Management of Proximal Femoral Fractures 2011 - aagbi

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Anaesthesia 2011Griffiths et al. | Guidelines: proximal hip fracturesPostoperative cognitive dysfunction ⁄ acute confusional stateThis is common (25%) in patients with hip fracture, interrupting routinemanagement and rehabilitation. Treatment involves multimodal optimisationof postoperative care requiring adequate analgesia, nutrition,hydration, electrolyte balance, appropriate medication, bowel habit andmobilisation, in conjunction with identifying and treating complicationssuch as chest infection, silent myocardial ischaemia and urinary tractinfection [43]. Drugs such as haloperidol or lorazepam should only beused to control symptoms in the short term. Cyclizine should be used withcaution in older persons, due to its antimuscarinic side effects.NutritionUp to 60% of patients with hip fracture are clinically malnourished onadmission to hospital. The calorie and protein density of hospital food isoften poor, and mortality (and possibly length of stay) may be reducedthrough the administration of nutritional supplementation and employmentof dietetic assistants [44, 45].RehabilitationThe rehabilitation process constitutes the majority of a patient’sinpatient stay after hip fracture, and continues for some time afterdischarge.Rehabilitation is ideally co-ordinated by orthogeriatricians, and isaimed at providing a patient-centred package of care that attempts toreturn the patient to levels of activity and residence similar to their prefracturestatus. To this end, patients usually require input fromphysiotherapists, occupational therapists, social workers, nursing staffand their own relatives. Secondary prevention of falls and osteoporosisshould be actively considered in the early postoperative period, assubsequent fragility fracture or periprosthetic fracture is associated with aparticularly poor prognosis.Anaesthetists may become involved in secondary surgical management(e.g. wound debridement, prosthesis revision) or in the provision oflonger-term analgesia or HDU facilities.Printed information describing the typical care pathways for hipfracture patients should be available for patients, carers and relatives.OutcomesOutcomes vary considerably in the UK.22 Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland
Griffiths et al. | Guidelines: proximal hip fractures Anaesthesia 2011MortalityMortality after hip fracture has remained relatively unchanged for the lasttwo decades. Currently, 8.4% of patients die within 30 days of surgery [6].However, it has been suggested that up to half of postoperative deaths arepotentially preventable [46]. Thirty-day mortality is increased for older,sicker, male patients. Up to 15–30% of patients die within a year ofsurgery.Length of acute inpatient stayThis is between eight and 30 days, with a mean of 16 days [6].Discharge destinationOnly 44% of patients admitted from home are discharged back to theirown homes within 30 days of surgery. A further 22% are discharged to aresidential or nursing home, and discharge may become prolonged inwaiting for admission to these facilities.Audit and researchCochrane reviews have consistently recognised the relative dearth ofevidence on which to base best practice guidance with regards to theclinical management of patients presenting with hip fracture. Consequently,practice varies widely across the country, as several audits haveshown [6, 7], resulting in wide variations in patient outcome.Clinical audit is fundamental to the process of improving the qualityof patient care. Local audit enables physicians both to identify specificareas of care that could be improved, and to assess performancelongitudinally. National audit enables hospitals to compare performanceagainst other hospitals, and identify specific paragons of practice that maythey might adopt. A number of audit tools are available for anaesthetists:Hip Fracture Perioperative Network (HFPN)This is an NHS-sponsored network developed under the auspices of theAge Anaesthesia Association, with the aim of improving evidence-based(anaesthetic) care for patients with hip fracture in the UK. The HFPNwebsite [47] includes freely available database and annual report templatesthat anaesthetists may use to audit hip fracture care in their own hospitals,as well as ideas for research, specimen patient information leaflets, preoperativecare information for junior surgeons, and hip fracture carepathway proformas.Anaesthesia ª 2011 The Association of Anaesthetists of Great Britain and Ireland 23
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