Delay in detection and treatment of perioperative anemia in hip fracture surgery and its impact on postoperative outcomes.

BACKGROUND: Elderly patients with hip fractures are at high risk for perioperative anemia as a result of fracture- and surgery-related blood loss. The detection of anemia is dependent on intermittent blood samples and therefore might be delayed, potentially leading to a significant delay in transfusion. This study aimed to investigate the possible delay in perioperative anemia detection, accumulated perioperative anemia-associated burden, peripheral perfusion, and their association with patient outcomes in elderly patients with hip fracture. METHODS: Elderly patients with acute hip fracture scheduled for surgery were enrolled in this prospective study from August 2016 to December 2016. All patients were monitored continuously for hemoglobin concentration (SpHb) and perfusion index (PI) with the Radical-7® Pulse CO-Oximeter® and Rainbow® R1 Adhesive Multi-parameter Sensors (Masimo Corp., Irvine, CA, US) from 12 h presurgery to 24 h postsurgery. RESULTS: Fifty-one patients were enrolled, and 41 were included in the final analyses. Mean delay in the detection of low Hb (<10 g/dL) using intermittent blood samples, when compared with SpHb, was 1.07 h (standard deviation, ±2.84 h). Median perioperative cumulated time with low SpHb (<10 g/dL for at least one min) was 25 min (interquartile range [IQR]: 21-690). There was a significant association between perioperative time with low SpHb and the occurrence of postoperative delirium (median cumulated time with low SpHb: 162 min in patients with delirium vs 22 min in patients without delirium, P = 0.034) and a nonsignificant trend for an association between perioperative time with low SpHb and 90-day mortality or medical complications (median cumulated time with low SpHb: 119 min for patients with mortality or severe complication vs 22 min for patients without mortality or severe complication, P = 0.104). PI values during the perioperative period were not significantly associated with patient outcomes. Cumulated time with low PI (<0.5) preoperatively (but not perioperatively) was significantly associated with the occurrence of postoperative delirium (P = 0.047). CONCLUSIONS: This study showed a delay in transfusion threshold detection, and the presence of significant associations between low SpHb or time with low SpHb and postoperative outcomes.

Methylprednisolone and inflammatory stress response in older people undergoing surgery for hip fracture: a secondary analysis of a randomized controlled trial.

PURPOSE: The inflammatory response to surgery can cause organ dysfunction that results in postoperative complications, including delirium. Methylprednisolone is an anti-inflammatory drug and could mitigate stress responses. This purpose of the study is to investigate the effects of a single high-dose methylprednisolone on various biomarkers in older people undergoing surgery for hip fractures. METHODS: In the primary study, 117 patients were included. The biomarkers investigated in this secondary analysis were interleukin (IL) -6, IL-10, troponin-T (TnT), tumor necrosis factor alpha (TNF-α), S100 calcium-binding protein B, and soluble urokinase-type plasminogen activator receptor. Blood samples were collected at four time points: (1) before the study intervention (Tbefore); (2) at time of surgery (Tsurgery); on the (3) 1st and (4) 3rd postoperative day (TP1 and TP3, respectively). RESULTS: Patients in the methylprednisolone group had significantly lower adjusted mean IL-6 at Tsurgery and TP1 than the placebo group [15.60 (1.13 pg/mL) vs 47.86 (1.12 pg/mL), p < 0.000 and 111.01 (31.64 pg/mL) vs 198.57 (24.00 pg/mL), p = 0.005]. Furthermore, adjusted mean TnT levels at Tsurgery were lower in the methylprednisolone group [20.61 (1.14 ng/mL) vs 24.28 (1.12 ng/mL), p = 0.024) as well as adjusted mean TNF-α levels TP1 (14.31 (1.08 pg/mL) vs 17.64 (1.04 pg/mL), p = 0.025]. CONCLUSIONS: In this secondary analysis, methylprednisolone had a significant effect on three biomarkers (IL-6, TnT, and TNF-α). The potential beneficial effects of methylprednisolone on inflammatory biomarkers reflecting surgical stress response in patients with hip fractures need to be investigated further.

Fatigue and pain limit independent mobility and physiotherapy after hip fracture surgery.

PURPOSE: The patient's ability to complete their planned physiotherapy session after hip fracture surgery has been proposed as an independent predictor for achieving basic mobility independency upon hospital discharge. However, knowledge of factors limiting mobility is sparse. We therefore examined patient reported factors limiting ability to complete planned physiotherapy sessions as well as limitations for not achieving independency in basic mobility early after hip fracture surgery. METHODS: A total of 204 consecutive patients with a hip fracture (mean (SD) age of 80 (9.9) years, 47 patients were admitted from a nursing home) were treated in accordance with a multimodal program. The Cumulated Ambulation Score was used to evaluate the patient's independency in three basic mobility activities: getting in and out of bed, sit-to-stand-to-sit from a chair and indoor walking. Pre-defined limitations; pain, motor blockade, dizziness, fatigue, nausea, acute cognitive dysfunction and "other limitations", for not achieving a full Cumulated Ambulation Score or inability to complete planned physiotherapy sessions were noted by the physiotherapist on each of the three first postoperative days. This period was chosen, because of its importance on how well the patients had regained their pre-fracture functional level. RESULTS: Fatigue and hip fracture-related pain were the most frequent reasons for patients not achieving an independent basic mobility level (> 85%) or not fully completing their planned physiotherapy (> 42%) on all three days. At hospital discharge (median day 10), only 54% of the patients had regained their pre-fracture basic mobility level. CONCLUSION: Based on the patient's perception, fatigue and pain are the most frequent limitations in not achieving independent basic mobility and not completing physiotherapy after hip fracture surgery. This raises questions whether multimodal peri-operative programs can be further optimized to enhance the early recovery of these frail patients. Implications for rehabilitation Early postoperative mobilization is essential for patients undergoing hip fracture surgery to regain the pre-fracture functional level, in not only the short but also in the long term. The most frequent reasons for not achieving an independent Cumulated Ambulation Score or completing physiotherapy, early after hip fracture surgery, are fatigue, pain, and the habitual cognitive status of patients. Knowledge concerning postoperative fatigue is important for rehabilitation professionals and should contribute as an essential factor when planning physiotherapy.

Endocarditis in Greenland with special reference to endocarditis caused by Streptococcus pneumoniae.

OBJECTIVES: The aim of this retrospective study was to determine the incidence and outcome of infectious endocarditis in Greenland with an emphasis on pneumococcal endocarditis. STUDY DESIGN: Retrospective, non-interventional study. METHODS: Review of files and medical history of all patients with infectious endocarditis from the Patient Registry in Greenland in the 11-year period 1995-2005. RESULTS: There were 25 cases of endocarditis, giving an incidence rate of 4.0/100,000 per year. Twenty-four percent of these cases were caused by Streptoccous pneumonia, which is significantly more frequent than in studies on Caucasian populations, where pneumococcal infection was seen in 1-3% of endocarditis cases. The overall mortality rate was 12%. Pneumococcal endocarditis (PE) had the clinical characteristics of fulminant disease with frequent heart failure, complications and need for surgery. Among cases with PE, 67% needed acute valve replacement and the mortality rate was 33%. CONCLUSIONS: The high incidence rate, clinical characteristics and grave prognosis of PE are consistent with another study of an Inuit population in Alaska.