We read with interest the article by Canty et al. [1] on pre-operative echocardiography in patients with hip fractures and have several observations we would like to share.

We note that patients were included based on an ASA status ≥3. Grading of ASA status is extremely variable between anaesthetists [2] and we believe the use of the Nottingham Hip Fracture Score would have improved consistency between the two groups of patients [3].

The authors state that the most frequently found abnormality on echocardiography was hypovolaemia. However, this finding would be expected in the majority of patients and does not require echocardiography for its diagnosis. We notice that the papers by Sinclair et al. [4] and Venn et al. [5] are referenced with respect to fluid resuscitation but a simple study [6] demonstrating that any fluid reduces hypovolaemia in these patients was omitted.

Within the article there is no mention of the causes of death within the two groups. This would be valuable information as many of the patients' deaths may not have been attributable to cardiac pathology.

As noted in the discussion, no information was collected regarding the experience levels of either the surgeon or the anaesthetist and this may have impacted on the morbidity and mortality [7].

We also wonder whether there was any difference in the times or day of surgery between the two study groups. Were the anaesthetists who performed the transthoracic echocardiograms more readily available during the working week? This would have implications for the quality of postoperative care due to differences in levels of staffing as evidenced by Foss et al. [7, 8].


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