Is a patient with an ejection fraction (EF) of 30% and fractures of the radius and femur fit for surgery, and what type of anesthesia is recommended?

Management of a Patient with EF 30% for Radius and Femur Fracture Surgery

A patient with an ejection fraction of 30% can undergo surgery for radius and femur fractures with appropriate perioperative management, preferably under regional anesthesia with careful hemodynamic monitoring. 1

Preoperative Assessment and Optimization

• Heart failure with reduced ejection fraction (HFrEF) is a significant risk factor for perioperative complications, particularly in orthopedic surgeries like femur fractures 2
• Preoperative optimization should include:
  • Assessment of current heart failure status and medication optimization 1
  • Evaluation of volume status and correction of hypovolemia 1
  • Correction of electrolyte abnormalities (sodium <120 or >150 mmol/L, potassium <2.8 or >6.0 mmol/L) 1
  • Hemoglobin optimization (target >8 g/dL) 1
  • Control of any arrhythmias with ventricular rate >120/min 1
  • Treatment of any acute left ventricular failure before proceeding 1

Anesthetic Considerations

• Regional anesthesia is preferred over general anesthesia for patients with severe LV dysfunction 1

  • For femur fracture: Spinal or epidural anesthesia provides adequate blockade of femoral, obturator, sciatic, and lower subcostal nerves 1
  • For radius fracture: Peripheral nerve blocks (brachial plexus) can provide adequate anesthesia 1

• If general anesthesia is necessary:

  • Use agents with minimal myocardial depression 1
  • Consider combined regional-general approach to minimize general anesthetic requirements 1
  • Ensure adequate analgesia with peripheral nerve blocks for postoperative pain management 1

Intraoperative Management

• Advanced hemodynamic monitoring is essential for patients with EF <30% 1
• Cardiac output-guided fluid administration reduces hospital stay and improves outcomes 1
• For cemented procedures, be vigilant about bone cement implantation syndrome (BCIS):
  • Increase inspired oxygen concentration during cementation 1
  • Avoid intravascular volume depletion 1
  • Consider additional hemodynamic monitoring 1
  • Be prepared to treat hypoxia/hypotension with oxygen, fluids, and vasopressors/inotropes 1

Postoperative Care

• Consider postoperative monitoring in a high-dependency unit, especially for the first 24 hours 1
• Administer supplemental oxygen for at least 24 hours postoperatively 1
• Early mobilization is critical to reduce mortality risk 3
• Continue heart failure medications as appropriate 1
• Monitor for complications, particularly:
  • Cardiovascular events (higher risk with EF <30%) 2, 4
  • Acute respiratory failure (increased risk with heart failure) 2
  • Acute renal failure (increased risk with heart failure) 2

Surgical Fitness Assessment Algorithm

1. Is the patient in acute decompensated heart failure?

   • If YES: Stabilize heart failure before surgery 1
   • If NO: Proceed to next step

2. Are there reversible cardiac issues?

   • Uncontrolled arrhythmias, electrolyte abnormalities, or acute LV failure require correction 1

3. Is the surgery urgent (e.g., femur fracture)?

   • If YES: Proceed with minimal delay after basic optimization 1
   • If NO (elective): Consider more extensive cardiac optimization 1

4. Risk stratification:

   • EF <30% indicates high risk for perioperative complications 4, 5
   • Additional risk factors include age >80, low BMI, dementia, and comorbidities 3

5. Anesthesia selection:

   • Regional anesthesia preferred when possible 1
   • If general anesthesia needed, combine with regional techniques 1

Important Caveats

• Patients with EF <30% have significantly higher perioperative risk but can still undergo necessary surgery with appropriate management 4, 5
• Delaying surgery for femur fractures beyond 24-48 hours increases mortality risk, so optimization should be expedited 1
• The decision to proceed should not be based solely on EF but should consider overall clinical status and urgency of surgery 1
• Early mobilization post-surgery is crucial, as inability to mobilize is associated with 10-fold increased mortality risk 3