Optimal insertion depth of central venous catheters–is a formula required? A prospective…

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Acute renal dysfunction following hip fracture.

Injury. 2010 Apr;41(4):335-8

Authors: Bennet SJ, Berry OM, Goddard J, Keating JF

We investigated the incidence, risk factors and outcome of acute renal dysfunction (ARD) in patients with a fractured neck of femur. 170 consecutive patients were prospectively included in the Scottish Hip Fracture Audit database and retrospectively analysed. Historically, lack of consensus definition has hindered accurate reporting of ARD. ARD was defined using the 'RIFLE' criteria. 27 patients (16%) developed ARD. Risk factors were male sex, vascular disease, hypertension, diabetes, chronic kidney disease and pre-morbid use of nephrotoxic medications (p<0.01). Inpatient, 30- and 120-day mortality was higher in the ARD group 19%, 22% and 41% respectively, versus 0%, 4% and 13% in the non-ARD group (p<0.01). Length of hospital stay was significantly longer in the ARD group. Pre- and post-operative complications were 12 and 5 times more frequent respectively in the ARD group (p<0.01). Awareness of risk factors and serial measurements of renal function allow early identification and focused monitoring of these patients.

PMID: 19729159 [PubMed - indexed for MEDLINE]

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Hip fractures after falls in hospital: a retrospective observational cohort study.

Injury. 2009 Feb;40(2):201-4

Authors: Johal KS, Boulton C, Moran CG

OBJECTIVES: To compare the prevalence and characteristics of hip fractures sustained after inpatient falls (hospital subgroup) to those presenting with a fall in the community (control group). DESIGN: Retrospective observational cohort study. SETTING: University teaching hospital. PARTICIPANTS: 5879 hip fractures occurred over an 8-year period, 327 of these took place after a fall as a hospital inpatient. OUTCOME MEASURES: Comparison of 30-day and 1 year mortality, co-morbidities, length of post-fracture hospital stay, specific complication rates and cognitive function between the hospital and control group. Other specific data on those falling in hospital was also collected. RESULTS: There were significantly higher rates (p<0.001) of cerebrovascular, chronic obstructive airways and renal disease, diabetes, malignancy and polypharmacy in patients suffering falls in hospital. Mini-mental test scores (MTS) were also significantly reduced in this subgroup (p<0.001). 30-day and 1 year mortality rates were 9% and 26%, respectively in the control group and almost double this in the hospital subgroup, being 18% and 47%, respectively (30 days, 95% CI 2.00 (1.54-2.60): p<0.001; 1 year, 95% CI 2.04 (1.73-2.40): p<0.001). There was no statistical difference between post-operative complications or length of stay post-fracture. 55% of falls in hospital took place on medical/geriatric wards with an additional 14% occurring on psychiatric units. DISCUSSION: Patients suffering hip fractures after falls in hospital are frailer with impaired cognitive function and have more co-morbidities than those suffering a fracture in the community. These patients have increased mortality, with almost 50% dead within 1 year of the fall. The majority of hip fractures after falls occur in medical or geriatric wards, but the highest risk group appears to be elderly patients on psychiatric wards. Therefore, falls risk assessment and falls prevention schemes in hospital elderly patients are of paramount importance.

PMID: 19100542 [PubMed - indexed for MEDLINE]

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Troponin T as a predictive marker of morbidity in patients with fractured neck of femur.

Injury. 2008 Jul;39(7):775-80

Authors: Dawson-Bowling S, Chettiar K, Cottam H, Worth R, Forder J, Fitzgerald-O’Connor I, Walker D, Apthorp H

INTRODUCTION: This study aims prospectively to assess perioperative measurement of Troponin T, a marker of myocardial injury, as a predictor of morbidity and mortality in patients undergoing surgery for fractured neck of femur. METHOD: All patients aged 65 years and over presenting with a fractured neck of femur over a 4-month period were initially included. Exclusion criteria were renal failure, polymyositis and conservative fracture management. Troponin T levels were measured on admission, day 1 and 2 post-surgery. According to local protocol, a level of >0.03 ng/mL was considered to be raised. Adverse outcome measures were cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay. RESULTS: One hundred and twenty-nine patients presented with femoral neck fractures. 108 patients were included after application of the exclusion criteria. 42 (39%) showed a Troponin rise. Of these, 25 sustained one or more outcome complications versus seven with no rise (p<0.001). The mean hospital stay was 25.7 days for patients with elevated Troponin, 18.3 days in the normal group (p<0.012). There were nine deaths in the raised Troponin group, and five with no rise (p<0.05). DISCUSSION: The principle causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive enzymatic marker of myocardial injury. The association between raised Troponin and hip fractures has not previously been made. In our series, 39% showed a perioperative Troponin rise. This was significantly associated with increased morbidity, mortality and longer hospitalisation. Many patients appear to be having silent events, causing significant morbidity. We recommend Troponin measurement in all patients to identify this risk and allow appropriate optimisation measures.

PMID: 18407276 [PubMed - indexed for MEDLINE]

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