A new study showed a development in perioperative analgesia and mortality scoring systems, changes to intra-operative anaesthetic technique and strategies to reduce the requirement for blood transfusion. Patients suffering a hip fracture are usually elderly, with a median age of 83 years, and co-existing chronic illnesses. Around 30% of patients with hip fracture also suffer from cognitive dysfunction and the requirement for urgent surgery in this patient group can be challenging to the anaesthetist.
It is well recognised that unnecessary delay to operative fixation of hip fractures is associated with increased mortality. Therefore, the aim of anaesthetic perioperative management is to investigate and ‘normalise’ the patient within the time constraints, to provide standardised care, tailored to individual patient needs. The anaesthetist’s role may be very broad in hip fracture care, and is not restricted to the provision of anaesthesia during surgery.
Pre-operatively the anaesthetist may be involved in providing analgesia in the form of a peripheral nerve block, ‘normalisation’ of the patient and providing information on certain risks of anaesthesia. Intra-operatively there remains significant debate regarding the most effective anaesthetic techniques, with an emphasis now being placed on avoiding intra-operative hypotension. Operative anaemia may adversely affect patient outcomes and careful consideration should be given to peri-operative blood transfusion.
Patients with hip fracture may have anaemia for a variety of reasons, including pre-existing medical conditions, treatment with anticoagulant medication or perioperative haemodilution. Blood loss from the fracture site itself is often underestimated and is relatively greater with extracapsular fractures, commonly exceeding 1000ml. This may well be because the total blood loss from hip fracture is several times greater than that which is apparent at surgery.
The use of a catheter inserted into the epidural space is another option for intraoperative anaesthesia and analgesia. This has a much slower onset than spinal anaesthesia, which may be beneficial in patients with cardiovascular instability. Post-operative epidural anaesthesia has been demonstrated to reduce opiate requirements during rehabilitation and provide effective dynamic analgesia without impairing motor function
Combined spinal epidural techniques can also be used, providing a rapid onset of anaesthesia and analgesia from the spinal anaesthetic with epidural analgesia which can be used intra-operatively if required, or solely for post-operative analgesia. Hip fracture anaesthesia is evolving in response to a growing evidence-base regarding the perioperative care of these patients. Timely surgery is associated with improved outcomes.
Consideration should be made to performing peripheral nerve blocks pre-operatively to avoid the adverse effects of opioids. Both general and spinal anaesthesia should be supplemented with peripheral nerve blockade and intra-operative hypotension should be avoided regardless of mode of anaesthesia. Developments in hip fracture anaesthesia will only be successful as part of a coordinated system of care for this frail patient group.