Fig. 7.1
Timeline of functional capacity after hip fracture with traditional anaesthetic care (blue line) vs proactive multidisciplinary care (red line)
The preoperative phase describes the period from fracture to the patient’s arrival in the operating theatre for surgery. Hip fracture is painful, if not always at rest, then usually on movement. Surgical fixation is the only method of providing analgesia and remobilisation in the long term, for which reason it should always be considered an option in preference to non-operative management. Conservative treatment carries the additional risks of immobility – thromboembolism, pressure ulceration, and loss of independence. The aim of the preoperative phase therefore, is to facilitate prompt preparation for surgery. Coordinated orthogeriatric/anaesthetic care enables standardised preoperative assessment (for example, delivered according to an agreed proforma, detailing history, examination, preoperative investigations and blood cross-matching), risk assessment using scoring systems, analgesia provision according to agreed protocols, fluid resuscitation, and organisational and patient-centred preparation for surgery.
Intraoperatively, the aim of anaesthesia is to mitigate the pathophysiological effects of surgery without destabilising the patient’s physiology. Patients are at comparatively high risk of perioperative morbidity and mortality, because they are usually frail and elderly (and so have limited physiological reserve), and have one or more comorbidities for which they take one or more drugs; cognitive dysfunction is common. Conceptually, anaesthesia is less about getting high-risk patients through 0.5–2 h of major, emergency surgery, but more about normalising a patient’s (patho)physiology so that they are able to return to their normal function within hours following surgery.
National audits have shown that a wide variety of anaesthesia techniques are used, a result of personal preference and the lack of conclusive evidence for superiority of one technique over another [1, 2]. However, observational studies and meta-analysis indicate certain anaesthesia techniques probably improve outcome [3, 4]. Of potentially greater relevance is the idea that hospitals should adopt standardised anaesthesia protocols, so that postoperative care and the management of inevitable complications of anaesthesia and surgery become predictable for orthogeriatricians.
Postoperatively, orthogeriatric care aims to remobilise, re-enable and remotivate patients in preparation for hospital discharge; ideally back to their place of residence before fracture. The early postoperative phase is critical, as delayed remobilisation is associated with a prolonged duration of inpatient stay. Good anaesthesia care facilitates early recovery, by providing non-opioid analgesia, and avoiding delirium, hypotension and anaemia.
Figure 7.1 shows a reconceptualised timeline of what joint anaesthesia/orthogeriatric care should aim to achieve. The blue line represents traditional anaesthesia care. The patient’s functional condition has been declining for some time, until they fall and break their hip (‘X’), at which point they become entirely dependent. They are taken to hospital but receive minimal care until surgery, and so experience no functional improvement. Intraoperatively, the fracture is fixed, analgesia, fluids/blood are given, the blood pressure monitored, and the patients functional status improves, which continues into the immediate postoperative period. However, perhaps the patient develops delirium or feels too nauseous to remobilise for several days in the early postoperative period, as a result of reliance on postoperative opioid analgesia. They recover function over the next few days, but then develop pressure sores or suffer a pulmonary embolism related to their prolonged bedrest, and their functional recovery is delayed again. Eventually, they recover, not quite to their pre-fracture level of function but enough to be discharged from hospital. However, their relatives report that the patient ‘was never quite the same’ after this episode, with a slow ongoing decline in function after discharge (dotted lines).
Instead, proactive multidisciplinary care (red line) aims to return patients quickly to their pre-fracture functional status. Simple resuscitation (analgesia, fluids, food) decreases the relative decline in function after fracture, and may indeed begin to improve function pre-operatively. The patient undergoes surgery sooner and for a shorter period, during which resuscitation and normalisation of function continues using standardised anaesthesia. The patient’s functional status rapidly returns to prefracture levels, there are no immobilising complications, the patient is discharged from hospital sooner and remains ‘well’ after discharge.
7.3 Preoperative Care
Guidelines published in 2012 by the Association of Anaesthetists of Great Britain and Ireland (AAGBI), in association with the British Geriatrics Society, detail organisational and interdisciplinary aspects of care for hip fracture patients [5]. Recommendations include the delivery of care by a multidisciplinary team of senior clinicians, fast-track hospital admission to an acute orthopaedic/hip ward, the provision of daily, and protected trauma lists that prioritise hip fracture surgery.
Several aspects of preoperative care involve coordinated anaesthetic and orthogeriatric input, including analgesia provision, pre-operative preparation and ethical/legal considerations.
7.3.1 Preoperative Analgesia
Hip fractures are usually low impact injuries sustained after a fall from standing height onto osteoporotic bone. Extracapsular fractures (intertrochanteric, subtrochanteric) are more painful than intracapsular fractures (subcapital, transcervical, basicervical), due to the greater degree of periosteal disruption.
Approximately a third of fractures are associated with mild pain, a third with moderate pain, a third with severe pain. Fractures are usually more painful on movement, for example, when the affected leg is raised passively by 20°.
After admission to hospital, pain is often poorly assessed. Numerical rating scales do not adequately describe pain duration or quality. Assessment needs to take place at rest and on movement, before and after the administration of analgesia. Communication difficulties (deafness, blindness, hemiplegia) can make assessment difficult, as can cognitive impairment related to dementia, or narcotic analgesia administered in the prehospital phase.
Standardised analgesia protocols ensure that pain is properly assessed and appropriately treated, such that analgesia is provided without opioid-induced cognitive compromise. In turn, this facilitates other aspects of preoperative care, such as physical assessment, communication, eating and drinking and self-care.
Paracetamol (acetaminophen) is an effective analgesic that is well tolerated by hip fracture patients, and should be prescribed routinely throughout the perioperative period.
Renal dysfunction is common (~40 %) among this patient group, and so non-steroidal anti-inflammatory drugs (and codeine and tramadol) should be used with caution, or avoided completely.
Opioid analgesics are effective, but can affect cognition and increasingly so with older age and/or declining renal function (in which patients the dose should be reduced and the dosing interval prolonged). Depending on availability, buprenorphine, fentanyl and oxycodone may be preferable to morphine for longer-term use.
With the aim of trying to minimise the administration of cognition-impairing analgesics, increasing attention is being focused on providing preoperative peripheral nerve block [6]. The sensory innervation of the hip involves the femoral, obturator and sciatic nerves and, in the skin surrounding the operative incision site, the lateral cutaneous nerve of the thigh. Femoral nerve block and fascia iliaca blocks have been used successfully to reduce pain and limit opioid use preoperatively. Although the efficacy of both blocks is improved by nerve stimulation and (more so) by ultrasound location [7], requiring additional equipment and expertise, both methods have proven to be relatively easy to learn by junior non-anaesthetists, and allied health professionals, such that their protocolised administration by orthogeriatricians should be possible without anaesthetic input. Although additional expertise is required, the use of tunneled femoral nerve/fascia iliaca catheters can be used to provide prolonged non-opioid analgesia in defined patients for whom surgery is not an option, or where surgery may delayed for medical reasons.
7.3.2 Preoperative Preparation
Hip fracture patients are often frail and old, with multiple comorbidities demanding polypharmacy. Any of these factors alone or in combination may have contributed to the fall that preceded the fracture, but it is only rarely that the outcome benefits of attempting to improve any of these factors outweighs the risk of delaying surgery. Instead, anaesthetists need re-assurance from orthogeriatricians that the patient is appropriately fit for anaesthesia and surgery – ‘normalised’ rather than ‘optimised’ – and encouragement that risk is best managed by administering an appropriate anaesthetic. Orthogeriatricians should understand what an ‘appropriate’ anaesthetic involves (see below), and discuss this with anaesthetists who are less familiar with anaesthetising hip fracture patients, and so more likely to cancel patients for medical reasons, delaying surgery.
The AAGBI guidelines detail common patient problems that can increase the risk of anaesthesia or its conduct, such as anticoagulation, valvular heart disease, pacemakers and electrolyte abnormalities, and recommend how these should be managed preoperatively [5]. Similarly, generic algorithms are available online that can be modified according to institutional protocols [8]. These are intended as aides–memoire for preoperative patient preparation, and are not intended to replace direct communication between anaesthetist and orthogeriatrician.
Most usefully, the AAGBI guidelines identify acceptable and unacceptable reasons for delaying surgery in order to treat certain conditions (Table 7.1). Even so, ‘acceptable’ is not synonymous with ‘obligatory’, and surgery may still proceed even if these are present, if the additional risk is managed appropriately. These recommendations serve as a useful starting point when anaesthetists and orthogeriatricians convene to discuss the timing of surgery.
Acceptable | Unacceptable |
|---|---|
Haemoglobin concentration <8 g∙dl−1 Plasma sodium concentration <120 or >150 mmol∙l−1 and/or potassium concentration <2.8 or >6.0 mmol∙l−1 Uncontrolled diabetes Uncontrolled or acute onset left ventricular failure Correctable cardiac arrhythmia with a ventricular rate >120 beats∙min−1 Chest infection with sepsis Reversible coagulopathy | Lack of facilities or theatre space Awaiting echocardiography Unavailable surgical expertise Minor electrolyte abnormalities |
7.3.3 Ethical and Legal Considerations
Hip fracture in elderly patients is associated with significant mortality, morbidity, psychosocial change and reduction in quality of life, although intraoperative mortality is uncommon (<0.5 %). Traditionally, discussion between doctors, patients and relatives about the risks and benefits of the various surgical options and recovery approaches has been limited, and hampered by difficulties quantifying risk. Recent national validation of the Nottingham Hip Fracture Score (NHFS) (Table 7.2) supports its use as a risk adjustment for estimating 30-day mortality after hip fracture, in addition to other evidence for its value in predicting 1-year mortality and likelihood of early hospital discharge [9, 10]. The NHFS serves as a useful starting point when discussing risk, but requires patient-specific adjustment. This is best achieved by preoperative communication between the anaesthetist and orthogeriatrician so that discussions with patients and their relatives accurately reflect the possible outcomes of their decisions about treatment.
Table 7.2
The Nottingham hip fracture score. A score out of ten is calculated by summating weighted points for eight criteria (left). The total score is used to predict the risk of a patient dying within 30 days of hip fracture surgery (right)
Variable | Points | Total score | Predicted 30 day postoperative mortality (%) |
|---|---|---|---|
Age 66–85 years | 3 | 0 | 0.4 |
Age 86 years or older | 4 | 1 | 0.6 |
Male | 1 | 2 | 1.0 |
Hb less than or equal to 10 g∙dl−1 on admission to hospital | 1 | 3 | 1.7 |
Abbreviated mental test score < = 6/10 at hospital admission | 1 | 4 | 2.9 |
Living in an institution | 1
Related posts: Pre-Operative Management
Rehabilitation Following Hip Fracture
The Orthogeriatric Approach: Progress Worldwide
 Hip Fracture: The Choice of Surgery
Multi Professional Team: Coordination and Communication
Management of Older People with Hip Fractures in China and India: A Systems Approach to Bridge Evidence-Practice Gaps
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