NDA Journal 2021

Clinical effectiveness of general versus spinal anaesthesia for short term outcomes in patients with hip fractures: Systematic Review and Meta-Analysis of recent Randomised Controlled Trials Dr Pravakar Hamal BACKGORUND: Elderly patients undergoing hip fracture surgery are at a serious risk of developing post-operative complications, especially postoperative delirium (POD). Mode of anaesthesia may influence morbidity and mortality yet there is a deficiency of high quality evidence supporting this. Systematic reviews have highlighted the lacking evidence base, however none have prioritised short term morbidity outcomes using only modern trials. METHODS: This systematic review examined the clinical efficacy of spinal versus general anaesthesia for short term postoperative outcomes (POD, new onset cardiac complications, new onset pulmonary complications, 30 day mortality and length of stay (LOS)) in hip fracture patients. Bibliographic databases were systematically searched from January 2010 to February 2021. Meta-analyses were performed, with subgroup analyses on patients > 80 years old. RESULTS: Five studies (662 patients) showed no statistically significant differences between the anaesthetic groups for POD (Relative risk (RR) 0.92, 95% Confidence interval (CI) [0.59, 1.43]), new onset cardiac complications (RR 0.42 95% CI [0.12, 1.43]), new onset pulmonary complications (RR 0.61 95% CI [0.23, 1.64]), 30 day mortality (RR 0.69 95% CI [0.25, 1.90]) or LOS (Mean difference 0.01 95% CI [-0.45, 0.47]). Subgroup analyses showed similar results. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework assessed the quality of evidence as very low for the primary outcome (POD) and low for all secondary outcomes. CONCLUSION: In hip fracture patients undergoing surgery there was insufficient evidence to determine no difference between the clinical efficacy of spinal and general anaesthesia for POD, new onset cardiopulmonary complications, 30 day mortality and LOS. IMPLICATIONS: Based on the limited evidence available, it is still challenging to determine which anaesthetic technique is superior, if any. This review emphasised the deficiency of large scale, high quality evidence in this area. By using modern trials and short term outcomes more connected to narrow anaesthetic window, this aimed to learn from the weaknesses of previous reviews. However, based on the paucity of high quality studies, similar limitations were met in outcome heterogeneity, sample size, generalisability and statistical significance. Results of large ongoing multicentre trials and research targeted towards the achievement of patient-centered, best practice anaesthetic care will provide a stronger evidence base for future guidance. BDKarki Memorial CupTrainee PresentationAbstracts An audit looking at the use of prophylactic enoxaparin (i.e., extended prophylaxis) in patients with IBD who have undergone surgical intervention. A life-saving intervention. Dr Ripak Purbe BACKGROUND: Inflammatory Bowel Disease (IBD) patients have twice the risk of venous thromboembolism compared to healthy controls. The exact etiology for this association between IBD and thromboembolism is unknown; but is thought to be due to multiple acquired and inherited factors increasing the tendency for thrombosis in the local intestinal microvasculature, as well as in the systemic circulation. We used the ECCO-ESCP (European Crohn ’ s and Colitis Organisation- European Society of Colo-Proctology) guidelines published in Consensus on Surgery for Crohn ’ s Disease (2018) as our standard. AIMS: To determine whether patients with IBD who have undergone surgical intervention have received extended pharmacological VTE prophylaxis postoperatively or not. Has it affected their predisposition to thromboembolic events? METHOD: We performed a retrospective study on the use of extended prophylactic in patients with IBD who have gone under the knife. We looked at the VTE complications such as pulmonary embolism and deep vein thrombosis. The data was collected, analyzed, and presented at clinical governance. RESULTS: A total of 268 patients were included in the audit. A shocking discovery of poor compliance with guidelines was noted. Only 11% of patients had received extended prophylaxis. 3 patients had developed VTE events during their in-patient stay; despite being on enoxaparin. This just goes on to show how significant the role of enoxaparin can be for other patients. 1 patient developed VTE within 90 days post-op. CONCLUSION/DISCUSSION: Inflammatory Bowel Disease (IBD) affects at least one in 250 people of the UK population and the prevalence is rising. Being a chronic illness; it in itself carries a huge burden for the patient. This combined with the likelihood of VTE disease post-surgery could lead to poor quality of life, increased length of hospital stays, and increased mortality. This needs to be addressed immediately. Hence, appropriate measures need to be put into place and reevaluated to assess the progress. Various measures would include: - Construction of trust guidelines to be available on the intranet. - Consultants and middle-grade doctors to ensure extended prophylaxis is a part of the discharge plan. - Liaise with the pharmacists to incorporate ECCO-ESCP guidelines in the trust and cross-check medications on NDA UK JOURNAL, JULY 2021