The use of LiDCO based fluid management in patients undergoing hip fracture surgery under spinal anaesthesia: neck of femur optimisation therapy - targeted stroke volume (NOTTS): study protocol for a randomized controlled trial.

Matthew D Wiles,Chris G Moran,Iain K Moppett,William J D Whiteley

doi:10.1186/1745-6215-12-213

Abstract

BackgroundApproximately 70,000 patients/year undergo surgery for repair of a fractured hip in the United Kingdom. This is associated with 30-day mortality of 9% and survivors have a considerable length of acute hospital stay postoperatively (median 26 days). Use of oesophageal Doppler monitoring to guide intra-operative fluid administration in hip fracture repair has previously been associated with a reduction in hospital stay of 4-5 days. Most hip fracture surgery is now performed under spinal anaesthesia. Oesophageal Doppler monitoring may be unreliable in the presence of spinal anaesthesia and most patients would not tolerate the probes. An alternative method of guiding fluid administration (minimally-invasive arterial pulse contour analysis) has been shown to reduce length of stay in high-risk surgical patients but has never been studied in hip fracture surgery.MethodsSingle-centre randomised controlled parallel group trial. Randomisation by website using computer generated concealed tables. Setting: University hospital in UK. Participants: 128 patients with acute primary hip fracture listed for operative repair under spinal anaesthesia and aged > 65 years. Intervention: Stroke volume guided intra-operative fluid management. Continuous measurement of SV recorded by a calibrated cardiac output monitor (LiDCOplus). Maintenance fluid and 250 ml colloid boluses given to achieve sustained 10% increases in stroke volume. Control group: fluid administration at the responsible (blinded) anaesthetist's discretion. The intervention terminates at the end of the surgical procedure and post-operative fluid management is at the responsible anaesthetist's discretion. Primary outcome: length of acute hospital stay is determined by a blinded team of clinicians. Secondary outcomes include number of complications and total cost of care.Funding NIHR/RfPB: PB-PG-0407-13073.Trial registration numberTrial registration: Current Controlled Trials ISRCTN88284896.

Highlights

70,000 patients/year undergo surgery for repair of a fractured hip in the United Kingdom
Study Objectives Primary Aims To investigate whether stroke volume (SV) guided fluid therapy for patients undergoing fractured hip surgery under a spinal anaesthetic affects: 1) the time the patient spends in acute care in hospital; Secondary Aims 2) To investigate if using SV guided fluid therapy a patient receives while having their fractured hip repaired under a spinal anaesthetic affects: a. the time until the patient is medically well enough to be discharged from hospital; b. the number of postoperative complications; c. the total amount of intravenous fluid given during surgery; d. the total cost of care
Gaining informed consent is problematic, an issue compounded by the large proportion of acutely and chronically confused patients who present with hip fracture: exclusion of such patients from the trial would severely limit the applicability of the results to clinical practice and measures are taken to allow their participation, including the involvement of the of kin or responsible consultant

Summary

Introduction

70,000 patients/year undergo surgery for repair of a fractured hip in the United Kingdom. This is associated with 30-day mortality of 9% and survivors have a considerable length of acute hospital stay postoperatively (median 26 days). Use of oesophageal Doppler monitoring to guide intra-operative fluid administration in hip fracture repair has previously been associated with a reduction in hospital stay of 4-5 days. 70,000 patients per year undergo surgery for repair of a fractured hip in the United Kingdom (UK) [1], at a cost of £25,424 per patient [2]. Hip fracture is associated with a high mortality (approximately 9% at 30 days postoperatively)[3] and a considerable length of acute hospital stay (median stay 26 days) [4]. During surgery the anaesthetist usually gives intravenous fluids based upon clinical judgement of all the above factors and clinical signs such as heart rate and blood pressure

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