What is the management for a patient with a neck of femur fracture and hypotension?

Management of Neck of Femur Fracture with Hypotension

A hypotensive patient with a neck of femur fracture requires immediate resuscitation with intravenous fluids to restore intravascular volume before proceeding to urgent surgical fixation within 24-48 hours, as many of these patients are hypovolemic preoperatively and optimized fluid management reduces morbidity and hospital stay. 1

Immediate Resuscitation Phase

Fluid Resuscitation

• Pre-operative fluid therapy should be prescribed routinely as many hip fracture patients become hypovolemic before surgery 1
• Optimized peri-operative fluid management reduces morbidity and hospital stay 1
• Cardiac output-guided fluid administration appears to reduce hospital stay and improve outcome 1
• Consider invasive blood pressure monitoring for beat-to-beat assessment, particularly in patients with limited left ventricular function or valvular heart disease 1
• Central venous pressure (CVP) monitoring should be considered for patients with limited left ventricular function 1

Initial Assessment and Monitoring

• Establish minimum monitoring standards including pulse oximetry, ECG, and non-invasive blood pressure 1
• Check hemoglobin levels using point-of-care analyzers to assess degree of anemia 1
• Identify the cause of hypotension: hypovolemia from inadequate fluid intake, occult bleeding, or underlying cardiac dysfunction 1
• Assess for concomitant injuries that may contribute to hemodynamic instability, particularly in high-energy trauma 2

Surgical Timing

Surgery should proceed within 24-48 hours after admission once the patient is hemodynamically optimized 1. The AAOS guidelines recommend time to OR between 24 and 48 hours after admission (limited strength of evidence, moderate strength recommendation) 1. While some evidence suggests emergent surgery may reduce vascular complications, the priority is achieving hemodynamic stability first 3.

Anesthetic Considerations for Hypotensive Patients

Choice of Anesthesia

• Either spinal or general anesthesia is appropriate (strong strength of evidence, strong strength recommendation) 1
• For hypotensive patients, use lower doses of intrathecal bupivacaine (<10 mg) to reduce associated hypotension 1
• The combination of spinal and general anesthesia simultaneously is NOT recommended as it is associated with precipitous falls in intra-operative blood pressure 1

Spinal Anesthesia Modifications

• Lower doses of intrathecal bupivacaine (<10 mg) appear to reduce associated hypotension 1
• Attempted lateralization of subarachnoid anesthesia using hyperbaric bupivacaine with the fractured hip inferior may ameliorate hypotension 1
• Supplemental oxygen should always be provided during spinal anesthesia 1
• Ketamine may be used theoretically to counteract hypotension, but may be associated with postoperative confusion 1

General Anesthesia Modifications

• Reduced doses of intravenous induction agents should be administered 1
• Inhalational induction is well tolerated by the elderly and allows for maintenance of spontaneous ventilation 1
• Higher inspired oxygen concentrations may be required as intra-operative hypoxemia is common 1

Enhanced Monitoring for Hypotensive Patients

Given the hemodynamic instability, there should be a low threshold for considering enhanced monitoring 1:

• Invasive arterial blood pressure monitoring for continuous beat-to-beat assessment, particularly for patients with limited left ventricular function or valvular heart disease 1
• Central venous pressure monitoring for patients with limited left ventricular function 1
• Cardiac output monitoring using transoesophageal Doppler or dilution techniques, as Doppler-guided fluid therapy may reduce hospital stay 1
• Core temperature monitoring should be used routinely 1

Intraoperative Management

Fluid Management

• Cardiac output-guided fluid administration should be employed to optimize hemodynamics and reduce hospital stay 1
• Avoid intravascular volume depletion, especially during cementation if using cemented implants 1
• Increase inspired oxygen concentration to 100% at the time of cementation 1

Tranexamic Acid

• Tranexamic acid should be given to reduce blood loss and need for transfusion (strong level of evidence, strong strength recommendation) 1

Temperature Management

• Active warming strategies should always be employed as older patients are susceptible to intra-operative hypothermia 1

Common Pitfalls to Avoid

• Do not proceed to surgery without adequate resuscitation - hypotension must be corrected to minimize risk of cerebral hypoperfusion and stroke, particularly in elderly patients with cardiovascular disease 4
• Avoid simultaneous spinal and general anesthesia as this combination causes precipitous blood pressure drops 1
• Do not use standard doses of spinal anesthetic in hypotensive patients - reduce bupivacaine to <10 mg 1
• Avoid excessive sedation which can worsen hypotension and cause postoperative confusion 1

Postoperative Care

• Supplemental oxygen should be administered postoperatively for at least 24 hours 1
• Continue active warming strategies postoperatively 1
• Ward care should provide a nurse:patient ratio of 1:4 with regular input from physicians specialized in medicine for the elderly 1