Big, painless step forward for hip fracture anaesthesia

A national sprint audit of anaesthesia for hip fracture surgery will be carried out in 2013, as part of a year of focus on the elderly by the Association of Anaesthetists of Great Britain and Ireland (AAGBI).

Anaesthesia issues directly relevant to elderly patients also form a large part of the AAGBI’s Winter Scientific Meeting. Hip fractures are prevalent, and on the rise, says Dr Richard Griffiths, AAGBI Honorary Secretary and lead on the Hip Fracture Anaesthesia Sprint Audit Project (ASAP). These are common and serious injuries of the elderly, associated with high morbidity and mortality, occupying a significant proportion of hospital resources, and leading to a serious financial burden to the UK’s National Health Service (NHS) and society costing an estimated £2 billion per year. Yet the evidence base for hip fracture anaesthesia is poor, with most studies having limited numbers, or seriously limiting exclusions such as patients with cognitive impairment, who make up around a third of those with hip fracture.

“There is a myriad of controversies surrounding best anaesthetic practice for this very common injury,” says Dr Amer Majeed, a member ASAP steering group. “Should echocardiography be routine? Is regional anaesthesia better or general? When to treat hypotension? What should be the threshold for blood transfusion? Should the provision of more complex care be routine? The list of questions is endless, and there is very little high quality evidence to help us answer these questions.”

The audit is a collaboration with the UK’s National Hip Fracture Database (NHFD) – the largest hip fracture audit in the world, currently holding 240,000 cases and growing at a rate of 5,000 cases per month. However, the NHFD currently collects only very limited anaesthetic data, and therefore cannot provide any detailed information about the impact of different anaesthetic techniques on outcomes. Now an AAGBI grant will allow collection of extra data specific to anaesthesia.

The ASAP project has been developing during the past year with the NHFD team and Professor Mike Grocott (University of Southampton).

 

Healthy ageing

Several speakers at the AAGBI meeting were invited specifically for their expertise on issues related to ageing. Professor Carol Jagger, of the Institute for Ageing and Health at Newcastle University, will analyse how we define healthy ageing and whether this is fit for purpose given the fastest growing section of our population is those aged 85 years and over. She will discuss the ongoing Newcastle 85+ Study, a unique longitudinal study of 849 people born in 1921 and aged 85 at first interview, in order to illustrate that today’s very old people are not all frail and dependent. The study finds that although on average, men had four diseases and women had five, 20 percent of participants were completely independent in all 17 daily activities. “This prevalence of multiple diseases or comorbidity challenges established medical practice which is focussed around single diseases,” says Jagger. She will also discuss the EU-funded project Futurage which has recently drawn up a Road Map of Ageing Research in Europe, specifying the gaps in our knowledge.

“Life expectancy looks set to continue increasing. We have to increase healthy years more than the increases in life expectancy, otherwise the result will be more years lived unhealthily and/or with disability,” said Professor Jagger. “One step in this process will be addressing the huge inequalities we have in healthy life years, not only internationally but also nationally and regionally.

“It is also important that clinical trials of therapeutic agents and procedures – including those related to anaesthesia – and lifestyle interventions should include more of the oldest old in order to build the body of evidence for effects in this age group.”

 

Biological vs chronological age

Dr Ana Valdes, King’s College London, discussed the concept of individual ageing, whereby a person’s “biological” age can be very different to their chronological age due to a various genetic, epigenetic, early developmental and environmental factors, such as smoking and obesity. This could open the doors to decisions related to anaesthesia (such as whether someone could survive a general anaesthetic safely) being based on biological age. For example, could a healthy 85-year-old be more likely to survive a major operation than a 60-year-old with many comorbidities?

“This is an everyday dilemma for anaesthetists in the UK,” said Dr Griffiths, anaesthetist at Royal Sussex Hospital. “Currently the AAGBI is updating its advice on the perioperative experience of older persons and this should be ready for publication in parallel with the ASAP results,” he concluded.

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