Hip Fracture (BJAed 5 Main points)
- Patients have relatively high risk of perioperative morbidity and mortality, related to their age and co-morbidities.
- High-quality care requires timely, integrated patient management by MDT - surgeons, anaesthetists, geriatricians, nursing staff, OT, physiotherapists.
- Early surgery facilitates effective analgesia and allows early mobilization, and is associated with reduced morbidity and mortality.
- The mode of anaesthesia provided is less important than the manner with which it is delivered with regard to the age and pathophysiological status of the individual patient.
- Perioperative anaemia is common; anaesthetists should assess haemoglobin levels in the immediate postoperative period.
Hip Fracture outcomes (BJAed 2013)
- Outcomes are relatively poor and have not improved greatly over the last 20 yr:
- Postop mortality rate is:
∼8% at 1 month
∼30% at 1 yr - ∼20% suffer at least one significant complication after operation,
- Only about one-third of patients return to their pre-fracture level of daily function.
- The median length of inpatient stay is 23 days, which is comparable with 10 yr ago.
Hip # : Why is DoH recommendation for surgery within 36h?
Meta-analysis shows: delay to surgery beyond 48 h is assoc with increased 30d postop mortality, complications, and length of inpatient stay.
Hip # : Acceptable reasons for delaying surgery (AAGBI)
- Severe anaemia <8 g dl−1
- [Sodium] <120 or >150 mmol litre−1
- [Potassium] <2.8 or >6.0 mmol litre−1
- Uncontrolled diabetes
- Uncontrolled/acute LV failure
- Correctable cardiac arrhythmia, HR >120 bpm
- Chest infection with sepsis
- Reversible coagulopathy
Hip # : Unacceptable reasons for delaying surgery (AAGBI)
- Lack of facilities or theatre space
- Awaiting echocardiography
- Unavailable surgical expertise
- Minor electrolyte abnormalities
The Nottingham Hip Fracture Score is…
…a tool which has been specifically developed and validated to predict mortality 30 days after hip fracture surgery.
Variables in Nottingham Hip Fracture Score to predict 30d mortality
Age 66–85 yr (3 points) Age 86 yr or older (4 points) Male Hb≤10 g dl−1 on admission AMTS ≤6/10 on admission Living in an institution More than one co-morbidity Active malignancy within last 20 yr
Anaesthesia for hip #: if ejection systolic murmur without echo (BJAed 2013)
- Treat as if they had at least moderate AS & administer anaesthesia accordingly
- Invasive arterial pressure monitoring and vasopressors
- Maintain coronary and cerebral perfusion pressure
- Deliver anaesthesia sympathetically to the patients age and co-morbidities.
Sensory innervation to the hip joint and capsule are supplied by:
- Branches of the lumbar plexus (femoral nerve L2–4, obturator nerve L2–4, supero-anterior capsule)
and
- Branches the sacral plexus (sciatic nerve L4–S3, posteroinferior capsule)
Skin overlying the hip joint (through which surgical access to the joint is obtained) is supplied by:
- iliohypogastric nerve (L1)
- lateral cutaneous nerve of the thigh (L2, 3),
- superior cluneal nerves (L1–3, posterolateral approaches),
- and rarely, the lower thoracic cutaneous nerves
List 6 morbidities assoc with Hb <80g/L (Hip #, BJAed)
- Delayed mobility
- Prolonged inpatient stay
- Cardiac ischaemia
- Cerebral ischaemia (manifest as acute confusional state in the postop period)
- lightheadedness
- fatigue
How does clopidogrel work?
Clopidogrel is a
- prodrug
- that irreversibly
- inhibits the P2Y12 subtype of ADP receptors
- inhibiting platelet aggregation
- by blocking activation of the IIb/IIIa glycoprotein complex
Hip # and clopidogrel.
Clinically, what to do?
- mortality might actually be increased by stopping therapy perioperatively
- Patients do not require periop plt transfusion unless clinically indicated
- Monitor closely for postoperative anaemia
- Spinal anaesthesia and lumbar plexus block are not absolutely CI, but their use is sensibly limited to patients in whom the benefits of such interventions outweigh the risk of bleeding and spinal haematoma.
Hip # GA v or neuraxial block? AAGBI advice:
- Either method of anaesthesia (but not both together) may be used
- Most importantly that they are administered sympathetically to any patient pathophysiology
- Using reduced doses of anaesthetic agent
- Combined with multimodal analgesia
- To limit rapid fluctuations in arterial pressure and consequent changes in cerebral and coronary perfusion pressures
