By Tom Heaton
Welcome back to the final part of our emergency surgery trilogy. In this series we have been looking at the ‘Big Three’ of emergency surgery: the ruptured AAA, the laparotomy, and the fractured hip. All three posts are based on the recent Anaesthesia supplement on the big three which you can get to through the link below (if you have managed to avoid it after the last few posts), focusing particularly on the elderly population. We wrap up with a look at those patients who have suffered a fractured hip, and all the problems that these patients encounter.
What's The Story?
Let’s start with a familiar tale; patients undergoing surgery for a fractured hip have significantly worse outcomes than their elective counterparts. The in hospital and 30 day mortality for the fractured hip is around 8.2% compared with a mere 1.2% for elective total hip replacement (and that’s in patient over 80 years old). It’s quite shocking to see that this ratio is almost as bad as the comparison between elective and emergency AAA surgery.
The poor outcome after a fractured hip is something I remember well from my medical student days. I think it has stuck so strongly in my mind because it didn’t really make that much sense to me at the time. My train of thought from back then (which might sound rather orthopaedic) was that it’s just a broken bone, all you need to do if fix it and things will be fine. It is clear that this is not the case and once again it isn’t just a case of worse mortality but includes significant morbidity and loss of independence for these patients. To top it off these are also patients that have a long and expensive rehabilitation process, with a mean hospital stay of 16 days (AAGBI guidelines).
Why is this the case? Is it linked to a poorer baseline status? The authors note (without giving details – though the AAGBI guidelines have a bit more) that the fall causing the fracture may have had an acute medical problem as a contributing factor (e.g. chest infection), and that the population that experience these events often possess significant co-morbidities. In this sense I think I can start to see where the total hip replacement might differ a bit more from the elective comparisons of the other emergency surgeries. The impact of severe hip osteoarthritis on quality of life is not in any way trivial, but I could see how the risk-benefit thinking behind going ahead with the surgery in a less well optimised patient may be different from those with a significant AAA or colorectal cancer, where the threat to life from not proceeding is significant. So the elective total hip replacement patient is probably fairly different from the patient with the fractured hip, but this still seems an injury with excessively poor outcomes and, as the authors point out, this starting point alone is unlikely to be contributing to these outcomes. Instead, they feel that some of the aspects of their peri-operative care may be contributing. This is an injury with post-op complications that include pneumonia, delirium, thromboembolic disease and wound infection. In addition, the injury itself can be a considerable insult to these patients resulting in dehydration (lying on the floor, nil by mouth) and an average peri-operative blood loss of about 25g.l-1.
What Can We Do?
In a similar way to the previous surgical procedures, the authors highlight some important areas that care of these patients can be optimised in order to improve outcome:
Pre-op
Pre-op
- Minimise time to theatre
- Consider regional anaesthetic techniques to minimise pain and opioid use pre-operatively (I see a lot of fascia iliaca blocks done in A&E for these patients)
- Be aware of the high incidence of anaemia and hypovolaemia in these patients
- Aim for a neuraxial technique (controversial and an unanswered question but suggestion of improved morbidity if not mortality).
- Early rehabilitation and mobilisation (and thus an anaesthetic approach that facilitates this)
- Implementation of appropriate care bundles (analgesia, management of anaemia, thromboembolism prophylaxis)
- Avoidance of delirium
- Use of critical care facilities where appropriate.
Again, I hope you can see a lot of recurring themes here when compared with the previous posts. The big one the authors highlight is the importance of minimising delay to theatre, with delay being shown to worsen all those outcomes for these patients. 48 hours after admission is the limit that is proposed in the AAGBI guidelines, with no more than a 24 hour delay after the decision to operate has been made. Unless there is a severe (and rapidly correctable) derangement, it’s best to crack on and get it done. I know there are a lot of tweaks to the care pathways of these patients to streamline this journey from A&E to the operating table, but as anaesthetists we are going to encounter patients that are not in the ideal shape for an anaesthetic and with whom we don’t have the time to optimise very much at all. As a junior trainee I have found it a bit more challenging to pull out which factors should delay theatre and which shouldn’t. One example that I have seen before is the incidental finding of a heart murmur in these patients. Is it justifiable to wait for an echo in all these patients? What time delay is acceptable (you’ve just seen the patient on Saturday morning with no echos until Monday at the earliest)? The authors don’t really go in to excessive detail on these sorts of questions in this review, and you have to go and have a look at other guidelines (such as the AAGBI ones on the topic, which I think are pretty good) to get some good advice. Much of this will be a clinical decision of risk versus benefit, but I think the main point that authors stress is that the risks associated with delaying surgical correction are pretty significant so there has to be a strong reason to do so.
Let's Wrap It Up
As with other parts of anaesthetic practice, solid recommendations by the authors are limited by the lack of solid evidence out there. Ideas such as use of regional blocks to reduce post-op opioid requirements (and their delirium risk) seem sensible, but the article goes little beyond this level of recommendation. Ultimately, there are often multiple factors that make these patients challenging to manage and as such it is widely recommended that these patients should have consultant level care to help navigate this jungle. These patients are generally at a worse baseline than the elective patients we are comparing them to, but there is almost certainly more that we can do to improve the outcomes for these patients.
Well that is it from this little trilogy. Thank you for reading and I hope it was at least mildly useful. As with the previous posts I have put together some more links to some resources that you might find useful. Some more great posts currently in the pipeline and I hope to see you again soon.
Tom Heaton
Well that is it from this little trilogy. Thank you for reading and I hope it was at least mildly useful. As with the previous posts I have put together some more links to some resources that you might find useful. Some more great posts currently in the pipeline and I hope to see you again soon.
Tom Heaton
Management of Proximal Femoral Fractures - The 2011 AAGBI guidelines on the management of hip fractures. Good for a bit more detail on the whole peri-operative management.
NICE Guidance - The 2011 NICE clinical guidelines on hip fractures
National Hip Fracture Database - Homepage of the NHFD, a national audit project aiming to improve hip fracture care.
Medscape: Hip Fractures - The weighty medscape pages on hip fractures
NICE Guidance - The 2011 NICE clinical guidelines on hip fractures
National Hip Fracture Database - Homepage of the NHFD, a national audit project aiming to improve hip fracture care.
Medscape: Hip Fractures - The weighty medscape pages on hip fractures
Image courtesy of Arztsamui/FreeDigitalPhotos.net
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