Routine echocardiography or invasive blood pressure monitoring for fractured neck of femur?

Authors


  • SW sat on the Working Party for the AAGBI Management of Proximal Femoral Fracture guidelines, and is an Editor of Anaesthesia. Previously posted on the Anaesthesia correspondence website: http://www.respond2articles.com/ana/.

I have followed the recent discussion about the importance of routine pre-operative echocardiography for patients with fractured neck of femur [1-3] with interest, and would like to add my concerns to those of others [4-7] about the suggestion that routine pre-operative testing should become a standard of care, outwith any methodological concerns in Canty et al.'s paper [3] (relating to: use of ASA grade for matching of patients; information about peri-operative fluid administration; rates of invasive blood pressure monitoring; specifics of the anaesthetic technique; and the outcomes measured).

Whilst the apparently long pre-operative lag between admission and operation in Heyburn and McBrien's hospital [8] lends itself to routine echocardiography, data suggest that pre-operative delay per se is correlated with poor outcome, and therefore any intervention, particularly a personnel-, time- and equipment-intensive one like echocardiography, requires evidence that it positively changes patient management. However, echocardiographic confirmation of valvular heart disease should not change clinical management: if a murmur is heard, or valvular heart disease is suspected, or indeed in every hip fracture patient, anaesthetists should strive to avoid absolute/relative hypotension and consequent heart and brain ischaemia, irrespective of whether spinal or general anaesthesia is administered.

To this end, a far more rational – and cheaper – approach to improving early postoperative outcome (it being non sequitur to suggest that a single, focused echocardiograph might influence mortality up to 30 days later) would be to monitor blood pressure invasively ‘beat-to-beat’ rather than at 2–5 minute intervals in every hip fracture patient, a practice currently undertaken by only 1.1% of trauma anaesthetists [9] and yet one that would be routinely performed, I venture, in any other inpatient surgical group with an 30-day mortality of 8%. Furthermore, routine invasive blood pressure monitoring, although not without practical complications, would allow for routine immediate postoperative measurement of haemoglobin concentration (further ameliorating peri-operative ischaemia), and non-Doppler cardiac output monitoring during preferable (low-dose) spinal anaesthesia.

There remains a wide national variation in the performance of UK hospitals with regards to outcome after hip fracture repair [8], and it seems illogical to redirect precious ‘Best Practice Tariff’ resources towards a single, unproven intervention before addressing other barriers to quality care of these vulnerable patients, in particular the underutilisation of orthogeriatricians. However, I do agree with Loxdale et al. [2] that focused transthoracic echocardiography is a useful skill for anaesthetists to learn, if only to screen for valvular heart disease and refer patients postoperatively as part of a preventative falls assessment process.