Cardiac overscreening hip fracture patients

Preoperative cardiology consultations for geriatric patients with hip fractures rarely provide additional recommendations and are associated with prolonged hospital stays and delayed surgery: a retrospective case control study

OBJECTIVES

Hip fractures are increasingly common among the elderly population, who often present with a high burden of comorbidities necessitating preoperative stabilization. As a result, preoperative cardiology consultations are frequently conducted in clinical practice. The aim of this study was to investigate the additional recommendations provided by preoperative cardiology consultations and the impact of consultations on the management and outcomes of elderly patients undergoing hip fracture surgery.

PATIENTS AND METHODS

This matched cohort study was performed to retrospectively assess the clinical data of patients who were treated for hip fractures at our institution between January 2016 and December 2017. Individuals who were 60 years old or older with available clinical and radiological data were included. A total of 262 patients who met these criteria were included, with 192 undergoing cardiology consultation and 70 not. Through matching for age, sex, ASA grade, fracture type, and surgery type, two groups (Group A, preoperative cardiology consultation requested; Group B, preoperative cardiology consultation not requested) of 50 patients each were formed. The duration between hospital admission and surgery, recommendations provided by cardiology consultation, type of anaesthesia and surgery, length of hospital stay, incidence of medical and orthopaedic complications, and one-year mortality status were compared between the groups.

RESULTS

The mean age of Group A was 78.5 (± 7.4) years, whereas that of Group B was 78.4 (± 7.4) years (p = 0.99). Both groups included 30 female patients and 20 male patients each. There were no significant differences in anaesthesia type or the incidence of medical or orthopaedic complications between the groups. However, Group A experienced a significantly longer duration between admission and surgery (5 [1/9] days vs. 3 [0/7] days; p = 0.00) and a longer hospital stay (7 [3/15] days vs. 5 [1/19] days; p = 0.01) than did Group B. The one-year mortality rate did not significantly differ between the groups (30% vs. 20%; p = 0.36). Notably, only 3 out of 50 patients received additional treatments following cardiology consultation beyond routine recommendations.

CONCLUSION

Preoperative cardiology consultations before hip fracture surgery rarely leads to a change in treatment. Additionally, these evaluations delay surgery and extend the hospital stay.

Preoperative transthoracic echocardiography does not lead to decreased postoperative mortality but with increased time to surgery and length of stay in Chinese geriatric hip fracture patients

PURPOSE

The present study aimed to investigate the influence of preoperative TTE on postoperative short-term mortality, surgery delay, as well as other economic and clinical outcomes in Chinese geriatric hip fracture patients.

METHODS

This retrospective, matched-cohort study enrolled geriatric hip fracture patients (≥ 60 years) who underwent surgical interventions at our center between 2015 and 2020. The primary exposure was inpatient preoperative TTE. Demographic and clinical data that were reported as risk factors for postoperative mortality were retrieved from the medical data center as the covariates. The primary clinical outcomes were all-cause mortality at 30 days, 90 days, 180 days, and 1 year. Time from hospital presentation to surgery, length of stay (LOS), inpatient cost, frequency of cardiology consultation and coronary angiography (CAG) were also assessed. The propensity score matching (PSM) was performed in a ratio of 1:1.

RESULTS

447 patients were identified and 216 of them received a preoperative TTE (48.3%). After successfully matching 390 patients (87.2%), patients receiving TTE showed significantly higher 30-day mortality (6.6% vs 2.0%, P = 0.044). But no significant difference was found in 90-day, 180-day, and 365-day mortality as well as the 1-year accumulated survival rate. Receipt of TTE was also associated with significant increases in LOS (13.6 days vs 11.4 days, P = 0.017), waiting time for surgery (5.9 days vs 4.3 days, P < 0.001), and lower proportion of receiving surgery within 48 h (7.2% vs. 26.2%, P < 0.001). According to the multivariable logistic analysis, only ejection fraction (30 days, 90 days), aorta diameter (30 days, 90 days, 180 days, 365 days), left ventricular posterior wall diameter (90 days, 180 days, 365 days), aortic valve velocity (90 days) and mitral valve A-peak (90 days, 180 days) were association with postoperative mortality among the 17 parameters in the TTE reports. Besides, TTE has no influence on the frequency of preoperative cardiology consultation.

CONCLUSION

Preoperative TTE does not lead to decreased postoperative mortality but with increased time to surgery and length of stay in Chinese geriatric hip fracture patients. The predictive ability of TTE parameters is limited for postoperative mortality.

Anesthesia Management of Hip Fracture Surgery in Geriatric Patients: A Review

Hip fractures are increasingly prominent concerns in healthcare, especially in light of a growing elderly population. These fractures contribute to mortality and morbidity in the elderly. Many hip fractures require emergent surgical intervention and may have consequences of serious postoperative complications. Multidisciplinary approaches of management have been utilized to optimize care and improve patient outcomes. Due to the myriad of multi-organ system comorbidities that are increasingly prevalent in the geriatric population, anesthetic management proves to be difficult to standardize. Enhanced Recovery After Surgery (ERAS) protocols have shown benefits for optimizing patient outcomes by focusing on premedication, nutritional support, and pain management; however, specific anesthetic management techniques are not discussed. This literature review aims to discuss ways to optimize hip fracture management in geriatric patients through effective preoperative evaluation, anesthetic considerations, and postoperative optimization and care. A review of currently available guidelines may help determine the optimal management for hip fractures in geriatric patients and improve immediate and lasting postoperative outcomes.

Preoperative Workup of Operative Hip Fracture Patients: A Survey

Background: There may be disagreement among stakeholders on the need for preoperative cardiac screening for elderly hip fracture patients. Purpose: We sought to assess preoperative workup perceptions among physicians for hip fracture patients across specialties, specifically considering a patient's cardiovascular risk. Methods: A case-based survey was distributed to 50 physicians in each of the 4 departments involved in preoperative patient care: orthopedic surgery (OS), anesthesiology (A), cardiology (C), and hospital medicine (HM). The survey asked about which clinical presentations required a cardiology consult, as well as about further preoperative imaging and laboratory work. Single score intraclass correlation coefficient (ICC) was used to compare agreement. Results: Of the 200 surveys sent out, 33 responses (16.5% response rate) were received. Between all specialties, there was 72% agreement about preoperative cardiology consult need (intraclass correlation coefficient [ICC] = 0.063 or poor) and 71% agreement about preoperative transthoracic echocardiogram (TTE) need (ICC = 0.188 or poor). Within each specialty (A, C, HM, OS) ICCs measuring agreement for the need for cardiology consult were 0.812 (good), 0.561 (moderate), 0.457 (poor), and 0.414 (poor), respectively, and for the need for preoperative TTE were 0.852 (good), 0.441 (poor), 0.848 (good), and 0.188 (poor), respectively. Common preoperative testing requested included complete blood count, basic metabolic panel in all cases, and electrocardiogram with troponins if perioperative acute coronary syndrome symptoms were present. Conclusion: This survey suggests that there may be varying levels of agreement within specialties and poor agreement between specialties on the need for cardiology consultation and preoperative imaging for hip fracture patients. This suggests the need for established, reliable preoperative workup protocols with input from different specialties to streamline preoperative care for patients before hip fracture surgery.

Delay to Surgical Treatment in Geriatric Hip Fracture Patients

Background

Hip fractures in the geriatric population are frequently encountered. There is increasing focus on minimizing the delay to surgery in these patients. This study was designed to evaluate factors responsible for a delay to surgery in a geriatric hip fracture population and how time to surgery affects mortality.

Methods

A retrospective cohort of patients sustaining low energy geriatric hip fractures in either an American College of Surgeons (ACS) verified Level 1 trauma center or a local university affiliated community teaching hospital were reviewed. The following variables were evaluated as independent risk factors for delay to surgery: demographic data, surgical details, use of cardiology resources, treatment center, and comorbidities. As a secondary objective, the effect of time to surgery on 1 year mortality was analyzed.

Results

1157 patients met inclusion criteria. The following factors increased the risk of delay to surgery greater than 48 hours: male sex, treatment in a community hospital (versus trauma center), older age, multiple comorbidities (eg, cardiovascular-related conditions or other fractures), cardiology consultation, and an American Society of Anesthesiologists physical status score of 3 or 4. Cardiology consultation was the strongest independent predictor of risk for delay to surgery of >48 hours (odds ratio, 6.68; 95% confidence interval, 4.40 to 10.14; P < .001). The 1-year mortality of patients did not differ when surgical treatment occurred before 48 hours or after 48 hours (Log-rank test P = .109).

Conclusion

The presence of cardiovascular comorbidities and cardiology consultations can delay surgical treatments for hip fractures in patients greater than 65 years old, but the delay did not influence 1-year all-cause mortality.

Level of Evidence

Level IV.

The effects of a multidisciplinary pathway for perioperative management of patients with hip fracture

OBJECTIVES

To determine if a multidisciplinary pathway focused on non-opioid pain management, delirium assessment, and resource utilization improved outcomes in geriatric hip fracture patients. The goal was to reduce opioid usage, consultation not congruent with guidelines, and increase use of regional anesthesia to reduce delirium and improve outcomes.

METHODS

An observational study was performed on hip fracture patients before and after the intervention. Hospitalists were educated on indications for preoperative cardiac consultation and specialized preoperative cardiac testing according to evidence-based guidelines with the inpatient cardiology service. Additional education on multimodal analgesia, limiting opioids, and peripheral nerve blocks was provided by the acute pain service. Pre-intervention outcomes from 1 July 20171 July 2017 to 31 May 201831 May 2018 (N = 92) were compared to post-intervention outcomes from 1 July 20181 July 2018 to 31 May 201931 May 2019 (N = 98) and included delirium, length of stay, 30-day readmission rate, time from arrival to procedure start time, time to first physical therapy session, and completion of cardiology consult time. We examined adherence, use of nerve blocks, and pre- and post-operative pain scores and opioid use.

RESULTS

Delirium was reduced from 50.0% (N = 46/92) to 28.6% (N = 28/98); p = 0.002. Postoperative opioid use (IV morphine milligram equivalents) decreased from an average of 57.2 mg (±67.7) to 42.6 mg (±58.2),P < .0001. There was a significant decrease in mean pre-operative (5.4 ± 4.14 to 5.05 ± 2.8, P < .0001) and post-operative pain scores (4.3 ± 5.2 to 3.2 ± 2.2, P < .0001). There was a significant reduction in time to cardiology consultation from 18 h] to 12 h ; p < .001).

CONCLUSIONS

A multidisciplinary collaboration between hospitalists, anesthesiologists, and cardiologists for hip fracture patients was associated with a reduction in pain and delirium and time to cardiologist evaluation. Prospective studies focusing on additional patient-centered outcomes are warranted.

Analysis of Cardiac Events and the Subsequent Impact for Geriatric Patients Undergoing Hip Fracture Surgeries

Perioperative complications, particularly cardiac events, compromised surgical outcomes for geriatric patients. This retrospective study intended to investigate the occurrence and subsequent impact of cardiac events for geriatric patients undergoing hip fracture surgeries. We collected 607 patients undergoing hip fracture surgeries from January 2017 to December 2022 that received transthoracic echocardiography (TTE) pre-operatively to screen for cardiac abnormalities. Except for demographic characteristics, the researchers recorded fracture type, surgical method, American Society of Anesthesiologists (ASA) class, anesthesia type, perioperative cardiac events, and in-hospital mortality. Statistical analysis was performed using SPSS 22.0 statistics software. Throughout the whole course of the study, 16 postoperative cardiac events occurred. The cardiac events included ten arrhythmias, three acute myocardial infarctions, two heart failures, and one sudden death. Notably, 12 of 16 patients with cardiac events presented with abnormal findings on TTE, except 15 of them had a history of cardiac disease. This study disclosed 93.7% of cardiac events developed in patients with a history of cardiovascular disease. Among patients that experienced cardiac events, 75% of patients had abnormal echocardiographic findings. Pre-operative transthoracic echocardiography deserves a recommendation for geriatric patients with histories of cardiac diseases undergoing hip fracture surgeries to detect the risk of developing cardiac events earlier.

Fractional spinal anesthesia and systemic hemodynamics in frail elderly hip fracture patients

Background: Systemic haemodynamic effects of intrathecal anaesthesia in an aging and frail population has not been well investigated. We examined the systemic haemodynamics of fractional spinal anaesthesia following intermittent microdosing of a local anaesthetic and an opioid. Methods: We included 15 patients aged over 65 with significant comorbidities, planned for hip fracture repair. Patients received a spinal catheter and cardiac output monitoring using the LiDCOplus system. All measurements were performed prior to start of surgery. Invasive mean arterial pressure (MAP), cardiac index (CI), systemic vascular resistance index (SVRI), heart rate and stroke volume index (SVI) were registered. Two doses of bupivacaine 2.25 mg and fentanyl 15 µg were administered with 25-minute intervals. Hypotension was defined as a fall in MAP by >30% or a MAP <65 mmHg. Results: The incidence of hypotension was 30%. Hypotensive patients (n=5) were treated with low doses of norepinephrine (0.01-0.12 µg/kg/min). MAP showed a maximum reduction of 17% at 10 minutes following the first dose. CI, systemic vascular resistance index and stroke volume index decreased by 10%, 6%, and 7%, respectively, while heart rate was unchanged over time. After the second dose, none of the systemic haemodynamic variables were affected. Conclusions: Fractional spinal anaesthesia administered prior to surgery induced a minor to moderate fall in MAP, mainly caused by a reduction in cardiac output, induced by systemic venodilation, causing a fall in venous return. Our results are contrary to the widely held belief that hypotension is mainly the result of a reduction of systemic vascular resistance.

Process mapping of hip fracture orthogeriatric care: Experience from a tertiary hospital in Malaysia

Background: Early surgical repair and mobilization postoperatively is associated with improved outcomes for older people with hip fractures. A process mapping exercise was performed to identify the delivery of this aspect of care in a tertiary center. Methods: Analysis was done on electronic health record data of those ≥65 years who had surgery over a 3-month period. Barriers to surgery within 48 h of admission, and mobilized within the day after surgery were identified. Results: Fourty-two patients had surgery where the majority were female, had an average age of 78 years, frail, and multimorbid. 10/42 (23.8%) and 9/42 (21.4%) patients were operated on and mobilized early. Eighteen (42.9%) patients had pre-operative cardiology assessment and 19 patients (45.2%) had pre-operative echocardiogram. None led to a change in the surgical management plan. Other reasons for the delay to early surgery included the need for further medical optimization, financial constraints, blood transfusion, and being on antiplatelet/anticoagulant. Barriers to early mobilization postoperatively were lack of weekend service, delayed referral to therapists, pain, hypotension, anemia, and delirium. Conclusions: Streamlining referrals, agreed clinical pathways, consolidating multidisciplinary involvement, and continuous audit would address the barriers identified in delivering early surgical repair and mobilization post-operatively.

Comparison of Prognostic Value of 10 Biochemical Indices at Admission for Prediction Postoperative Myocardial Injury and Hospital Mortality in Patients with Osteoporotic Hip Fracture

Aim: To evaluate the prognostic impact at admission of 10 biochemical indices for prediction postoperative myocardial injury (PMI) and/or hospital death in hip fracture (HF) patients. Methods: In 1273 consecutive patients with HF (mean age 82.9 ± 8.7 years, 73.5% women), clinical and laboratory parameters were collected prospectively, and outcomes were recorded. Multiple logistic regression and receiver-operating characteristic analyses (the area under the curve, AUC) were preformed, the number needed to predict (NNP) outcome was calculated. Results: Age ≥ 80 years and IHD were the most prominent clinical factors associated with both PMI (with cardiac troponin I rise) and in-hospital death. PMI occurred in 555 (43.6%) patients and contributed to 80.3% (49/61) of all deaths (mortality rate 8.8% vs. 1.9% in non-PMI patients). The most accurate biochemical predictive markers were parathyroid hormone > 6.8 pmol/L, urea > 7.5 mmol/L, 25(OH)vitamin D < 25 nmol/L, albumin < 33 g/L, and ratios gamma-glutamyl transferase (GGT) to alanine aminotransferase > 2.5, urea/albumin ≥ 2.0 and GGT/albumin ≥ 7.0; the AUC for developing PMI ranged between 0.782 and 0.742 (NNP: 1.84−2.13), the AUC for fatal outcome ranged from 0.803 to 0.722, (NNP: 3.77−9.52). Conclusions: In HF patients, easily accessible biochemical indices at admission substantially improve prediction of hospital outcomes, especially in the aged >80 years with IHD.

Evaluation of a Novel Multidisciplinary Preoperative Workup Strategy for Geriatric Hip Fractures

OBJECTIVE

To determine the financial and clinical impact of a standardized, multidisciplinary team for surgical clearance and optimization in geriatric hip fracture patients.

DESIGN

Retrospective case series.

SETTING

Level-1 trauma center.

PATIENTS

One hundred twenty-four geriatric patients (age >65 years old) in the preprotocol group (cohort 1; January 2017-December 2018) and 98 geriatric patients in the postprotocol group (cohort 2; October 2019-January 2021) with operative hip fractures.

INTERVENTION

Implementation of a multidisciplinary team protocol consisting of Anesthesiology, Internal Medicine and Orthopedic Surgery departments for the assessment of medical readiness and optimization for surgical intervention in geriatric hip fractures.

MAIN OUTCOME MEASURES

Rate of cardiology consultation, need for cardiac workup (echocardiography stress testing, heath catheterization), time to medical readiness (TTMR), time to surgery, case-cancellation rate, length of stay (LOS), and total hospitalization charges.

RESULTS

Following implementation of the new protocol, there were significant ( P < 0.001) decreases in TTMR (19 vs. 11 hours), LOS (149 vs. 120 hours), case cancellation rate, and total hospital charges ($84,000 vs. $62,000). There were no significant differences with respect to in-hospital complications or readmission rates/mortality rates at 1 year.

CONCLUSIONS

Following implementation of a protocolized, multidisciplinary approach to optimizing geriatric fracture patients, we were able to demonstrate a reduction in unnecessary preoperative testing, TTMR for surgery, case cancellation rate, LOS, and total hospitalization charge-without a concomitant increase in complications or mortality. This study highlights that standardization of the perioperative care for geriatric hip fracture patients can provide effective patient care while also lowering financial and logistical burden in care for these injuries.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.