4. Postoperative care

monitoring. Transoesophageal Doppler, Transthoracic Doppler or LIDCO can be used for

Bispectral index (BIS) monitors may be used to monitor the depth of anaesthesia as it will allow for dose reduction and hence avoid potential hypotension. Initial BIS levels may be

Cerebral oxygen saturation: Postoperative cognitive dysfunction is associated with reduced

AAGBI emphasises the finding in the NCEPOD reports 'Extremes of Age (1999)' and 'An Age Old Problem (2010)' that, in spite of being among the sickest patients with the worst outcomes in hospitals, elderly hip fracture patients were not intensively monitored during surgery, and recommend a greater consideration be given to invasive arterial pressure monitoring and use of cardiac output (e.g. Doppler, LiDCO) and cerebral function (e.g., bispectral index, cerebral

Antibiotic prophylaxis significantly reduces overall wound infections. Antibiotics should be administered within 1 h of skin incision according to AAGBI recommendations. Hospital

Perioperative optimisation of fluid management helps to reduce morbidity. Cardiac outputguided fluid administration in this group of patients could reduce hospital stay and improve

The following strategies will help reduce the risk of deep vein thrombosis-thromboprophylactic stockings or intraop usage of intermittent calf compressors, regional anaesthesia, early surgery

Active warming techniques like body warmers and warm IV fluids should be used as elderly

Patients with hip fractures can have significant blood loss. The rate of blood transfusion in the perioperative period for hip fracture patients is reported between 20 and 60%.These patients have multiple comorbidities making them more susceptible to adverse events from blood loss. Antifibrinolytics, such as tranexamic acid (TXA), have been used to limit bleeding in orthopae-

abnormally low in alcoholic patients and patients with dementia.

cardiac output monitoring.

44 Total Hip Replacement - An Overview

cerebral oxygen saturation.

oxygen saturation) monitors.

antibiotic protocols should be followed.

3.4. Infection control

3.5. Fluid management

3.6. Thromboprophylaxis

and early mobilisation.

3.8. Tranexamic acid

3.7. Prevention of hypothermia

patients are prone to intraoperative hypothermia.

dic surgery and prevent the need for blood transfusion.

outcome [19].

AAGBI recommends use of point-of-care Hb analysers (e.g., Hemocue or similar) routinely at the end of surgery to assess the degree of anaemia and guide blood transfusion. Haemoglobin and electrolytes need to be monitored postoperatively. An analysis of postoperative haemoglobin levels in patients with a fractured neck of femur demonstrated that a haemoglobin value taken on D2 postoperatively represents the largest drop in a patient's circulating haemoglobin with statistical and also clinical significance [28]. Certain groups will require close daily monitoring of haemoglobin levels such as patients with chronic renal, cardiac disease and patients taking any form of anticoagulation.

Good nursing care with regular input from orthogeriatricians, adequate analgesia, hydration and nutrition are all important for good postoperative outcomes.

Early rehabilitation helps return the patient to their pre-morbid level of activity.

#### 4.1. Postoperative cognitive dysfunction

This is common in this group of patients. Management includes adequate analgesia, nutrition and hydration, electrolyte balance, appropriate medication, optimising bowel habit, mobilisation and also identifying and treating any infection or silent myocardial ischaemia. Drugs such as haloperidol or lorazepam should only be used for short-term control of symptoms.

[2] Association of Anaesthetists of Great Britain and Ireland. Management of proximal femo-

Perioperative Management of Hip Fracture Patients Undergoing Total Hip Replacement

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[3] Scottish Intercollegiate Guidelines Network. Management of Hip Fracture in Older People. National Clinical Guideline 111, 2009. http://www.sign.ac.uk/pdf/sign111.pdf

[4] NHS Institute for Innovation and Improvement. Delivering Quality and Value. November. 2005. http://www.dh.gov.uk/prod\_consum\_dh/groups/dh\_digitalassets/@dh/@en/documents/

[5] Scottish Standards of Care for Hip Fracture Patients. 2016. www.shfa.scot.nhs.uk/\_docs/

[6] Rocos B, Whitehouse MR, Kelly MB. Resuscitation in hip fractures: A systematic review.

[7] Wiles MD, Moran CG, Sahota O, Moppett IK. Nottingham hip fracture score as a predictor of one year mortality in patients undergoing surgical repair of fractured neck of femur.

[8] The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Guidelines for the management of atrial fibrillation. European Heart

[9] Association of Anaesthetists of Great Britain and Ireland. DNAR Decisions in the Perioperative Period. May, 2009. http://www.aagbi.org/publications/guidelines/docs/dnar\_09.pdf

[10] Parker MJ, Handoll HHG, Griffiths R. Anaesthesia for hip fracture surgery in adults.

[11] Luger TJ, Kammerlander C, Gosch M, et al. Neuroaxial versus general anaesthesia in geriatric patients for hip fracture surgery: Does it matter? Osteoporosis International.

[12] Luger TJ, Kammerlander C, Luger MF, Kammerlander-Knauer U, Gosch M. Mode of anesthesia, mortality and outcome in geriatric patients. Zeitschrift für Gerontologie und

[13] White SM, Moppett IK, Griffiths R. Outcome by mode of anaesthesia for hip fracture surgery. An observational audit of 65, 535 patients in a national dataset. Anaesthesia.

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[15] Neuman MD, Silber JH, Elkassabany NM, Ludwig JM, Fleisher LA. Comparative effectiveness of regional versus general anesthesia for hip fracture surgery in adults. Anesthe-

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