Care of the Hip Fracture Patient.ppt

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1、Care of the Hip Fracture Patient,An Evidence Based ReviewDebra L. Bynum, MD Division of Geriatric Medicine University of North Carolina,Outline,Hip Fracture: Some Background Preoperative Assessment and Cardiac risk stratification Perioperative Beta Blockade Other Perioperative Management Options Pre

2、vention of Venous thromboembolic events (VTE) Postoperative Care Delirium Other complications following surgery Prevention of Future Fractures Discharge Planning,The Internists/Family Physicians Role in the Care of the Hip Fracture Patient,Case: 84 year old man with mild dementia who lives at an ass

3、isted care facility is found on the floor complaining of severe hip and groin pain. He is taken to the ED and found to have an intertrochanteric hip fracture. Because of his past history of a CABG 15 years ago, HTN, CRI and dementia, he is admitted to the medicine service.,Questions,Men over the age

4、 of 90 have a _% chance of having a hip fracture A. 10 B. 20 C. 30 D. 40 One year mortality following a hip fracture is nearly _% A. 5 B. 10 C. 20 D. 50,The Problem: Hip Fractures,Fastest growing US population: over 65 (20% by 2025) Life expectancy at age 65: 18.9 years; 75=11yrs; 85=7 yrs 10% peopl

5、e over age 90 will live to 100 Hip fracture= 2nd leading cause for hospitalization in older patientsIncreased incidence with increased age 4% in men age 64-69, 31% risk in men over age 90 Women over age 50: 15% lifetime risk hip fractureBad Predictor Increased mortality No significant decline in mor

6、tality since 1980s 20% mortality over first year Decreased functional status 30% survivors discharged to skilled nursing facility,The Case,The patient has a mild dementia, but is clear enough to direct you to his advanced directives and DNR form.He also is clear that he wishes to proceed with surger

7、y, he was previously ambulatory and independent in his ADLs.,?Conservative Management,Without surgery, many patients left with significant pain, shortened leg, immobility (without surgery, patient will be nonambulatory)May be option in severely demented, very ill, nonambulatory, or terminal patients

8、 if they are comfortableGoals of surgery: pain control, ambulation, decreased complicationsDo Not Hospitalize orders: often opt out clause that includes fracture/injury for symptom control,Advanced Directives,DNR order not contraindication to surgical interventionClarify with patient/family/guardian

9、 UNC anesthesiology will not anesthetize patient unless DNR order is suspendedOutcome of suspending DNR order: patients with prior DNR order that was suspended during this period who had cardiopulmonary arrest had NO survival benefit,Capacity and Informed Consent,Consistency in response Able to clea

10、rly describe situation and reason why or why not they wish to have or not have procedure Consistent with prior life events and decisions Consistent with family and cultural beliefs Not only related to underlying cognitive ability,Preoperative Assessment,The Case,Although he had a CABG years ago, he

11、has had no chest pain, no syncope, no DOE or PND and has no overt evidence of CHF on exam. His exercise tolerance is poor, and his baseline creatinine is 2.1 and albumin is 2.8.Does he need further cardiac testing? Should surgery be delayed? What are some possible negative outcome predictors?,Questi

12、ons,Predictors of bad cardiac outcome include: A. creatinine over 2 B. insulin requiring diabetes C. CAD with prior CABG but no recent symptoms D. CHF on exam E. all of the above F. A, B, D Hip fracture surgery may be considered inherently more risky given that it is usually an emergent procedure in

13、 an elderly, frail patient True/False,Cardiac Risk Assessment,1970s: Goldman Risk Assessment Tool1999: Revised Cardiac Risk Index (Lee et al) Identified independent predictors of adverse perioperative CV events from 2800 patients, then prospectively validated in 1400 patients,Cardiac Risk and Hip Fr

14、actures,Perioperative myocardial ischemia may occur in up to 35% of elderly patients undergoing HFSStudies of patients undergoing noncardiac surgery suggest that only 15% with perioperative MI have chest pain, only 53% will have any clinical symptomsSupports other observations that up to 50% of pati

15、ents with perioperative ischemia go unrecognized?hidden symptoms with analgesia, ?symptoms (inc HR, dec oxygen, inc RR) attributed to other causes?,Cardiac Risk and Hip Fracture,Hip fracture surgery inherently more riskyOlder patients, more likely to have underlying CAD and other comorbiditiesFalls/

16、fracture as marker of frailty and poor outcomes,Revised Cardiac Risk Index,1. Ischemic Heart Disease (hx MI, q waves , hx of + exercise test, current ischemic type chest pain, use of SL NTG; does not include prior CABG/ PCI unless those features present) 2. CHF (hx CHF, pulmonary edema, PND, rales,

17、s3, cxr edema) 3. Cerebrovascular disease (CVA or TIA) 4. DM treated with insulin 5. Creatinine 2 6. High risk surgery (peritoneal,thoracic, vascular)Risk of CV event (MI, pulm edema, vfib, cardiac arrest) 0 points: 0.4-0.5% risk 1 point: 0.9 -1.3% 2 points: 4-6.6% risk = 3 points: 9-11 % risk,Surgi

18、cal Procedure Risks,High (CV risk over 5%) Emergent major operation in elderly Aortic/major vascular surgery Peripheral vascular surgery Long procedures with fluid shifts/blood lossIntermediate (CV risk 5%) Carotid endarterectomy Head and neck procedures Intraperitoneal/intrathoracic Orthopedic Pros

19、tateLow (CV risk 1%) Endoscopic Cataract breast,Functional Status and Preoperative Risk,Patients reporting poor exercise tolerance known to have increased perioperative complications 20% vs 10% risk MI/CV event/ CNS event,Other Preoperative Predictors,Serum Creatinine Dementia Serum albumin Signific

20、ant predictor of 30 day mortality Marker for frailityPredictors of overall mortality and morbidity, not just CV events,Question,A functional study that is “positive” for evidence of ischemia indicates at least a 50% chance of a negative cardiac event in the perioperative period True/False,?Noninvasi

21、ve Cardiac Testing,NPV Dobutamine echo/nuclear perfusion tests near 100% for perioperative MI/CV deathPPV only 20%; Low + LR for perioperative CV eventNegative study may help decrease probability of CV event; positive study does not help much,Question,If a patient is at high risk for a negative card

22、iovascular outcome with surgery, then undergoing cardiac catheterization with stent placement prior to surgery will improve the overall outcome True/False,?Noninvasive Cardiac Testing,Big Question: will results of test change management?Options: Perioperative Coronary revascularization Perioperative

23、 PCI with stent Optimize medical management,Options? Perioperative coronary revascularization,Coronary Artery Surgery Study (CASS) registry: retrospective dataPatients with CAD/CABG had decreased perioperative CV events compared to similar patients managed medicallyConfounder: mortality with CABG (2

24、.6%) may outweigh any benefit (the “survivors” more likely to survive future surgery),? Revascularization,Coronary Artery Revascularization Prophylaxis (CARP trial) Patients with stable but significant CAD randomized to preoperative coronary revascularization (59% PCI, 41% CABG) vs medical managemen

25、tMost patients considered intermediate risk with RCRI =2No difference in 30 d or 2 year mortality,? Revascularization,Stents May be increased CV events immediately after Not clear how long to wait Stent months/years prior likely same protective value as prior CABG (Bypass Angioplasty Revascularizati

26、on Investigation, BARI) Most suggest need to wait at least 6 months Complicated further by use of antiplatelet agents and risk of bleeding,Preoperative Assessment,In general, based upon RCRI and data re noninvasive testing: 1 point: no beta blocker, no test 2 points: beta blocker, med management, no

27、 test = 3 points: beta blocker, ?preoperative test to further risk stratifyIn general, thought to do preoperative test in patient one would consider doing in regardless of surgery,Preoperative Cardiac Assessment: Summary,Hip Fracture Surgery considered emergent/urgent Preoperative cardiac testing wi

28、th low predictive valueNo evidence that invasive intervention with revascularization of benefit, stenting may be of harmRisk stratify by clinical criteria; little role for noninvasive testing; high risk patients need more intense monitoring for silent ischemia and optimization of medical managementS

29、elected patients: Echo to evaluate LV function,The Case,Despite his prior history of CAD, he has not been on a beta blocker. The reason is not clear in the chart work he comes with to the ED. Should he be started on a beta blocker? Is there anything else in the preoperative time that may be of benef

30、it to him?,Question,Beta Blockers, when used in the perioperative period, have been shown to reduce mortality and CV events, but the overall benefit is likely modest and must be weighed with the risk of significant bradycardia and other side effects in the elderly True/False,Perioperative Beta Block

31、ers,Widespread acceptance of beta blockers prior to surgery to decrease risk of CV events/deathTheory: decrease catecholamine surge Guidelines in reality based upon results from one dominant trial; other trials not so overwhelmingMeta-analysis data: 11 RCTs, total 866 patients; overall only 20 total

32、 deaths, 18 MI 8 deaths in BB groups, 12 in placebo groups; 2 MIs in BB group, 16 in placebo group 90 episodes brady in BB group, 26 in placebo,Beta Blockade: Poldermans trial,1999 RCT: patients with positive dobutamine echo undergoing major elective vascular surgeryBisoprolol vs placeboDecrease in

33、cardiac death: 3.4% vs 17%Decrease in nonfatal MI: 0% vs 17%Overall risk of death/MI in placebo group: 34%,Beta Blockade: Mangano trial,Effect of atenolol on mortality and CV morbidity after noncardiac surgery (1996)Atenolol given before and during hospitalization onlyPatients followed for 2 years (

34、n=192/200)Initial mortality: 0% vs 8% in placebo group1 year: 3% vs 14% mortality2 years: 10% vs 21% mortality,Perioperative Beta Blockade,Total numbers heavily skewed by data from Poldermans trial Patients with positive dobutamine echo undergoing elective vascular surgery Higher risk, higher events

35、 Overall data seems to support benefit for BB use with RRR of 15-35% range,Perioperative Beta Blockade: Is the Jury Out?,PeriOperative Ischemic Evaluation (POISE) trial Designed to look at 30 days metoprolol to prevent major CV events with any type noncardiac surgery Planned to enroll 10,000 patient

36、sOverall beta blockade in mod/high risk patients reasonable and likely modest benefit with RRR of 30% for CV mortality/nonfatal MIHigher risk patients= higher number of events,= more likely to see benefitUnclear in lower risk patients; risk of bradycardia may outweigh benefit in lower risk patients

37、with LOW RISK OF EVENTS,Preoperative Management,Optimize fluid status, renal function Optimize fluid balance if patient has symptomatic CHF Other possible medications: Alpha Blockers Statins Preoperative Pain control,?Alpha Blockers in the Perioperative Setting,Best evidence from one large study usi

38、ng Mivazerol (not available in US) Multiple small studies using clonidine in US All show modest benefit Data not too different from Beta Blockade trials,What about Statins,HMG CoA reductase inhibitors in retrospective trials show decrease in perioperative CV eventsSmall RCT with 100 patients, atorva

39、statin vs placebo prior to major vascular surgery (14 day prior, continued for 45 d after): combined outcome of CV death/MI/stroke found in 8% patients with tx, 26% patients with placeboMay be of benefit, not clear during urgent procedures,PRE operative Analgesia,Theory: decrease catecholamine respo

40、nse ? Preoperative epidural analgesia vs conventional tx RCT of 77 elderly patients with hip fracture Epidural analgesia started in ED Outcome: CV mortality, MI, CHF, new afib Control group: 7 events (4 deaths) vs 0 events in treatment group Postoperative pain scores higher in control group for 1st

41、2 days, then equal Problem with study: patients waited 1.6-3.5 days prior to surgery; may see more benefit when wait is longer,Other Preoperative Management needs,Diabetes: Metabolic control Hyperglycemia without prior diagnosis of DM in elderly with acute event = bad predictor Discontinue oral agen

42、ts initially May need to cover with insulin, usually will need some amount of baseline insulin to avoid extreme fluctuations (infusion or glargine),Other Preoperative needs,Review and discontinue medications that are not needed/potentially harmfulReview for medications that need to be restarted (ant

43、idepressants, antihypertensives) once stableReview for medications that may cause a problem with withdrawal (benzodiazepines, SSRIs),Preoperative Traction,Previously standard of care 5-10 lbs applied to lower leg Intended to decrease preoperative pain and improve ease of fracture reduction Systemati

44、c review: no statistical benefit with pain control or surgery Use will therefore depend upon center and individual surgeon preference Preoperative traction should be used for patient comfort only,Preoperative Antibiotics,Given 30 minutes prior to skin incision and continued for 24 hours after surger

45、y1st generation cephalosporin (cefazolin) or clindamycinCochrane review: significant decrease in deep tissue infections and UTI,Question,What is the optimal timing for proceeding with surgery?,Timing of Surgery,Several earlier studies show that early surgery (first 24-48 hrs after fracture) associat

46、ed with decreased mortality, pressure ulcers, deliriumConfounder: patients with CHF or other acute issues or more comorbidities more likely to have delayed surgery and bad outcome; not clearly causal relationshipNot ethical to do RCT General consensus: earlier the better, once stable,Surgical Manage

47、ment,Intertrochanteric Sliding hip screw Long femoral nails for unstable intertrochanteric or subtrochanteric fracture Lower OR time and less blood loss than hip screw Subcapital Nondisplaced: Percutaneous screws Displaced: standard is hemiarthroplasty or total hip arthroplasty (vs internal fixation

48、 if not displaced); longer/more risk surgery Hemiarthroplasty = 60 min OR time THR = 150 min OR time,Intertrochanteric Fracture,Sliding hip screw Intramedullary nail,Femoral Neck Fractures,Screw fixation Hemiarthroplasty,General or Regional Anesthesia?,Lots of small studies and several meta-analyses

49、Some conflicting dataLargest systematic review: over 2500 patients; 1/3 mortality reduction; decreased DVT by 44%, PE by 55%Other studies indicate decreased pneumonia, transfusion with regional blockade vs general,The Case,He does well with the surgery; The resident wants to know if he should be started on heparin for DVT prevention What is the evidence to support anticoagulation in this setting? Is he at higher risk for bleeding or thrombotic events?,Question,List 3 options for prevention of DVT/PE for hip fracture patients that are supported by clinical care guidelines,