Transcript Managing post-op complications

Taipei Veterans General Hospital
Geriatric Fellows update
August 29-31st 2010
Medical management of fragility
fractures in older people
Orthogeriatrics
Dr Finbarr C Martin
Consultant Geriatrician
Department of Ageing & Health
Guy’s and St Thomas’ NHS Foundation Trust
Ageing and Health, Guy’s and St Thomas’
Hip Fractures
•
•
•
•
•
•
•
•
•
Commonest acute orthopaedic ward admission
UK > 80,000 hip fractures each year
UK costs £1.7 billion per year
Average age in 2009 -82,
Women over 85: 4% incidence
One month mortality – variable ~10%
Excess One year mortality ~ 20%
Functional recovery rate: less than 70%
Up to 35% of community living patients are admitted to a
nursing home within one year after fracture
Parker M, Johansen A. BMJ 333:27-30,2006
Vidan M, Serra JA. JAGS 53:1476-1482,2005
Ageing and Health, Guy’s and St Thomas’ Naglie G, Tansey C. Can Med Assoc J. 167:25-32,2002
Patient Characteristics
•
•
•
•
•
Frail elderly
Average 82-84 years of age (women > men)
Co-morbidity
Cognitive impairment
Polypharmacy
Ageing and Health, Guy’s and St Thomas’
Pathophysiology hip fracture
• Blood loss : up to 20% blood volume
• Dehydratation: hypovolaemia undererestimated
and undertreated
• Postoperative course: stress response +
postop.pain → ↑cardiorespiratory work → ↑HR
↓PO2
• O2 Supply-demand compromise: blood loss
Ageing and Health, Guy’s and St Thomas’
Outcomes influenced strongly by co-morbidity
Age
1,77 (1.21-2.58)
1.15 (0.56-2,32)
Male sex
Number of diseases
1.18(0.95-1.47)
Cardiac risk
1.81 (1.18-2.72)
Dementia
3.51 (1.58-7.82)
ADL index
0.93 (0.77-1.12)
Independent predictors
of mortality or major
complications
0
Ageing and Health, Guy’s and St Thomas’
1
2
3
4
Variations in care seem to matter
Data from the national analyses from official data sources
by Dr Foster
and the NHS Institute for Innovation and Improvement
Ageing and Health, Guy’s and St Thomas’
Variation in acute hospital LOS
- all 150 England hospitals doing Hip #
Average length of spell
40.00
35.00
Average length of spell
30.00
25.00
20.00
15.00
Median = 23.5
10.00
5.00
0.00
Trusts (n=150)
Ageing and Health, Guy’s and St Thomas’
Variation in performance of 150
hospitals taking hip #s
In hospital
mortality
(unadjusted)
% patients
operated
on days 0-2
% patients
emergency
readmission
within 28 days
% patients
discharged
home within
28 days
Maximum
15.3%
91.3
15.7%
83%
Minimum
4.6%
23.0
2.1%
23%
Highest 25%
performers
7.7%
76.1
7.3%
56%
Lowest 25%
performers
10.5%
60.0
10.4%
42%
Median
9.3%
67.7
8.8%
48%
Ageing and Health, Guy’s and St Thomas’
Mortality associated with delay in
operation after hip fracture
Fig 1 Odds ratios of death within hospital by operative delay relative to at most one day's delay,
after adjustment for age, sex, deprivation, type of procedure (fixation and replacement only), and
selected comorbidities
Bottle, A. et al. BMJ 2006;332:947-951
Copyright ©2006 BMJ Publishing Group Ltd.
Ageing and Health, Guy’s and St Thomas’
Differences in numbers who died
Fig 2 Mean annual difference between observed and expected deaths in hospital per 1000
admissions by trust associated with an operative delay of more than one day
Bottle, A. et al. BMJ 2006;332:947-951
Copyright ©2006 BMJ Publishing Group Ltd.
Ageing and Health, Guy’s and St Thomas’
Why does surgery need to be early?
•
Delays of more than 48 hours will
increase morbidity
-Pressure sores
-Thromboembolic
-Pneumonia
-UTI
• For every 8 hours of delay results in an
increased of hospital stay of 1 day
Ageing and Health, Guy’s and St Thomas’
Siegmeth AW et al J Bone Joint Surg 2005
Pathway for patients
50
45
40
35
30
25
20
15
10
5
0
Previous #
after
Previous fall
unpredicatble
40
35
Dead at 1
month
30
Care homes
25
20
before
15
10
5
0
Ageing and Health, Guy’s and St Thomas’
Dead at 1 year
Regain pre#
ADL
Re-fracture
Objectives for hip fracture care
• Minimise # incidence
– Secondary prevention
• After first fragilty fracture (50%)
• Treat osteoporosis in likely fallers
• Optimise treatment of patient with #
– Best outcomes
• Reduce mortality
• Restore function
– Most efficient
• Reduce LOS
• Avoid complications
• Prevent recurrence
Ageing and Health, Guy’s and St Thomas’
Pathway of care after fracture
•
•
•
•
•
•
•
•
•
•
Arrival with injury
Diagnosis of #
Pre-op care
Assessment for surgery
Plan the surgery
Perform good surgery
Post op recovery
Mobilisation
Rehabilitation in the ward
Discharge and resettlement
at home
• Secondary prevention
Ageing and Health, Guy’s and St Thomas’
• Rapid XRay & treat pain
• Prompt admission to suitable ward
• Rapid comprehensive assessment
– medical, surgical, anaesthetic
• Surgery within 36hr
• Senior staff, best procedure
• Identify medical complications
• Mobilisation by 24hr
• Multidisciplinary rehabilitation
• Early supported discharge and
ongoing community rehabilitation
• Bone protection and falls
Blue Book Standards 2007
1.
2.
3.
4.
5.
6.
All patients with hip fracture should be admitted to an acute orthopaedic
ward within 4 hours of presentation
All patients with hip fracture who are medically fit should have surgery
within 48 hours of admission, and during normal working hours
All patients with hip fracture should be assessed and cared for with a
view to minimising their risk of developing a pressure ulcer
All patients presenting with a fragility fracture should be managed on an
orthopaedic ward with routine access to orthogeriatric medical support
from the time of admission
All patients presenting with fragility fracture should be assessed to
determine their need for antiresorptive therapy to prevent future
osteoporotic fractures
All patients presenting with a fragility fracture following a fall should be
offered multidisciplinary assessment and intervention to prevent future
falls
Ageing and Health, Guy’s and St Thomas’
Key aspects of acute care
Ageing and Health, Guy’s and St Thomas’
FLUID THERAPY
• Fluid resuscitation matters BUT choice of fluid does not
influence outcome following hip fracture
Parker MJ,:Preoperative saline versus gelatin f
or hip fracture patients, a randomized trial of 396 patients.
Br J Anaesthesia 2004 Jan 92(1), 67-70
Ageing and Health, Guy’s and St Thomas’
FLUID THERAPY
• Cochrane rewiew 2003:
Intraoperative invasive techniques for fluid
resuscitation may reduce hospital stay
Ageing and Health, Guy’s and St Thomas’
Fluid Therapy:Oesophageal Doppler Monitor
Pooled analysis showed
• Reduced hospital stay , fewer complications and ICU
admissions, and less requirement for inotropes in the
intervention
• Return of normal gastro-intestinal function was also
significantly faster in the intervention
Abbas SM & Hill AG. Systematic review of the literature for the use of oesophageal
Doppler monitor for fluid replacement in major abdominal surgery. Anaesthesia, 2008:
63:44–51
Ageing and Health, Guy’s and St Thomas’
Fluid Therapy: Oesophageal Doppler Monitor
in the ODM group
•
•
•
•
•
Fewer deaths OR 0.13, 95% CI 0.02–0.96
Fewer major complications OR 0.12, 95% CI 0.04–0.31
Fewer total complications OR 0.43, 95% CI 0.26–0.71)
Shorter length of stay 95% CI –2.21 to –0.57
Return of normal gastro-intestinal function was also significantly
faster in the intervention
Systematic review of the clinical effectiveness and costeffectiveness of oesophageal Doppler monitoring in critically ill
and high-risk surgical patients
Health Technol Assess 2008;13(7):1–118
Ageing and Health, Guy’s and St Thomas’
Problems with pre Operative Analgesia
 Orders of “nil by mouth”
 Morphine Based Analgesia
-Nausea
-Constipation
-Delayed gastric emptying
Ageing and Health, Guy’s and St Thomas’
Problems with medications
• Medication review –careful about abrupt
stopping of certain treatments eg SSRI, Benzo
· Warfarin
· Clopidogrel
Ageing and Health, Guy’s and St Thomas’
Pre op assessment : Warfarin
• 1:28 patients (914)
• 21 (64%) delay to surgery (72hr 48-120)
• Watch & wait policy used in 11 pts (33%)
Al Rashid, Parker. Injury 2005; 36: 1311-15
 Vit K (oral / iv)
 FFP
 Recombinant activated factor VII
Prosthetic valves-early haematology involvement
Ageing and Health, Guy’s and St Thomas’
Clopidogrel
• 2.3% (17/740)
• Hip surgery delayed 1-10 days
(mean 5.4 days)
mean
No delay (7)
Delay (10)
2.7 days
7.3 days
Falls in Hb
3.7
2.4
Max fall in Hb
4.4
4.5
3
2
Time to surgery
Max blood
transfusion
Ageing and Health, Guy’s and St Thomas’
Johansen, White, Turk. Injury 2008; 39: 1188-90
But dangers of delay
• - DVT & PE
Management
• Risks of early versus late need to be balanced
• Stop clopidogrel-reassess vascular risk
Ageing and Health, Guy’s and St Thomas’
Assessment of Vascular Risk
If risks of bleeding outweigh those of arterial events
and immobilisation - surgery day 5
If risks of vascular events or immobilisation more
significant- surgery at 48 hours
(some anti-platelet protection will persist, but active
metabolites cleared)
[platelet transfusion effective in the event of serious
peri-operative bleeding]
Ageing and Health, Guy’s and St Thomas’
Acceptable Reasons for Delaying Surgery
• Anaemia: Hb < 9 g / l.
• Dehydratation or acute uraemia
• Severe electrolyte imbalance:
Na < 120 or > 150 mmol./l.
K < 2.8 or > 6.0 mmol./l.
• Uncontrolled diabetes
• Uncontrolled heart failure
• Correctable cardiac arrhythmia
• NOT aortic murmur ??aortic stenosis
• Exacerbation of chronic chest or acute chest infection
Ageing and Health, Guy’s and St Thomas’
Managing post-op complications
•
·
·
·
·
·
Good wound care
Optimising analgesia
Urinary / bowel care
Preventing delirium
Nutrition
Early mobilisation
Ageing and Health, Guy’s and St Thomas’
Managing post-op complications
• Good wound care
· Optimising analgesia
Paracetamol 1g qds
Tramadol 50-100mg qds
Celocoxib 200mg bd
· Urinary / bowel care
· Preventing delirium
· Nutrition
· Early mobilisation
Ageing and Health, Guy’s and St Thomas’
Managing post-op complications
• Good wound care
· Optimising analgesia
· Urinary / bowel care
Remove catheter within 24 hours
Laxatives
-
· Preventing delirium
· Nutrition
· Early mobilisation
Ageing and Health, Guy’s and St Thomas’
Managing post-op complications
 Good wound care
 Optimising analgesia
· Urinary / bowel care
• Preventing delirium
Re-orientation
Medication
Sleep enhancement
Vision/hearing protocol
Bowel/bladder care
Euvolaemia
 Nutrition
 Early mobilisation
Ageing and Health, Guy’s and St Thomas’
Managing post-op complications






Good wound care
Opitimising analgesia
Urinary / bowel care
Preventing delirium
Nutrition
Early mobilisation
Ageing and Health, Guy’s and St Thomas’
Problems of Post Operative Nutrition
•
·
·
·
·
·
·
·
Orders of “nil by mouth”
Pain / Constipation
Onset of an acute medical problem
Dementia and depression
Edentulism / reduction of secretion of saliva
Medication (nausea)
Poorly mobile or bed bound patients,
Greater nutritional demand (catabolic stress)
Ageing and Health, Guy’s and St Thomas’
Observational study of Post Operative
Nutrition
• Average Daily Calorific Intake (kCal)
• Using 3 day consecutive diet sheet
• Food recorded as
eat all, eaten half, number of spoonfuls
where approp (nutritional supplements)
• kCal calculated by experienced dietician
Ageing and Health, Guy’s and St Thomas’
Almost none have adequate intake
Distribution of Calorific Intake
<1000 kcal
Ageing and Health, Guy’s and St Thomas’
Treating post-operative nutrition risk
• Limited studies
Inadequate numbers of people, methodological
problems
• Clinical guide: Many patients malnourished before
their injury and dietary intake in hospital poor
• Nutritional supplementation consisting of oral
protein and energy feeds of potential benefit
• The benefits of nasogastric feeding are uncertain
- probably reserved for severe malnourishment
where oral supplementation is not possible
Ageing and Health, Guy’s and St Thomas’
Oliver D, Sahota O, Griffiths R BMJ Cliin Evid 2008
Hip Fractures- Post Operative Nutrition
• Diet Assisted participants had a significantly
greater mean daily energy intake and were less
likely to die in the acute ward
• 1000k/cal day decreased mortality by :
30 days 60% (4.1% from 10.1%, p=0.041)
4 months 43% (13.1% from 22.9%, p=0.036)
• Identifying high risk patients and providing
support may be plausible
Ageing and Health, Guy’s and St Thomas’
Clinical trials of OG 1 (US)
OBJECTIVES: early multidisciplinary geriatric intervention
DESIGN/SETTING: RCT in Orthopaedic ward, University Hospital
PARTICIPANTS: 319 patients aged 65 + hip fractures
INTERVENTION: Daily geriatric MDT (n=155)
or usual care (n=164)
OUTCOMES LOS, morbidity, mortality, ADL, mobility
(3, 6, 12 m)
Vidan M, Serra JA. Efficacy of a Comprehensive Geriatric Intervention in Older Patients hospitalized
for hip fracture: a randomized controllled trial. JAGS. 2005;53:1476-82
Ageing and Health, Guy’s and St Thomas’
RESULTS:
Intervention
Usual
p
LOS days
16 (13-19)
18 (13-24)
0.06
Med. complications
70 (45.2%)
In-hospital mortality
1 (0.%)
9 (5.55)
0.03
Long term survival
81.1%
74.7%
0.18
Partial recovery 3m
82/144
(57%)
59/124
(44%)
0.03
Total recovery* 3m
89/144
(62%)
56/124
(47%)
0.02
Ageing and Health, Guy’s and St Thomas’
100 (61.7%) 0.003
Clinical trials of OG 2
• Prospective observational study, with
retrospective control
(Australian teaching hospital)
• Standard care -Consultation service
-Orthogeriatrician
Reported reduction in
medical complications
21% (p<0.01)
30 day mortality
3% (p<0.01)
6 month mortality
20% (p=0.47)
Fisher et al, J Orthop Trauma 2006
Ageing and Health, Guy’s and St Thomas’
CONCLUSIONS
• Early geriatric intervention during the acute phase of
hip fracture in a non selected older population
– reduces
• medical complications
• in-hospital mortality
– Has modest benefits in
• length of stay
• long term functional outcomes
• Further studies needed on post acute rehabiliation, eg
early supported discharge teams
Ageing and Health, Guy’s and St Thomas’
Clinical Trials of OG 3
RCT of intensive OG rehabilitation for
patients with dementia
o Significantly shorter median LOS for patients with
mild or moderate dementia
o Patients with mild dementia were as successful as
patients with normal cognitive function in returning to
independent living.
o Significantly fewer patients with moderate dementia
were in institutional care after one year.
Huusco et al. BMJ 2000;321:1107-1111
Ageing and Health, Guy’s and St Thomas’
Cochrane Database of Systematic
Reviews 2007
Inpatient acute/rehab liaison
Objectives
To examine the effects of co-ordinated multidisciplinary inpatient rehabilitation,
compared with usual (orthopaedic) care, for older patients with hip fracture.
•Selection criteria
Randomised and quasi-randomised trials of post-surgical care using specialised
rehabilitation of mainly older patients (aged 65 years or over) with hip fracture.
•Main results
•Nine included trials (1887 patients).
•Combined outcomes of death or requiring institutional care: NSE (trend)
•LOS and cost data: considerable heterogeneity
•Combined outcome of death and deterioration in function: RR= 0.91 (95%
confidence interval 0.83 to 1.01).
•No quality of life measures were reported
•Carer burden (two trials): NS
Ageing and Health, Guy’s and St Thomas’
Thank you
• Some additional resources are in the slide set handout
Ageing and Health, Guy’s and St Thomas’
Resources 1
• National Hip fracture Database reports
www.nhfd.co.ug
Ageing and Health, Guy’s and St Thomas’
Resource 2
The Blue Book, 2nd edition,
(September 2007)
Jointly produced by
BOA and BGS
With support from Age Anaesthesia,
RCN, Endocrine Society, Faculty of PH
Medicine, National Osteoporosis
Foundation
Available from www.boa.ac.uk
(as pdf file, publications for download)
Ageing and Health, Guy’s and St Thomas’
Resources 3
Jointly produced by
International Osteoporosis
Foundation
International Society for Fracture
Repair
Bone and Joint Decade
Available from
www.fractures.com
Ageing and Health, Guy’s and St Thomas’
Resource 4
Scottish Intercollegiate
Guideline Network (SIGN)
Number 56 – Prevention and
management of hip fractures in
older people.
http://www.sign.ac.uk/guideline
s/fulltext/56/index.html
Available from www.sign.ac.uk
Ageing and Health, Guy’s and St Thomas’
Resource 5
Report from the NHS Institute
Available as a pdf file from
www.institute.nhs.uk
Ageing and Health, Guy’s and St Thomas’