Hypotension during hip fracture surgery and postoperative morbidity

Abstract

Background Hip fracture is a growing healthcare challenge, with 6-8% 30-day mortality and 20-30% of patients incurring major morbidity, including impaired mobilisation and ability to live independently. While observational studies have shown no benefit of general versus spinal anaesthesia on 30-day mortality, intraoperative hypotension during hip fracture surgery is associated with increased 30-day mortality regardless of anaesthetic technique. Although a recent trial on younger patients demonstrated reduced postoperative complications by maintaining intraoperative arterial blood pressure close to preoperative baseline, there are no data correlating intraoperative hypotension during hip fracture surgery with postoperative morbidity. Objective We evaluated the hypothesis that duration and severity of intraoperative hypotension during hip fracture surgery is associated with increased postoperative morbidity. Methods A retrospective analysis was carried out on n = 52 patients undergoing hip fracture surgery between January and June 2017. Measurements of patients' intraoperative systolic arterial pressure (SAP) and mean arterial pressure (MAP) during anaesthesia, logged electronically through an anaesthesia information management system, were reviewed. We calculated the total duration of time where SAP or MAP were below pre-defined thresholds for hypotension (MAP < 75 mmHg, MAP < 55 mmHg, SAP ≤ 80% admission baseline or SAP ≤ 80% pre-induction baseline). Univariate and bivariate descriptive statistics were generated for all relevant variables. With multivariable regression models containing known predictors, cumulative duration of hypotension was correlated with postoperative comorbidities as quantified by the Clavien-Dindo and Comprehensive Complication Indices. Results Mean age (± SD) was 78 ± 13 years, 75% were female, 87% were ASA II or III and 60% underwent spinal anaesthesia. Mean Comprehensive Complication Index was 20.4 ± 19.2. Lowest absolute SAP and MAP values were 82 ± 18 mmHg and 55 ± 12 mmHg respectively. Cumulative time of SAP < 80% pre-induction value adjusted to gender, age and the Charlson Comorbidity Index was associated with progression to a higher Clavien-Dindo classification (odds ratio 1.020 per additional minute; 95% CI 1.008-1.035; P = 0.003). Conclusions In this exploratory retrospective analysis, the cumulative time of hypotension during hip fracture surgery correlated with extensive postoperative morbidity when adjusting to other known predictors. Intraoperative cumulative time of hypotension may be a good candidate for larger prediction studies as a predictor of postoperative complications. A randomised controlled trial evaluating the effect of actively minimising intraoperative hypotension on postoperative morbidity in hip fracture patients seems warranted.

Successful peripheral nerve block under dexmedetomidine sedation for femoral neck fracture fixation in a 97-year-old patient

“… 5 Internationally, the 30-day mortality rate after hip fracture surgery is 6%–8%; intraoperative hypotension is associated with increased 30-day mortality. 1 Although GA or SA is usually selected for hip fracture ORIF, the incidence of intraoperative absolute hypotension (lowest systolic blood pressure <90 mm Hg) is high in both GA and SA (49.2% and 28.2%, respectively). 5 In recent years, PNB has proven to be effective in various orthopaedic procedures.…”

“…Intraoperative hypotension occurs commonly during hip fracture surgery, especially in elderly patients with a higher number of comorbidities 5. Internationally, the 30-day mortality rate after hip fracture surgery is 6%–8%; intraoperative hypotension is associated with increased 30-day mortality 1. Although GA or SA is usually selected for hip fracture ORIF, the incidence of intraoperative absolute hypotension (lowest systolic blood pressure <90 mm Hg) is high in both GA and SA (49.2% and 28.2%, respectively) 5.…”

“…Hip fracture is a common injury and has been associated with increased major morbidity and mortality. 1 In Japan, people aged over 65 years are classified into three groups as follows: age, 65–74 years as preold, >75 years as old and >90 years as super-old individuals. 2 The number of patients, the old and super-old patients in particular, with hip fractures has drastically increased.…”

Effect of Goal-directed Haemodynamic Therapy Guided by Non-invasive Monitoring on Perioperative Complications in Elderly Hip Fracture Patients Within an Enhanced Recovery Pathway.

“…Preoperative chronic conditions and insu cient preoperative optimization in this patient pro le, associated with intraoperative conditions such as intraoperative bleeding and hypovolemia, predispose these elderly patients to hemodynamic instability or arrhythmias during surgery (Alecu et al 2010); (Rocos et al 2017). The occurrence of intraoperative complications may compromise the balance between tissue oxygen delivery and oxygen consumption, and increase the patient's susceptibility to postoperative complications (Merry and Mitchell 2018); (Beecham et al 2020).…”

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

“…However, both techniques frequently induce hypotension treated by fluid resuscitation and/or vasopressors. Perioperative hypotension is a problem disposing patients to organ hypoperfusion with consequences as; myocardial injury, delirium and renal failure [8]. The physiological origin of the hypotension is unclear, but many anesthesiologists believe that the decrease of systemic vascular resistance is the main cause of hypotension [9], while others believe that hypotension is caused by a fall in cardiac output [10].…”