Hip fracture specialists facilitate low-dose spinal anaesthesia in fractured neck of femur surgery.

Fractured neck of femur is a common but potentially devastating complication of frailty. In other surgical specialities, there is an inverse relationship between surgical experience and duration of surgery; however, this has not been quantified in hip trauma. In perioperative hip fracture care, prolonged surgery may be associated with increased morbidity and significantly impacts on the conduct of anaesthesia. Specifically, low-dose spinal anaesthesia, which is associated with improved haemodynamic stability, cannot be used if surgery is likely to be prolonged. We studied the duration of hip fracture surgery undertaken in our institution and compared this to surgical expertise. We retrospectively explored our theatre database to identify patients who underwent hip fracture surgery in our hospital over a 62-month period, recording duration of surgery and primary operating surgeon. Surgeons were classified into one of 3 groups: Consultant hip surgeon (specialist interest in hip surgery), Consultant orthopaedic surgeon but non-hip specialist, or Non-consultant (trainee or non-training grade). We identified 1426 hip fracture procedures. Consultant hip surgeons performed all types of hip fracture surgery faster, and with reduced variation in surgical duration, than did either non-hip specialist consultants or non-consultant grades. Consultant hip surgeons consistently performed hip fracture surgery in under 60 minutes. Specialist consultant hip surgeons make low-dose spinal anaesthesia (with shorter block duration but increased haemodynamic stability) feasible. Our data supports the development of dedicated hip fracture trauma lists where patients should be operated on by specialist hip surgeons or trainees directly under their supervision.

The Effect of Frailty on Long Term Outcomes in Vascular Surgical Patients.

OBJECTIVE: Frailty is a multidimensional vulnerability due to age associated decline. The impact of frailty on long term outcomes was assessed in a cohort of vascular surgical patients. METHODS: Patients aged over 65 years with a length of stay greater than two days admitted to a tertiary vascular unit over a single calendar year were included. Demographics, mode of admission, and diagnosis were recorded alongside a variety of frailty specific characteristics. Using the previously developed Addenbrookes Vascular Frailty Score (AVFS - 6 point score: anaemia on admission, lack of independent mobility, polypharmacy, Waterlow score > 13, depression, and emergency admission) the effect of frailty on five year mortality and re-admission rates was assessed using multivariable regression techniques. The AVFS was further refined to assess longer term outcomes. RESULTS: In total, 410 patients (median age 77 years) were included and followed up until death or five years from the index admission. One hundred and thirty-four were treated for aortic aneurysm, 75 and 96 for acute and chronic limb ischaemia respectively, 52 for carotid disease, and 53 for other pathologies. The in hospital mortality rate was 3.6%. The one, three, and five year survival rates were 83%, 70% and 59%; and the one, three, and five year re-admission free survival rates were 47%, 29%, and 22% respectively. Independent predictors of five year mortality were age, lack of independent mobility, high Charlson score, polypharmacy, evidence of malnutrition, and emergency admission (p < .010 for all). Patients with AVFS 0 or 1 had restricted mean survival times which were one year longer than those with AVFS 2 or 3 (p < .001), who in turn had restricted mean survival times over one year longer than those with AVFS of 4 or more (p < .001). CONCLUSION: Frailty factors are strong predictors of long term outcomes in vascular surgery. Further prospective studies are warranted to investigate its utility in clinical decision making.

The seven P's in battalion level combat health support in the Military Operations in Urban Terrain environment: the Fallujah experience, summer 2003 to spring 2004.

Combat health support in the Military Operations in Urban Terrain (MOUT) environment represents a common challenge on today's battlefield. We identified seven key aspects of battalion level health support which required consideration before combat operations in this type of environment. We called these the "seven P's" of combat health support: prevention, proportion, preparation, portability, proximity, protection, and projection. We developed an easy to use framework for using these principles to quickly develop combat health support plans during periods of high operations tempo.