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Perioperative Care of Elderly Patients with Hip Fracture

Perioperative Care of Elderly Patients with Hip Fracture. J Rush Pierce Jr, MD, MPH Hospitalist Best Practices Conference May 5, 2009.

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Perioperative Care of Elderly Patients with Hip Fracture

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  1. Perioperative Care of Elderly Patients with Hip Fracture J Rush Pierce Jr, MD, MPH Hospitalist Best Practices Conference May 5, 2009

  2. A 78 year old woman fell at church. She complained of left hip pain and was unable to arise. EMS was activated and transported her to the ED where x-rays disclose a hip fracture. She has a history of hypertension, hyperlipidemia, and coronary artery disease. She suffered a myocardial infraction seven years ago. She has not had any chest pain or symptoms of CHF. Her medicines are lisinopril, atenolol, aspirin, and atorvastatin. She lives with her husband who reports that she is active, does housework and walks everyday. She has had some memory difficulty and has poor vision. On examination she complains of pain, The left leg is external rotated. Heart and lung exam is normal. She has no edema. Her Folstein MMSE is 23 and Mini COG is 2. Her laboratory reveals a normal CBC and electrolytes. BUN is 25 and creatinine is 1.0. CXR is normal. EKG shows Q waves in limb leads 2, 3 , and AVF.

  3. Hip fracture in the elderly • How will this likely affect her life? • What evaluation does she need before surgery? • What is the best evidence based care? • Preoperative • Operative • Postoperative • What can we do to prevent another hip fracture in the future?

  4. Hip Fracture – epidemiology & natural history • 350,000 hip fxs yearly in USA • Lifetime risk for hip fx = 17.5% ♀, 6.0% ♂ • Mortality: • 5% during index hospitalization • 13% @ 3 mos • 24% @ one year • 50% require assistance device @ one year • 25% in LTC @ one year

  5. What type of pre-operative evaluation does she need?

  6. Assessing the cause of the fall • Did she have syncope? • Most falling in the elderly not due to syncope • Syncope suggest possibility of cardiac arrhythmias • Has she fallen before (6 months)? • Suggest frailty and poorer prognosis • Medication review especially important

  7. Causes of syncope in the elderly “In contrast with previous reports, prodromic symptoms were remarkably frequent in this older population but proved to be poorly specific and, hence, of limited utility in orienting the diagnosis toward neurally mediated syncope.” Ungar A, et al. J Amer Geriatrics Soc 2006;54:1531-6

  8. “She needs Clearance”

  9. “We need clearance!”

  10. Preoperative Risk Assessment

  11. Preoperative management • Traction – no benefit with regard to pain or ease of fracture reduction • Pressure sore prevention • Foam mattress (RR = 0.34) • Alternating pressure mattress (RR=0.20) • Beta blockers – recent meta-analysis showed no benefit for non-cardiac surgery (Lancet. 2008 Dec 6;372:1962-76)

  12. Meta-analysis of peri-operative beta blockers • 33 trials included 12,306 patients. β blockers were not associated with any significant reduction in the risk of all-cause mortality, cardiovascular mortality, or heart failure, but were associated with a decrease (odds ratio [OR] 0·65, 95% CI 0·54–0·79) in non-fatal myocardial infarction (number needed to treat [NNT] 63) and decrease (OR 0·36, 0·26–0·50) in myocardial ischaemia (NNT 16) at the expense of an increase (OR 2·01, 1·27–3·68) in non-fatal strokes (number needed to harm [NNH] 293). The beneficial effects were driven mainly by trials with high risk of bias. For the safety outcomes, β blockers were associated with a high risk of perioperative bradycardia requiring treatment (NNH 22), and perioperative hypotension requiring treatment (NNH 17). We recorded no increased risk of bronchospasm. (Lancet. 2008 Dec 6;372:1962-76)

  13. Her children are coming from out of state and ask that surgery be delayed for two days until they arrive. What is the best timing of surgery in this woman?

  14. Timing of Surgery • Early repair (24 – 48 hrs) [Evidence based, mostly level 2] • ↓ one-year mortality • ↓ pressure sores (RR= 0.46) • ↓ major medical complication (RR=0.26) • Reduced LOS by 1.94 days • Reasons to delay surgery [Opinion] • Acute coronary syndrome • Acute CVA • Sepsis • Severe hypoxemia

  15. Hip fracture in the elderly - anatomy • Femoral neck (1/3) • Non displaced– usually internal fixation with nail/pin • Displaced - hemiarthroplasty • Intertrochanteric (2/3) • Open reduction with internal fixation (ORIF) Zuckerman. N Engl J Med 1996;23:1519-1525

  16. Intertrochanteric fracture Zuckerman. N Engl J Med 1996;23:1519-1525

  17. Non-displaced femoral neck fracture Zuckerman. N Engl J Med 1996;23:1519-1525

  18. Displaced femoral neck fracture Zuckerman. N Engl J Med 1996;23:1519-1525

  19. Parker and Gurusamy. Disability and Rehab 2005; 27:1045 – 1051.

  20. Operative management • Type of surgery - arthroplasty for displaced femoral neck fxs • Pre-operative antibiotics (1 or 2 doses of long-acting cephalosporin) • Decreased post-op wound infection (RR=0.36) • Decreased post-op UTI (RR=0.66) • Regional anesthesia • Decreased 30 day mortality (RR=0.69) • Decreased proximal DVT (RR=0.64) • Decreased post-op pneumonia (RR=0.61)

  21. Post-operative management • Pain management • Decreased cardiac complications with epidural (1 study); better pain management with epidural • Expert opinion: avoid meperidine & propoxyphene • Urinary catheter • UTI occurs in 25% • Little evidence about catheter type and UTI • Post-op urinary retention – normal voiding returns 4.3 days sooner with intermittent vs. indwelling catheter (1 study)

  22. Thromboembolic prophylaxis • Prevalence: DVT = 48%; fatal PTE = 4 -14% • Benefit to all modalities (RR~0.6); no one clearly preferred, most use an anticoagulant • Heparin, LMWH, low dose coumadin, ASA + SCD • Begin preoperatively • Heparin, coumadin - day before • LMWH – not before 12 hrs preoperatively • Duration – not well studied; suggest need for 6 weeks

  23. Post-operative management (cont) • Nutrition • Oral supplements reduced LOS (one study) • Multidisciplinary team • No level 1 benefit shown but difficult to study

  24. Rehab and Recovery • Early mobilization important – 24 hours [evidence based] • Earlier discharge • ↓ costs • ↑ functional status • Gait training and occupational therapy decrease risk of recurrence [evidence based] • Organized rehab assoc with 10% ↓ in death and institutionalization - pts with mild dementia most likely to benefit [evidence-based]

  25. Is post-operative delerium likely in this woman?

  26. Postoperative delerium • Common • 3.8% low risk (0 risk factors) • 11% middle risk (1 - 2 risk factors) • 37% high risk (3 – 4 risk factors) • Risk factors: • Visual impairment (>20/70) • MMSE < 24 pre-op • APACHE II >16 • BUN/creat ratio >= 18 Kalisvarrt et al: JAGS 2006; 54:817-822.

  27. Postoperative delerium • Pre-existing dementia very common, but often not diagnosed • Pre-operative Mini-Cog (0-2 + abnormal Clock drawing test) five times as likely to develop

  28. Postoperative delerium – assessment and treatment • Look for treatable causes • Hypoxemia • Electrolyte abnormalities • Hypotension • Avoid sedative/hypnotics, drugs with anticholinergic properties, narcotics • Reassurance, reorientation, geriatric nursing care Huddleston & Whitford: Mayo Clin Proc 2001; 76:295-298.

  29. How do we prevent this from happening again?

  30. Hip fracture – prevention of recurrence • Almost all accompanied by osteopenia or osteoporosis • Calcium and Vit D in hospital • Consider bisphosphonates • Hold estrogens (thromboembolic potential) • Fall prevention

  31. Falls in the Elderly - Epidemiology • 30% community dwelling adults over 65 years old fall at least once each year • Over 50% nursing home residents fall yearly • Over 10% of falls result in serious injury • About 5 – 6 % of Medicare expenditures result of falls

  32. Medications associated with hip fractures in epidemiologic studies • Benzodiazepines • Antidepressants • Antipsychotics

  33. Fall prevention – evidence of benefit • Education – not helpful • Exercise programs (balance training > strength or endurance) – benefit only for targeted community dwelling adults • Environmental assessment – benefit outside home as well as in home • Withdrawal of psychotropic drugs – but studies show that most patients resume withdrawn medications within one year

  34. Fall prevention – extent of benefit • Most studies show modest (10 -15% reduction in falls) • Best multi-component intervention programs show 35% reduction (30% - 20%) • Repeated falling in the elderly often predicts general physical and cognitive decline – review living situation and driving

  35. Clinical Bottom Line • Telemetry for syncope [opinion] • “Clear” almost all patients • Push for early surgery (24-48 hrs) and regional anesthesia • Pre-operatively order a mattress, peri-operative antibiotics , DVT prophylaxis • Post-operatively get Foley out; ambulate early; order PT/OT; avoid meperidine & propoxyphene; anticipate delerium; order Ca and Vit D; consider bisphosphonates; rehab

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