Can a 71 year old female with a hip fracture and mild to moderate hyponatremia be cleared for the operating room?

Management of Hip Fracture in a 71-Year-Old Female with Hyponatremia (Na 129)

A 71-year-old female with a hip fracture and mild hyponatremia (sodium 129 mmol/L) should proceed to surgery without delay, as the benefits of early surgical intervention outweigh the risks of mild hyponatremia.

Rationale for Proceeding with Surgery

• The American Academy of Orthopaedic Surgeons (AAOS) guidelines strongly recommend that hip fracture patients undergo surgery within 24-48 hours of admission to decrease complications and improve outcomes 1.
• Mild hyponatremia (sodium 129 mmol/L) is not a contraindication for surgery, as:
  • It falls within the mild hyponatremia range (130-135 mmol/L)
  • The incidence of pre-operative hyponatremia in hip fracture patients is relatively common (approximately 17%) 2
  • Delaying surgery for correction of mild hyponatremia may lead to worse outcomes due to prolonged immobilization

Pre-operative Considerations

Assessment and Management of Hyponatremia

• Determine if hyponatremia is acute or chronic:

  • Review previous sodium measurements if available
  • Chronic hyponatremia (>90 days) is associated with increased long-term mortality but not with immediate surgical risk 2
  • Recent onset hyponatremia may be associated with post-operative sepsis 2

• Identify and address potential causes:

  • Medication-induced (especially thiazide diuretics)
  • Infection (urinary tract or respiratory)
  • Volume status (hypovolemia or hypervolemia)
  • Other medical conditions (heart failure, SIADH)

• Monitor sodium levels but do not delay surgery for correction unless:

  • Sodium is <125 mmol/L (severe hyponatremia)
  • Patient is symptomatic (confusion, seizures)
  • Rapid correction is required (which carries its own risks)

Other Pre-operative Optimization

• Ensure adequate hydration with isotonic fluids
• Provide supplemental oxygen to prevent hypoxia 3
• Implement active warming strategies to prevent hypothermia 3
• Consider multimodal analgesia including peripheral nerve blocks 1

Anesthetic Considerations

• Either spinal or general anesthesia is appropriate (strong recommendation) 1
• If using spinal anesthesia:
  • Check INR if patient is on anticoagulants (should be <1.5 for neuraxial anesthesia) 1
  • Consider invasive blood pressure monitoring if cardiac concerns exist

Post-operative Management

• Continue monitoring sodium levels post-operatively
• Allow weight-bearing as tolerated unless otherwise specified 1, 3
• Implement VTE prophylaxis for 4 weeks post-operatively (strong recommendation) 1, 3
• Remove urinary catheters as soon as possible to reduce infection risk 3
• Initiate early rehabilitation 3

Potential Complications to Monitor

• Hyponatremia is associated with:
  • Higher incidence of perioperative complications 4
  • Increased risk of falls and fractures 5, 6
  • Higher 30-day, 1-year, and overall mortality 4

Key Takeaways

• Mild hyponatremia (Na 129) should not delay surgical intervention for hip fracture in a 71-year-old female
• Early surgery (within 24-48 hours) is strongly recommended to improve outcomes
• Monitor sodium levels but prioritize fracture repair
• Address underlying causes of hyponatremia during the perioperative period
• Implement standard hip fracture care protocols including early mobilization and VTE prophylaxis