Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods:We randomised 2970 patients from 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were ≥45 years of age were eligible. Patients were randomly assigned to accelerated surgery (goal of surgery within 6 hours of diagnosis; 1487 patients) or standard care (1483 patients). The co-primary outcomes were 1.) mortality, and 2.) a composite of major complications (i.e., mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Outcome adjudicators were masked to treatment allocation, and patients were analysed according to the intention-to-treat principle; ClinicalTrials.gov, NCT02027896. Findings:The median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] 4-9) in the accelerated-surgery group and 24 hours (IQR 10-42) in the standard-care group, p<0.0001. Death occurred in 140 patients (9%) assigned to accelerated surgery and 154 patients (10%) assigned to standard care; hazard ratio (HR) 0.91, 95% CI 0.72-1.14; absolute risk reduction (ARR) 1%, 95% CI -1-3%; p=0.40. The primary composite outcome occurred in 321 patients (22%) randomised to accelerated surgery and 331 patients (22%) randomised to standard care; HR 0.97, 95% CI 0.83-1.13; ARR 1%, 95% CI -2-3%; p=0.71.Interpretation: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared to standard care.

Background The Lancet Commission on Global Surgery established the Three Delays framework, categorising delays in accessing timely surgical care into delays in seeking care (First Delay), reaching care (Second Delay), and receiving care (Third Delay). Globally, knowledge gaps regarding delays for fracture care, and the lack of large prospective studies informed the rationale for our international observational study. We investigated delays in hospital admission as a surrogate for accessing timely fracture care and explored factors associated with delayed hospital admission. MethodsIn this prospective observational substudy of the ongoing International Orthopaedic Multicenter Study in Fracture Care (INORMUS), we enrolled patients with fracture across 49 hospitals in 18 low-income and middle-income countries, categorised into the regions of China, Africa, India, south and east Asia, and Latin America. Eligible patients were aged 18 years or older and had been admitted to a hospital within 3 months of sustaining an orthopaedic trauma. We collected demographic injury data and time to hospital admission. Our primary outcome was the number of patients with open and closed fractures who were delayed in their admission to a treating hospital. Delays for patients with open fractures were defined as being more than 2 h from the time of injury (in accordance with the Lancet Commission on Global Surgery) and for those with closed fractures as being a delay of more than 24 h. Secondary outcomes were reasons for delay for all patients with either open or closed fractures who were delayed for more than 24 h. We did logistic regression analyses to identify risk factors of delays of more than 2 h in patients with open fractures and delays of more than 24 h in patients with closed fractures. Logistic regressions were adjusted for region, age, employment, urban living, health insurance, interfacility referral, method of transportation, number of fractures, mechanism of injury, and fracture location. We further calculated adjusted relative risk (RR) from adjusted odds ratios, adjusted for the same variables. This study was registered with ClinicalTrials.gov, NCT02150980, and is ongoing. Findings Between April 3, 2014, and May 10, 2019, we enrolled 31 255 patients with fractures, with a median age of 45 years (IQR 31-62), of whom 19 937 (63•8%) were men, and 14 524 (46•5%) had lower limb fractures, making them the most common fractures. Of 5256 patients with open fractures, 3778 (71•9%) were not admitted to hospital within 2 h. Of 25 999 patients with closed fractures, 7141 (27•5%) were delayed by more than 24 h. Of all regions, Latin America had the greatest proportions of patients with delays (173 [88•7%] of 195 patients with open fractures; 426 [44•7%] of 952 with closed fractures). Among patients delayed by more than 24 h, the most common reason for delays were interfacility referrals (3755 [47•7%] of 7875) and Third Delays (cumulatively interfacility referral and delay in emergency department: 3974 [50•5%]), while Second Delays ...

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CONTEXT: Post-operative pain is the major morbidity of most of the surgeries. This study aims to find out the analgesic property of MAGNESIUM SULPHATE as it blocks N-Methyl DAspartate receptor. AIMS: To study the effect of Peri-operative IV Magnesium sulphate on Postoperative pain management and to determine the adverse reactions, if any. SETTINGS AND

Peri-operative management of opioid resistant pain is major clinical problem especially in the immediate postoperative period. The role of NMDA receptor in the processing of nociceptive input has lead naturally to renewed clinical interest in NMDA receptor antagonist such as ketamine. This paper reviews the use and efficacy of adding low dose ketamine to morphine in management of acute post-operative pain in patients who perceive pain in spite of large consumption of morphine and added advantages of decreasing opioid consumption and there by resulting in minimizing dose related side effects. We conducted a randomized double blind study on 120 patients undergoing major abdominal surgery. All patients were kept in PACU post operatively and were given basal analgesia with IV morphine till maximum of 100µg /kg within 30 min period, but if patient still complained of pain (≥6 of 10 on VAS) with an acceptable cognition state (≥15 in the MMSE) and who rated themselves not sedated (≥5 of 10 on VAS) were taken as resistant to morphine and were enrolled in one of the two treatment groups. The MS group received 3 boluses of 30 µg/kg of morphine plus saline whereas MK group received 3 boluses of 15 µg of morphine plus 250 µg/kg of ketamine. The total dose of morphine required by MK patients (0.42±0.12 mg/kg) was significantly less than MS patients (1.21±0.43mg/kg). (P<0.0001). The quality of analgesia was in favor of MK group even in terms of rescue analgesia as amount of diclofenac required was double in MS patients than in MK patients. (186.84 ± 37.83 vs. 83.57 ±30.28, P= 0.0001). The VAS score at rest and ambulation was significantly less in MK group as compared to MS group at 180 minutes (P<0.001). The 10 minute level of wakefulness (1-10 VAS) in the MS group (6.88±1.09) was significantly (P < 0.0001) less than MK group (8.28 ± 0.43). Postoperative nausea and vomiting was seen in 68.37% of MS patients as compared to only 8.30% of MK patients (P=0.0001). No hemodynamic ill effects or psychosomatic effects were seen in MK group. We concluded that the postoperative administration of concomitant small doses of MK provided rapid and sustained improvement in pain control in major abdominal surgeries.