent anesthesia and analgesia for many surgical procedures. Anesthesiologists and patients must understand the risks in addition to the benefits of RA to make an informed choice of anesthetic technique. Many studies that have investigated neurologica

Neurological complications after regional anesthesia: contemporary estimates of risk.

Background
The majority of people with hip fracture are treated surgically, requiring anaesthesia

Objectives
To compare different types of anaesthesia for surgical repair of hip fractures (proximal femoral fractures) in adults

Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (November 2003), MEDLINE (1996 to February week 2 2004), EMBASE (1988 to 2004 week 10) and reference lists of relevant articles

Selection criteria
Randomised and quasi-randomised trials comparing different methods of anaesthesia for hip fracture surgery in adults The primary focus of this review was the comparison of regional (spinal or epidural) anaesthesia versus general anaesthesia The use of nerve blocks preoperatively or in conjunction with general anaesthesia is evaluated in another review The primary outcome was mortality

Data collection and analysis
Two reviewers independently assessed trial quality and extracted data

Main results
Twenty two trials, involving 2567 predominantly female and elderly patients, comparing regional anaesthesia with general anaesthesia were included All trials had methodological flaws and many do not reflect current anaesthetic practice Pooled results from eight trials showed regional anaesthesia to be associated with a decreased mortality at one month (56/811 (69%) versus 86/857 (100%)); however, this was of borderline statistical significance (relative risk (RR) 069, 95% confidence interval (CI) 050 to 095) The results from six trials for three month mortality were not statistically significant, although the confidence interval does not exclude the possibility of a clinically relevant reduction (86/726 (118%) versus 98/765 (128%), RR 092, 95% CI 071 to 121) The reduced numbers of trial participants at one year, coming exclusively from two trials, preclude any useful conclusions for long-term mortality (80/354 (226%) versus 78/372 (210%), RR 107, 95% CI 082 to 141)

Regional anaesthesia was associated with a reduced risk of deep venous thrombosis (39/129 (30%) versus 61/130 (47%); RR 064, 95% CI 048 to 086) However, this finding is insecure due to possible selection bias in the subgroups in whom this outcome was measured Regional anaesthesia was also associated with a reduced risk of acute postoperative confusion (11/117 (94%) versus 23/120 (192%), RR 050, 95% CI 026 to 095)

There was insufficient evidence to draw any conclusions from a further four included trials, involving a total of 179 participants, which compared other methods of anaesthesia (a 'light' general with spinal anaesthesia; intravenous ketamine; nerve blocks)

Authors' conclusions
Overall, there was insufficient evidence available from trials comparing regional versus general anaesthesia to rule out clinically important differences Regional anaesthesia may reduce acute postoperative confusion but no conclusions can be drawn for mortality or other outcomes

Anaesthesia for hip fracture surgery in adults

Hip fracture surgery is common and the population at risk is generally elderly. There is no consensus of opinion regarding the safest form of anaesthesia for these patients. We performed a meta-analysis of 15 randomized trials that compare morbidity and mortality associated with general or regional anaesthesia for hip fracture patients. There was a reduced 1-month mortality and incidence of deep vein thrombosis in the regional anaesthesia group. Operations performed under general anaesthesia had a reduction in operation time. No other outcome measures reached a statistically significant difference. There was a tendency towards a lower incidence of myocardial infarction, confusion and postoperative hypoxia in the regional anaesthetic group, and cerebrovascular accident and intra-operative hypotension in the general anaesthetic group. We conclude that there are marginal advantages for regional anaesthesia compared to general anaesthesia for hip fracture patients in terms of early mortality and risk of deep vein thrombosis.

General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials.

There should be protocol-driven, fast-track admission of patients with hip fractures through the emergency department. Patients with hip fractures require multidisciplinary care, led by orthogeriatricians. Surgery is the best analgesic for hip fractures. Surgical repair of hip fractures should occur within 48 hours of hospital admission. Surgery and anaesthesia must be undertaken by appropriately experienced surgeons and anaesthetists. There must be high-quality communication between clinicians and allied health professionals. Early mobilisation is a key part of the management of patients with hip fractures. Pre-operative management should include consideration of planning for discharge from hospital. Measures should be taken to prevent secondary falls. 10. Continuous audit and targeted research is required in order to inform and improve the management of patients with hip fracture.

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2044.2011.06957.x

Management of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain and Ireland.

Aims This study was designed to estimate trends in the number of proximal femoral fractures (PFFs), and consequent bed day requirements and financial implications for England until 2033. Methods Trends in the number of coded PFFs from 1998 to 2008 (collected from Hospital Episode Statistics Online) were projected forward to 2033, and modified according to published data concerning population demographics and declining PFF prevalence. Estimates of 30 day postoperative mortality were calculated according to projected demographic data. Financial estimates were calculated according to current cost and adjusted according to projected inflation. Results Despite a decline in the prevalence of PFF among the aging population (2.98% since 2002), we estimate that approximately 100,000 patients annually will require surgery for fractured neck of femur by 2033 in England, with a 30d mortality of 8.9–9.3%, costing £3.6–5.6 billion (inflation adjusted) in total care. Conclusions The evaluation and implementation of cost-effective preventive and therapeutic strategies in the short term may help to ameliorate the future financial burden of PFF, and, more importantly, improve the outcome and quality of life for the elderly after fracture.

Projected incidence of proximal femoral fracture in England: a report from the NHS Hip Fracture Anaesthesia Network (HIPFAN).

BACKGROUND Various nerve blocks using local anaesthetic agents have been used in order to reduce pain after hip fracture. OBJECTIVES To determine the effects of nerve blocks (inserted either pre-operatively, operatively or post-operatively) as part of the treatment for a hip fracture. SEARCH STRATEGY The Cochrane Musculoskeletal Injuries Group specialised trials register, MEDLINE, and bibliographies of trial reports were searched. Date of the most recent search: October 2000. SELECTION CRITERIA Randomised and quasi-randomised trials involving the use of nerve blocks as part of the care of a hip fracture patient. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trial quality, by use of a nine item scale, and extracted data. Wherever appropriate, results of outcome measures were pooled. MAIN RESULTS Seven randomised or quasi-randomised trials involving 269 patients were included. Two trials related to insertion of a nerve block pre-operatively and the remaining five to peri-operative insertion. Nerve blocks resulted in a reduction of the quantity of parenteral or oral analgesia administered to control pain from the fracture/operation or during surgery and a reduction in reported pain levels. It was not possible to demonstrate if this reduction in analgesia use was associated with any other clinical benefit. REVIEWER'S CONCLUSIONS Because of the small number of patients included in this review and the differing type of nerve blocks and timing of insertion, it is not possible to determine if nerve blocks confer any significant benefit when compared with other analgesic methods as part of the treatment of a hip fracture. Further trials with larger numbers of patients and full reporting of clinical outcomes would be justified.

Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures

Background The Nottingham Hip Fracture Score (NHFS) was developed and validated in a single centre in 2007 as a predictor of 30 day mortality. It has subsequently been shown to predict longer term and functional outcomes. We wished to assess the ability of NHFS to predict outcomes in other centres and to investigate the change in outcome after hip fracture over time. Methods The NHFS was calculated for all patients with data from three UK hip fracture units: Peterborough (1992–2009), Brighton (2008–9), and Nottingham (2000–9) including 4804, 585, and 1901 patients, respectively. The logistic regression was used to recalibrate the NHFS to 30 day mortality across the three units using a random selection of 50% of the data set. Calibration was assessed using the Hosmer–Lemeshow goodness of fit. Results The median (inter-quartile range) NHFS values were Peterborough [4.0 (1–6)], Brighton [5.0 (3–7)], and Nottingham [5.0 (3–7)]. There was no correlation between 30 day mortality and time (R2=0.05, P=0.115). The proportion of patients with NHFS≥4 showed a weak correlation with time (R2=0.2, P=0.003). The original NHFS equation overestimates mortality in the higher-risk groups. A modified equation shows good calibration for all three centres {30 day mortality (%)=100/1+e[(5.012×(NHFS×0.481)]}. The hospital was not a predictor of 30 day mortality. Conclusions The NHFS, with an updated equation, is a robust predictor of 30 day mortality after hip fracture repair in geographically distinct UK centres.

R. Griffiths

Papers

General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials.

Management of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain and Ireland.

Projected incidence of proximal femoral fracture in England: a report from the NHS Hip Fracture Anaesthesia Network (HIPFAN).

Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures

Nottingham Hip Fracture Score: longitudinal and multi-centre assessment