14.1 NOF

Question 1

A 90-year-old woman sustains a fractured neck of femur following a fall. She is scheduled for surgery.
a) What aspects of this patient’s care will have the greatest impact on outcome? (45%)

Answer 1

1. Multidisciplinary care within a Hip Fracture Programme, to include the following:

• Rapid optimisation of correctable conditions for surgery, e.g. anaemia, anticoagulation, volume depletion, electrolyte imbalance, uncontrolled
diabetes, uncontrolled heart failure, correctable cardiac arrhythmia/ ischaemia, acute chest infection, exacerbation of chronic chest
conditions.

• Orthogeriatrician input.

• Individualised rehabilitation goals.

• Liaison with related services (mental health, falls prevention, primary care, social services).

2. Surgery on planned trauma list on day of or day after admission. Team to include senior anaesthetist and surgeon.
3. Surgical approach:
   • Total hip replacement (rather than hemiarthroplasty) for displaced intracapsular fracture if the patient is previously fit, active and cognitively intact.

• Extramedullary implant for trochanteric fracture above and including the lesser trochanter (cheaper and less likely to be involved in periprosthetic fracture than intramedullary implant).
• Intramedullary nail for subtrochanteric fracture.

4. Rehabilitation:
   daily, to start no later than the
   day after surgery and to
   continue after hospital discharge.

Question 2

b) Outline the recommendations
made by the National Institute for
Health and Clinical Excellence
(2011) for the management of
acute pain in this patient. (30%)

Answer 2

Even if you haven’t read the guidance, you will still have had experience of managing such patients and will understand the need for an escalating, step-wise approach to pain relief.
Don’t forget to talk about the need for pain assessment.

> > Assess pain:
• Immediately on admission.

• 30 minutes after analgesia given.

• Hourly until settled on ward.

• As part of routine observations thereafter.

> > Analgesia to be given immediately on admission with suspected hip fracture, even if cognitively impaired.

> > Pain control should be adequate to allow investigations.

> > Step-wise, multimodal analgesia:

• Paracetamol six hourly unless contraindicated.
• Opioid as necessary.
• Nerve block (e.g. fascia iliaca block) by trained personnel.
• NSAIDs not recommended.

Question 3

c) What causes of a fall in this patient might impact on the anaesthetic management? (25%)

Answer 3

> > Respiratory: exacerbation of chronic obstructive pulmonary disease, pneumonia. Regional anaesthesia may be preferable to avoid interference with lung mechanics.

> > Cardiovascular: brady- or tachyarrhythmias, myocardial infarction, valvular heart disease (e.g. aortic stenosis), structural abnormalities (e.g. hypertrophic obstructive cardiomyopathy).
Higher levels of monitoring such as invasive blood pressure and cardiac output monitoring may be employed in the presence of significant comorbidities.

Neuraxial techniques relatively contraindicated by left ventricular outflow-limiting disease.

> > Neurological: stroke, peripheral neuropathy, dementia, Parkinson’s. Confusion or other difficulty with positioning may cause problems complying with neuraxial approach. Pre-existing neuropathy should be
documented prior to any form of anaesthesia.

> > Endocrine: diabetes mellitus causing hypoglycaemia or diabetic ketoacidosis
Awake surgery would permit ongoing neurological monitoring (once fit for surgery).

> > Pharmacology: polypharmacy in the elderly causes a multitude of side effects such as hypotension, bradycardia, electrolyte disturbance. More invasive monitoring and adjusted doses of drugs may be required.

> > Infection, immune: sepsis causing confusion, hypoxia. Sepsis may contraindicate neuraxial technique.

> > Cutaneoumusculoskeletal: arthritic conditions causing pain and deformity.
May cause difficulty with positioning for regional or neuraxial techniques