Aims

We chose unstable extra-capsular hip fractures as our study group because these types of fractures suffer the largest blood loss. We hypothesised that tranexamic acid (TXA) would reduce total blood loss (TBL) in extra-capsular fractures of the hip.

Our aim was to determine the total blood loss associated with surgery for fracture of the hip and to identify risk factors for increased blood loss. We prospectively studied 546 patients with hip fracture. The total blood loss was calculated on the basis of the haemoglobin difference, the number of transfusions and the estimated blood volume. The hidden blood loss, in excess of that observed during surgery, varied from 547 ml (screws/ pins) to 1473 ml (intramedullary hip nail and screw) and was significantly associated with medical complications and increased hospital stay. The type of surgery, treatment with aspirin, intra-operative hypotension and gastro-intestinal bleeding or ulceration were all independent predictors of blood loss.

We conclude that total blood loss after surgery for hip fracture is much greater than that observed intra-operatively. Frequent post-operative measurements of haemoglobin are necessary to avoid anaemia.

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.