Anaesthesia for emergency and elective hip surgery

403 Pages·2015·4.73 MB·English

Kearns, Rachel Joyce (2015) Anaesthesia for emergency and elective hip
surgery: improving patient outcomes. MD thesis.

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

Thesis by
Rachel Joyce Kearns
MBChB, MRCP (UK), FRCA

Submitted for the degree of Doctor of Medicine

To
The University of Glasgow

From

Anaesthesia, Pain and Critical Care Medicine,
GRI Campus,
School of Medicine,
College of Medical, Veterinary and Life Sciences,
University of Glasgow
August 2015
2

Acknowledgement
I am greatly indebted to Professor John Kinsella for the opportunity to perform
this work and for his patience, expert guidance and encouragement throughout.
I am grateful to the European Society for Regional Anaesthesia and Pain Therapy
for providing funding for the randomised controlled trial described in this thesis.
I would like to acknowledge and thank Dr Alan Macfarlane, Dr Andrew Grant, Dr
Paul Harrison and Dr Kathryn Puxty for their help with recruitment when I was
unavailable to do it myself during external rotations and more recently, while on
maternity leave. I am grateful to Dr Keith Anderson for his ideas and advice and
without whom this study would not have taken place, and to Dr Tara Quasim
whose infectious enthusiasm and guidance has motivated me throughout.
I am indebted to the orthopaedic surgeons at Glasgow Royal Infirmary, in
particular, Mr. Roland Ingram and Mr. Andrew Stark for agreeing to allow me to
recruit patients from their operating lists. I am also very grateful to my
anaesthetic colleagues, in particular Dr Stephen Hickey, Dr Colin Rae and Dr
Traven McLintock who performed the spinal injections in the study and who have
been hugely supportive. Thanks must also go to Dr Bill Macrae who has provided
departmental backing for this work.

I would like to thank Dr Martin Shaw for his statistical advice and Dr Laura Moss
for her input into the role of computing science in the implementation of clinical
guidelines. I am indebted to Dr Gilda Piaggio PhD (Honorary Professor Medical
Statistics Department, London School of Hygiene and Tropical Medicine, London,
UK) and to Dr Janet Wittes PhD (Statistics Collaborative, Inc., Washington DC)
for their expert advice in the interpretation of the analyses pertaining to the
Primary Outcome of 24 hour morphine consumption.

I am grateful to Miss Katherine Cameron whom I supervised during an
intercalated BSc degree. She performed the data collection and analysis for the
work on outcomes in hip fracture surgery in Glasgow Royal Infirmary under my
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direction. She also designed the graphics used in the protocol to guide
management in patients taking warfarin and requiring hip fracture repair.
I would like to give special thanks to the orthopaedic nursing staff and
physiotherapists of ward 62, Glasgow Royal Infirmary who provided a high level
of post-operative care to the study patients.
Finally, I would like to thank my family who have supported me throughout. This
thesis is dedicated to them and my new family, Paul and Hamish who encourage
and motivate me every day.

Word Count
74,072 (excluding Appendices)
4

Author’s Declaration
The work described in this thesis was carried out by me while I was employed as
an StR on the West of Scotland School of Anaesthesia training scheme and
latterly, as a Consultant Anaesthetist in Glasgow Royal Infirmary. This work was
performed between May 2011 and January 2015.
The majority of patient recruitment was performed by me. The remainder of
patient recruitment was performed by colleagues who are acknowledged in this
thesis. Data collection and data analysis for the work on hip fracture outcomes
and warfarin management in GRI was collected by Miss Katherine Cameron, a 3rd
year medical student whom I supervised during an intercalated BSc degree. The
concept for this work was my own. Ongoing data collection, analysis and quality
improvement work were performed by myself.
The remainder of the work was carried out by myself. The writing of the thesis
was entirely my own work.
The review of clinical guidelines for hip fracture was published in the journal
Anaesthesia, 2013 and the protocol for the study; “Intrathecal opioid versus
ultrasound guided fascia iliaca block for total hip arthroplasty – a randomised,
controlled, double blind, non-inferiority study” was published in the journal
Trials 2011.

R Kearns
August 2015
5

Table of Contents
Anaesthesia for emergency and elective hip surgery: improving patient outcomes. ........................ 1
Acknowledgement .............................................................................................................................. 2
Word Count ......................................................................................................................................... 3
Author’s Declaration ........................................................................................................................... 4
List of Figures .................................................................................................................................... 14
Abstract ............................................................................................................................................. 16
Grants ................................................................................................................................................ 19
Publications ....................................................................................................................................... 19
Peer reviewed correspondence ........................................................................................................ 19
Abstracts ........................................................................................................................................... 20
Presentations .................................................................................................................................... 20
Definitions / Abbreviations ............................................................................................................... 22
PART 1 ............................................................................................................................................... 27
Chapter 1 ........................................................................................................................................... 27
Introduction ...................................................................................................................................... 27
1.1 The ageing population and societal expectations on health care delivery....................... 28
1.2 The global burden of disease ............................................................................................ 31
1.3 Femoral pathology in adults. Why is it associated with ageing? ...................................... 33
1.3.1 Osteoporosis ............................................................................................................. 33
1.3.2 Degenerative hip disease and osteoarthritis ............................................................ 34
1.4 The medical profession and the difficulties with this patient group. ............................... 35
1.4.1 Frailty......................................................................................................................... 37
1.4.2 Deprivation and “The Glasgow Effect” ..................................................................... 38
1.5 Peri-operative risk stratification ....................................................................................... 40
1.5.1 The Nottingham Hip Fracture Score ......................................................................... 42
1.6 Chapter 1 Summary .......................................................................................................... 46
Chapter 2 ........................................................................................................................................... 47
Evidence to date – Emergency surgery for fractured femur ............................................................ 47
2.1 Burden to the NHS and expected projections .................................................................. 48
2.2 Emergency surgery – proximal femoral fracture .............................................................. 50
2.2.1 Anatomy of the hip joint ........................................................................................... 51
2.2.2 Types of femoral fracture.......................................................................................... 54
2.3 National Audits of proximal femoral fracture ................................................................... 56
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2.3.1 The National Hip Fracture Database ......................................................................... 56
2.3.2 Scottish Hip Fracture Audit ....................................................................................... 57
2.3.3 The Hip Fracture Peri-operative Network ................................................................. 59
2.4 Chapter 2 Summary .......................................................................................................... 63
Chapter 3 ........................................................................................................................................... 64
Anticoagulation in the peri-operative period. .................................................................................. 64
3.1 Thromboprophylaxis ......................................................................................................... 65
3.1.1 Mechanical compression devices.............................................................................. 65
3.1.2 Heparin ...................................................................................................................... 66
3.1.3 Aspirin ....................................................................................................................... 67
3.1.4 Fondaparinux ............................................................................................................ 67
3.1.5 Dabigatran ................................................................................................................. 69
3.1.6 Rivaroxaban ............................................................................................................... 70
3.2 Warfarin in the peri-operative period .............................................................................. 70
3.2.1 Monitoring of warfarin therapy ................................................................................ 70
3.2.2 Management strategies for warfarin in the peri-operative period .......................... 71
3.3 Guidelines for the management of warfarin in the peri-operative period ....................... 72
3.4 Management of warfarin in patients undergoing repair of proximal femoral fracture ... 74
3.4.1 The role of bridging therapy ..................................................................................... 75
3.5 Chapter Summary ............................................................................................................. 79
Chapter 4 ........................................................................................................................................... 80
Clinical Practice Guidelines and their role in the management of hip fracture................................ 80
4.1 Clinical Practice Guidelines ............................................................................................... 81
4.1.1 Problems with guidelines – volume of information .................................................. 81
4.1.2 Problems with guidelines - methodology ................................................................. 82
4.1.3 Problems with guidelines – conflict .......................................................................... 84
4.1.4 Problems with guidelines - applicability ................................................................... 85
4.1.5 Problems with guidelines - adherence ...................................................................... 86
4.1.6 Problems with guidelines – accessibility and reliability ............................................ 87
4.2 A comparison of clinical practice guidelines for proximal femoral fracture ..................... 87
4.2.1 Background ............................................................................................................... 87
4.2.2 Methods .................................................................................................................... 88
4.2.3 Results ....................................................................................................................... 88
4.2.4 General recommendations and timeline .................................................................. 89
4.2.5 Analgesia ................................................................................................................... 89
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4.2.6 Anaesthesia ............................................................................................................... 90
4.2.7 Anticoagulation and antiplatelet therapy ................................................................. 91
4.2.8 Cardiac murmur and anaemia ................................................................................... 93
4.2.9 Discussion .................................................................................................................. 96
4.2.10 Competing interests ................................................................................................ 100
4.3 Chapter 4 Summary ........................................................................................................ 101
Chapter 5 ......................................................................................................................................... 102
A one year retrospective audit of the management of patients with hip fracture in Glasgow Royal
Infirmary .......................................................................................................................................... 102
5.1 Rationale ......................................................................................................................... 103
5.2 Methods .......................................................................................................................... 103
5.3 Results ............................................................................................................................. 105
5.3.1 Benchmarking data from GRI against national data ............................................... 105
5.3.2 Patients admitted to Intensive Care Unit................................................................ 107
5.4 Discussion ........................................................................................................................ 109
5.4.1 Glasgow Royal Infirmary versus National Data ....................................................... 109
5.4.2 Subgroups of interest - Intensive Care Unit: ........................................................... 111
5.5 Limitations ....................................................................................................................... 112
5.5.1 Anaesthesia Sprint Audit of Practice ....................................................................... 113
5.6 Conclusions ..................................................................................................................... 114
5.7 Chapter 5 Summary ........................................................................................................ 115
Chapter 6 ......................................................................................................................................... 116
An audit of the management of patients taking warfarin and admitted with hip fracture in
Glasgow Royal Infirmary ................................................................................................................. 116
6.1 Rationale and methods ................................................................................................... 117
6.2 Analysis of results ............................................................................................................ 118
6.3 Discussion ........................................................................................................................ 121
6.4 Design of a protocol to direct management in patients on warfarin undergoing surgical
repair of hip fracture .................................................................................................................. 122
6.4.1 Re-audit results ....................................................................................................... 125
Chapter 6 Summary .................................................................................................................... 128
PART 2 ............................................................................................................................................. 129
Chapter 7 ......................................................................................................................................... 129
Elective total hip arthroplasty - evidence to date ........................................................................... 129
7.1 Total Hip Athroplasty ...................................................................................................... 130
7.1.1 Epidemiology and burden of disease ...................................................................... 130
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7.1.2 Surgical procedure .................................................................................................. 132
7.1.3 Outcomes in total hip arthroplasty ......................................................................... 132
7.1.4 Cost effectiveness of total hip arthroplasty ............................................................ 134
7.2 Chapter 7 Summary ........................................................................................................ 136
Chapter 8 ......................................................................................................................................... 137
Anaesthesia for Total Hip Arthroplasty ........................................................................................... 137
8.1 Subarachnoid block ......................................................................................................... 138
8.1.1 Spinal opioids .......................................................................................................... 138
8.2 Peripheral Nerve Blockade .............................................................................................. 143
8.3 Femoral Nerve Block and “3 in 1 block” ......................................................................... 143
8.3.1 Femoral Nerve Block – Technique using peripheral nerve stimulation .................. 145
8.3.2 Femoral Nerve Block – Ultrasound Guided technique ........................................... 145
8.3.3 “3 in 1” Block ........................................................................................................... 147
8.4 Femoral and “3 in 1 nerve blocks” – literature review ................................................... 147
8.4.1 Quality Scoring ........................................................................................................ 148
8.4.2 Results ..................................................................................................................... 149
8.4.3 Discussion – femoral nerve block and “3 in 1” block .............................................. 158
8.5 Lumbar (or Psoas) Plexus Block ...................................................................................... 158
8.5.1 Lumbar plexus block – Technique using peripheral nerve stimulation .................. 159
8.5.2 Lumbar (psoas) plexus block – literature review .................................................... 161
8.5.3 Results ..................................................................................................................... 163
8.5.4 Lumbar plexus block - discussion ............................................................................ 176
8.6 Sciatic Nerve Block .......................................................................................................... 176
8.6.1 Sciatic nerve block – Technique using peripheral nerve stimulation ..................... 177
8.6.2 Sciatic nerve block – ultrasound guided technique ................................................ 179
8.6.3 Literature review – sciatic nerve block ................................................................... 179
8.6.4 Results ..................................................................................................................... 180
8.6.5 Discussion ................................................................................................................ 183
8.7 Fascia iliaca block ............................................................................................................ 183
8.7.1 Fascia ilaca block – landmark technique ................................................................. 184
8.7.2 Fascia iliaca block – ultrasound guided technique .................................................. 185
8.7.3 Literature review – Fascia iliaca block..................................................................... 185
8.7.4 Results ..................................................................................................................... 186
8.7.5 Discussion – fascia iliaca block ................................................................................ 190
8.8 Chapter 8 Summary ........................................................................................................ 191
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Chapter 9 ......................................................................................................................................... 192
Spinal opioid versus ultrasound guided fascia iliaca plane block for analgesia after primary hip
arthroplasty: study protocol for a randomised, blinded, non-inferiority controlled trial .............. 192
9.1 Background ..................................................................................................................... 193
9.2 Methods / Design ............................................................................................................ 194
9.2.1 Overview ................................................................................................................. 194
9.2.2 Hypothesis ............................................................................................................... 194
9.2.3 Objectives ................................................................................................................ 195
9.2.4 Primary outcome ..................................................................................................... 195
9.2.5 Secondary outcomes ............................................................................................... 195
9.2.6 Study centre ............................................................................................................ 197
9.2.7 Patients and enrolment .......................................................................................... 197
9.2.8 Consent ................................................................................................................... 197
9.2.9 Randomisation ........................................................................................................ 198
9.2.10 Blinding.................................................................................................................... 199
9.2.11 Intra-operative management .................................................................................. 200
9.2.12 Postoperative management .................................................................................... 200
9.2.13 Criteria for discontinuation ..................................................................................... 201
9.2.14 Data Collection ........................................................................................................ 201
9.2.15 Sample Size and Statistical Considerations ............................................................. 201
9.2.16 Adverse Event Reporting and Safety ....................................................................... 203
9.3 Discussion ........................................................................................................................ 204
9.3.1 Risk Benefit Assessment.......................................................................................... 204
Chapter 10 ....................................................................................................................................... 207
Statistical considerations ................................................................................................................ 207
10.1 Non-inferiority................................................................................................................. 208
10.1.1 Hypotheses in a non-inferiority trial ....................................................................... 208
10.1.2 Study design ............................................................................................................ 209
10.1.3 Analysis .................................................................................................................... 209
10.1.4 Interpretation of results .......................................................................................... 211
10.1.5 Statistical software ‘R studio’ .................................................................................. 213
10.1.6 Statistical considerations for the study: Spinal opioid versus ultrasound guided
fascia iliaca plane block for analgesia after primary hip arthroplasty: a randomised, blinded,
non-inferiority controlled trial. .............................................................................................. 213
10.1.7 Linear regression ..................................................................................................... 216
10.1.8 Logistic regression ................................................................................................... 219