1.7 Postoperative medical management
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1 Introduction
The early postoperative period after hip fracture repair is characterized by dynamic physiological changes in individuals with little functional reserve. Traditional approaches to postoperative care are typically poorly coordinated and primarily reactive to medical complications as they arise. These approaches put geriatric patients at risk for multiple adverse events, excessive testing and consultations, and polypharmacy ( Fig 1.7-1 ) [1].
In contrast, high-performing geriatric fracture centers can lower complication rates, length of hospital stay, and mortality following hip fracture repair. Best practice strategies require collaborative surgical and medical management, standardized protocols to address common clinical issues, a focus on early mobility, and early discharge planning [2]. Frequent medical assessments enable tailored symptom control, early recognition and treatment of postoperative complications and optimal postoperative recovery.
This chapter outlines a practical approach to the postoperative period following hip fracture repair. Emphasis is placed upon proactive, collaborative care and understanding the unique challenges faced by the older adult during this vulnerable time.
Key points are:
Postoperative care using geriatric principles is essential to optimal outcomes
Early mobilization, pain control, restoration of adequate intravascular volume, and avoidance of iatrogenic harm are essential
Some home medications may not be appropriate to resume during the postoperative period, particularly those that lower blood pressure
Discharge communication and handoffs are particularly important
2 Management of postoperative anemia
Maintaining adequate intravascular volume is an important goal of the early postoperative period. Older adults are likely to need blood and volume resuscitation postoperatively, but the timing and the amount should be tailored to the individual based on baseline and perioperative circumstances. In the early perioperative period, the risks of hypovolemia include orthostasis and syncope, acute stroke and acute kidney injury. In the late perioperative period, edema and hypervolemia can complicate wound healing and postoperative recovery. For most patients, maintaining adequate intravascular volume to support standing blood pressure and end organ perfusion is the first priority, particularly in the first 48 hours after surgery.
2.1 Isotonic fluids
Isotonic fluids, eg, 0.9% sodium chloride solution, can help maintain perioperative intravascular volume.
Continuous fluid infusion is generally started prior to hip fracture surgery and discontinued on the first or second postoperative day, after reestablishing stable intravascular volume and resuming oral intake.
Daily assessments of volume status and monitoring for signs of hypovolemia are necessary.
2.2 Blood transfusion
Standards for transfusion are in flux as emerging data has shed light on the lack of benefit and in some cases harm with liberal transfusion policies. The best data at the time of this writing comes from the FOCUS trial [3] and suggests that typical hip fracture patients can be safely managed with a transfusion blood hemoglobin threshold of 8 g/dL.
Patients in the FOCUS trial who were transfused at the 8 g/dL threshold received 65% fewer blood products than those transfused at a threshold of 10 g/dL with similar rates of death, acute coronary syndrome, and the ability to ambulate at 60 days.
Harm has also been found with liberal transfusion policies in nonhip fracture populations, though the severity of this remains largely unknown. A recent study of patients with acute gastrointestinal bleeding found significantly higher all-cause mortality at 6 weeks with a transfusion threshold of 9 g/dL compared to 7 g/dL [4]. Volume overload is the most common risk of transfusion, and this risk increases with higher volumes of infused red cells or a history of heart failure [5].
It is unlikely that a single threshold will be appropriate for all patients, and clinicians should consider the proportion and rate of blood loss in addition to the absolute hemoglobin value. Signs and symptoms due to anemia warrant transfusion regardless of threshold. Tachycardia, hypotension, altered mental status, chest pain, and dyspnea can suggest symptomatic anemia. Expected hemodynamic changes can be suppressed by comorbidity or medications, eg, beta-blocker blunting tachycardia. Higher transfusion thresholds may be needed for patients with a bleeding predisposition, those with large volume intraoperative blood loss, or higher prefracture hemoglobin levels from chronic pulmonary disease.
3 Early mobility
Early mobilization is a cornerstone in prevention of postoperative complications, including pressure ulcers, prolonged pain, and functional decline. Some factors may limit early mobility, such as delirium, tethers, and medical illness. All medical plans should be evaluated with mobility in mind.
Many patients will have nonmodifiable risk factors such as sarcopenia, motor weakness, gait disturbance, bradykinesia, impulsivity, poor proprioception, and low vision/blindness.
Physical therapy consultation on the first postoperative day and every day thereafter is necessary for promoting early physical recovery.
Physician orders should be written in a manner to encourage activity unless there is a special mobility consideration. A surgical repair that allows for weight bearing as tolerated will help to facilitate this process.
3.1 Limiting tethers and excessive monitoring
Medical equipment used for monitoring and treating hospitalized patients also “tethers” them to the bed and represent functional restraints. Tethers significantly limit mobility and can lead to complications when removed by patients. A restrained patient is more likely to develop delirium.
Clinicians should evaluate the need for such tethers on every visit and remove them as soon as possible.
More specific issues concerning common tethers include:
Urinary catheters are most appropriate for patients awaiting hip fracture surgery in order to accurately measure urine output and provide comfort to the bedridden patient who cannot toilet himself. Postoperatively, catheters hinder mobility, lead to infection and can often be removed within the first 2 postoperative days. See topic 10.2 in this chapter for further discussion of urinary catheters.
Continuous intravenous infusions represent a major barrier to mobility and are cumbersome for both nurses and patients, often distracting from the most important postoperative care goals. Most infusions can be stopped on postoperative day 1 or 2, once the patient is hemodynamically stable. If intravenous infusions are necessary, consider giving intermittently to avoid conflicts with activity or physical therapy sessions.
Continuous cardiac monitoring is only indicated in patients with unstable or newly diagnosed cardiac arrhythmias and is not indicated as part of standard postoperative care.
Supplemental oxygen should only be used to treat target signs or symptoms, and should be discontinued in patients with adequate oxygenation.
Frequency of obtaining vital signs should weigh the usefulness of this information with the burden to the patient. If the patient is hemodynamically stable, consider abstaining from vital sign checks for an 8-hour period at night to promote sleep.
Physical restraints should be avoided due to their ability to cause significant physical and psychological harm. Restraints do not prevent falls, and can promote agitation and cause significant injury and death as restrained individuals attempt to escape [6, 7]. Avoiding restraint use in hospitalized older adults can best be achieved through the prevention or prompt treatment of delirium see chapter 1.14 Delirium. Alternatives to physical restraints include companion or family sitters, changes to the patient′s environment (eg, lighting and noise), and low-dose antipsychotic medications when necessary.
4 Delirium
Delirium is the most common complication of hip fracture surgery and characterized by acutely disordered thinking and altered levels of alertness, often with fluctuating severity. It is an independent predictor of in-hospital as well as postdischarge mortality [8]. Prompt recognition and treatment of delirium is important for early and effective rehabilitation as well as other aspects of recovery.
For further discussion of delirium, see chapter 1.14 Delirium.
5 Malnutrition
Many older patients are malnourished at the time of the hip fracture; this can negatively impact their recovery as well as 1-year mortality [9]. Not surprisingly, older adults also struggle to maintain adequate nutrition during the postoperative period. Appetite can be reduced from anesthesia-induced gut stasis. The act of eating may be hindered by lethargy, throat discomfort following intubation, lack of dentures, undesirable food choices, or new or worsened dysphagia. Poor in-hospital nutrition is associated with increased mortality and functional decline [10, 11].
It remains unclear whether optimized in-hospital nutrition can mitigate or neutralize these negative outcomes; however, optimizing in-hospital nutrition remains an important goal with at least theoretical benefits of improvements in gut motility, intravascular volume, and mood.
Older adults consume more food when diets do not impose severe restrictions in salt, refined sugar, or saturated fat [12]. Similarly, oral consumption generally improves when small, high-calorie portions are available throughout the day. Feeding conditions should be optimized and tailored to the needs of the patient (eg, meal set-up, proper positioning, hand feeding).
Nutritional supplements do not have a well-defined role in hospital care of older adults. They do not appear to reduce complications or mortality in hip fracture patients [13].
Dysphagia is relatively common in older adults, and can worsen in the perioperative period. Ensure that the appropriate diet consistency is ordered and that feeding assistance is given (ie, meal supervision is sometimes necessary). If clinicians are unsure about the safety of oral intake, a swallowing evaluation can be helpful. For further discussion of malnutrition see chapter 1.11 Sarcopenia, malnutrition, frailty, and falls.
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