Post-operative Management



Fig. 8.1
Four models of in-hospital management of hip fracture elderly patients, characterised by an increasing involvement of the geriatrician and a decreasing participation of the orthopaedic surgeon. (a) Traditional Care in the Orthopaedic Ward: the surgeon is responsible for the overall healthcare, including medical queries, and different physicians may see the patient as consultants. (b) Geriatric Consultant in the Orthopaedic Ward: the overall responsibility of the healthcare pathway is under the orthopaedic surgical staff, but geriatrician assess the patients daily, preventing and managing complications. (c) Orthogeriatric Co-Managed Care: The orthopaedic surgeon and geriatrician share responsibility and leadership from admission to discharge. (d) Geriatric-Led Model: Patient is admitted to the Geriatric Ward and is under the leadership of the geriatrician; the geriatrician, orthopaedic surgeon and anaesthesiologist manage the patients together in the peri-operative phase; in the post-operative phase, the orthopaedic surgeon is a consulting physician that follows the patients until complete wound healing



The Ortho-Geriatric Co-Managed model of care has evolved over the last 15 years with gradual improvements added with time, and it is now the most popular model worldwide. Basically the orthopaedic surgeon and the orthogeriatrician (a geriatrician skilled in the management of older adults with orthopaedic issues) share responsibility and leadership from admission to discharge. The traditional roles are maintained, with the orthopaedic surgeon assessing the trauma and fracture site and managing the fracture, and the geriatrician facing clinical issues, promoting early mobilisation, coordinating discharge, and, assessing the risk of falls and further fractures. However decisions regarding surgical fitness, optimal timing of surgery, clinical, functional and discharge targets are generally shared. An interdisciplinary team including several healthcare professionals (anaesthesiologist, physiotherapist, clinical nurse, nutritionist and social worker) supports this co-direction. In the short-term, the Ortho-Geriatric Co-Managed Care model has been shown to reduce length of in-hospital stay, time to surgery, in-hospital complications and in-hospital mortality, compared to the traditional model [35].

More recently, Geriatric-Led Fracture Services, where the geriatrician is the primary attending physician for all patients from hospital admission to discharge, have been implemented. An interdisciplinary team, including different healthcare professionals, is integrated in these services, participating in the care of the patients. Particularly in the post-operative phase, the most relevant needs of elderly hip fracture patients are generally related to medical or geriatric issues, therefore, the contribution of the orthopaedic surgeon is limited and he/she could be involved as a consultant. For these reasons, this geriatrician-led model of care could be more advantageous in terms of cost-effectiveness [6]. An early experience of Geriatric-Led Fracture Service has been implemented at the Sheba Hospital in Tel Aviv in 1999 [7]. This experience is quite unique since the patient is managed throughout the acute and post-acute rehabilitative phases in the same setting under the responsibility of the geriatrician, with an overall high length of stay. In most recent experiences, patients are usually admitted to a dedicated Geriatric Ward directly from the Emergency Department [8] or immediately after surgical repair [9] and are early transferred to a rehabilitation setting, with the attention focused on reducing the time to surgery and acute in-hospital stay.



8.2 Early Mobilisation


The evidence supporting the beneficial effects of early and accelerated mobilisation after hip fracture are actually few, deriving from small studies, but they are substantially consistent. On the other hand, short- and long-term immobilisation is implicated in the pathogenesis of relevant clinical complications such as thrombosis, pneumonia, respiratory failure, and pressure sore. Therefore, shortening the time of bed rest contributes to reducing these complications as well as orthostatic hypotension and delirium [10]. Thus, early mobilisation including standing and ambulation within the first post-operative day is now a standard of care in the management of hip fracture patients. Early mobilisation impacts also the long-term functional status and improves the likelihood of achieving full recovery of ambulation [11]. Although pre-fracture functional status and baseline characteristics of the patients are the main predictors of functional and ambulation recovery after hip fracture, the mobility achieved in the first post-operative days is also related to long-term functional outcomes. Therefore, an intensive rehabilitative intervention, starting early after surgical repair, should be recommended in all hip fracture patients, albeit good quality studies demonstrating its efficacy are still lacking. Cumulated Ambulation Score (CAS), which measures the ability to get in and out of bed, rise from a chair and walk around indoor with walking aid during the first three post-operative days, is a simple and reliable test that could be used to assess early mobility [10].

Achieving the goal of early mobilisation requires a stable surgical repair that allows the patient to bear weight as tolerated, as well as effective pain control and fluid management protocols that ensure volume adequacy and avoid orthostatic hypotension. With rehabilitation programmes addressing all critical issues of the post-operative phase, almost 80 % of subjects, able to walk before fracture, achieve the ability to walk with aids within the first two post-operative days [12]. As previously noted, adequate pain management and avoidance of post-operative hypotension prevention play a key role in early mobilisation.


8.2.1 Pain Management


Standardised pain management protocols include the administration of intravenous acetaminophen every 6–8 h combined with oral or parenteral opiates. Nerve blocks (including femoral nerve or lumbar plexus block and continuous epidural block) seem more effective in reducing pain during rehabilitation [13] and could offer advantages in early mobilisation. When comparative studies investigating the effects of opiate and regional nerve blocks on pain at rest have been undertaken, no significant differences were found. However, regional nerve blocks have been demonstrated to reduce opiate consumption, which has been associated with several adverse effects in elderly patients. Adequate pain management interventions are essential to ensure that patients are able to recover their functional abilities. In the peri-operative period, pain levels should be regularly checked, in order to ensure that the patient is feeling comfortable whether in bed, sitting, or standing.


8.2.2 Post-operative Hypotension and Fluid Management


Irrespective of the type of anaesthesia, a significant drop in blood pressure can take place early in the post-operative phase, with a further drop occurring while the patient is taking part in rehabilitation, during weight-bearing and in the standing position. In some cases, this may produce symptomatic hypotension, reducing participation in rehabilitation. Several factors may contribute to post-operative hypotension in older adults. These include:



  • the effect of ageing that decreases the ability to compensate and maintain pressure homeostasis when the body is stressed,


  • anaemia due to acute blood loss,


  • dehydration secondary to poor oral intake of fluids,


  • the effects of anaesthetic agents,


  • the side effects of drugs frequently used in the post-operative phase (e.g., opiates and antiemetics).

Strategies for preventing post-operative hypotension include medication adjustment and fluid management. All antihypertensive drugs should be checked and stopped, starting in the pre-operative phase, with the exception of beta-blockers and those with rebound effects like clonidine. Beta-blockers should be continued during the peri-operative phase, however their use is no longer recommended in naive patients, as suggested by earlier studies since, although the pre-operative introduction of beta-blockers can reduce myocardial complications, it may increase the rates of stroke and mortality, possibly due to hypotension [14]. Antihypertensive drugs discontinued before surgical intervention should be resumed in the post-operative period based on the clinical status and blood pressure values. In some cases, it may be advisable to resume these pharmacological agents only after discharge.

Isotonic intravenous fluids are recommended during the pre-operative, intraoperative and post-operative phases. During surgery, the anaesthetist administers intravenous fluids, on the basis of his clinical judgement and according to clinical signs (e.g., heart rate and blood pressure). In the post-operative phase, the administration of about 1.5–3 l of crystalloids is usual practice to attain and maintain intravascular volume [15]. Nevertheless, fluid management should be tailored and individualised, considering vital signs, oral fluid intake and cardiovascular status. In general, even patients with acknowledged ventricular dysfunction benefit from intravascular volume restoration, since the risk of dehydration and hypotension are likely to exceed the risks of excessive volume administration. The only exceptions are:



  • patients with severe renal failure or on dialysis that require a cautious and controlled fluid administration, and the control and measurement of fluid balance


  • patients with severe heart failure or previous episodes of acute pulmonary oedema.


8.3 Post-operative Medical Complications


In older adults, medical complications after hip fracture repair are very common and may significantly affect outcomes, by increasing length of stay, delaying recovery or even influencing long-term outcomes. Major complications affect about 20 % of hip fracture patients [16, 17] but up to 50 % of patients may require pharmacological interventions due to clinical issues arising during the first post-operative days (Fig. 8.2). The predominant causes for short-term mortality after hip fracture are infectious and cardiac diseases [18]. In some cases, in-hospital complications are strongly related to prevalent and pre-existing organ dysfunction. For example, cardiovascular diseases may predispose patients to acute heart failure, while chronic lung diseases may increase the risk of chest infections [16]. Different scores have been proposed to predict the risk of post-operative complications after hip fracture. Indeed, patients with the highest pre-fracture comorbidity and disability are those at greater risk of developing clinical complications postoperatively [19]. Therefore, patients characterised by a higher degree of comorbidity and vulnerability should be strictly monitored during the post-operative days, with attention particularly focused on signs and symptoms of cardiovascular disturbance or infections.

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Fig. 8.2
Rate of post-operative medical complications (Data refer to a cohort of 930 consecutive patients admitted to ASMN Hospital (Reggio Emilia, Italy) over 3 years (2012–14). Irrespective of the severity of the complication, about 50 % of patients required some pharmacological treatment due to medical issues)


8.3.1 General Measures to Prevent Medical Complications



8.3.1.1 Early Intervention


Several studies found an association between surgical delay and the risk of complications [17, 18], and one meta-analysis reported a significantly reduced incidence of pneumonia and pressure ulcers in patients undergoing surgery within 24–48 h from admission [20]. Therefore, time to surgery appears to be one of the most influential and potentially modifiable risk factor for post-operative complications. In this context, implementing the practice of early surgery in frail older people with pre-fracture functional impairment represents one of the best strategies to improve overall outcomes [21].


8.3.1.2 Standardised Approaches and Protocols in the Post-operative Phase


In the post-operative phase, a number of issues should be regularly checked, and all patients should undergo standardised procedures. The best way to face the complex needs of older adults presenting with hip fracture, to improve the quality of the interventions, to minimise errors and omissions, and to reduce post-operative complications is to:



  • define check lists, individualised for each healthcare professional, that should drive healthcare decisions


  • standardise and implement specific protocols for the most common issues

Tailored and individualised interventions based on patients’ characteristics, specific needs or clinical instability should be an integral part of daily healthcare, but the overall post-operative management should be as highly standardised as possible. In this context, protocols, based on the best available evidence, must be developed, shared and implemented by the multidisciplinary team, taking into account local resources. A minimum set of standardised protocols that should be implemented in the orthogeriatric setting include the following



  • prophylaxis of venous thromboembolism


  • antibiotic prophylaxis


  • urinary catheter utilisation


  • pain control


  • skin care and provision of air-filled mattresses


  • constipation and stool impaction prevention


  • delirium prevention


  • post-operative haemoglobin monitoring and blood transfusions


  • malnutrition detection and correction


  • monitoring of vital physiological parameters


  • providing supplemental oxygen when appropriate


  • early mobilisation.

In addition, depending on the clinical status, intravenous therapies should be replaced by oral formulations as soon as possible.


8.3.1.3 Caloric Supplementation


Routine nutritional assessment should be a standard procedure in the management of older hip fracture patients, as some of them may be already malnourished on admission. In addition, many patients may undergo a deterioration of their nutritional status during hospital stay, due to increased energy expenditure related to metabolic stress, and to reduced food intake related to lack of appetite, nausea and psychological factors. It has been estimated that, in the post-operative period, a quarter of patients consume less than 25 % of meals offered by hospital, and about half of patients consume between 25 % and 50 % of meals [22]. Several studies have linked protein and energy malnourishment with adverse clinical outcomes in the acute setting. The negative effects of undernourishment include muscle wasting and weakness, impaired mobility, pulmonary complications, pressure ulcers, and impaired immune response, further predisposing to increased post-operative infections and mortality [23]. Irrespective of pre-fracture functional status, patients with a post-operative dietary intake less than 25 % have a higher number of complications [22]. Oral nutritional supplementation may be a suitable approach to enhance energy and protein intake. A recent meta-analysis concluded that oral nutritional supplementation in elderly patients after hip fracture surgery promotes early rehabilitation, reduces complications and decreases infection rate [24]. Given the difficulty many patients experience in meeting energy requirements in the early post-operative phase, even patients who were normally nourished pre-fracture may well benefit from oral nutritional supplements [25]. Finally, more aggressive nutritional interventions, such as tube feeding or parenteral supplies, should be reserved only for patients with a low level of consciousness or to malnourished patients unable to eat.


8.3.1.4 Management of Postsurgical Anaemia


Post-operative anaemia is extremely frequent, related to blood loss during surgical procedure and haemodilution, and is associated with reduced ambulation and functional independence. Recent guidelines based on randomised-controlled trials [26] recommend a restrictive threshold for transfusion, not greater than 8 g/dl of haemoglobin, in post-operative patients. It has been suggested that blood transfusions may be harmful to patients, by reducing the recipient’s immune response and thereby increasing the susceptibility to infections [27]. However, transfusion protocols should be based also on other clinical features of patients. Particularly, the presence of cardiac or renal diseases, a low pre-injury haemoglobin level, or specific abnormalities of vital signs may influence the decision to transfuse despite a haemoglobin value greater than 8 g/dl. For instance, a more liberal transfusion strategy has been shown to increase overall survival patients from residential nursing homes [28].


8.3.1.5 Vitamin D Supplementation


A high proportion of hip fracture patients present with vitamin D deficiency [29] at the time of fracture. Hypovitaminosis D has been related to increased risk of post-operative medical complications [30] and poor functional recovery [31]. Thus, optimisation of the vitamin D level should start early after admission.


8.3.2 Prevention and Management of Specific Complications



8.3.2.1 Delirium


Delirium is a common complication that affects about one third of elderly hip fracture patients in the peri-operative period. It has a detrimental effect on functional and clinical outcomes, producing longer length of hospitalisation and slow and incomplete recovery. It is still not clear if delirium may affect long-term survival or recovery [32]. Hyperactive delirium may be easily diagnosed, being characterised by psychomotor agitation, interfering with patients’ care and safety. On the other hand, the hypoactive variant, characterised by a decreased level of consciousness and apathy, may be grossly under-diagnosed. It should be acknowledged that some patients may present with a mixed variant of delirium, fluctuating between hyperactive and hypoactive states. Therefore, all patients must be daily screened and assessed, starting in the first post-operative day, using standardised tools. Both the geriatric nurses and the physicians should be involved in the early detection of delirium.

Patients at risk of developing incident post-operative delirium can already be identified at hospital admission, since a number of risk factors have been described. Pre-fracture cognitive impairment is the strongest risk factor, followed by body mass index/albumin and prevalent multiple comorbidities [33]. Delirium in the frail elderly can represent the first symptom of an underlying/undercurrent complication, such as an infection, coronary syndrome, urinary retention, constipation or dehydration. Therefore, once a patient presents with a new episode of delirium, it is absolutely mandatory to undertake a comprehensive clinical assessment, appropriate laboratory diagnostic work-up and other specific diagnostic tests.

The early detection and prompt correction of clinical/laboratory abnormalities and risk factors is probably the most effective approach to prevent delirium in hip fracture elderly patients. The preventive intervention should be multi-component, and, usually, non-pharmacological, and should include:



  • monitoring of vital physiological parameters,


  • avoiding of surgical delay by supporting early surgery,


  • reduction of immobilisation and bed rest,


  • oxygen supplementation,


  • hydration,


  • nutritional support,


  • early detection and correction of metabolic/laboratory abnormalities,


  • medication review, including restriction of drugs with anticholinergic properties.

This approach requires a multidisciplinary team and is part of the orthogeriatric model of care. This multi-component intervention has been demonstrated to decrease by 40 % the incidence of delirium compared to the traditional care approaches [34], and to be cost-effective in hip fracture patients [35]. Since pain is one of the main triggers for post-operative delirium, effective analgesia is essential in prevention strategies. Acetaminophen and nerve blocks should be preferred to opiates, which may increase the risk of delirium.

The type of anesthesia (particularly neuraxial versus general anesthesia) does not appear to affect the incidence of delirium, but deep sedation has been associated with a higher risk of post-operative delirium [36]. Thus, the use of intra-operative monitoring of depth of anesthesia and the choice of a lighter sedation are likely to be effective in reducing post-operative delirium.

Pharmacological prevention of delirium through administration of low dose of neuroleptic drugs is still a matter of debate. Current evidence does not support the routine use of antipsychotics, albeit, in some trials, they demonstrated reduced incidence of post-operative delirium, particularly in orthopaedic patients at higher risk [37].

Once delirium has occurred, it should be tackled through a multifactorial approach, not dissimilar from preventive strategies. Non-pharmacological procedures should be always implemented and exacerbating factors should be identified and addressed. In case of agitation that can hamper the healthcare or rehabilitation, or even be dangerous for patient and caregiver, pharmacological treatment with antipsychotics is usually employed. Notably, antipsychotics do not treat delirium but simply reduce symptoms. Antipsychotics should never be used in the hypoactive variant. These pharmacological agents should be used at the lowest effective dose, dosing regimens should be individualised for each patient, and, the treatment effects should be monitored daily in order to correct the dose or discontinue the therapy when appropriate. The antipsychotics commonly used are: haloperidol (0.25–2 mg oral or intramuscular), risperidone (0.5–2 mg oral), quetiapine (25–100 mg oral), olanzapine (2.5–10 mg oral). QT prolongation contraindicates all these drugs. Benzodiazepines should be avoided in patients with delirium, except for subjects with severe agitation and violent inclination in which short-acting formulation (e.g., midazolan 1–5 mg intramuscular or intravenous) may produce a rapid tranquillisation. In patients with sleep deprivation, the drug of choice is trazodone (25–100 mg oral).

Some patients experience a more subtle cognitive disorder, affecting a wide range of cognitive domains, particularly memory and executive function. This condition, dissimilar from delirium, is generally designated as post-operative cognitive dysfunction (POCD) and it may not be evident during the first post-operative days. Compared to delirium, POCD shows a less acute onset, is characterised by normal consciousness, and may last weeks to months. For an accurate diagnosis, neuropsychological testing is required but a pre-fracture evaluation is usually lacking in hip fracture patients for comparison. There are many risk factors for POCD: advanced age, pre-existing cardio-vascular disease and mild cognitive impairment. POCD is generally reversible, albeit in some patients with persistent dysfunction, the apolipoprotein E4 genotype has been found, suggesting a link with the development of dementia [38].


8.3.2.2 Cardiovascular Complications


Ischaemic heart disease and cardiac failure account for more than one third of early deaths after hip fracture [39]. The incidence of cardiac complications after hip fracture is quite variable in epidemiological studies, depending on the diagnostic criteria considered. Patients with a history of cardiac disease, stroke or peripheral vascular disease are at high risk of developing cardiac complications in the post-operative phase [40]. These subjects should be accurately monitored after surgery. In most of the cases, hip fracture patients with acute coronary syndrome or with ST elevation do not experience typical chest pain; they may present with delirium, congestive heart failure or may even be asymptomatic. The routine measurement of troponin and ECG assessment are thus mandatory for the diagnosis. In some studies [41] troponin changes have been found in a high rate of patients without clinical symptoms or new signs of ischemia in the ECG, however, currently troponin assessment should be reserved for patients with suspicious symptoms or risk factors. In high-risk subjects, antiplatelet drugs should not be stopped preoperatively or should be re-started early after surgery.

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Aug 29, 2017 | Posted by in ORTHOPEDIC | Comments Off on Post-operative Management
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