Ultrasound Assessment of Heart and Lungs for Hip Fracture Procedure
Condition: Hip Fractures
MeSH terms: Fractures, Bone; Hip Fractures
Study type: Interventional

Summary: 
      The investigators would like to investigate whether performing ultrasound assessments in
      patients undergoing surgery for hip fractures is able to identify previously undiagnosed
      heart or lung conditions. The investigators would like to determine whether information
      provided by this ultrasound assessment is significant enough to alter the anesthetic
      management plan of these patients. This study has the potential to demonstrate that
      ultrasound could be used as a diagnostic bedside tool in the perioperative period, possibly
      altering standard of care for this patient population.
    

Detailed description: 
      Ultrasound (US) guidance plays an important role in many commonly performed perioperative
      anesthetic procedures, including central venous catheter (CVC) insertion and regional nerve
      blocks[1]. The benefits of US guidance in improving patient safety and procedural efficacy
      have been widely recognized; studies have shown that US guidance reduced the failure rates
      and the number of attempts required for needle insertion[1, 2]. Multiple national clinical
      practice guidelines, including those issued by the National Institute for Health and Care
      Excellence (NICE) in the UK, and the Canadian Anesthesiologists' Society[3, 4], have
      recommended the routine uses of US guidance for performing invasive anesthetic procedures.
      The NICE guidelines stated that "US guidance should be used in most clinical circumstances
      where CVC insertion is necessary and that all those involved in placing CVCs using US
      guidance should undertake appropriate training to achieve competence[3]." Despite these
      recommendations, the routine use of US guidance has not been fully adopted by
      anesthesiologists in South Western Ontario in the past. Matava et al. conducted a survey in
      2011 across Ontario and found that only 60% of anesthesiologists at academic hospitals and
      33% at community hospitals use US guidance routinely for CVC insertion[5]. In addition, 56%
      and 31% of academic and community hospital practitioners (respectively) use US guidance
      routinely for performing regional nerve block[5]. Lack of training and perceived need were
      identified as the major reasons why they did not routinely use US guidance, reflecting a
      knowledge gap and deficit in training opportunity in our local region. The interests of using
      US to provide clinical information in guiding patient management have been demonstrating
      increasing parallels with the wide availability of US for central line insertion in various
      settings. Specifically, ultrasound examinations have been developed for emergency medicine
      (FAST protocol) and intensive care for managing trauma and hemodynamically unstable
      patients[6]. The same development and application of US has also been true in anesthesia,
      where the use of Transesophageal echocardiogram has been the standard of care for cardiac
      surgical procedures for over a decade. The utility of ultrasound for non-cardiac surgery is
      only just beginning to be explored for perioperative patients, especially for emergency
      surgery or cases of unexplained hypotension, hemodynamic instability or cardiac arrest. In
      the past few years, point of care assessment of the heart and lungs with US has become more
      frequent among anesthesiologists. It was suggested that the uses of US in emergency
      situations frequently changed the patients' bedside management[7]. The uses of US can also
      assess volume status and predict hypotension after anesthesia induction. The existing
      evidence suggests US assessment can lead to more accurate preoperative assessments; however,
      there is lack of evidence that illustrates how US assessment specifically impacts anesthetic
      management and patient/procedural outcomes. This information is fundamental to further expand
      the indications of US applications from purely a procedural guidance tool to a point-of-care
      diagnostic tool. In Canada, there are approximately 40,000 cases of hip fractures per
      year[8]. Our institute, the London Health Sciences Centre, in London, Ontario, sees
      approximately 400 patients a year who have experienced hip fractures and require surgery for
      treatment. These patients are generally elderly, making this population likely to present
      with additional comorbidities. Despite the multiple Anesthesia practice guidelines that
      recommend using US for variety of procedures[3, 4], it is not standard of practice to be used
      as a preoperative assessment tool for these patients undergoing surgery for hip fractures.
      Especially considering the advanced age of these patients and potential for underlying
      comorbidities, using US to assess these patients for cardiac and lung conditions during the
      perioperative period has the potential to alter their anesthetic management plan if
      previously undiagnosed conditions are discovered. Introducing the use of point-of-care US
      assessment for these hip fracture patients has the potential to result in increased patient
      safety and more favourable patient outcomes. The proposed project involves a prospective
      cohort study to investigate the utility of US as a clinical assessment tool for patients
      undergoing hip fracture surgery. In general, patients with hip fractures are elderly with
      multiple comorbidities, and are at a higher risk for complications. Our current standard of
      care does not involve the use of US to assess the heart and lung comorbidities of these
      patients. The use of US has the potential to provide critical information about heart and/or
      lung diseases that was previously unknown, possibly altering the perioperative management
      plan and potentially improving care for these patients. Also, careful assessment of the intra
      vascular volume may help with induction management and Anesthesia technique.The
      anesthesiologist providing the anesthetic will suggest their anesthesia plan before and after
      the results of the study will be introduced.

      This is a prospective, cohort study. This study will be conducted at the LHSC, London,
      Ontario. The investigators will include adult patients with a hip fracture scheduled for
      urgent surgery and exclude patients who have a known heart or lung condition that mandates
      the appropriate anesthetic plan. Based upon the routine pre-surgical assessments that are
      performed in accordance with standard of care, the Anesthesiologist will develop and record
      the plan for anesthetic management for the patient. All patients will receive a preoperative
      US examination assessment of the heart and lungs (6 basic transthoracic US views ). The US
      results will be available to the anesthesia and surgical teams, but will only be divulged
      after a preliminary anesthetic plan is prepared by the anesthesiologist. Following completion
      of this US assessment, the investigators will ask the Anesthesiologist to re-evaluate their
      anesthetic plan and document any changes that were made as a result of the US finding and
      provide feedback about the benefit (or lack thereof) of the information provided by the
      ultrasound assessment. The primary endpoint of this study is a composite outcome of change in
      anesthetic technique and choice of monitoring and fluid management. A questionnaire will be
      distributed to the attending anesthesiologist to record their anesthetic plan pre and post
      divulgation of US results. The investigators will assess whether the use of perioperative
      ultrasound provided a significant unknown information that affected the anesthesia plan.
    

Intervention name(s): Ultrasound assessment of heart and lungs
Intervention type(s): Diagnostic Test
Intervention description(s): Patients will receive an ultrasound assessment of their heart and lungs.
Intervention model: Single Group Assignment
Intervention model description: Patients over the age of 18 who arrive to the hospital requiring surgery for hip fracture repair.
Masking: None (Open Label)
Primary purpose: Diagnostic
Keywords: ultrasound assessment