Peri-operative care

Peri-operative care

Improving the peri-operative care of fragility fracture sufferers has, and will continue to be a major focus for FFN members and a theme of FFN Congresses.

The 2 key components of peri-operative care are:

Anaesthesiology

Guidance

In 2011, the Association of Anaesthetists of Great Britain and Ireland (AAGBI) published guidelines on management of proximal femoral fractures for anaesthetists. These guidelines advocated the orthopaedic-geriatric co-care model and made specific recommendations regarding anaesthesia, which included:

  • Surgery is the best analgesic for hip fractures.
  • Surgery and anaesthesia must be undertaken by appropriately experienced surgeons and anaesthetists.
  • Continuous audit and targeted research is required in order to inform and improve the management of patients with hip fracture.

The important issue of anaesthesia in patients taking anticoagulant therapy, including clopidogrel, is considered in this guideline.

See:

Management of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 2012 Jan;67(1):85-98. PubMed ID 22150501

Audit

In 2014, the Anaesthetic Sprint Audit of Practice (ASAP) in the UK was undertaken to profile individual hospitals’ compliance with standards for peri-operative care described in the AAGBI guideline above. ASAP is available from the NHFD website – http://www.nhfd.co.uk/.

Also in 2014, a large scale observational audit was published on data from the UK National Hip Fracture Database. Outcomes for more than 59,000 patients who received general anaesthesia or spinal anaesthesia included:

  • No significant difference in either cumulative 5-day (2.8% vs 2.8%, p = 0.991) or 30-day (7.0% vs 7.5%, p = 0.053) mortality between 30,130 patients receiving general anaesthesia and 22,999 patients receiving spinal anaesthesia.
  • This remained so when 30-day mortality was adjusted for age and ASA physical status (p = 0.226).
  • Mortality within 24 hours after surgery was significantly higher among patients receiving cemented compared with uncemented hemiarthroplasty (1.6% vs 1.2%, p = 0.030).

See:

Outcome by mode of anaesthesia for hip fracture surgery. An observational audit of 65 535 patients in a national dataset. Anaesthesia. 2014 Mar;69(3):224-230. PubMed ID 24428375

Orthopaedic-geriatric co-care

During the last decade, multidisciplinary models of care for hip fracture sufferers have emerged in a growing number of countries. Central to this fundamental overhaul of the way in which healthcare systems are managing hip fractures is development of the orthopaedic – geriatric co-care model. The feature which differentiates co-care models, as compared to traditional models of care, is that an orthopaedic surgeon and a geriatrician share responsibility for delivery of best practice in combination with a multidisciplinary team.

The links below provide information on what orthopaedic-geriatric co-care models have achieved and offer resources to support establishment of new programs:

In countries where the speciality of geriatric medicine is well established, implementation of co-care models is gaining momentum. A key question yet to be answered is how to deliver best practice in peri-operative care of hip fractures in emerging economies, where geriatric medicine is not so well established. This question will be a focus of debate at the 3rd FFN Global Congress in Madrid in September 2014.