BSOA ASM London 2013: Key Points

I recently attended the British Society of Orthopaedic Anaesthetists Annual Scientific Meeting, November 2013.

In order to allow those who were unable to attend the meeting to gain a flavour of the topics covered by the speakers I have created a summary of the key points of each talk (in my opinion).

The RCOA Matrix Codes for each talk are shown (in my opinion, the organisers didn’t provide them), along with the details of the speaker.

An orthogeriatric perspective on the peri-operative care of patients with fractured neck of femur (2A07): Dr Celia Gregson, Bristol

  • Avoid drugs with anticholinergic effects due to risk of delirium in NOF. Remember constipation as a cause of confusion. Use Lactulose!
  • Orthogeriatrics view on NOF. Usual Hb drop 2.5g (4g in IM nail). Do Hemocue in PACU. Transfuse early so can mobilise next day.

Perioperative orthopaedics: The perfect translational research model (1A02): Dr Gareth Ackland, UCL

  • VISION study (JAMA 2012); 40K pats, age>45, non-cardiac SxGA. 12% had T-I inc (>50% asymptomatic w/o ECG changes). Assoc with inc LOS.
  • Research update: postop complications double mortality up to 10 yr postop! This includes “small” complications like wound infections.

What matters in cervical spine injury (2A01): Dr Rob McCahon, Nottingham

  • Direct laryngoscopy induces forces primarily at C0-C2 BUT lots of room here for the cord to flex & extend (only takes up 25% of available room). The space is decreased if your rotate the neck – avoid rotational forces at all costs.
  • Risk factors for c-spine injury: pelvic #, ISS > 15, age < 40. [Clayton Injury 2012]. Max-fax injuries not a factor (despite ATLS teaching).
  • < 50% of the normal population aged over fifty have evidence of canal stenosis/impingement on MRI. Don’t just take care in trauma cases!

Paediatric regional anaesthesia (2D05, 2G03): Prof Peter Marhofer, University of Vienna

  • aPPT frequently abnormal < 45 weeks post conceptual age. Not a CI to central neuraxial blockade.
  • ADARPEF study (2010) Complication rate for RA in children 0.12% (Central:Peripheral 6:1). No serious morbidity.
  • Paed RA: Supraclavicular best for upper limb as axillary nerves as superficial and difficult to visualise with USS

Lower limb arthroplasty, regional anaesthesia and outcome (2G01): Dr Barrie Fischer, Redditch

  • No clear benefit between analgesic technique & functional outcome or LOS. The total package of care is more important.
  • PROSPECT Guidelines: THR: SAB plus IT opiate or GA plus LPB. Little evidence for LIA. TKR: SAB plus IT opiate or GA plus FNB (not SNB)
  • THR/TKR: Meta-analyses show RA less blood loss, pain, PONV, and possibly VTE. In US >75% GA only 11% SAB. SAB decreases postop comps & RIP.
  • TKR: femoral nerve catheters are not associated with better analgesia compared to single-shot FNB and just impair mobilisation.
  • Enhanced Recovery & FNB. Adductor canal blockade may be no better in terms of ability to mobilise (RAPM 2013;38).
  • Local anaesthetic infiltration: not beneficial in THR; may be of value for 6-12 h in TKR (if used as part of multimodal analgesia regimen)
  • Do not ignore pain in favour of non-EBM local anaesthetic infiltration techniques. 36% of TKR pats end up with chronic pain, or which having severe early postoperative pain is a predictor.

Ultrasound for regional anaesthesia: Teaching, learning and competence (1H02): Dr John Barcroft, Royal National Orthopaedic Hospital

  • Training in USS & RA: 1. Go on good course 2. Learn sonoanatomy 3. Practice on phantoms & cadavers 4. Try on patients with an expert.
  • Dreyfus Skill Levels: 1. Novice 2. Competent 3. Proficient 4. Expert 5. Master. We should aim for expertise not competence in USS RA.
  • Newly acquired motor skills (e.g. USS RA skills) will almost degrade to baseline if not used for 18 days! No place for occasional USS RA!
  • Create your own USS phantom: 4 x packets of supermarket jelly with 25% of the recommended water, filled with some olives. Cost < £4!!
  • “Only those who have the patience to do simple things perfectly ever acquire the skills to do difficult things easily”. Practice USS!!

Pathophysiology and management of acute coagulopathy of trauma (ATC) (1A01, 2A05): Mr Ross Davenport, The Royal London

  • Acute trauma coagulopathy (ATC): 24% on arrival to ED. ATC directly related to ISS & base deficit and increases RIP by 400%.
  • ATC thought to be caused by “thrombin switch”. Thrombin production decreased and aPC activated (decreasing factors V & VIII).
  • ATC predominately aPC mediated thrombinolysis, not DIC (other clotting factors often still > 75%). Platelet dysfunction is also a factor.
  • Only 50% of those with ATC will have PT that is abnormal and the test will take > 60 mins. Use ROTEM/TEG for a diagnosis in < 5 mins.
  • ROTEM can miss occult fibrinolysis. Most of your trauma patients with ISS > 16 will be fibrinolytic and will need tranexamic acid.
  • Ratio of PRC:FFP:Plts still unknown. Probably not 1:1:1 but optimal ratios unclear. RCT in progress (PROPPR) – results awaited.

Damage control resuscitation and anaesthesia for major trauma (2A02): Major Claire Park, King’s College Hospital.

  • Trauma Team Dynamics. Good review J R Army Corps 2001; 157: S299-304. Concepts such as tunnel vision, situational awareness, task fixation.
  • Damage control anaesthesia: suggestion for RSI Fentanyl:Ketamine:Rocuronium 3:2:1 (reducing to 1:1:1 if unstable).
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One thought on “BSOA ASM London 2013: Key Points

  1. 321 FKR is the HEMS protocol for RSI to avoid hypertension on laryngoscopy and it probably works. I suspect though that post induction hypotension may have become more of a problem as a result. Perhaps alfentanil would be a better choice but fentanyl chosen because it may be the more familiar drug in some environments.

    Reply

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