Development of a Core Outcome Set for studies evaluating the effects of anaesthesia on perioperative morbidity and mortality following hip fracture surgery.

BACKGROUND: Perioperative studies of patients following hip fracture have large heterogeneity within their reported outcomes. This study aimed to develop a core outcome set for use in perioperative studies comparing the types of anaesthesia for hip fracture surgery. METHODS: The consensus process consisted of a systematic review of the literature, three rounds of a Delphi survey, two consensus webinars, and face-to-face patient meetings. RESULTS: The Delphi participants represented nine stakeholder groups. The numbers of participants completing Rounds 1-3 were 242, 186, and 169, respectively. Seventeen outcomes that met the predefined consensus criteria were considered at two consensus meetings. A final set of 10 core outcomes was agreed: mortality, time from injury to surgery, acute coronary syndrome, hypotension, acute kidney injury, delirium, pneumonia, orthogeriatric input, being out of bed at day 1, and pain. CONCLUSIONS: We generated a consensus-based set of core outcomes recommended for use in all perioperative trials evaluating the effects of anaesthesia for hip fracture surgery. An important next step is developing consensus-based consistency on how they should be measured. CLINICAL TRIAL REGISTRATION: http://www.comet-initiative.org/studies/details/757.

Perioperative outcomes in the context of mode of anaesthesia for patients undergoing hip fracture surgery: systematic review and meta-analysis.

BACKGROUND: Previous meta-analyses on the anaesthetic management of patients undergoing surgery for hip fracture have focused on randomized trials. Furthermore, heterogeneity in outcome reporting across the studies has made it difficult to inform best practice guidelines for patient care. METHODS: This systematic review examined how perioperative outcomes were reported and defined in the context of comparing modes of anaesthesia for hip fracture surgery. Outcomes were included from randomised and non-randomised studies published between January 2000 and July 2017. Meta-analyses were performed for regional versus general anaesthesia, with sensitivity analyses performed for spinal versus general anaesthesia. RESULTS: By including data from 15 large observational studies in this meta-analysis, we have increased the number of patients for whom outcomes were assessed from approximately 3000 to 202 000. There was no significant difference in 30-day mortality (OR 1.02; 95% CI 0.96, 1.07, I2 31%; n=200 616), prevalence of pneumonia (OR 1.07; 95% CI 0.94, 1.23, I2 34%; n=65 011), acute myocardial infarction (OR 0.96; 95% CI 0.88, 1.04, I2 0%, n=64 904), delirium (OR 1.07; 95% CI 0.72, 1.58, I2 93%, n=19 923), or renal failure (OR 0.94; 95% CI 0.54, 1.64, I2 0%, n=27 873) for regional compared with general anaesthesia [corrected]. There was a small statistically significant difference for length of stay (standardized mean difference -0.03; 95% CI -0.05, -0.02; I2 0%; n=78 711) favouring regional anaesthesia, which is unlikely to be clinically significant. Sensitivity analyses for the same outcomes examining spinal only vs general anaesthesia showed minor statistical significance for length of stay favouring spinal. We also present data highlighting the scale of the inconsistencies in reported outcomes across 32 studies, making evaluation in a standardized manner very difficult. As an example, mortality was reported in nine different ways throughout the studies. CONCLUSIONS: We highlight the need for agreement on outcome definitions and for a minimum core outcome set to be measured and reported in hip fracture studies. This would strengthen the evidence-based approach to delivering optimal care.

Management of 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) decisions in the perioperative period.

It is increasingly common for patients to be scheduled for anaesthesia and surgery with a 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) decision in place. Updated guidelines for the implementation and management of DNACPR decisions were published jointly by the British Medical Association (BMA), the Resuscitation Council (UK) and the Royal College of Nursing (RCN) in 2014 (BMA, RC(UK), RCN 2014). The Association of Anaesthetists of Great Britain and Ireland (AAGBI) published specific guidelines in 2009 to guide the perioperative management of such patients (AAGBI 2009). In this article, we explain these guidelines with a focus on how DNACPR decisions are made and how they can be modified in order to permit appropriate surgery to take place.

A comparison of three variable performance devices for postoperative oxygen therapy.

Eleven patients in the intensive care unit following major abdominal surgery with a nasogastric tube in situ and receiving oxygen via facemask were allocated to receive in a random sequence oxygen at 4 l.min-1 via a Hudson mask, nasal cannulae or a nasal catheter with foam collar at the distal end. A significantly greater PaO2 was achieved using both the nasal catheter with foam collar (p < 0.01) and Hudson mask (p < 0.05) compared to the nasal cannulae. There were no significant differences in the PaCO2 or SpO2 values obtained between the devices. In the majority of postoperative patients in whom a variable performance device is indicated, nasal devices appear preferable in terms of patient comfort and compliance. The nasal catheter with foam collar produced a significantly greater PaO2 than nasal cannulae in patients with a nasogastric tube in situ.