The Fascia Iliaca Block as the Primary Intraoperative Anesthesia for Hip Fracture Surgery: A Preliminary Study.

BACKGROUND: Early surgical intervention for hip fractures in the elderly has proven efficacious. However, surgical delays commonly occur in this patient population due to comorbid conditions that put these patients at a high risk for hypotension-related complications of general or neuraxial anesthesia or anticoagulants that delay the safe use of neuraxial anesthesia. QUESTIONS/PURPOSES: The questions/purposes of this study are (1) to investigate if a fascia iliaca block in conjunction with light to moderate sedation could provide adequate analgesia throughout open surgery for intertrochanteric hip fractures (AO/OTA 31-1) without requiring conversion to general anesthesia with airway support and (2) to assess its perioperative complication profile. METHODS: A retrospective chart review was conducted to identify patients with intertrochanteric hip fractures who underwent anesthesia with a fascia iliaca block over a 1.5-year period. RESULTS: In the six patients identified, there were no intraoperative conversions to general anesthesia requiring airway support. Additionally, there were no intraoperative complications, no mortalities within 30 days, 2 patients on anticoagulation who required a blood transfusion, and a single patient who developed a postoperative hospital-acquired pneumonia that resolved with an antibiotic course. CONCLUSIONS: In this series of patients, we demonstrate that a fascia iliaca block can reliably be utilized as the primary anesthetic for patients undergoing surgical fixation of intertrochanteric hip fractures, with an acceptable perioperative complication profile. Although concomitant sedation was provided with the block, this anesthesia strategy has the potential to reduce preoperative delays and minimize the overall burden of sedative and anesthetic medications in a geriatric population. These initial findings may serve as a basis for future, higher-quality prospective and comparative studies.

Improvement in Outcomes of Major Obstetric Hemorrhage Through Systematic Change.

OBJECTIVE: To report the outcomes over 14 years of sustained systematic institutional focus on the care of women with major obstetric hemorrhage, defined as estimated blood loss greater than 1,500 mL. METHODS: A retrospective cohort study of women with major obstetric hemorrhage at our hospital from 2000 to 2014 compares baseline conditions (age, multiparity, prior cesarean delivery, morbidly adherent placenta), morbidity (lowest mean temperature, lowest mean pH, coagulopathy, hysterectomy), and mortality among three time periods (period 1=January 2000 to December 2001, period 2=January 2002 to August 2005, period 3=September 2005 to December 2014). We also describe the systematic changes that helped to sustain our improved outcomes. RESULTS: During the three time periods, there were 5,811, 12,912, and 38,971 births; the rate of major obstetric hemorrhage increased over these periods: 2.1, 3.8 and 5.3 cases per 1,000 births, respectively. Two deaths from hemorrhage occurred in period 1 and none thereafter. Among women who experienced massive hemorrhage, morbidity significantly improved in each successive period: median lowest pH increased from 7.23 to 7.34 to 7.35 (periods 2 and 3 significantly higher than period 1), median lowest maternal temperature (°C) improved, 35.2 to 36.1 to 36.4 (all difference significant), and the rate of coagulopathy decreased, 58.3% to 28.6% to 13.2% (period 3 significantly lower than periods 1 and 2) (all P values <.001). Peripartum hysterectomies were more frequent and more frequently planned over time rather than urgent in each successive period: 0 of 6 to 6 of 18 (33%) to 31 of 64 (48.4%) (P=.044). During period 3, we reorganized the obstetric rapid response team, instituted a massive transfusion protocol and use of uterine balloon tamponade, and promoted a culture of safety in two ways-through more intensive education regarding hemorrhage and escalation (encouraging all staff to contact senior leaders). CONCLUSION: A sustained level of patient safety is achievable when treating major obstetric hemorrhage, as shown by a progressive decrease in morbidity despite increasing rates of hemorrhage.

Improving hospital systems for the care of women with major obstetric hemorrhage.

OBJECTIVE: When 2 maternal deaths due to hemorrhage occurred at New York Hospital Queens in 2000-2001, a multidisciplinary team implemented systemic change. Our objective was to improve outcomes of episodes of major obstetric hemorrhage. METHODS: We report outcomes before (2000-2001) and after (2002-2005) the introduction of a patient safety program aimed at improving the care of women with major obstetric hemorrhage. Process changes were instituted in late 2001 at the direction of a multidisciplinary patient safety team. A rapid response team was formulated using the cardiac arrest team as a model. Protocols for early diagnosis, assessment, and management of patients at high risk for major obstetric hemorrhage were developed and communicated to staff. RESULTS: There were significant increases in cesarean births (P < .001), repeat cesarean births (P = .002), and cases of major obstetric hemorrhage (P = .02) between the periods of 2000-2001 and 2002-2005. There was a significant improvement in mortality due to hemorrhage (P = .036), lowest pH (P = .004), and lowest temperature (P < .001) when comparing 2000-2001 with 2002-2005. There were no differences in measures of severity of obstetric hemorrhage between the 2 periods, including Acute Physiology and Chronic Health Evaluation II scores, occurrence of placenta accreta and estimated blood loss. CONCLUSION: Despite a significant increase in major obstetric hemorrhage cases, we found improved outcomes and fewer maternal deaths after implementing systemic approaches to improve patient safety. Attention to improving the hospital systems necessary for the care of women at risk for major obstetric hemorrhage is important in the effort to decrease maternal mortality from hemorrhage.