Association between preoperative evaluation with lung ultrasound and outcome in frail elderly patients undergoing orthopedic surgery for hip fractures: study protocol for an Italian multicenter observational prospective study (LUSHIP)

Luigi Vetrugno, Enrico Boero, Elena Bignami, Andrea Cortegiani, Santi Maurizio Raineri, Savino Spadaro, Federico Moro, Stefano D'Incà, Loris D'Orlando, Felice Eugenio Agrò, Mattia Bernardinetti, Francesco Forfori, Francesco Corradi, Sandro Pregnolato, Mario Mosconi, Valentina Bellini, Federico Franchi, Pierpaolo Mongelli, Salvatore Leonardi, Clemente Giuffrida, Marco Tescione, Andrea Bruni, Eugenio Garofalo, Federico Longhini, Gianmaria Cammarota, Edoardo De Robertis, Giuseppe Giglio, Felice Urso, Tiziana Bove, LUSHIP Study Investigators, Lisa Mattuzzi, Nicola Federici, Silvia Delrio, Francesco Meroi, Luca Flaibani, Clara Zaghis, Daniele Orso, Serena Tomasino, Bruno Dottore, Michele Divella, Sabrina Mussetta, Gaia Musso, Angela Minunno, Carlo Barbero, Mattia Puppo, Francesco Saturno, Alberto Nicolò Galvano, Mariachiara Ippolito, Leo Massari, Margherita Bianconi, Gaetano Caruso, Riccardo Ragazzi, Carlo Alberto Volta, Silvia Mongodi, Francesco Mojoli, Filippo Riccone, Sabino Scolletta, Sebastiano Macheda, Serafino Vulcano, Giovanni Cosco, Eugenio Vadalà, Erika Taddei, Alessandro Isirdi, Luigi Vetrugno, Enrico Boero, Elena Bignami, Andrea Cortegiani, Santi Maurizio Raineri, Savino Spadaro, Federico Moro, Stefano D'Incà, Loris D'Orlando, Felice Eugenio Agrò, Mattia Bernardinetti, Francesco Forfori, Francesco Corradi, Sandro Pregnolato, Mario Mosconi, Valentina Bellini, Federico Franchi, Pierpaolo Mongelli, Salvatore Leonardi, Clemente Giuffrida, Marco Tescione, Andrea Bruni, Eugenio Garofalo, Federico Longhini, Gianmaria Cammarota, Edoardo De Robertis, Giuseppe Giglio, Felice Urso, Tiziana Bove, LUSHIP Study Investigators, Lisa Mattuzzi, Nicola Federici, Silvia Delrio, Francesco Meroi, Luca Flaibani, Clara Zaghis, Daniele Orso, Serena Tomasino, Bruno Dottore, Michele Divella, Sabrina Mussetta, Gaia Musso, Angela Minunno, Carlo Barbero, Mattia Puppo, Francesco Saturno, Alberto Nicolò Galvano, Mariachiara Ippolito, Leo Massari, Margherita Bianconi, Gaetano Caruso, Riccardo Ragazzi, Carlo Alberto Volta, Silvia Mongodi, Francesco Mojoli, Filippo Riccone, Sabino Scolletta, Sebastiano Macheda, Serafino Vulcano, Giovanni Cosco, Eugenio Vadalà, Erika Taddei, Alessandro Isirdi

Abstract

Background: Hip fracture is one of the most common orthopedic causes of hospital admission in frail elderly patients. Hip fracture fixation in this class of patients is considered a high-risk procedure. Preoperative physical examination, plasma natriuretic peptide levels (BNP, Pro-BNP), and cardiovascular scoring systems (ASA-PS, RCRI, NSQIP-MICA) have all been demonstrated to underestimate the risk of postoperative complications. We designed a prospective multicenter observational study to assess whether preoperative lung ultrasound examination can predict better postoperative events thanks to the additional information they provide in the form of "indirect" and "direct" cardiac and pulmonary lung ultrasound signs.

Methods: LUSHIP is an Italian multicenter prospective observational study. Patients will be recruited on a nation-wide scale in the 12 participating centers. Patients aged > 65 years undergoing spinal anesthesia for hip fracture fixation will be enrolled. A lung ultrasound score (LUS) will be generated based on the examination of six areas of each lung and ascribing to each area one of the four recognized aeration patterns-each of which is assigned a subscore of 0, 1, 2, or 3. Thus, the total score will have the potential to range from a minimum of 0 to a maximum of 36. The association between 30-day postoperative complications of cardiac and/or pulmonary origin and the overall mortality will be studied. Considering the fact that cardiac complications in patients undergoing hip surgery occur in approx. 30% of cases, to achieve 80% statistical power, we will need a sample size of 877 patients considering a relative risk of 1.5.

Conclusions: Lung ultrasound (LU), as a tool within the anesthesiologist's armamentarium, is becoming increasingly widespread, and its use in the preoperative setting is also starting to become more common. Should the study demonstrate the ability of LU to predict postoperative cardiac and pulmonary complications in hip fracture patients, a randomized clinical trial will be designed with the scope of improving patient outcome. Trial registration ClinicalTrials.gov, NCT04074876. Registered on August 30, 2019.

Conflict of interest statement

LV received travel support from Cook Medical in relation to a congress lecture. The others authors declare to have no competing interests. FM received fees for lectures from GE Healthcare, Hamilton Medical, SEDA SpA, outside the present work. SM received fees for lectures from GE Healthcare, outside the present work.

Figures

Fig. 1
Fig. 1
Each hemithorax is divided in six regions: two anterior, two lateral, and two posteriors, following to anatomical landmarks set by parasternal, anterior and posterior axillary lines. Each region is divided in superior and inferior. To perform an examination, adjacent intercostal spaces are explored in each region of interest, sliding the probe along intercostal space
Fig. 2
Fig. 2
Study flow enrolment

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