objectives
The client (An Hospital in Germany) wanted to investigate the impact of intraoperative fluid volume on outcomes in geriatric patients undergoing hip fracture surgery.
Data Information
Retrospective single-center study with data from the hospital information systems was available. The study included patients aged 70 years or older who had sustained a proximal femur fracture. Patients with pathologic, periprosthetic, or peri-implant fractures and those with missing data were excluded.
Variables in the Data Set
- Fallnummer – Case Number
- Alter – Age
- Geschlecht – Gender
- Heimbewohner – Nursing Home Resident
- Aufnahme_SAP – Admission (SAP)
- Aufnahmeuhrzeit_SAP – Admission Time (SAP)
- Operation_SAP – Operation (SAP)
- OP Beginn_SAP – Operation Start Time (SAP)
- Zeit_Schnitt_Naht – Time from Incision to Suture
- Aufnahme (D_U)_SAP – Admission (D_U) (SAP)
- OP (D_U)_SAP – Operation (D_U) (SAP)
- Datedif_Auf_OP_SAP – Date Difference from Admission to Operation (SAP)
- OP Dienst – Operation Service
- Todesdatum – Date of Death
- Tod Tage postOP – Death Days Post-Operation
- Frakturtyp – Fracture Type
- ISAR – ISAR (Geriatric Medicine Risk Score)
- ASA – ASA (American Society of Anesthesiologists) Classification
- Gammanagel – Gamma Nail
- Duokopf – Dual Head
- HTEP – Hip Total Endoprosthesis
- Hämoglobin – Hemoglobin
- Leukozyten – Leukocytes
- Thrombozyten – Platelets
- Kreatinin – Creatinine
- CRP – C-Reactive Protein
- Quick – Prothrombin Time Quick
- INR – International Normalized Ratio
- aPPT – Activated Partial Thromboplastin Time
- Albumin – Albumin
- BMI – Body Mass Index
- Größe in m – Height in meters
- Gewicht in kg – Weight in kilograms
- Zementreaktion_Donaldson – Cement Reaction (Donaldson)
- Niereninsuffizienz…35 – Renal Insufficiency (abbreviated)
- Antikoagulation – Anticoagulation
- Herzinfarkt – Myocardial Infarction
- CHF – Congestive Heart Failure
- pAVK – Peripheral Arterial Disease
- CVA/TIA – Stroke/Transient Ischemic Attack
- Demenz – Dementia
- Chron Lungen – Chronic Lung Disease
- Kollageneose – Collagenosis
- Ulkusleiden – Peptic Ulcer Disease
- mild Leber – Mild Liver Disease
- Diabetes mellitus – Diabetes Mellitus
- Hemiplegie – Hemiplegia
- Niereninsuffizienz…48 – Renal Insufficiency (abbreviated)
- D.M. + Organ – Diabetes Mellitus with Organ Involvement
- Tumor – Tumor
- Leukämie – Leukemia
- Lymphom – Lymphoma
- schwer. Leber – Severe Liver Disease
- met sol Tumor – Metastatic Solid Tumor
- AIDS – AIDS
- CCI Summe – Charlson Comorbidity Index Sum
- Dindo_Klass – Dindo Classification
- Ek Gabe /Anzahl – Ectopic Bone Grafts/Number
- HWI – Urinary Tract Infection
- Pneumonie – Pneumonia
- Wundheilungssstörung – Wound Healing Disturbance
- Zweiteingriff – Second Intervention
- Sonstige_Komplikation – Other Complications
- Intraop_Kristalloid/ml – Intraoperative Crystalloid Fluid Volume (ml)
- Intraop_Kolloidal – Intraoperative Colloidal Fluid Volume
- Intraop_Katecholamine – Intraoperative Administration of Catecholamines
- Reanimation_Intraop – Intraoperative Resuscitation
Grouping variable of interest
For this particular analysis and based on the fluids given, we divided patients into high-volume and low-volume groups: Excessive Intraoperative Fluid Administration (Sum of Intraoperative Crystalloid and Colloidal Fluids > 1500 ml vs. <= 1500):
Group A: Sum of Intraoperative Crystalloid and Colloidal Fluids > 1500 ml
Group B: Sum of Intraoperative Crystalloid and Colloidal Fluids <= 1500
Univariate Analyse
We employ statistical analyses to derive valuable insights from the dataset, employing a range of methods to enhance our understanding. The provided R code generates descriptive statistics and conducts hypothesis tests, facilitating a comprehensive exploration of the dataset.
The analysis primarily focuses on a detailed comparison of specified variables across distinct groups, specifically evaluating the impact of Excessive Intraoperative Fluid Administration (Sum of Intraoperative Crystalloid and Colloidal Fluids > 1500 ml vs. <= 1500). This comparison is instrumental in understanding the distribution and potential differences for each variable in the two groups.
The statistical tests performed are tailored to the nature of the variables under consideration. For continuous variables, we employ Wilcoxon Rank-Sum tests, while for categorical variables, we perform [insert specific statistical tests used]. This multifaceted approach ensures a thorough examination of the dataset, providing valuable insights that support subsequent statistical inference and decision-making processes.
Multivariate Analysis
Multivariate Analysis, adjusted for age, gender, American Society of Anesthesiologists (ASA) grade, CCI , fracture type :
For each of the following outcomes, multiple logistic regressions were performed, each adjusted for age, gender, American Society of Anesthesiologists (ASA) grade, CCI [BD], and fracture type [P]. The objective was to analyze the influence of Excessive Intraoperative Fluid Administration (Sum of Intraoperative Crystalloid and Colloidal Fluids > 1500 ml vs. <= 1500) on the following outcomes: a. Mortality [BE=5] b. Complications (Dindo) [BE] c. Intraop Crystalloid [BL] d. Intraop Colloidal [BM] e. ICU [BW]
objectives
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Propensity Score Matching
Propensity Score Matching: Adjusted for Age, ASA , Gender, CCI
The matching criterion used is the nearest neighborhood. It matches control individuals to the treated group and discards controls who are not selected as matches. In more details,
The link function used in estimating the distance measure is the logit function. In other words, logistic regression propensity scores (including the covariates given)
Then, we proceed to the Comparison of matched samples
- Research Question: Is there a difference between the groups in terms of:
- a. Cement reaction in the OR
- b. Mortality
- c. Administration of catecholamines
- d. Intraoperative crystalloid volume
- e. Intraoperative colloid volume
- f. Intraoperative resuscitation
- g. Postoperative intensive care
- h. Central venous catheter rate
- i. Artery rate
- j. Duration of surgery
Subanalysis
Variables
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R Code for the analysis
For each of the analyses, the R code is available under request. WE have comprehensive and replicable r-codes
Results and conclusion
Patients with a higher American Society of Anesthesiologists (ASA) grade and more comorbidities were more likely to receive more than 1500 ml of fluids. We observed significant differences in anesthesiologic management between the two groups, with a higher rate of invasive blood pressure management (IBP) and central venous catheter usage in the high-volume group. High-volume therapy was associated with a higher rate of complications (69.7% vs. 43.6%, p < 0.01), a higher transfusion rate (odds ratio 1.91 [1.26–2.91]), and an increased likelihood of patients being transferred to an intensive care unit (17.1% vs. 6.4%, p = 0.009). These findings were confirmed after adjusting for ASA grade, age, sex, type of fracture, Identification-of-Seniors-At-Risk (ISAR) score, and intraoperative blood loss.
Our study suggests that intraoperative fluid volume is a significant factor that impacts the outcome of hip fracture surgery in geriatric patients. High-volume therapy was associated with increased complications.