Anaesthesia for emergency and elective hip surgery: improving patient outcomes.

This thesis is presented in two parts. The first is concerned with the management of patients undergoing repair of hip fracture while the second part describes a randomised controlled trial examining analgesic options after total hip replacement. Musculoskeletal disease has the fourth greatest impact on the health of the world’s population (when both death and disability are considered) and is the second most common cause of disability globally. Disability due to musculoskeletal disease has risen by 45% over the last 20 years compared to the 33% average increase seen across other disease groups. This is likely to increase unless action is taken to resolve some of the problems. This has been recognised by The European Parliament Leading Committee on the Horizon 2020 Programme (the European Union Research Framework Programme) resulting in the identification of rheumatic and musculoskeletal conditions as a priority for research over the next 7 years. Glasgow Royal Infirmary is a tertiary referral centre for orthopaedic and trauma surgery undertaking a high volume of both elective and emergency procedures each year. I wished to investigate current standards of care relating to patients undergoing emergency surgery and to establish whether by benchmarking our practice against national data, we could identify areas for improvement. Hip fracture repair was chosen for analysis as it is a common, serious and costly condition that occurs in an increasingly elderly, frail and dependent patient population. Hip fracture is a worldwide concern and a significant public health challenge. Important patient outcomes such as time to theatre, 30 day mortality and length of stay were analysed and compared against national audit data. These data compared favourably. Prior to commencing this work, staff members were asked to communicate any opportunities they saw for care to be improved. Certain sub-populations were identified by staff as meriting particular attention. These were patients admitted to ICU and patients taking warfarin. The sub-population of patients who were taking warfarin and required admission for repair of hip fracture were particularly frail and resulted in a number of management challenges for staff. A quality improvement endeavour was employed in order to standardise management, reduce confusion, expedite time to theatre and ensure adequate thromboprophylaxis throughout the peri-operative period. This work resulted in the production of a protocol to guide management and is subject to ongoing review and audit. The role of anaesthesia in the performance of elective total hip replacement surgery was also investigated. Total hip replacement is one of the most commonly performed surgical procedures in the United Kingdom, can result in improved quality of life, and is considered to be cost effective. In Glasgow Royal Infirmary, anaesthesia is most commonly performed using spinal anaesthetic with the addition of an opioid. Spinal opioids, whilst effective, are associated with side-effects of which the most serious is respiratory depression. Other adverse effects such as pruritus and nausea and vomiting may delay recovery and impact upon a patient’s satisfaction with their experience. I carried out a randomised controlled, double blinded trial to assess whether a regional anaesthetic technique (ultrasound guided fascia iliaca block) could be used as an alternative to spinal morphine. This technique has not yet been assessed clinically in the published literature, though it has shown promise as being more reliable when compared to the landmark based technique. A non-inferiority design was employed in order to compare these two techniques. The primary outcome was 24 hour intravenous morphine consumption. After obtaining the necessary approvals from the West of Scotland Research and Ethics Committee and the West of Scotland Research and Development Department, recruitment was commenced in May 2011. Peer review was received from a journal of trial methodology and the protocol was published. Further peer review and funding was received from the European Society for Anaesthesia and Pain Therapy as well as a local peri-operative research fund. This study shows that ultrasound guided fascia iliaca block is not non-inferior to spinal morphine, or in other words, that ultrasound guided fascia iliaca block is unacceptably worse than spinal morphine in the provision of analgesia after hip replacement. Adverse effects were not statistically significantly different between groups and reassuringly, there were no episodes of respiratory depression or sedation in either group. This study has clear implications for practice and would suggest that spinal morphine remains an effective anaesthetic and analgesic agent in this patient group

Neonatal and early childhood outcomes following maternal anesthesia for cesarean section: a population-based cohort study

Background: The fetus is vulnerable to maternal drug exposure. We determined associations of exposure to spinal, epidural, or general anesthesia on neonatal and childhood development outcomes during the first 1000 days of life. Methods: Population-based study of all singleton, cesarean livebirths of 24+0 to 43+6 weeks gestation between January 2007 and December 2016 in Scotland, stratified by urgency with follow-up to age 2 years. Models were adjusted for: maternal age, weight, ethnicity, socioeconomic status, smoking, drug-use, induction, parity, previous cesarean or abortion, pre-eclampsia, gestation, birth weight, and sex. Results: 140 866 mothers underwent cesarean section (41.2% (57,971/140,866) elective, 58.8% (82,895/140,866) emergency) with general anesthesia used in 3.2% (1877/57,971) elective and 9.8% (8158/82,895) of emergency cases. In elective cases, general anesthesia versus spinal was associated with: neonatal resuscitation (crude event rate 16.2% vs 1.9% (adjusted RR 8.20, 95% CI 7.20 to 9.33), Apgar <7 at 5 min (4.6% vs 0.4% (adjRR 11.44, 95% CI 8.88 to 14.75)), and neonatal admission (8.6% vs 4.9% (adjRR 1.65, 95% CI 1.40 to 1.94)). Associations were similar in emergencies; resuscitation (32.2% vs 12.3% (adjRR 2.40, 95% CI 2.30 to 2.50)), Apgar <7 (12.6% vs 2.8% (adjRR 3.87, 95% CI 3.56 to 4.20), and admission (31.6% vs 19.9% (adjRR 1.20, 95% CI 1.15 to 1.25). There was a weak association between general anesthesia in emergency cases and having ≥1 concern noted in developmental assessment at 2 years (21.0% vs 16.5% (adjRR 1.08, 95% CI 1.01 to 1.16)). Conclusions: General anesthesia for cesarean section, irrespective of urgency, is associated with neonatal resuscitation, low Apgar, and neonatal unit admission. Associations were strongest in non-urgent cases and at term. Further evaluation of long-term outcomes is warranted

International consensus on anatomical structures to identify on ultrasound for the performance of basic blocks in ultrasound-guided regional anesthesia

There is no universally agreed set of anatomical structures that must be identified on ultrasound for the performance of ultrasound-guided regional anesthesia (UGRA) techniques. This study aimed to produce standardized recommendations for core (minimum) structures to identify during seven basic blocks. An international consensus was sought through a modified Delphi process. A long-list of anatomical structures was refined through serial review by key opinion leaders in UGRA. All rounds were conducted remotely and anonymously to facilitate equal contribution of each participant. Blocks were considered twice in each round: for "orientation scanning" (the dynamic process of acquiring the final view) and for the "block view" (which visualizes the block site and is maintained for needle insertion/injection). Strong recommendations for inclusion were made if ≥75% of participants rated a structure as "definitely include" in any round. Weak recommendations were made if >50% of participants rated a structure as "definitely include" or "probably include" for all rounds (but the criterion for "strong recommendation" was never met). Thirty-six participants (94.7%) completed all rounds. 128 structures were reviewed; a "strong recommendation" is made for 35 structures on orientation scanning and 28 for the block view. A "weak recommendation" is made for 36 and 20 structures, respectively. This study provides recommendations on the core (minimum) set of anatomical structures to identify during ultrasound scanning for seven basic blocks in UGRA. They are intended to support consistent practice, empower non-experts using basic UGRA techniques, and standardize teaching and research. [Abstract copyright: © American Society of Regional Anesthesia & Pain Medicine 2021. No commercial re-use. See rights and permissions. Published by BMJ.

Recommendations for anatomical structures to identify on ultrasound for the performance of intermediate and advanced blocks in ultrasound-guided regional anesthesia

Recent recommendations describe a set of core anatomical structures to identify on ultrasound for the performance of basic blocks in ultrasound-guided regional anesthesia (UGRA). This project aimed to generate consensus recommendations for core structures to identify during the performance of intermediate and advanced blocks. An initial longlist of structures was refined by an international panel of key opinion leaders in UGRA over a three-round Delphi process. All rounds were conducted virtually and anonymously. Blocks were considered twice in each round: for ``orientation scanning'' (the dynamic process of acquiring the final view) and for ``block view'' (which visualizes the block site and is maintained for needle insertion/injection). A ``strong recommendation'' was made if \geq75% of participants rated any structure as ``definitely include'' in any round. A ``weak recommendation'' was made if >50% of participants rated it as ``definitely include'' or ``probably include'' for all rounds, but the criterion for strong recommendation was never met. Structures which did not meet either criterion were excluded. Forty-one participants were invited and 40 accepted; 38 completed all three rounds. Participants considered the ultrasound scanning for 19 peripheral nerve blocks across all three rounds. Two hundred and seventy-four structures were reviewed for both orientation scanning and block view; a ``strong recommendation'' was made for 60 structures on orientation scanning and 44 on the block view. A ``weak recommendation'' was made for 107 and 62 structures, respectively. These recommendations are intended to help standardize teaching and research in UGRA and support widespread and consistent practice