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Anaesthesia for fractured neck of femur
Orthopaedics
Anaesthesia for fractured neck of femur
Flaws in the evidence base for best practice Common flaws include: • Failure to randomize patients so that all factors that may influence outcome are included. • Failure to recognize confounding factors present within descriptive statistics; for example, patients who are bed bound prior to surgery cannot mobilize and are at higher risk of complications and death. • Defining exclusions that render the population studied different from the ‘normal’ population presenting to most anaesthetists; for example, when comparing spinal with general anaesthesia, patients at risk of abnormal bleeding are excluded because they are unfit for the former and those with acute respiratory infections because they are unfit for the latter. • Failure to follow up patients for more than 1 month. Deaths directly related to hip fracture occur for at least 6 months and probably longer after injury.
Anne J Sutcliffe
Abstract In the UK, 70,000 patients per year fracture their hips and the annual incidence is rising. There is an inevitable hospital mortality rate of 4–6% associated primarily with carcinomatosis. The 30% mortality rate at 1 year has not improved significantly over 25 years. The evidence base for best practice is weak and leads to conflicting conclusions. Many aspects of care advocated in guidelines are determined by consensus opinion. Early anaesthesia and surgery are championed but should not be rigidly offered at the expense of neglecting investigations such as echocardiography to identify significant aortic stenosis or the acute treatment of hypovolaemia, dysrhythmias, hypertension, cardiac ischaemia, cardiac failure, pulmonary insufficiency and poorly controlled diabetes. Anaesthesia should be tailored to each individual patient’s needs. Regional anaesthesia has only marginal advantages compared with general anaesthesia and is contraindicated if coagulation is abnormal. The closer involvement of anaesthetists in the management of resuscitation, perioperative fluid balance, postoperative pain relief and postoperative nutrition may improve outcome. Mortality rates vary between hospitals and within hospitals year by year. Regular departmental audit is advised to identify local areas of good or deficient practice.
Factors influencing outcome and management recommendations Not all the factors that influence outcome after femoral neck fracture are amenable to interventions that might improve patient outcome. Table 1 shows these factors and also non-anaesthetic factors thought to alter outcome. Table 2 shows factors relevant to anaesthetists and useful interventions.
Factors beyond the control of the anaesthetist that may influence mortality
Keywords anaesthesia; echocardiography; fracture; general; hip; neck of femur; regional; resuscitation; timing
Age • Mortality increased if age>85 years • 4–6% of deaths may be inevitable Gender • Men claimed to do worse
The UK incidence of hip fracture is about 70,000 per annum and is increasing by 2% each year. Nationally, mortality at 30 days is 10% and at 1 year is 33%. These figures have shown little improvement since 1983. Nearly all survivors have persistent pain or disability and 10% are unable to return to their previous residence. Internationally, anaesthetists and surgeons1,2 have reviewed best practice and their conclusions are often included in guidelines.3,4 Unfortunately, the evidence base used for guidelines is far from comprehensive and different authors reviewing the same literature sometimes reach different conclusions. Furthermore, research designed to assess the impact of a single intervention often fails to show a clear improvement in outcome. It is probable that better studies are needed and that a ‘bundle’ of interventions will have more impact on outcome than a single intervention.
Drug history • Benzodiazepines and antidepressants may cause sedation and increase the risk of falls Pre-injury mobility • If bed bound, risk of postoperative pneumonia and pressure sores • Surgery provides pain relief and aids nursing care Mental status • Confusion and/or dementia may hinder ability to mobilize and increase complications Surgical procedure • Type of fracture determines surgical procedure. Differing mortalities related to procedures reported but may depend on physiological factors associated with injury type and age • Increasing duration of surgery may increase risk of thromboembolic complications
Anne J Sutcliffe, MBChB, FRCA, is a Consultant Anaesthetist at the Alexandra Hospital, Redditch, Worcestershire, UK. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
Table 1
© 2008 Elsevier Ltd. All rights reserved.
Orthopaedics
Current concepts of best anaesthetic practice Resuscitation • Estimate blood loss and dehydration • Rehydrate with intravenous crystalloid or oral fluid • Replace volume with blood or colloid aiming for haemoglobin of 8.0 g/dl or greater Preoperative pain relief • Lumbar epidural analgesia or peripheral nerve blocks may be useful Comorbid conditions • Echocardiography recommended to identify significant aortic stenosis • Treat dysrhythmias (e.g. fast atrial fibrillation, conduction defects that compromise cardiac output) • Treat poorly controlled cardiac failure (digitalis, diuretics) • Treat poorly controlled cardiac ischaemia (nitrate patches) • Treat poorly controlled hypertension (diuretics, beta-blockers, analgesia, midazolam 0.5–1 mg intravenously at induction for ‘white coat’ hypertension) • Treat pulmonary insufficiency (antibiotics, physiotherapy, bronchodilators) • Treat endocrine abnormalities (insulin, thyroxine) • Treat hypothermia (slow warming) • Treat incipient renal failure (crystalloid, colloid) Timing of surgery • Delays acceptable for investigation or acute treatment of comorbid conditions • Facilitate surgery when additional investigation/intervention unlikely to improve patient’s physiological condition • Minimize preoperative fasting (6 hours for solids, 2 hours for clear fluids, enforced perioperative nutrition and hydration especially if surgery postponed) Thromboembolic prophylaxis • Consider fresh frozen plasma for rapid correction of raised INR if patient otherwise fit for anaesthesia and surgery • Daily enoxaparin 40 mg subcutaneously. Consider mechanical compression devices if enoxaparin contraindicated Infection control • Routine MRSA screening • Give prophylactic antibiotic intravenously at induction, local guidelines for preferred agent remembering risk of Clostridium difficile Anaesthesia • Individualized technique based on comorbidities (e.g. fixed cardiac output, abnormal clotting, respiratory insufficiency) • Regional anaesthesia preferred but advantages are marginal and may be inappropriate if surgery at distant sites planned • Metaraminol boluses or infusion to treat hypotension • Consider non-invasive cardiac output monitoring to guide fluid replacement Postoperative care • Epidural bupivacaine 1.25 mg/ml with morphine 0.05 mg/ml at 4 ml/h, paracetamol 1 g four times daily supplemented by NSAIDs as necessary (beware renal insufficiency) • Titrate analgesia to facilitate intensive physiotherapy and mobilization on the day of surgery • Monitor Spo2. Consider supplemental oxygen from admission to 72 hours after surgery • Encourage ward team to give adequate fluids and nutrition INR, international normalized ratio; MRSA, methicillin-resistant Staphylococcus aureus; NSAID, non-steroidal anti-inflammatory drug.
Table 2
Timing of surgery The British Orthopaedic Association (BOA) recommends that surgery should take place within 48 hours of admission if patients are medically fit.3 With disarming confidence the Association suggests that ‘experienced anaesthetists and orthogeriatric physicians should work together to ensure that delays do not occur. Pre-operative assessment and optimization must be a clinical priority.’ The Association goes on to note that systolic murmurs are common in elderly patients and may indicate significant
Multidisciplinary approach to care A team approach to care is essential and should include surgeons, anaesthetists, orthogeriatric physicians and nursing staff. Patients presenting with fractured neck of femur are commonly female, over 80 years old and have multiple comorbidities and polypharmacy.1 A team approach should enable a clear treatment plan to be agreed that encompasses preoperative, perioperative and postoperative care, as well as rehabilitation and discharge planning.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
© 2008 Elsevier Ltd. All rights reserved.
Orthopaedics
aortic stenosis, which is ‘a relative contraindication to a spinal [anaesthetic] technique’, and that the 2001 National Confidential Enquiry into Perioperative Deaths (NCEPOD) report recommended echocardiographic assessment of all cardiac murmurs, but, says the BOA, ‘this is not always possible prior to urgent surgery’ and ‘the absence of echocardiography should not lead to delays in fixing the fracture’.
were unavoidable owing to terminal carcinoma and 15% were probably unavoidable resulting from comorbidities present on admission, for example pneumonia, uncompensated heart failure and dysrhythmias. Thus, there is probably an inevitable hospital mortality rate of between 4% and 6% following femoral neck fracture. How can we improve outcome? Hospital mortality rates regularly exceed the predicted inevitable mortality rate and show great variation both between hospitals and within hospitals year by year. This suggests that certain aspects of the quality of care, both clinical and organizational, must make a difference. From an anaesthetic perspective, attention to detail is vital (Table 2). Careful preoperative assessment and meticulous anaesthetic technique tailored to each patient are essential. The necessity for senior advice and assistance should always be considered. Given the variations between hospitals, regular local audits are encouraged and may highlight areas where a department excels or areas ripe for improvement. Anaesthetists are continually extending their sphere of influence outside the operating theatre. More effective resuscitation and insisting on detailed attention to fluid balance in the perioperative period might help. The contribution of anaesthetists to effective postoperative pain relief is vital for early mobilization and reducing the incidence of life-threatening pneumonia and pressure sores. Adequate postoperative nutrition is often stressed but poorly managed. ◆
Delay does not increase mortality or hospital length of stay: for many years, surgeons have believed that surgery should be performed urgently within 48 hours of injury because this will improve outcome; a view reinforced by Dr Foster.5 Early surgery undoubtedly reduces pain and facilitates nursing care and early mobilization. The first two goals are important for the care of all patients, including those who may not survive to hospital discharge. Kenzora et al.6 were the first to challenge the beneficial effect of early surgery on mortality. They write that their 1984 study was conceived to ‘urge more vigorously the anaesthesiologist to anaesthetize the hip fracture patient as promptly as possible following admission’. In fact, patients anaesthetized between days 2 and 4 after admission had the lowest mortality, which suggested that a delay to permit resuscitation and optimization of comorbidities might be beneficial. These authors conclude that ‘it was only as the final data were examined and reviewed that the authors were confronted with the possibility that the tenets they had held for so many years might not be true’. A more recent study,7 using multivariate analysis to tease out the effects of various factors that delay surgery, confirms that delay does not increase mortality and has a minimal effect on length of hospital stay. The study compares outcomes in two US states and two Canadian provinces. This is relevant because most of the ‘evidence’ for the benefits of early surgery comes from the USA. The important conclusion of this study is that sequential analysis of confounding factors is essential for any study and that, in the population studied, timing of surgery is most influenced by differences in reimbursement policies between the two countries.
References 1 Parker M, Johansen M. Hip fracture. BMJ 2006; 333: 27–30. 2 Beaupre LA, Jones CA, Saunders LD, et al. Best practices for elderly hip fracture patients. J Gen Intern Med 2005; 20: 1019–25. 3 British Orthopaedic Association. The care of patients with fragility fracture. Available from: http://www.boa.ac.uk/site/showpublications. aspx?ID=59, 2007 [accessed 24. 08.08]. 4 Chilov MN, Cameron ID, March LM. Evidence-based guidelines for fixing broken hips: an update. Med J Aust 2003; 179: 489–93. 5 Bottle A, Jarman B, Aylin P, et al. Dr Foster’s case notes: some way to go for consistent implementation of guidance on hip fracture. BMJ 2004; 328: 1097. 6 Kenzora JE, McCarthy RE, Lowell JD, et al. Hip fracture mortality. Clin Orthop Relat Res 1984; 186: 45–56. 7 Ho V, Hamilton BH, Roos LL. Multiple approaches to assessing the effects of delays for hip fracture patients in the United States and Canada. Health Serv Res 2000; 34: 1499–518. 8 Sandby-Thomas M, Sullivan G, Hall JE. A national survey into the peri-operative anaesthetic management of patients presenting for surgical correction of fractured neck of femur. Anaesthesia 2008; 63: 250–8. 9 Urwin SC, Parker MJ, Griffiths R. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomised trials. Br J Anaesth 2000; 84: 450–5. 10 Foss NB, Kehlet H. Mortality analysis in hip fracture patients: implications for design of future outcome trials. Br J Anaesth 2005; 94: 24–9.
Preoperative echocardiography: a study published in 20088 shows that only 20% of anaesthetists insist on a preoperative echocardiogram. This may reflect a perceived need to proceed to surgery quickly and, more importantly, the unavailability of urgent echocardiography services in many hospitals. The authors note that clinical signs and a plain chest radiograph may assist diagnosis. Nevertheless, echocardiography is the NCEPOD gold standard and the evidence supporting the benefit of early surgery is weak. Best anaesthetic practice A number of interventions probably improve the patient’s fitness for anaesthesia, but the benefits of these interventions or a specific anaesthetic technique are difficult to support using an evidence-based approach. There is only marginal evidence in favour of regional anaesthesia,9 although many anaesthetists prefer this technique.8 Consensus opinion supports the interventions and techniques described in Table 2. Included are most of the interventions used by Foss and Kehlet,10 who, in 2005, studied what many would concur was then best evidence-based practice. Their results were disappointing with a 30-day mortality rate of 13.3%. An important finding was that 28% of deaths
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
© 2008 Elsevier Ltd. All rights reserved.
Orthopaedics
Further reading Jiang HX, Majumdar SR, Dick DA, et al. Development and initial validation of a risk score for predicting in-hospital and 1-year mortality in patients with hip fractures. J Bone Miner Res 2005; 20: 494–500. Orosz GM, Magaziner J, Hannan EL, et al. The timing of surgery for hip fracture and its effects on outcomes. JAMA 2004; 291: 1738–43.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
Price JD, Sear JJW, Venn RRM. Perioperative fluid volume optimization following proximal femoral fracture (review). Cochrane Database Syst Rev 2004; Art No: CD003004. Venn R, Steele A, Richardson P, et al. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth 2002; 88: 65–71.
© 2008 Elsevier Ltd. All rights reserved.
Anaesthesia for fractured neck of femur
Flaws in the evidence base for best practice Common flaws include: • Failure to randomize patients so that all factors that may influence outcome are included. • Failure to recognize confounding factors present within descriptive statistics; for example, patients who are bed bound prior to surgery cannot mobilize and are at higher risk of complications and death. • Defining exclusions that render the population studied different from the ‘normal’ population presenting to most anaesthetists; for example, when comparing spinal with general anaesthesia, patients at risk of abnormal bleeding are excluded because they are unfit for the former and those with acute respiratory infections because they are unfit for the latter. • Failure to follow up patients for more than 1 month. Deaths directly related to hip fracture occur for at least 6 months and probably longer after injury.
Anne J Sutcliffe
Abstract In the UK, 70,000 patients per year fracture their hips and the annual incidence is rising. There is an inevitable hospital mortality rate of 4–6% associated primarily with carcinomatosis. The 30% mortality rate at 1 year has not improved significantly over 25 years. The evidence base for best practice is weak and leads to conflicting conclusions. Many aspects of care advocated in guidelines are determined by consensus opinion. Early anaesthesia and surgery are championed but should not be rigidly offered at the expense of neglecting investigations such as echocardiography to identify significant aortic stenosis or the acute treatment of hypovolaemia, dysrhythmias, hypertension, cardiac ischaemia, cardiac failure, pulmonary insufficiency and poorly controlled diabetes. Anaesthesia should be tailored to each individual patient’s needs. Regional anaesthesia has only marginal advantages compared with general anaesthesia and is contraindicated if coagulation is abnormal. The closer involvement of anaesthetists in the management of resuscitation, perioperative fluid balance, postoperative pain relief and postoperative nutrition may improve outcome. Mortality rates vary between hospitals and within hospitals year by year. Regular departmental audit is advised to identify local areas of good or deficient practice.
Factors influencing outcome and management recommendations Not all the factors that influence outcome after femoral neck fracture are amenable to interventions that might improve patient outcome. Table 1 shows these factors and also non-anaesthetic factors thought to alter outcome. Table 2 shows factors relevant to anaesthetists and useful interventions.
Factors beyond the control of the anaesthetist that may influence mortality
Keywords anaesthesia; echocardiography; fracture; general; hip; neck of femur; regional; resuscitation; timing
Age • Mortality increased if age>85 years • 4–6% of deaths may be inevitable Gender • Men claimed to do worse
The UK incidence of hip fracture is about 70,000 per annum and is increasing by 2% each year. Nationally, mortality at 30 days is 10% and at 1 year is 33%. These figures have shown little improvement since 1983. Nearly all survivors have persistent pain or disability and 10% are unable to return to their previous residence. Internationally, anaesthetists and surgeons1,2 have reviewed best practice and their conclusions are often included in guidelines.3,4 Unfortunately, the evidence base used for guidelines is far from comprehensive and different authors reviewing the same literature sometimes reach different conclusions. Furthermore, research designed to assess the impact of a single intervention often fails to show a clear improvement in outcome. It is probable that better studies are needed and that a ‘bundle’ of interventions will have more impact on outcome than a single intervention.
Drug history • Benzodiazepines and antidepressants may cause sedation and increase the risk of falls Pre-injury mobility • If bed bound, risk of postoperative pneumonia and pressure sores • Surgery provides pain relief and aids nursing care Mental status • Confusion and/or dementia may hinder ability to mobilize and increase complications Surgical procedure • Type of fracture determines surgical procedure. Differing mortalities related to procedures reported but may depend on physiological factors associated with injury type and age • Increasing duration of surgery may increase risk of thromboembolic complications
Anne J Sutcliffe, MBChB, FRCA, is a Consultant Anaesthetist at the Alexandra Hospital, Redditch, Worcestershire, UK. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
Table 1
© 2008 Elsevier Ltd. All rights reserved.
Orthopaedics
Current concepts of best anaesthetic practice Resuscitation • Estimate blood loss and dehydration • Rehydrate with intravenous crystalloid or oral fluid • Replace volume with blood or colloid aiming for haemoglobin of 8.0 g/dl or greater Preoperative pain relief • Lumbar epidural analgesia or peripheral nerve blocks may be useful Comorbid conditions • Echocardiography recommended to identify significant aortic stenosis • Treat dysrhythmias (e.g. fast atrial fibrillation, conduction defects that compromise cardiac output) • Treat poorly controlled cardiac failure (digitalis, diuretics) • Treat poorly controlled cardiac ischaemia (nitrate patches) • Treat poorly controlled hypertension (diuretics, beta-blockers, analgesia, midazolam 0.5–1 mg intravenously at induction for ‘white coat’ hypertension) • Treat pulmonary insufficiency (antibiotics, physiotherapy, bronchodilators) • Treat endocrine abnormalities (insulin, thyroxine) • Treat hypothermia (slow warming) • Treat incipient renal failure (crystalloid, colloid) Timing of surgery • Delays acceptable for investigation or acute treatment of comorbid conditions • Facilitate surgery when additional investigation/intervention unlikely to improve patient’s physiological condition • Minimize preoperative fasting (6 hours for solids, 2 hours for clear fluids, enforced perioperative nutrition and hydration especially if surgery postponed) Thromboembolic prophylaxis • Consider fresh frozen plasma for rapid correction of raised INR if patient otherwise fit for anaesthesia and surgery • Daily enoxaparin 40 mg subcutaneously. Consider mechanical compression devices if enoxaparin contraindicated Infection control • Routine MRSA screening • Give prophylactic antibiotic intravenously at induction, local guidelines for preferred agent remembering risk of Clostridium difficile Anaesthesia • Individualized technique based on comorbidities (e.g. fixed cardiac output, abnormal clotting, respiratory insufficiency) • Regional anaesthesia preferred but advantages are marginal and may be inappropriate if surgery at distant sites planned • Metaraminol boluses or infusion to treat hypotension • Consider non-invasive cardiac output monitoring to guide fluid replacement Postoperative care • Epidural bupivacaine 1.25 mg/ml with morphine 0.05 mg/ml at 4 ml/h, paracetamol 1 g four times daily supplemented by NSAIDs as necessary (beware renal insufficiency) • Titrate analgesia to facilitate intensive physiotherapy and mobilization on the day of surgery • Monitor Spo2. Consider supplemental oxygen from admission to 72 hours after surgery • Encourage ward team to give adequate fluids and nutrition INR, international normalized ratio; MRSA, methicillin-resistant Staphylococcus aureus; NSAID, non-steroidal anti-inflammatory drug.
Table 2
Timing of surgery The British Orthopaedic Association (BOA) recommends that surgery should take place within 48 hours of admission if patients are medically fit.3 With disarming confidence the Association suggests that ‘experienced anaesthetists and orthogeriatric physicians should work together to ensure that delays do not occur. Pre-operative assessment and optimization must be a clinical priority.’ The Association goes on to note that systolic murmurs are common in elderly patients and may indicate significant
Multidisciplinary approach to care A team approach to care is essential and should include surgeons, anaesthetists, orthogeriatric physicians and nursing staff. Patients presenting with fractured neck of femur are commonly female, over 80 years old and have multiple comorbidities and polypharmacy.1 A team approach should enable a clear treatment plan to be agreed that encompasses preoperative, perioperative and postoperative care, as well as rehabilitation and discharge planning.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
© 2008 Elsevier Ltd. All rights reserved.
Orthopaedics
aortic stenosis, which is ‘a relative contraindication to a spinal [anaesthetic] technique’, and that the 2001 National Confidential Enquiry into Perioperative Deaths (NCEPOD) report recommended echocardiographic assessment of all cardiac murmurs, but, says the BOA, ‘this is not always possible prior to urgent surgery’ and ‘the absence of echocardiography should not lead to delays in fixing the fracture’.
were unavoidable owing to terminal carcinoma and 15% were probably unavoidable resulting from comorbidities present on admission, for example pneumonia, uncompensated heart failure and dysrhythmias. Thus, there is probably an inevitable hospital mortality rate of between 4% and 6% following femoral neck fracture. How can we improve outcome? Hospital mortality rates regularly exceed the predicted inevitable mortality rate and show great variation both between hospitals and within hospitals year by year. This suggests that certain aspects of the quality of care, both clinical and organizational, must make a difference. From an anaesthetic perspective, attention to detail is vital (Table 2). Careful preoperative assessment and meticulous anaesthetic technique tailored to each patient are essential. The necessity for senior advice and assistance should always be considered. Given the variations between hospitals, regular local audits are encouraged and may highlight areas where a department excels or areas ripe for improvement. Anaesthetists are continually extending their sphere of influence outside the operating theatre. More effective resuscitation and insisting on detailed attention to fluid balance in the perioperative period might help. The contribution of anaesthetists to effective postoperative pain relief is vital for early mobilization and reducing the incidence of life-threatening pneumonia and pressure sores. Adequate postoperative nutrition is often stressed but poorly managed. ◆
Delay does not increase mortality or hospital length of stay: for many years, surgeons have believed that surgery should be performed urgently within 48 hours of injury because this will improve outcome; a view reinforced by Dr Foster.5 Early surgery undoubtedly reduces pain and facilitates nursing care and early mobilization. The first two goals are important for the care of all patients, including those who may not survive to hospital discharge. Kenzora et al.6 were the first to challenge the beneficial effect of early surgery on mortality. They write that their 1984 study was conceived to ‘urge more vigorously the anaesthesiologist to anaesthetize the hip fracture patient as promptly as possible following admission’. In fact, patients anaesthetized between days 2 and 4 after admission had the lowest mortality, which suggested that a delay to permit resuscitation and optimization of comorbidities might be beneficial. These authors conclude that ‘it was only as the final data were examined and reviewed that the authors were confronted with the possibility that the tenets they had held for so many years might not be true’. A more recent study,7 using multivariate analysis to tease out the effects of various factors that delay surgery, confirms that delay does not increase mortality and has a minimal effect on length of hospital stay. The study compares outcomes in two US states and two Canadian provinces. This is relevant because most of the ‘evidence’ for the benefits of early surgery comes from the USA. The important conclusion of this study is that sequential analysis of confounding factors is essential for any study and that, in the population studied, timing of surgery is most influenced by differences in reimbursement policies between the two countries.
References 1 Parker M, Johansen M. Hip fracture. BMJ 2006; 333: 27–30. 2 Beaupre LA, Jones CA, Saunders LD, et al. Best practices for elderly hip fracture patients. J Gen Intern Med 2005; 20: 1019–25. 3 British Orthopaedic Association. The care of patients with fragility fracture. Available from: http://www.boa.ac.uk/site/showpublications. aspx?ID=59, 2007 [accessed 24. 08.08]. 4 Chilov MN, Cameron ID, March LM. Evidence-based guidelines for fixing broken hips: an update. Med J Aust 2003; 179: 489–93. 5 Bottle A, Jarman B, Aylin P, et al. Dr Foster’s case notes: some way to go for consistent implementation of guidance on hip fracture. BMJ 2004; 328: 1097. 6 Kenzora JE, McCarthy RE, Lowell JD, et al. Hip fracture mortality. Clin Orthop Relat Res 1984; 186: 45–56. 7 Ho V, Hamilton BH, Roos LL. Multiple approaches to assessing the effects of delays for hip fracture patients in the United States and Canada. Health Serv Res 2000; 34: 1499–518. 8 Sandby-Thomas M, Sullivan G, Hall JE. A national survey into the peri-operative anaesthetic management of patients presenting for surgical correction of fractured neck of femur. Anaesthesia 2008; 63: 250–8. 9 Urwin SC, Parker MJ, Griffiths R. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomised trials. Br J Anaesth 2000; 84: 450–5. 10 Foss NB, Kehlet H. Mortality analysis in hip fracture patients: implications for design of future outcome trials. Br J Anaesth 2005; 94: 24–9.
Preoperative echocardiography: a study published in 20088 shows that only 20% of anaesthetists insist on a preoperative echocardiogram. This may reflect a perceived need to proceed to surgery quickly and, more importantly, the unavailability of urgent echocardiography services in many hospitals. The authors note that clinical signs and a plain chest radiograph may assist diagnosis. Nevertheless, echocardiography is the NCEPOD gold standard and the evidence supporting the benefit of early surgery is weak. Best anaesthetic practice A number of interventions probably improve the patient’s fitness for anaesthesia, but the benefits of these interventions or a specific anaesthetic technique are difficult to support using an evidence-based approach. There is only marginal evidence in favour of regional anaesthesia,9 although many anaesthetists prefer this technique.8 Consensus opinion supports the interventions and techniques described in Table 2. Included are most of the interventions used by Foss and Kehlet,10 who, in 2005, studied what many would concur was then best evidence-based practice. Their results were disappointing with a 30-day mortality rate of 13.3%. An important finding was that 28% of deaths
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
© 2008 Elsevier Ltd. All rights reserved.
Orthopaedics
Further reading Jiang HX, Majumdar SR, Dick DA, et al. Development and initial validation of a risk score for predicting in-hospital and 1-year mortality in patients with hip fractures. J Bone Miner Res 2005; 20: 494–500. Orosz GM, Magaziner J, Hannan EL, et al. The timing of surgery for hip fracture and its effects on outcomes. JAMA 2004; 291: 1738–43.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 10:1
Price JD, Sear JJW, Venn RRM. Perioperative fluid volume optimization following proximal femoral fracture (review). Cochrane Database Syst Rev 2004; Art No: CD003004. Venn R, Steele A, Richardson P, et al. Randomized controlled trial to investigate influence of the fluid challenge on duration of hospital stay and perioperative morbidity in patients with hip fractures. Br J Anaesth 2002; 88: 65–71.
© 2008 Elsevier Ltd. All rights reserved.