A randomised trial of non-invasive cardiac output monitoring to guide haemodynamic optimisation in high risk patients undergoing urgent surgical repair of proximal femoral fractures (ClearNOF trial NCT02382185)

S J Davies,D R Yates,A Gibson,T Collyer,R J T Wilson,V Allgar,Z Murphy

doi:10.1186/s13741-019-0119-x

Abstract

BackgroundHip fracture is a procedure with high mortality and complication rates, and there exists a group especially at risk of these outcomes identified by their Nottingham Hip Fracture Score (NHFS). Meta-analysis suggests a possible benefit to this patient group from intravascular volume optimisation. We investigated whether intraoperative fluid and blood pressure optimisation improved complications in this group.MethodsPatients with a NHFS ≥ 5 were enrolled into this multicentre observer-blinded randomised control trial. Patients were allocated to either standard care or a combination of fluid optimisation and blood pressure control using a non-invasive system. The primary outcome was the number of patients with one or more complications in each group. Secondary outcomes included hospital length of stay (LOS), incidence of hypotension and fluid and vasopressor usage.ResultsForty-six percent of patients in the intervention group suffered one or more complications compared to the 51% in the control group (OR 0.82 (95% CI 0.49–1.36)). Per-protocol analysis improved the OR to 0.73 (95% CI 0.43–1.24). Median LOS was the same between both groups; however, the mean LOS on a per-protocol analysis was longer in the control group compared to the intervention group (23.2 (18.0) days vs. 18.5 (16.5), p = 0.047).ConclusionsHaemodynamic optimisation including blood pressure management in high-risk patients undergoing repair of a hip fracture did not result in a statistically significant reduction in complications; however, a potential reduction in length of stay was seen.Trial registrationA randomised trial of non-invasive cardiac output monitoring to guide haemodynamic optimisation in high risk patients undergoing urgent surgical repair of proximal femoral fractures (ClearNOF trial NCT02382185).

Highlights

Hip fracture is a procedure with high mortality and complication rates, and there exists a group especially at risk of these outcomes identified by their Nottingham Hip Fracture Score (NHFS)
It is estimated that the number of patients that will sustain a hip fracture will reach 100,000 per annum by 2033 with a cost to the UK health services alone of some £ 2.7 billion (White & Griffiths, 2011)
The Nottingham Hip Fracture Score (NHFS) is a validated scoring system that predicts patients at increased risk of both 30-day and 1-year mortality (Wiles et al, 2011; Maxwell et al, 2008). This high-risk group, with an increased mortality rate, may have an increased complication rate, and any effective intervention may have a greater impact on these outcomes

Summary

Introduction

Hip fracture is a procedure with high mortality and complication rates, and there exists a group especially at risk of these outcomes identified by their Nottingham Hip Fracture Score (NHFS). Given that the incidence of hypotension in the Anaesthesia Sprint Audit of Practice (ASAP) (White et al, 2016) was significant with 56% of patients undergoing neck of femur (NOF) repair having a systolic blood pressure of less than 90 mmHg, and one third having a mean arterial pressure (MAP) of less than 55 mmHg, and the association of hypotension with adverse events (Salmasi et al, 2017; Sun et al, 2015), this may be a valid treatment strategy in this group Within this group of elderly patients, a high-risk group exists. This high-risk group, with an increased mortality rate, may have an increased complication rate, and any effective intervention may have a greater impact on these outcomes

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