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Current Anaesthesia & Critical Care (2005) 16, 23–33

KEYWORDHip fractuElderly;OptimizatiCare bundAnaesthesi

0953-7112/$ - sdoi:10.1016/j.c

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FOCUS ON: THE ELDERLY

The anaesthetic management of upperfemoral fracture

Ian Stanley�

Blackburn Royal Infirmary, Blackburn BB2 3LR, UK

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54 687235.ess: ianstanley@doctor

Summary Patients presenting with upper femoral fracture are usually elderly andtherefore a significant proportion will have co-existent disease. The insult of afracture and its subsequent repair pose demands upon the physiological reserve thatsome of this high risk patient population will be unable to meet without invasivelymonitored therapy. This is reflected in the high mortality rate for this procedure.The application of evidence-based practice will increase the proportion of thispopulation able to survive the physiological insult and improve their recovery andlength of stay. This evidence base encompasses practice specific to hip fracturepatients and to high risk patients in general. Much of this evidence base is appliedalready but the application of all of the evidence in a ‘care bundle’ approach shouldlead to significant improvements in outcome. Initially this may appear costly interms of manpower and resources, but the longer term improvements andsubsequent increased independence of patients mean that overall this approach iscost effective as well as best medical practice.& 2005 Elsevier Ltd. All rights reserved.

The repair of fractured neck of femur is anincreasingly common operation.1 The proportionof the United Kingdom population over 65 years oldis increasing.2 A proportion of this population willhave co-existent disease which is being controlledadequately to allow normal function but whichlimits the ability to respond to the physiologicalstress placed upon them by injury, surgery andrecovery. A further cohort will be generally unfitwith significant co-morbidity. As a result anaesthe-

Elsevier Ltd. All rights reserv

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tists will encounter a higher number of these highrisk patients presenting for surgery.

Over the past few years the anaesthetic litera-ture has seen a number of strategies that have beenadvocated for improving outcome in the high riskpatient presenting for anaesthesia. There is con-troversy regarding the use of beta adrenoceptorstimulants or beta blockade. There has beenevidence regarding the restrictive use of bloodtransfusion in the critical care and surgical patientand some debate remains about the optimalanaesthetic technique to be employed as well asthe need or otherwise for pharmacological throm-boprophylaxis.

ed.

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Volume status of the fractured neck offemur patient

The initial insult of the fall and fracture stimulate astress response, mediated by an increase incirculating mineralo and glucocorticoids and cate-cholamines. The physiological aims of this are toincrease circulating blood volume and cardiacoutput, release synthetic precursors to facilitatetissue repair and maintain blood flow and oxygendelivery to vital organs. The pathophysiologicalconsequences of this stress response may includean increase in myocardial oxygen requirement, witha consequent imbalance in myocardial oxygendemand and supply, increased protein breakdownand catabolism, hyperglycaemia and electrolyteimbalances. This stress response and its conse-quences occur within minutes of the initial trauma.3

In major surgery and trauma oxygen requirementcan increase from 110 to 170ml/min/m2.4 Theability to generate this level of response has beenshown to correlate strongly with survival.5,6 Theinability of the patient to meet the requirementsfor an increase in oxygen delivery to the tissuesleads to a number of consequences with impairedrenal and splanchnic perfusion,7 decreased cere-bral perfusion and reduced skin blood flow. This canlead to postoperative renal impairment, increasedgut bacterial translocation and bacteraemia,8

neurological dysfunction and breakdown of the skinleading to the development of pressure sores.9

Many elderly patients are taking prescribedmedication to treat or prevent cardiac failure atthe time of admission. They often limit their fluidintake because of a fear of incontinence or thedifficulty of mobilizing to the toilet rendering themrelatively hypovolaemic and even more prone tothe development of a low cardiac output state andan impaired ability to generate an increase inoxygen delivery in response to a surgical ortraumatic stress. The use of fluid therapy in theelderly hip fracture population has been investi-gated in a number of studies. Sinclair et al.10

studied the effect of guided fluid loading upon timeto achieve discharge fitness, duration of in-patientstay and mortality. They randomly assigned 40elderly patients to control or treatment groups.The control group received general anaesthesiamaintained with enflurane and nitrous oxide/oxygen and imtermittent positive pressure ventila-tion. Peri-operative analgesia was maintained by alateral femoral cutaneous nerve block, fentanyland nitrous oxide. In addition to this both groupswere monitored with an oesophageal Dopplerprobe. In the study group fluid challenges weregiven until stroke volume and corrected flow time

were deemed optimal. The study group receivedsignificantly more fluid than the control group andstroke volume, cardiac output and corrected flowtime were also significantly increased, whereas inthe control group they fell. There was no statisti-cally significant difference in mortality but time todischarge and overall length of stay was reduced inthe protocol group. Again, standard care withroutine monitoring was shown to leave the patientfunctionally hypovolaemic and unable to respond tothe surgical stimulus with an increase in cardiacoutput and oxygen delivery.

Venn et al.11 examined the use of central venouspressure (CVP) monitoring in hip fracture patientsto determine if this was as useful as oesophagealDoppler in optimizing fluid status. They randomlyassigned 114 patients to three groups; to receivestandard care, standard guide and fluid optimiza-tion guided by oesophageal Doppler measurements,or standard care and CVP-guided fluid manage-ment. All patients again received general anaes-thesia supplemented by a local anaesthetic nerveblock. Fluids in the oesophageal Doppler groupwere managed similarly to in the previous study. Inthe CVP group the response in CVP to a fluidchallenge was assessed and fluids administereduntil the circulation was judged to be optimallyfilled. Again the protocol groups received signifi-cantly more fluid. The protocol groups demon-strated a reduction in the incidence ofintraoperative hypotension, a trend towards re-duced morbidity and faster postoperative recovery.

These studies had followed work aimed atincreasing oxygen delivery in the high risk surgicalpatient. Boyd et al.12 studied a population of highrisk surgical patients undergoing both elective andemergency surgical procedures. 107 patientswere randomized into study and control groups.The control group received best standard care. Thestudy group had, in addition, treatment to increaseoxygen delivery to greater than 600ml/min/m2.This was commenced pre-operatively and main-tained throughout the peri-operative period. It wasachieved by use of pulmonary artery cathetermonitoring of cardiac output and the use of fluidloading and in addition dopexamine infusion ifrequired. There was a significant reduction inmortality of 75% in the treatment group and areduction in the total number of complications of50%. Interestingly one major difference in the twotreatment groups was in the amount of fluid given.

Similarly Wilson and Woods13 randomly assigned138 patients deemed at high risk of postoperativecomplications due either to the type of surgeryor pre-existing co-morbidity. Three groups werestudied. The first group received standard care.

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The anaesthetic management of upper femoral fracture 25

One group received invasive monitoring, fluid anddopexamine to increase oxygen delivery to greaterthan 600ml/min/m2. The third group receivedadrenaline as the inotrope. The treatment groupsdemonstrated a significant reduction in mortality,and in the dopexamine group length of stay wasshortened. Again the major difference betweentreatment and control patients was the extra fluiddelivered to the treatment group pre-operatively Itwas the presence of invasive monitoring that led tothe administration of this extra fluid and it could beimplied that routine, less invasive monitoring maybe leaving the patient relatively hypovolaemic andunable to increase oxygen delivery as required.

The studies by Boyd and Wilson were bothconducted on patients considered high risk but alsoundergoing high risk procedures in whom the stressresponse and consequent systemic inflammatoryprocess would be greater. The elderly patientpresenting for hip fracture surgery would fulfillthe criteria as a high risk patient but the surgicalinsult could be considered to be less stimulating toa surgical stress response. However, the hipfracture patient is subject to two traumatic insultsin a short space of time; any inadequacy of initialresuscitation and subsequent generation of oxygendebt could be further compounded by a secondinsult in the form of corrective surgery. Thestrategies used to increase global oxygen deliveryconcentrate upon the increase of cardiac outputand the inability to increase cardiac work in thelight of fluid resuscitation has been shown tocorrelate with increased complications and de-creased survival.14,15

These studies demonstrate that the use of fluidscarefully titrated to a monitored response canimprove outcome in this population of patients. Inthe elderly population left ventricular compliancemay be compromised and injudicious fluid therapyto increase cardiac filling pressures may precipitatecardiac failure. The variability in the amounts offluid given to individual patients in the treatmentgroups of both studies demonstrates that a one-size-fits-all approach is not appropriate and fluidchallenges need to be tailored to the individualdepending upon the response. This requires inva-sive monitoring as non-invasive means of monitor-ing have appeared normal in the presence of occulthypovolaemia and oxygen debt.5

Is there a role for beta-blockers?

The increase in oxygen delivery brought about bythese interventions and by the effects of the stress

response will require an increase in myocardialwork. The incidence of significant co-morbidity inthis patient group is high,16 and the number ofpatients presenting for surgery with overt or occultcardiac disease is expected to increase signifi-cantly.17 Increases in myocardial work may pre-cipitate myocardial ischaemia or infarction. Thereis increasing evidence that in patients with sig-nificant risk factors for ischaemic heart disease theadministration of beta-blocking drugs will improveoutcome. Mangano and colleagues18 were the firstto investigate the potential benefits of beta-blockade in those deemed at high risk of myocardialischaemia undergoing major surgery. Two hundredpatients were randomized to receive placebo oratenolol in the immediate pre-operative period andto be continued for 7 days postoperatively. Therewas no difference in early postoperative mortalitybut at 6 months event-free survival was signifi-cantly increased in the treatment group.

Poldermans et al.19 investigated the beneficialeffect of bisoprolol on peri-operative mortality andmyocardial infarction. They investigated 112 pa-tients who had been identified as very high risk formyocardial ischaemia by virtue of the presence ofknown risk factors and a positive dobutamine stresstest. These patients were also listed for high riskvascular surgery. Beta blockade was commenced 1week prior to surgery and continued for 30 dayspostoperatively. The placebo group demonstratedan incidence of cardiac complications of 34%, thestudy group 3.4%.

Both of these studies appear to demonstrate adramatic effect upon cardiac complications; whichthe hip fracture population is at high risk ofdeveloping. However the paper by Mangano hasbeen criticized for a number of reasons. Its size hasbeen criticized, as has its inability to demonstrateany benefit during the time of atenolol administra-tion, despite a reduction in Holter monitordetected myocardial ischaemia.20 The placebogroup contained some patients in whom pre-operative beta-blockade was discontinued. Thestudy by Poldermans included only those patientswith proven impairment in myocardial blood flow.These patients were at high risk of peri-operativecardiac events and this is reflected in the highevent rate in the placebo group. The interventionof beta blockade had dramatic effects but itsapplication to a patient population in whom surgeryis expected within 24 h of presentation is notpossible as the study patients received bisoprololfor 1 week prior to surgery.

Other studies have demonstrated a reduction inperi-operative myocardial ischaemia by adminis-tration of beta blockers, though no differences in

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mortality were demonstrated.21–23 A meta-analy-sis20 demonstrated only a marginal decrease inmyocardial-related deaths in the treatment arm.The questions of who should receive beta blockade,when it should be started, how long it shouldbe continued for and how the patients should bemonitored during its implementation remain unan-swered.

Is this feasible in current UK practice?

It would appear that there are two conflictingstrategies both of which have been shown todemonstrate an improvement in outcome. Whichstrategy should be employed for which patient?This apparent conflict has been addressed with thedescription of ‘the tortoise or hare approach.24 Thepatient most at risk of myocardial ischaemiarequires an approach to reduce myocardial oxygenrequirement whilst those who could tolerate itwould be most benefited from an approach leadingto increased myocardial work and global oxygendelivery.

In the fractured neck of femur population, itwould seem sensible to achieve optimal fluidloading and volume status and to implement betablockade therapy in those patients most at risk ofischemic heart disease. In United Kingdom practicehowever the use of invasive monitoring may not beavailable on a routine basis and the anaesthetictechnique employed may exclude the use ofoesophageal Doppler. The use of invasive monitor-ing has been shown to be associated with improvedoutcome in elderly trauma patients25 and asproposed in Comprehensive Critical Care level 2critical care facilities should be available for highrisk hip fracture patients.26 The low level ofintraoperative monitoring and postoperative criti-cal care availability for hip fracture patients washighlighted as an area of concern in the 1993–1994NCEPOD report.27 Personal experience does notlead me to believe that this has changed.

The optimal technique for monitoring the hae-modynamic status of a conscious patient in the pre-and peri-operative phases has still to be confirmedand this may well be an area for research into theuse of pulse contour analysis techniques, such asPicco and LidCO, which are much less invasive andcan be used pre- and postoperatively. Fluidchallenges can be nurse administered according toprotocol.

When and where to perform this pre-operativeoptimization also needs to be addressed; theanaesthetic room may be too late as a significant

oxygen debt or period of myocardial ischaemia maywell have built up in the intervening period. Thismay explain the disappointing findings of aCochrane analysis of peri-operative fluid optimiza-tion. The authors concluded that although invasivemethods of optimizing fluids in the peri-operativeperiod are associated with decreased hospital staythere were no available data to confirm a benefit inlonger term patient-centered outcomes.28 Withincritical care literature there is growing evidencethat early appropriate intervention improves out-come in septic patients29 whereas a similar inter-vention performed later on in the disease processhas not been shown to be beneficial.30 Again theissue of resources for high standards of care for thisgrowing patient population needs to be addressed.

What fluids should be used for pre-operative resuscitation?

The type of fluid used for volume optimizationneeds to be carefully considered. Elderly patientshave impaired ability to handle high solute loads.The use of high volumes of sodium chloride candeliver a high chloride load with consequentdevelopment of a metabolic acidosis and subse-quent problems.31 The use of low sodium contentfluids has also been associated with the develop-ment of significant hyponatraemia, especiallyin females.32,33 The optimum fluid may well there-fore be Hartmann’s solution to overcome theseproblems along with regular serum electrolytemeasurements.

Transfusion requirements

Pre-operative blood transfusion has traditionallybeen used when haemoglobin level falls below10 g/dl. A study of elective orthopaedic patientsrefusing transfusion investigated the effect oflower haematocrit levels.34 At haematocrit levelsof 24% and below there was an increase in theincidence of ST segment changes, most pronouncedin ASA III patients. There were no peri-operativemyocardial infarctions in this group. The use ofblood in critical care patients has changed recentlyin light of evidence that critically ill patientsrandomized to receive blood only when the serumhaemoglobin level fell below 7 g/dl had no worseoutcome than those who had a transfusion triggerof 9 g/dl.35 Subgroup analysis revealed that thedifference in outcome was most noticeable in thosewho were younger (o50 years of age ) and less

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The anaesthetic management of upper femoral fracture 27

unwell (APACHE 2 scoreo20). There was nodifference in outcome in patients with ischaemicheart disease between either group. The use of arestrictive transfusion policy has been specificallystudied in the hip fracture population. Pre-opera-tive anaemia is associated with increased length ofstay, higher risk of death and readmission within 60days of discharge.36 Transfusion of blood to patientswith a haemoglobin level below 10 g/dl wasassociated with decreased levels of readmissionbut had no effect upon mortality or rate to achievefunctional mobility.37 Using a transfusion trigger of8 g/dl was not associated with any increase inmortality at 30 or 90 days.38 It would appeartherefore that in those without significant ischae-mic heart disease a restrictive blood transfusionpolicy is acceptable.

Supplementary oxygen therapy is advocated inall hip fracture patients for a number of reasons.When they first present they are essentially avictim of trauma and require some degree ofresuscitation. This will include oxygen therapy.39

The stress response will be operating with theconsequent need for increased oxygen delivery.Peri-operative oxygen supplementation has beenassociated with a decrease in the incidence ofsurgical wound infection40 and an increase incutaneous oxygen tension which would contributeto a reduction in pressure area problems. It hasbeen reported that persistent hypoxia may bepresent in all hip fracture patients from the timeof admission until up to 5 days postoperatively.41,42

Episodes of myocardial ischaemia occur in post-operative patients in the early hours of the morningand are most common on the second postoperativeday.43 Hypoxaemia can be detected by using pulseoximetry regularly to check oxygen saturationlevels. Not surprisingly, it has been shown thatmonitoring oxygen saturation using pulse oximetryreduces the incidence of hypoxaemia.44 Providingsupplementary oxygen increases the mean oxygensaturation and is recommended for all patients inthe immediate postoperative period (24 h) andovernight for the first three nights. Short periodsof oxygen supplementation do not cause resorptionatelectasis.45

When to operate and who should do it?

It might appear that there is considerable pre-operative preparation to be performed before apatient should be taken to theatre and this mayresult in delays in performing definitive surgery.The East Anglia audit demonstrated a relationship

between early surgery and improved outcome.46 Aswell as causing distress to the patient, delay inoperative fixation is associated with increasedmorbidity and mortality. Delays in surgery greaterthan 48 h are associated with prolonged length ofstay, delayed mobilization and greater incidence ofcomplications, especially respiratory, and the de-velopment of pressure sores as well as reducedchance of successful internal fixation and rehabili-tation.47,48 Whether this merely reflects the factthat sicker patients take longer to prepare fortheatre or whether there is a causal relationship isnot clear. However early surgery (within 24 h)reduces the risk of deep vein thrombosis (DVT)49

and of fatal pulmonary embolism (PE) after hipfracture.50 Prompt action to prepare a patient fortheatre and surgery as soon as practical afteroptimization will lead to improved outcomes.51–53

One year survival has been shown to be improved inpatients operated on the day of presentation, withpatients over 80 years of age showing the mostpronounced benefit.54 However performing surgeryon an under-prepared patient may also be deleter-ious and this poses significant clinical questionswhen faced with a patient with ongoing pathology.An operation on an under-prepared patient merelyto satisfy political directives or star ratings criteriais not justified. It is just as important not to chaseunrealistic medical goals with resulting delay. Forexample, a patient with an early diagnosis of achest infection, in whom early surgery would allowbetter mobilization and chest physiotherapy,should not be delayed to allow medical treatmentas the resultant delay will lead to a higher level ofcomplications.55 This again raises the question ofresources to provide an area for appropriatemonitoring and expertise to prepare these patientsin a timely manner. Where this strategy has beenadopted with the involvement of a multi-disciplin-ary team mortality, length of stay and overallmorbidity have improved.56

To facilitate prompt surgery on a fully preparedpatient there must be adequate provision oftheatre space staffed by appropriately trainedsurgeons and anaesthetists. Anaesthesia provisionfor elderly patients was addressed in the NCEPODreports ‘Who operates when?’57 and ‘Extremes ofAge’.33 They found that a significant number ofelderly patients with significant co-morbiditieswere being anaesthetized by non-consultantstaff in ‘out of hours’ operating sessions. Thiswas reflected in an Audit Commission reportwhich showed wide variations in practice inthe anaesthetic management of hip fracturepatients.1 Patient outcomes are better whenperi-operative management is undertaken by

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experienced anaesthetic personnel.58,59 Surgicaltreatment conducted as a night-time emergencyincreases mortality.57,59 They recommended theprovision of dedicated trauma sessions 7 days aweek staffed by consultant grade anaesthetists andsurgeons.1

What type of anaesthetic should be used?

The type of anaesthetic technique used for hipfracture surgery has been extensively studied. Ameta-analysis showed a reduction in mortality atone month in patients treated with regional (spinalor epidural) anaesthesia, compared to those re-ceiving general anaesthesia.60 A Cochrane review61

found that patients receiving regional anaesthesiahad a reduced mortality at one month comparedwith patients receiving general anaesthesia. How-ever the difference in 30-day mortality is ofborderline statistical significance and many of thestudies included in these reviews are more than 10years old, since when techniques for generalanaesthesia have significantly improved and manyanaesthetists now supplement general anaesthesiawith nerve blocks.62 More recent comparativestudies have failed to demonstrate any differencein early postoperative mortality (7 days),63 at 1month or at one year.64 The overall numbersincluded in the longer term studies are limitedand any benefit may be masked by this fact. Itwould seem apparent that any differences inoutcome are small and it may be that experienceand competence of the anaesthetic practitioner ismore important than the type of anaestheticperformed. However, further studies comparingmodern general and regional anaesthesia with orwithout supplementary nerve blocks are war-ranted. The benefits of regional anaesthesia havebeen elucidated by a systematic review of 141 RCTsinvolving over 9500 patients undergoing all types ofmajor surgery. Hip fracture surgery patients wereincluded in this review which found a 30% reductionin 30-day mortality in the patients receivingregional anaesthesia.65 Other measures of outcomehave been examined. Several studies have shown areduction in asymptomatic DVT following spinalanaesthesia, and a non-significant reduction in theincidence of fatal PTE.61 Time to ambulation maybe quicker in patients receiving regional anaesthe-sia66 and other early benefits of regional andneuraxial blockade do include a decrease in theshort term incidence of cardiovascular and respira-tory complications.60 This may be a reflection ofthe blunting of the systemic stress response, the

benefit of which is overcome by other longer termfactors. Overall, regional anaesthesia appears tooffer short-term benefits to the patient. Absence oflong-term benefit in hip fracture patients may be areflection that long-term outcome is dependantupon a number of factors which mask the earlybenefit conferred by the choice of anaesthetictechnique.

Hypotension and regional anaesthesia are oftenassociated. The Cochrane review found a non-significant increase in the incidence of hypotensionfollowing regional compared with general anaes-thesia.61 This hypotension may be deleterious inthe elderly population in whom normotension isconsiderably higher with a subsequent re-setting ofthe limits of the range of blood pressure over whichautoregulation of bloodflow occurs. Periods ofhypotension may be associated with adverseeffects upon end organ perfusion and myocardialischaemia.43 NCEPOD found a high level of hypo-tensive episodes going untreated.33 Hypotensiondue to neuraxial block requires prompt action,usually most suitably with an alpha adrenoceptoragonist to restore blood pressure and limit anytachycardic response.67,68

What strategy should be used to preventthrombo-embolic disease?

Patients undergoing orthopaedic surgery representone of the highest risk groups for the developmentof venous thromboembolism (VTE).69 Clinical trialshave shown that prophylaxis with the low-molecu-lar-weight heparins is a safe and effective way ofreducing the incidence of deep venous thrombosisand total VTE,70 and a meta-analysis demonstrateda reduction in symptomatic VTE with extendedprophylaxis after hip replacement surgery.71 How-ever a Cochrane review of thromboprophylacticregimes in hip fracture patients found insufficientevidence to confirm either protection againstpulmonary embolism, or to distinguish betweenvarious applications of heparin,72 and the use ofheparin prophylaxis was not associated with reduc-tion in symptomatic VTE in the PEP trial.73

A systematic review of the use of anti-plateletagents74 and a subsequent large RCT found areduction of deep venous thrombosis of about onethird, with a small associated increase in bleedingcomplications.73

In those in whom pharmacological agents arecontra-indicated, foot and calf pumping devicesmay be used. A Cochrane review of trials assessingcompression devices found that they may protect

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against DVT and pulmonary embolism but that datawere insufficient to establish any effect on theincidence of fatal pulmonary embolism and overallmortality. Problems with skin abrasion and com-pliance were reported.72 The authors recommendthat good quality trials of mechanical methods aswell as direct comparisons with heparin and lowdose aspirin should be considered.

The interpretation of these studies has led todiffering recommendations being drawn up. TheScottish Intercollegiate Guidelines Network (SIGN)recommends the use of aspirin in all patients unlesscontra-indicated continuing for 35 days combinedwith mechanical compression and early mobiliza-tion. They recommend that heparin is reserved forthose at specific high risk of thromboembolicdisease, or in whom aspirin is contra-indicated.55

An Australian review of the same literatureargued that the hip fracture population is knownto be high risk for VTE75 and so adoption of aheparin based thromboprophylactic regime mightappear more logical. Extrapolation of large studynumbers from surgical and elective orthopaedicpopulations would suggest a significant benefit inreduction of risk in this high risk population.76

Neuraxial anaesthetic techniques are associatedwith a decrease in thromboembolic complicationsthrough a decreased activation of the coagulationsystem and due to improved flow in the vasodilatedstate. The combination of neuraxial anaesthesiaand either of the above strategies may be ade-quate. This question has not been addressedspecifically, but the use of a neuraxial techniqueper se does confer significant peri-operative pro-tection against thrombo-embolic complications.

The efficacy and safety of fondaparinux, a newsynthetic thrombin inhibitor were investigated in twolarge studies. Based on their findings, the authorsclaim that 4-week fondaparinux treatment maybecome the standard thromboprophylaxis after hipfracture surgery, though no clear benefit in terms ofreduction in symptomatic pulmonary embolism ormortality was apparent.77,78 There is also concernthat its long duration of action makes its adminis-tration and timing of neuraxial block difficult.

Temperature regulation

Maintenance of normothermia is essential. Theelderly patient is more prone to the developmentof hypothermia due to reduced body fat andimpaired thermoregulatory mechanisms. Minorlevels of hypothermia have been associated withsignificant increases in surgical wound infection in a

number of surgical procedures79,80 due to localvasoconstriction and reduced tissue oxygen tensionleading to decreased free radical production andbacterial killing by neutrophils. This wound infec-tion increase has led to increased length of stay anddelayed mobilization.80 As well as increasing woundinfection rates hypothermia leads to increasedblood loss and transfusion requirements in hiparthroplasty surgery81 and an increase in proteincatabolism and nitrogen excretion in the immedi-ate postoperative period. Postoperative shiveringwill increase total oxygen requirement and theconsequent peripheral vasoconstriction will in-crease afterload, both factors contributing to animbalance in the myocardial oxygen demand andsupply equation. Peri- and posthypothermia isassociated with myocardial ischaemia in the post-operative period.82

Strategies to prevent hypothermia have provedeffective in reducing wound infection80 blood lossand transfusion requirements in hip arthroplastysurgery81,83 and as a result may reduce length ofstay, time to discharge and overall costs of care.84

Warm air blankets and active warming have beenshown to be superior to passive, reflective devicesfor maintaining normothermia in joint replacementsurgery.85

Antibiotics

A systematic review of randomized trials indicatesthat the administration of antibiotic prophylaxis inpatients undergoing surgery for a hip fracture isassociated with a reduced incidence of superficialand deep wound infection, urinary tract infectionand respiratory infection. There is evidence thatmultiple dose antibiotic administration is no moreeffective than single dose administration.86 How-ever some guidelines advocate that if surgery takeslonger than two hours or there is blood loss greaterthan 2 l (which are both unlikely during hip surgerybut possible in complex cases), a second dose maybe administered during the operation.87 Moreprolonged use of broad spectrum antibiotics maybe associated with gastrointestinal complications inthis patient group.

Pressure care and nutrition

Pressure areas are of great concern in the elderlypopulation. A number of factors contribute to ahigh incidence of pressure area breakdown. In thispopulation strategies can be adopted to reduce the

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risk of pressure area damage. These includemaintenance of adequate hydration and nutrition,specialized mattresses including their early use inthe accident and emergency department and onthe operating table.88,89 Maintenance of nor-mothermia, early surgery and mobilization haveall been shown to reduce pressure area problems.89

Many elderly patients are malnourished onadmission to hospital. Many factors lead to geriatricanorexia. The acute stress response to surgery, pre-operative fasting and poor mobility in the post-operative period render the patient at great risk ofdeveloping severe malnutrition. Prolonged pre-operative fasting and repeated cancellations onlyserve to exacerbate this. This is associated withimpaired immune function, impaired wound heal-ing, increased incidence of pressure sores, pro-longed length of stay and increased mortality.90,91

It is vital that patients’ nutritional status isaccurately assessed and appropriate interventionsplanned to prevent malnutrition and trace elementdeprivation. It is important to maintain a normaleating pattern for the patient. Prolonged starvingfor a patient on an afternoon list is not indicated.Why can such a patient not be given breakfast?Specific strategies aimed at improving nutritionalstatus do suggest an improvement in outcome inthe elderly hospital population.92

As well as providing adequate nutrition care mustbe maintained to prevent the development ofhyperglycaemia. Tight control of glucose by use ofinsulin has been shown to improve outcome incritical care and cardiac patients.93,94 Persistenthyperglycaemia is associated with an increase ininfective complications. Care must be taken toprevent hypoglycaemia and this again emphasizesthe need for high levels of care in the appropriateenvironment for these patients.

Where to care for these patients

Comprehensive Critical Care was published in 2000.It emphasized that the patient should be cared forin the area of the hospital best able to deliver thecare that patient required.95 In some hip fracturepatients with minimal co-morbidity and good pre-admission health, routine ward care is appropriate.However in the sick, elderly patient with significantco-morbidity, there is a need for careful and timelypre-operative optimization and the likelihood ofintensive monitoring and nurse interventions in theimmediate postoperative period. These patientsare level 2 critical care patients and their manage-ment requires a critical care setting, with appro-

priate multidisciplinary involvement to facilitateoptimal recovery and rehabilitation.

Summary

There are now a number of evidence-based inter-ventions specific to the hip fracture population.There are others which pertain to the critically illand high risk patient in general. The use of guidedfluid loading, administration of beta blockers tothose with significant risk factors for myocardialischaemia, transfusion of blood only if the haemo-globin is below 8 g/dl should all be considered inthe early pre-operative phase. Prompt preparationof the patient should occur, with surgery for thosefit for theatre within 24 h, performed by experi-enced anaesthetists and surgeons in normalworking hours. Postoperatively, normothermia,correction of malnutrition and early mobilizationshould occur under the care of a multi-disciplinaryteam. A number of clinical guideline have beenformed.55,75,96 The application of these guidelinesis not, however, universal. A repeat Audit Commis-sion study into hip fracture management found thatmany of their recommendations had not beenimplemented.1

Within critical care best practice for manage-ment of a specific condition is brought together in acare bundle. This approach is aimed at maximizingimplementation of evidence-based medicine andalso offers a standard against which practice can beaudited. It has also recently been highlighted bythe Modernization Agency as a preferred techniqueto implement best practice. Issues surroundingprovision of adequately trained staff and resourcesto prepare these patients for theatre quickly,perform corrective surgery within the correcttimescale and provide high quality postoperativecare and rehabilitation remain. These patientsrequire high input of medical, nursing and alliedhealthcare professional input, which equates withcost in the short term. However where thisapproach is followed there is evidence of improvedpatient outcome, reduced length of stay and anoverall reduction of cost.56 Until this fundamentalissue is addressed this may be the limiting factor inthe provision of the service these patients reallyrequire and the long term socioeconomic costs maycontinue to rise.

References

1. Audit Commission. United they stand: co-ordinating care forelderly patients with hip fracture: update. London: Audit

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Commission for Local Authorities and the National HealthService in England and Wales; 2000.

2. Office for National Statistics. Census 200: national reportfor England and Wales. London: Office for NationalStatistics; 2003.

3. Edwards JD, Redmond AD, Nightingale P, Wilkins RG. Oxygenconsumption following trauma: a reappraisal in severelyinjured patients requiring mechanical ventilation. Br J Surg1988;75(7):690–2.

4. Older P, Smith R. Experience with the preoperative invasivemeasurement of haemodynamic, respiratory and renalfunction in 100 elderly patients scheduled for majorabdominal surgery. Anaesth Intensive Care 1988;16(4):389–95.

5. Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS.Prospective trial of supranormal values of survivors astherapeutic goals in high-risk surgical patients. Chest1988;94(6):1176–86.

6. Bishop MH, Shoemaker WC, Appel PL, Meade P, Ordog GJ,Wasserberger J, et al. Prospective, randomized trial ofsurvivor values of cardiac index, oxygen delivery, andoxygen consumption as resuscitation endpoints in severetrauma. J Trauma 1995;38(5):780–7.

7. Shoemaker WC, Appel PL, Kram HB. Role of oxygen debt inthe development of organ failure sepsis, and death in high-risk surgical patients. Chest 1992;102(1):208–15.

8. Schubert V. Hypotension as a risk factor for the developmentof pressure sores in elderly subjects. Age Ageing 1991;20(4):255–61.

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