Abstract
The incidence of hip fractures is rising, and at the same time the patients are getting increasingly frail and elderly. Patients in Europe have a median hospitalization time of as much as 28 days, and the peri-operative morbidity and mortality is high1. Most interventional studies have been unimodal with very heterogeneous results and at present, limited data are available from multimodal intervention according to the established principles of fast-track care2. This study has very positive results with a reduction in hospitalization from 21 till 11 days. Anaesthesiological intervention in a fast track regimen must be peri-operative in such a high-risk group of patients. Early operation is probably preferable3. Pre-operative regional analgesia potentially reduces cardiovascular morbidity, if instituted immediately after arrival4. The effect of regional anaesthesia and postoperative regional analgesia on morbidity and mortality in hip fracture patients may be advantageous5.
Postoperative epidural analgesia can be provided without restrictions on patient mobility and rehabilitation, provides superior dynamic pain relief and reducing the influence of pain as a restricting factor on physiotherapy6. A potential effect of intra-operative volume optimization has been shown, although the effect on morbidity and mortality is unclear7. No information exists for postoperative fluid therapy regimens, but fluid excess is probably important to avoid8. Hip fracture patients often suffer from malnutrition at the time of admission and protein and energy supplementation potentially reduces mortality and morbidity9. Therefore a short perioperative fasting period combined with aggressive peri-operative oral nutrition and anaesthesia and analgesia techniques, that minimizes catabolism and PONV seems rational. Since mortality and morbidity is so high these patients should be treated in close cooperation between surgeons and anaesthesiologists both in the pre and postoperative phase10, as established practice in other high risk patients. Mortality is not the optimal parameter the for success of intervention in this population, as effects are extremely difficult to document, since as much as 50–75 % of the perioperative mortality may be unrelated to the treatment regimen11.
The cumulated evidence for the peri-operative care of this patient group is scarce and fast-track rehabilitation regimens should look to other operational procedures for available evidence12. Future research should focus on broadening the evidence for relevant pre-operative optimization, the influence of regional analgesia on rehabilitation potential and optimized peri-operative fluid therapy, transfusion and nutrition regimens.
Theses abstracts were prepared by Professor Roger Lemaire. Correspondence should be addressed to EFORT Central Office, Freihofstrasse 22, CH-8700 Küsnacht, Switzerland.
References:
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