I was never formally taught how to give an anaesthetic to a patient for hip fracture surgery. I’m guessing I’m not alone in this confession.
As a junior anaesthetist 20 years ago, I was left on my own to anaesthetise hip fracture patients after little more than basic training in anaesthesia. I gave general anaesthesia and opioids to intubated patients, but no blocks and no regional anaesthesia because I hadn’t been taught how to do them. I learnt epidurals, and started adding these to GAs. I learnt spinal anaesthesia in obstetrics, and started using ‘obstetric’ spinals for really sick hip fracture patients to avoid giving them a GA, although they may have got one anyway because I was never taught sedation. I learnt some theoretical knowledge about the physiology and pharmacology of old age for the FRCA, and dialled down my drug doses a bit. I learnt stimulation-guided femoral nerve block, and sometimes used this instead of epidurals. Various consultants contributed nuggets of knowledge, some of which I incorporated into my own technique.
And then I became a consultant myself.
Has anything really changed much? Trainees are far less likely to anaesthetise hip fracture patients single-handedly after minimal training, but most knowledge is still passed on informally from consultants to juniors. It’s a vocational model that has stood the test of time, but has one big flaw: if consultants don’t keep up-to-date with the evidence, juniors don’t learn to give the best evidence-based anaesthetics.
National data suggest this is a problem. The Anaesthesia Sprint Audit of Practice (ASAP, p. 21) of 11, 000 hip fracture anaesthetics echoed findings from the National Hip Fracture Database (NHFD, p. 31) that anaesthetists administer pretty much every type of general/regional/nerve block anaesthesia combination possible. It may be that anaesthetics are given according to patient’s individual needs and wishes, but I think we all know that it’s far more likely that type of anaesthesia is determined by the anaesthetist’s personal choice and/or their institutional tradition.
Looking closer at the ASAP and NHFD data, it is clear that many patients do not receive evidence-based anaesthesia for hip fracture surgery. ASAP, for example, found that only 56% of patients received an intraoperative nerve block, a figure which varied from 8-92% depending on which hospital patients were admitted to.
So why don’t we follow evidence-based practice in hip fracture anaesthesia? Anaesthetists don’t set out to give a ‘poor’ anaesthetic – we all try and do the best we can for our patients – but what we do probably does have an effect on mortality and morbidity after hip fracture surgery, and so should be improved by doing it in an evidence-based way: think ‘enhanced recovery for hip fracture’.
However, there are three big barriers to evidence-based care in anaesthesia for hip fracture. Firstly, audit evidence is limited. Every anaesthetist does something different, so it’s difficult to spot ‘best practice’ in observational studies or national audit. What is needed is a quality improvement approach – develop some standards based on current best evidence, and then test whether following them improves outcome compared to not following them, then modify the standard accordingly.
Secondly, research evidence is limited. Randomised, controlled trials can seem difficult and expensive to do in this patient population, especially if you’re not in an ‘academic’ institution. But with a bit of help navigating the regulatory framework, and possibly a bit of collaboration with other researchers, trials are not impossible.
Finally, education is limited. It’s really not easy to find good, published evidence about hip fracture anaesthesia, resources to help with service improvement or accessible information about how to do a fascia iliac block, for example.
And, I guess, that’s what I’m hoping to achieve with this website. It’s for junior anaesthetists who want to check whether Dr. Smith or Dr. Jones teaches the better techniques. It’s for senior anaesthetists rostered to cover their first trauma list in 5 years, and need a quick reminder about what’s best practice. It’s for the trauma anaesthetists, who might like to do some research or debate online about how to make anaesthesia better for hip fracture patients. It’s for patients and their relatives to find out information about what to expect when they’re in hospital.
Anyway, let me know what you think – all suggestions gratefully received!