1 Department of Orthopaedicsand 2 Department of Anaesthesia, Peterborough District Hospital, Thorpe Road, Peterborough PE3 6DA, UK. 3 Department of Emergency Medicine,Addenbrookes Hospital, Cambridge, UK
*Corresponding author. E-mail: mjparker@doctors.org.uk
Accepted for publication: August 21, 2003
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Abstract |
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Methods. Randomized, double blind, controlled trial of i.v. saline vs colloid for 396 patients having hip fracture surgery admitted to a district general hospital. Patients were followed up for 1 yr.
Results. There was no statistically significant difference between groups for mortality (30-day mortality 9/198 for saline group vs 19/198 for colloid group, 95% confidence intervals 0.211.02), length of hospital stay (22.5 days vs 17.3 days, 95% CI 10.78 to 0.38), or occurrence of postoperative complications.
Conclusions. The inclusion of 500 ml of colloid solution to the i.v. fluid regime before hip fracture surgery does not improve outcome.
Br J Anaesth 2004; 92: 6770
Keywords: fluids, i.v., crystalloid solution; fluids, i.v., gelatin colloid; surgery, hip fracture
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Introduction |
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Methods |
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Patients details recorded included age, sex, living in their own home (as opposed to institutional care), American Society of Anesthesiologists (ASA) grade, Mental test score,4 mobility score,5 type of anaesthesia used (general or regional), type of fracture (intracapsular or extracapsular), and type of surgery (arthroplasty or internal fixation). The mental test score is a series of 10 simple questions on recall and orientation. The mobility score provides an estimate of the patient pre-fracture mobility, from being able to walk and undertake shopping unaided (score 9), through to being bedridden (score 0). For the first 204 patients entered in the study the volume of preoperative, intraoperative, and postoperative (up to 5 days) i.v. fluids was recorded. Recording of these data was discontinued after the first 204 cases as it was time consuming to record and analysis of the data revealed no apparent difference between groups.
All patients were treated surgically with standard operative monitoring (intermittent arterial pressure, continuous ECG, pulse oximetry, capnography, and inhalation agent monitoring for general anaesthetic cases), but no invasive monitoring (arterial line, central venous pressure, or oesophageal Doppler ultrasonography). All surviving patients were followed until 1 yr from injury with no patient being lost to follow-up.
The primary outcome measure was mortality with secondary outcome measures of hospital stay, intraoperative decrease in arterial pressure, and medical complications. A decrease in arterial pressure was defined as a decrease of greater than 40 mm systolic from the preoperative value recorded on the theatre checklist chart. The criteria for the medical complications were: myocardial infarctionchest pain, raised enzymes and ECG changes; congestive cardiac failureclinical signs requiring diuretic therapy; cerebrovascular accidentCT confirmation of clinical signs of hemiplegia; deep vein thrombosisconfirmed by ultrasound venography; and pulmonary embolismconfirmed by post-mortem, isotope scanning or CT.
The study was limited to 396 patients when the two trial solutions used for the study ceased to be made by the manufacturer in identical packaging. Statistical analysis between groups was with the Fisher exact test for binary variables and the un-paired t-test for continuous variables. A P-value of less than 0.05 was considered statistically significant. Mortality difference was studied with the log-rank test for equality of survivor functions throughout the whole trial and KaplanMeier survival curves were plotted.
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Results |
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Discussion |
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In contrast to these findings, a systematic review of the use of crystalloid vs colloid solutions for critically ill patients7 identified 37 randomized trials involving 1622 patients. There was a tendency to an increased mortality in those allocated to receive colloid solution. There have been no previous randomized studies using protocol-guided i.v. fluid therapy without invasive monitoring techniques in hip fracture patients. The present study also used patients having either general or regional anaesthesia, which was not possible for the studies of Sinclair2 and Venn.3 Spinal anaesthesia may be associated with a marginally lower early mortality for hip fracture patients but has no effect on long-term outcomes.8
Our study was not able to demonstrate that the inclusion of a fixed volume of 500 ml of colloid solution to the preoperative fluid regime had any demonstrable effect on either mortality or hospital stay, although there was a tendency to shorter total hospital stay (P=0.067) for those allocated to the colloid group (Table 2). This result may therefore have become significant if a larger number of patients had been included in the study. Nor were we able to demonstrate any benefits for subgroups of patients. In our study, we gave the colloid preoperatively but it may be that to be effective the colloid has to be given during surgery as in the studies of Sinclair2 and Venn.3 It is also possible that a future study would demonstrate that more invasive investigation of patients before or during surgery would be able to identify a sub-group of patients in whom colloid therapy or a more precise control of fluid balance or vasopressor use would be of benefit.
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Acknowledgements |
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References |
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2 Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture; randomised control trial. BMJ 1997; 315: 90912
3 Venn RM, Steele A, Richardson P, Grands RM, Newman P. Monitoring for optimisation of the hip risk surgical patientarterial pressure, CVP or stroke volume? Int Care Med 2000; 26 (Suppl. 3): S333
4 Qureshi KN, Hodkinson HM. Evaluation of a ten-question mental test in the institutionalized elderly. Age Ageing 1974; 3: 1527[Medline]
5 Parker MJ, Palmer CR. A new mty score for predicting mortality after hip fracture. J Bone Joint Surg 1993; 75B: 7978
6 Price J, Sear J, Venn R. Perioperative fluid volume optimization following proximal femoral fracture (Cochrane Review). In: The Cochrane Library, Issue 1. Oxford: Update Software, 2003
7 Schierhout G, Roberts I. Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials. BMJ 1998; 316: 9614
8 Parker MJ, Griffiths R, Urwin S. Anaesthesia for hip fracture surgery in adults (Cochrane Review). In: The Cochrane Library, Issue 2. Oxford: Update Software, 2003