Peer Reviewed
Perioperative Anesthesia Management in a Septuagenarian with Multiple Comorbidities and a Hip Fracture
Introduction
Hip fracture is a common, debilitating condition and is increasing in incidence as the population ages. In 1990, there were an estimated 1.7 million hip fractures worldwide, and 90% of these injuries occurred in patients over the age of 50 years. This number is expected to grow to as many as 6.3 million globally by 2050.1
This case report describes the inherent complexity of providing a safe, continuous spinal anesthetic to a septuagenarian who presented with a host of comorbidities, including acute myocardial infarction (MI) and renal dysfunction, and underwent a surgical repair for hip fracture. Unfortunately, this patient died postoperatively of a cardiac catheterization contrast-induced acute renal insufficiency and respiratory failure. This article reviews literature relevant to perioperative management and anesthesia techniques for this patient population with hip fracture and comorbidities.
Case Presentation
A 73-year-old, 174-pound (79 kg) man fell down while weeding his yard and was taken to an outside medical facility. He was hospitalized with the diagnoses of left femoral neck fracture and acute non-ST segment elevation MI. He had no clear recollection of the events regarding his fall.
The patient’s medical history included: coronary artery disease, for which he had undergone 4-vessel coronary artery bypass grafting nine years prior to this admission; hypertension; a history of living related donor renal transplantation eight years earlier; a history of stroke one year earlier; insulin-dependent diabetes; benign prostatic hypertrophy; and peripheral vascular disease. His medications at home included nitroglycerin 0.4 mg daily, metoprolol 35 mg twice daily, terazosin 5 mg at bedtime, lisinopril 20 mg daily, cyclosporine 125 mg twice daily, prednisone 7.5 mg daily, aspirin/extended-release dipyridamole 2.5 mg twice daily, insulin injection 20 units daily, metformin 400 mg twice daily, finasteride 5 mg daily, amitriptyline 25 mg at bedtime, iron sulfate 325 mg daily, docusate, metoclopramide, and vitamins E and C.
Following admission to the outside hospital, he was initially given two doses of hydromorphone hydrochloride 0.2 mg for pain control. He subsequently became lethargic and hypotensive, with labored breathing. As a result of this constellation of symptoms, the patient was given naloxone 0.4 mg, after which he suffered seizure-like activity. This was terminated with diazepam, and a follow-up computed tomography (CT) scan was negative for any acute intracranial process. Laboratory tests at the outside hospital were remarkable for an elevated troponin I, 18 ng/mL (< 0.04 ng/mL). A Cardiology consult was requested for acute change on the electrocardiogram (EKG) and the increased level of troponin. A transthoracic echocardiogram showed an acute decrease in ejection fraction (EF) of 20-25% as compared to his baseline EF of 40-45%. During his hospitalization at the outside facility, the patient also experienced a marked increase in blood creatinine, increasing from 1.4 mg/dL on hospital day 1 to 3.3 mg/dL on hospital day 4, which continued to deteriorate with oliguria and a urine output of less than 400 mL per day.
Four days after hospitalization and without significant medical improvement, the patient was transferred to a tertiary trauma hospital for definitive care. On admission, he was intubated and sedated with stable vital signs: blood pressure 139/50 mmHg; heart rate 83 bpm; afebrile; and on mechanical ventilation. Laboratory data showed white blood cell count 9.4×103/µL, hemoglobin 12.7 g/dL, and platelets 145×103/µL. His chemistry panel was remarkable for elevated blood urea nitrogen (BUN) of 69 mg/dL, blood creatinine of 3.3 mg/dL, and elevated blood glucose of 225 mg/dL. Cardiac enzymes demonstrated a troponin I of 1.46 ng/mL and creatine kinase-MB (CK-MB) of 6.20 units/L. His EKG showed first-degree atrioventricular block, left ventricular hypertrophy, late r/s transition, and borderline elevations in the anterior ST segments. His chest radiograph was negative.
His physicians requested an immediate consult by the Orthopedic and Cardiology services. Orthopedics recommended proceeding with a bipolar hip replacement as soon as the patient was medically stable. The Cardiology service stated that the patient would ideally need a heart catheterization to verify coronary artery patency prior to surgery, but was concerned that, in view of his acute renal failure and his history of renal transplant, associated contrast exposure would worsen the patient’s renal status. The Cardiology service recommended that the patient, therefore, be medically managed optimally in preparation for surgery. He was extubated two days after this admission. A repeat transthoracic echocardiogram showed improvement in left ventricular function with EF 50-55%, hypertrophy, and mild diastolic dysfunction. He was given heparin infusion to treat acute MI and for the prevention of deep vein thrombosis (DVT).
Four days after this admission (8 days post-fracture and MI), the patient was scheduled for bipolar hip replacement. After review of his history, physical examination, and laboratory and diagnostic tests, his physicians agreed that the benefits of proceeding with the procedure in this patient on continued immobilized bedrest outweighed the risks of hip replacement. After obtaining informed consent and verifying a normal coagulation profile, the patient was brought to the anesthesia block room where a spinal catheter was placed using an 18-gauge Tuohy needle and an epidural catheter. The catheter was placed uneventfully at the L4-L5 interspace, and was bolused with 1.5 mL of 0.75% bupivacaine (isobaric). A radial arterial catheter was placed. The block set up as expected, and was re-dosed once with 0.5 mL of 0.75% bupivacaine. The patient remained hemodynamically stable and comfortable for what turned out to be an uncomplicated procedure that lasted two hours. There were no indications of myocardial ischemia throughout the case either reported by the patient or noted on the EKG. The patient did well immediately postoperatively.
On postoperative day 6, a coronary angiography using 190 mL of iodixanol contrast solution showed diffuse coronary artery disease. No stent was placed. After catheterization, the patient’s renal function sharply declined and creatinine was increased from 1.5 mg/dL on postoperative day 5 to 4.2 mg/dL on postoperative day 7. The patient subsequently also developed left lower lobe pneumonia and respiratory insufficiency. His medical conditions continued to deteriorate, and he died on postoperative day 15.
Discussion
Hip fracture repair and total hip arthroplasty are routinely performed on older patients who have chronic and/or acute illnesses and present with a high prevalence of preoperative medical problems.1- Preoperative evaluation and medical optimization, intraoperative monitoring and managements including choice of anesthesia technique, and postoperative follow-up for these patients require thoughtful planning and collective collaboration between medical subspecialties.
Should Hip Surgery Have Been Delayed in This Case?
The potential risks of postponing surgical repair of hip fracture are well documented2-4 and primarily include the increased incidence of healing complications (nonunion and osteonecrosis of the femoral head) in patients younger than age 50 years, as well as greater surgical technical difficulties. The immobilization that accompanies an unrepaired hip fracture also leads to a significant risk of DVT, pulmonary embolism, pneumonia, urinary tract infection, and decubitus ulcer formation. However, at the same time, the same literature has also emphasized the importance of the preoperative preparation for patients with serious coexisting diseases.2-4 Covert and Fox3 have shown that elderly patients with multiple comorbidities require medical stabilization before surgery. Sexson and Lehner4 implied that on the basis of their study, healthy patients should undergo surgery within 24 hours after, and less healthy patients should be medically treated and stabilized before undergoing surgery without adding increased risk from the delay.
The delay of surgery may also be associated with a higher incidence of mortality in patients after hip fracture repair, especially in persons with otherwise low risk.5,6 Shiga et al5 reported in their review that an operative delay in patients with hip fracture beyond 48 hours after admission may increase the odds of 30-day all-cause mortality by 41% and one-year all-cause mortality by 32%. They suggested that an undue delay may be harmful to patients with hip fracture, particularly those who are young or at otherwise relatively low risk. On the other hand, they simultaneously stated that the residual confounding factors may limit definitive conclusions.
To complicate this further, other reports have shown that the delay of surgery actually does not increase the incidence of mortality in patients after hip fracture repair.7-9 For example, Orosz and colleagues7 observed that early surgical repair of hip fracture was not associated with improved function or mortality, but was associated with reduced pain and length of hospital stay. Grimes et al8 found that the timing of surgical repair of hip fracture is not associated with short- or long-term mortality after risk-adjusting for active medical problems. Except for the increased risk of decubitus ulcer formation, delay of surgery did not adversely affect patients’ outcomes.8
Overall, early as compared with late surgical treatment for patients with hip fracture is associated with an improved ability to return to independent living,2,10 a decreased risk for the development of pressure ulcers,2,10 reduced pain, and a shortened hospital stay.2,7-10
The optimal time for proceeding to surgery for any patient who has suffered hip fracture should be individualized. Medical teams should balance the risks among preexisting comorbidities, prolonged bedridden complications, and potential perioperative complications. In the case patient, considering the complexity of his multiple comorbidities, surgery was not performed until he was felt to be medically stabilized four days after the admission to the tertiary trauma hospital (8 days post-MI on anticoagulation therapy).
Was Regional Anesthesia Superior to General Anesthesia in This Case?
There is a difference of opinion as to the choice of regional versus general anesthesia for hip repair surgery, especially in geriatric patients with accompanying chronic and/or acute illness.
Although anesthetic technique for hip fracture surgery does not appear to significantly alter morbidity or mortality,3,10 some studies have shown that regional anesthesia is a better choice for patients with hip fracture than general anesthesia.3,11 Covert and Fox3 have demonstrated that regional anesthesia for hip surgery in elderly patients reduced DVT, pulmonary embolism, and blood loss, and may be the preferred technique, alone or in combination with general anesthesia, for this population. In a systematic review, Macfarlane and colleagues11 identified 18 studies involving 1239 patients and concluded that blood loss may be reduced in patients who have hip surgery and are receiving regional anesthesia rather than general anesthesia. To the contrary, O’Hara et al12 concluded that regional anesthesia is not associated with a better outcome than general anesthesia in geriatric patients with hip fracture requiring surgery.
Our impression is that regional anesthesia is also favored by anesthesiologists. Sandby-Thomas et al13 investigated this impression and found that regional anesthesia is preferred by 75.8% of anesthesiologists, with 95.5% of these employing a spinal technique. Their findings revealed that combined general anesthesia with a regional technique is preferred by 14.4% of anesthesiologists, and general anesthesia alone is preferred by 9.8% of anesthesiologists.
As compared to general anesthesia, the main drawbacks of regional anesthesia for hip surgery include adding the degree and frequency of hypotension, and sometimes being contraindicated due to perioperative anticoagulation for DVT and pulmonary embolism.3
The case patient’s physicians chose regional anesthesia on the basis of its advantages over general anesthesia, the fact that appropriate titrating of local anesthetic for neuraxial anesthesia will set up a dense block without any difficulty in managing hemodynamic instability, and the concern of the case patient’s multiple comorbidities. The negative blood coagulation profile3 and the titratable continuous spinal anesthetic14 offset the theoretic side effects of regional anesthesia in this case.
Did Comorbidities Lead to Higher Probability of Mortality in This Case?
Hip fractures in the elderly are substantial sources of morbidity and mortality.15,16 Foss and Kehlet17 reported a 13.3% 30-day mortality in patients with hip fracture. Eiskjaer and Ostgård18 demonstrated a 20% six-month mortality and a 28% one-year mortality, and found that the deaths of patients with hip fracture are related to their previous medical history. Cardiac risk factors, status as a nursing home patient, chronic pulmonary disease, high serum creatinine level, pneumonia, previous MI, duration of surgery, and gender all significantly affect mortality.18
The two most predominant comorbidities in this case that could have significantly increased the mortality of this case patient were MI and renal dysfunction.18-20 Komarasamy et al19 observed that mortality at one and six months was 45.4% and 63.5%, respectively, in patients with a recent MI, which is significantly higher than those in healthy patients17 and elderly patients.18 Nitsch and colleagues20 showed that chronic kidney disease also significantly increases hip fracture–related mortality.
Should Coronary Angiography Have Been Performed in This Case?
Postprocedure acute renal failure is not uncommon after cardiac angiography because of contrast-induced acute renal injury.21,22 Renal transplant recipients, despite having improved renal function after transplantation, commonly suffer from some degree of acute renal dysfunction after cardiac catheterization.21 It has been suggested that contrast media used during cardiac catheterization can cause dose-dependent renal insufficiency.22 In this case, the patient presented with renal dysfunction on admission to the hospital and was a renal transplant recipient. He was given a generous amount of iodixanol (190 mL) during the cardiac catheterization, after which his renal function sharply deteriorated. He subsequently developed pneumonia and respiratory insufficiency that confounded his medical condition. The patient died of respiratory and renal failure several days later. James et al23 observed that the risk of death with pneumonia is greater in patients with renal injury.
The case patient’s cardiac function was stabilized, and treatment was medically optimized before and after the hip surgery. Considering that he was at a very high risk of acute renal injury, coronary angiography may not have been medically indicated in this case. However, in the context of a recent MI and known coronary disease and recommendation from the consulting cardiologist, we believe that many would have done similarly.
Conclusion
Perioperative management of elderly patients with hip fracture and multiple comorbidities such as the case patient is complex. Postponing the hip surgery and optimizing a patient’s preoperative comorbidities is sometimes medically indicated. Use of a continuous spinal anesthetic technique worked well in the case patient without a coagulation abnormality. Postoperative cardiac catheterization may arguably be more harmful than beneficial to a patient such as the one presented and may have been better delayed until renal function was back to pre-fracture baseline.
The authors report no relevant financial relationships.
Dr. Yang is from the Department of Anesthesiology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China; Dr. Wang is from the Department of Anesthesiology, Hangzhou Red Cross Hospital, Hangzhou, China; and Drs. Hyde and Peng are from the Department of Anesthesiology, University of Florida College of Medicine, Gainesville.
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