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Summary

  1. Top of page
  2. Summary
  3. Emergency abdominal aortic aneurysm repair
  4. Emergency laparotomy
  5. Hip fracture
  6. Competing interests
  7. References

National reports recommended that peri-operative care should be improved for elderly patients undergoing emergency surgery. Postoperative mortality and morbidity rates remain high, and indicate that emergency ruptured aneurysm repair, laparotomy and hip fracture fixation are high-risk procedures undertaken on elderly patients with limited physiological reserve. National audits have reported variations in care quality, data that are increasingly being used to drive quality improvement through professional guidance. Given that the number of elderly patients presenting for emergency surgery is likely to rise as the population ages, this review summarises the evidence on which such guidance is based, and provides information about how anaesthetists might participate in audit and research aimed at improving local and national outcomes for these most vulnerable of patients.

In the UK, national reports have consistently and repeatedly recommended that peri-operative care should be improved for elderly patients undergoing emergency surgery [1-3]. Over the last decade, postoperative mortality and (costly) morbidity rates have remained unacceptably high in comparison with relative improvements in outcome after similar procedures undertaken electively. For example, postoperative in-hospital or 30-day mortalities are ~38%, ~15% and 8.2% after emergency open ruptured aortic aneurysm repair [4], laparotomy [5] and hip fracture [6] fixation, compared with ~5%, ~6% and 1.2% after elective open surgery for abdominal aortic aneurysm (AAA) [4], colorectal cancer [7] and primary total hip replacement (aged > 80 years) [8]. Emergency ruptured aneurysm repair, laparotomy and hip fracture fixation are high-risk procedures [9] undertaken primarily on elderly patients who have limited physiological reserve and co-morbidities, are often frail and take numerous medications. However, compared with younger patients, the elderly are less likely to be admitted for critical care postoperatively [10].

More recently, national audits have reported several-fold variations in the care of elderly emergency surgical patients in the UK [4-6], and importantly, these data are beginning to be used to drive quality improvement [11] through professional guidance [12-14] that advocates early, focused, multidisciplinary care, and targeted research. This review summarises the evidence on which such guidance is based.

Emergency abdominal aortic aneurysm repair

  1. Top of page
  2. Summary
  3. Emergency abdominal aortic aneurysm repair
  4. Emergency laparotomy
  5. Hip fracture
  6. Competing interests
  7. References

In the UK in 2008–9, approximately 9000 patients were admitted to hospital with AAA, of which one third had ruptured [15]. Overall mortality for ruptured AAA remains at ~75%, with half the patients never reaching hospital and nearly half of those that do reach hospital dying as a result. However, as a result of improvements in surgical technique, peri-operative anaesthetic management and postoperative intensive therapy over the last 50 years, there have been modest improvements in 30-day postoperative patient survival of approximately 2.5% per decade [16].

Historically, many district general (local) hospitals in the UK undertook emergency AAA surgery, but health regions in the UK now centralise vascular resources at a single tertiary hospital, because outcome for aortic surgery is better in high-volume compared with low-volume vascular centres [17]. Concomitant increases in the transfer time to hospital faced by patients with ruptured AAA do not appear to affect mortality adversely. In 2005, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report Abdominal Aortic Aneurysm: a Service in Need of Surgery? [2] identified 264 AAA ruptures, with a 30-day mortality of 36% (94/264); the survival of patients transferred was better (30-day mortality 28%), implying that being considered fit enough to survive an ambulance ride conveys a survival benefit. However, mortality increased markedly with increasing age (Fig. 1).

image

Figure 1. Survival following surgery for ruptured abdominal aortic aneurysm stratified according to patient age (reprinted with the permission of NCEPOD).

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Indeed, age is an independent risk factor for postoperative mortality after AAA rupture in the two most commonly used scoring systems used to predict hospital mortality – the Hardman index [18] and the Glasgow Aneurysm Score [19]. The former is calculated by scoring 1 point for each of age > 76 years, creatinine > 0.19 mmol.l−1, loss of consciousness after arrival, haemoglobin concentration < 90 g.l−1 and any electrocardiographic evidence of ischaemia. The latter is calculated from the sum of weighted variables (age in years, + 17 if shocked, + 7 if myocardial disease present, + 10 if cerebrovascular disease present, + 14 if renal disease present). In-hospital mortality increases in proportion to score (area under receiver operator characteristic curves ~0.75), with a Hardman index ≥ 3 or Glasgow aneurysm score > 85 currently the best predictors of postoperative mortality. Unfortunately, no predictive scoring systems for patients with ruptured AAA have 100% specificity and sensitivity, and patients scored as high-risk can still survive, so should not be denied surgery based on the scoring system alone [20].

Two recent interventions may help reduce the mortality from ruptured AAA in the future, namely abdominal ultrasound screening and endovascular aneurysm repair (EVAR). Approximately 95% of ruptured AAAs occur in men, who are six times more likely than women to develop an aneurysm. From 2013, implementation of the  NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP) will offer every 65-year-old UK male an abdominal ultrasound scan, and referral to a vascular surgeon if their aortic diameter is 5.5 cm or above, with the aim of reducing the rate of premature death from ruptured AAA in this age group by up to 50% [21].

Endovascular aneurysm repair has become increasingly available in the UK for ruptured AAA, and is preferred to open repair in some hospitals. Compared with open repair, EVAR may offer significant survival benefits in elective surgery patients aged over 80 years (risk ratio 3.87, 95% CI 3.19–4.68) and a lower prevalence of complications [22, 23]. A large randomised controlled trial (the IMPROVE trial) comparing EVAR and open repair for ruptured AAA is currently recruiting participants in the UK, and is due to report in 2014/15 [24].

The management of patients undergoing elective AAA repair was recently overhauled by the Abdominal Aortic Aneurysm Quality Improvement Program (AAAQIP) (http://www.aaaqip.com), a collection of best practice protocols and standards initiated following a grant from the Health Foundation to help achieve a 4% absolute reduction (from 7.5% to 3.5%) in the mortality associated with elective AAA surgery by 2013. Whilst the AAAQIP did not specifically address the management of patients with ruptured AAA, there are likely to be improvements in care resulting from new surgical techniques (EVAR or open repair), the availability of interventions such as cell salvage, and a reduction in ‘cold’ rupture, occurring in patients who have not been previously assessed by a vascular multidisciplinary team.

The seniority and expertise of surgeons and anaesthetists providing out-of-hours peri-operative care for ruptured AAA remain contentious. There is recent evidence that the presence of a vascular anaesthetist improved outcome in 1000 patients undergoing elective vascular surgery [25], although the numbers for emergency vascular surgery were smaller and did not achieve significance. Despite this, few, if any, hospitals in the UK maintain a vascular anaesthetist on-call rota, the majority of patients being cared for by ‘general’ anaesthetists. However, the Vascular Society expects out-of-hours emergency vascular surgery to become less common after the introduction of both AAA screening and the provision of more daytime operating lists in dedicated vascular ‘hubs’ (personal communication, Mr Mike Wyatt, Honorary Secretary).

The anaesthetic management of open ruptured AAA repair has not changed appreciably in the last five years. Important principles of treatment continue to include limited fluid resuscitation until the aortic cross-clamp is applied [26], adequate vascular access, intra-arterial blood pressure monitoring before induction of anaesthesia, some form of non-invasive cardiac output monitoring, and careful induction of anaesthesia in the operating theatre after the patient has been draped for surgery, a urinary catheter has been inserted and the surgeon is ready to start. Twenty-four-hour access to intra-operative cell salvage should be a standard of care in vascular centres. Peri-operative point-of-care testing of acid-base balance, haemoglobin concentration and coagulation status (thrombelastography) facilitate appropriate clinical decisions about fluid therapy and administration of blood products. Tranexamic acid may be of use in the treatment of fibrinolysis-dominant disseminated intravascular coagulopathy associated with AAA [27].

Specific problems that may develop include significant blood loss requiring transfusion of red cells and other blood products [28], acidosis due to blood loss and prolonged aortic cross-clamping, and hypothermia due to environmental exposure and administration of cold intravenous fluids pre-operatively. Peri-operative death usually results from either failure to prevent haemorrhage by proximal cross-clamping or cardiac arrest, with early postoperative mortality more related to multiple organ failure. Postoperatively, it is rarely possible to extubate the patient's trachea immediately due to hypothermia, acidosis and haemodynamic instability, and a period of controlled ventilation on an intensive care unit is common. Epidural analgesia is rarely, if ever, indicated due to pre-operative time constraints and concerns about coagulation status.

For the patient undergoing emergency EVAR, the initial and most crucial part of the operation, in which a balloon is placed above the site of rupture of the aorta to achieve haemostasis, is commonly performed under local anaesthesia, with general anaesthesia induced once the patient has become haemodynamically more stable [29, 30].

In conclusion, survival rates of elderly patients presenting with acute ruptured AAA have made modest improvements over the last 50 years. The postoperative risk of death increases significantly with age. Further reductions in mortality may result from aortic screening programme, advances in endovascular techniques, national audit and, most importantly, vascular teamwork, involving standardisation of care pathways and treatments (similar to the AAAQIP for elective AAA repair), together with the familiarisation of theatre and ward personnel that results from the centralisation of expertise.

Emergency laparotomy

  1. Top of page
  2. Summary
  3. Emergency abdominal aortic aneurysm repair
  4. Emergency laparotomy
  5. Hip fracture
  6. Competing interests
  7. References

The elderly patient may require emergency laparotomy for a variety of underlying pathologies. Diverticular disease affects approximately half of the population aged over 80 years, and patients may require emergency surgery for diverticular abscess, perforation or fistulae [31]. The incidence of ulcerative colitis and Crohn's disease has a secondary age peak in the eighth decade, and patients may present debilitated due to chronic disease and long-term steroid use [32]. Delayed presentation for emergency surgery after failure of medical treatment for acute colitis is often associated with systemic sepsis. Colorectal cancer is approximately four times more common amongst 80-year olds than 60-year olds and may require emergency surgery for haemorrhage or obstruction [33]. Although the prevalence of peptic ulcer disease has decreased significantly with increased prescription of proton pump inhibitors, failure of endoscopic ligation often results in the presentation of patients moribund and hypovolaemic for emergency gastroduodenal surgery.

Outcomes

Outcomes following emergency laparotomy in the elderly are poor when compared with younger patients, and do not appear to have improved significantly over the last 15 years. Cook and Day reported an in-hospital postoperative mortality among elderly emergency laparotomy patients aged ~80 years of 44% in 1998 [34] and 42% in 2007 [35], similar to other recent studies in the UK (21% 30-day aged over 70 years [36]) and USA (32% for emergency colorectal surgery in octogenarians [37]). In a prospective audit of almost 1900 patients undergoing emergency laparotomy, the UK Emergency Laparotomy Network reported a direct relationship between age and 30-day mortality; for patients in their 50s, mortality was ~10%, increasing by ~5% per decade, such that patients in their 80 s had a 30-day mortality of 24.4% and in their 90 s, 32% [5].

Compared with elective laparotomy, postoperative complication rates after emergency surgery are also higher in the elderly (88% vs 39%, respectively), with discharge home considerably less likely (69% vs 6.5%) [37].

Several factors are associated with poorer outcome. Some, such as age, urgency of surgery and surgical pathology are less amenable to interventions that improve outcome [35, 38]. Thirty-day mortality following emergency small bowel resection, for example, is 21% compared with 8.8% for emergency right hemicolectomy [39]. However, targeting other factors relating to the delivery of high-quality clinical care in a timely fashion, including haemorrhage and sepsis management, may yield improvements in postoperative mortality and morbidity. It has been appreciated since 1990, for example, that pre-operative delay of more than 24 h is associated with in-hospital mortality of 45% among octogenarians undergoing emergency laparotomy, compared with 6% if surgery is expedited before 24 h [40], figures which are similar to the five-fold increase in in-hospital mortality if emergency surgery for perforated peptic ulcer is delayed in octogenarians beyond 12 h from hospital admission [41]. In the presence of sepsis, there is clear evidence that early administration of antibiotics is associated with improved survival, and in the context of a surgical source of sepsis, this is augmented by early source control [42].

The provision of postoperative critical care also affects outcome, mainly by reducing attendant complications. A recent analysis of high-risk emergency general surgical admissions recorded by the NHS Hospital Episode Statistics database found that hospital Trusts with low 30-day mortality provided significantly more intensive care beds per 1000 hospital beds [43]. The concept of ‘failure to rescue’ high-risk patients has been recognised as an important cause of postoperative morbidity and mortality, with a 38% in-hospital mortality rate occurring among patients discharged to a standard ward before critical care admission, compared with 30% for patients admitted directly to intensive care from the operating theatres [10].

The occurrence of a major complication within 30 days of surgery has been found to be more important than pre-operative or intra-operative factors in determining survival after major surgery [44]. However, the development of a major complication does not automatically increase mortality, and hospitals have been found to have mortality rates independent of their similar prevalence of major complications [45].

Pre-operative management

Given the likelihood of sepsis, patients should receive prompt antibiotic administration, as this is associated with immediate improvements in survival [42]. Although the patient may benefit from a period of pre-operative resuscitation, this should not unduly delay surgery. Multidisciplinary input by senior clinicians is important in deciding the most appropriate treatment, guided ideally by pre-operative computerised tomography, reported by a consultant radiologist specialising in gastrointestinal imaging.

Endoscopic stent insertion as a ‘bridge to surgery’ allows for patient stabilisation before non-emergency surgery, and is associated with higher primary anastomosis and lower overall stoma rates, with no significant difference in complications or mortality [46, 47]. In some cases, a defunctioning or loop ileostomy/colostomy as a palliative procedure to relieve symptoms may be more appropriate.

Assessment of the risks and benefits of emergency surgery in an elderly patient with significant co-morbidities presents challenges. Although data from the Emergency Laparotomy Network audit suggest that ~70% of patients aged over 90 survive at least 30 days after surgery, the Scottish Audit of Surgical Mortality found that the most common ‘adverse event’ was a concern that, in retrospect, the operation should not have been carried out [48], emphasising the importance of multidisciplinary decision-making.

Intra-operative management

There is a lack of research providing specific evidence of best practice for emergency laparotomy in the elderly patient [49, 50]. Therefore, anaesthetic management is extrapolated from data on younger patients, adjusted for reduced physiological reserve [51], and includes fluid therapy guided by appropriate monitoring aimed towards treating critically ill patients with signs of sepsis.

Invasive arterial blood pressure monitoring should be utilised in elderly patients due to the high prevalence of co-morbidity and anticipated physiological derangement caused by surgery and sepsis, and its use has increased since early NCEPOD reports [1, 3]. It also facilitates near-patient testing of haemoglobin concentration acid/base status and oxygen exchange, the latter two parameters being important in deciding on postoperative destination. The use and method of goal-directed fluid therapy in elderly patients (particularly) undergoing emergency surgery is controversial [52, 53]. NCEPOD highlighted hypovolaemia as a major contributor to hypotension during the peri- and postoperative period, particularly after emergency abdominal surgery [1, 3]. However, a recent Cochrane review concluded that goal-directed therapy does not reduce mortality, but suggested that postoperative complications (renal and respiratory failure, and wound infection) and length of stay were reduced, although evidence was lacking about use in emergency surgery [54]. The use of epidural analgesia should balance the potential risks of hypotension and epidural sepsis [55] against the proven benefit of reducing respiratory complications [56]. There is early evidence suggesting that peri-operative opioids may be linked to recurrence after cancer surgery [57].

Core temperature should be measured and appropriate warming instituted [58].

Postoperative management

‘Care Bundles’ standardise the provision of care, and have been shown to increase the reliability of key steps of care, for example, by reducing the prevalence of ventilator-associated pneumonia [11, 59]. Recent guidelines recommend that the need for postoperative critical care is based on an assessment of risk of mortality and morbidity, with admission to critical care for all patients with a predicted mortality greater than 10% [12, 60]. Given that all elderly patients have an expected hospital mortality rate above 15%, there would seem to be a strong argument in favour of admitting all elderly patients to a critical care facility postoperatively. Ongoing postoperative care should include routine input from a senior specialist in elderly medicine.

National Emergency Laparotomy Audit

Many of the issues discussed above have been the subjects of national reports and guidelines, dating as far back as 1999 [1, 3, 61]. Despite this, there is little evidence that outcomes have improved [5, 35, 37, 62]. However, the National Emergency Laparotomy Audit has been recently established in the UK, with the aim of improving outcome after emergency laparotomy [63]. NELA will publish named hospital risk-adjusted outcomes for patients, and inform quality improvement programmes designed to disseminate best practice identified in the hospitals with the lowest mortality, measuring care provision against published standards (summarised in Table 1) [12, 60].

Table 1. National Emergency Laparotomy Audit standards of care for patients undergoing emergency laparotomy.
 
Risk assessment

High-risk patients identified as those with predicted mortality > 10% should receive surgery under the direct supervision of consultant in anaesthesia and surgery

In addition to objective risk calculation, the following patients also have a > 10% mortality:

 ● Patients aged > 65 years

 ● Patients with shock of any cause, any age group

Pre-operative

Prompt surgical review required with assessment of risk (P-POSSUM recommended)

If sepsis present – sepsis bundle with early antibiotics < 1–3 h

Appropriate imaging to define pathology (computerised tomography recommended)

Adequate communication between consultant surgeon and anaesthetist

Access to theatres according to surgical urgency:

 ● ongoing haemorrhage – immediate surgery

 ● septic shock – surgery within three hours of the decision to operate

 ● severe sepsis (with organ dysfunction) – surgery within six hours to minimise deterioration into septic shock

Intra-operative

Antibiotic therapy in line with specific hospital policy

Goal-directed fluid therapy

Ensure normothermia

Assessment of base excess and serum lactate

Effective analgesia

End of surgery care bundle

Reassess risk in light of operative findings: P-POSSUM recommended

Within 30 min of the end of surgery, assess:

 ● lactate/base excess

 ● PO2/FIO2 ratio

Admission to critical care if:

 ● High-risk patient (e.g. any elderly patient)

 ● > 10% predicted mortality (P-POSSUM)

 ● Lactate > 4 mmol.l−1

 ● PO2/FIO2 ratio < 40

 ● Hypothermia < 36 °C

Assess neuromuscular blockade

Prescribe antibiotics and fluids for the postoperative period

Multidisciplinary care
In the elderly, continuing care/rehabilitation with assistance from consultant in medicine for the care of older people

Hip fracture

  1. Top of page
  2. Summary
  3. Emergency abdominal aortic aneurysm repair
  4. Emergency laparotomy
  5. Hip fracture
  6. Competing interests
  7. References

Hip fracture patients epitomise the hazards of emergency surgery for the frail elderly. The global prevalence of hip fracture has been forecast to rise in line with demographic changes in population, and the median age at which patients present is currently rising in Northern Europe (by about 1 year of age every 5 years) [64]. In addition to high peri-operative mortality and morbidity, hip fracture is associated with extensive, expensive rehabilitation and loss of independence, and more commonly if patients experience delay before surgery, inadequate analgesia, blood loss, dehydration, unsympathetic anaesthesia, surgical stress, malnourishment and hypoxia, or secondary complications, such as delirium, pneumonia, cardiac failure, thromboembolism and wound infection [65]. Uncomplicated, expedited recovery requires multidisciplinary intervention and multimodal peri-operative rehabilitation programmes [13, 66].

Pre-operative optimisation

Hip fracture most commonly occurs after a simple fall from standing height in patients with a high prevalence of co-morbidities, which may be complicated by an acute medical problem, such as a chest infection. Traditionally, surgery was postponed until patients had recovered from any acute illness and were deemed ‘fit’ for anaesthesia and surgery, resulting in pre-operative delay. There is now very strong evidence that delay from hospital admission to surgery increases mortality, lengthens hospital stay and delays functional recovery [67, 68]. Delays normally relate to either organisational (51%) or medical (44%) problems, both of which are amenable to managed reduction [69]. The majority of early deaths after hip fracture surgery are attributable to pneumonia, myocardial ischaemia or heart failure [70], but there is no evidence to support pre-operative delay for medical treatment as a method of reducing mortality, possibly excepting severe (but rapidly treatable) derangements of physiology [13]. Improving patient care pathways towards facilitating ward admission from the emergency room and early corrective surgery are probably of more benefit [67, 70]. Randomised controlled studies of the effectiveness of specific pre-operative optimisation in reducing postoperative mortality and morbidity are urgently needed.

Hip fractures can be associated with severe pain in the pre-operative period, particularly on movement [71]. Peripheral neural blockade of the lumbar plexus in the form of a femoral nerve or fascia iliaca block has been shown to reduce pain and opioid consumption in the pre-operative period [72], but the effect on outcome is less certain [72, 73]. Epidural analgesia, although out of favour currently in the UK [6], provides very effective pain control in the pre-operative period, and reduces the number of cardiac events [74].

At hospital admission, hip fracture patients are often anaemic, due to fracture haemorrhage, and hypovolaemic, secondary to dehydration and worsened by subsequent pre-operative fasting, potentiating intra-operative hypotension. Research is required to calculate how much pre-operative fluid resuscitation is required to improve peri-operative outcome [75, 76].

Intra-operative management

It remains uncertain whether general or neuraxial anaesthesia is associated with better outcomes after hip fracture surgery, although evidence currently points towards neuraxial anaesthesia as the best technique for reducing postoperative morbidity (if not necessarily mortality) [77-79], as reflected in professional guidance [13].

However, direct research comparison of ‘regional’ vs ‘general’ anaesthesia is a complex issue [80], and many questions remain unanswered, for example, such as whether general anaesthesia should involve intubation/mechanical ventilation, co-administration of peripheral nerve blockade and age-adjusted administration of inhalational/intravenous agents, or whether intrathecal/epidural anaesthesia should be administered after peripheral nerve blockade or sedation [81] or at lower doses [82].

Hip fracture patients lose the equivalent of ~25 g.l−1 haemoglobin peri-operatively, from the fracture site, surgery, haemodilution and postoperative haemorrhage, most of which is unobserved [83] and which is potentiated by co-administered anticoagulant drugs. Regional anaesthesia and anti-fibrinolytic agents (tranexamic acid) potentially reduce intra-operative bleeding [77, 84], but their effect on outcome linked specifically to anaemia and/or transfusion is unknown.

A recent Cochrane review of (cardiac output-) guided fluid therapy was inconclusive due to lack of evidence, but appears to show reduced postoperative complication rates and length of stay [85]. If only intra-operative goal-directed therapy is used, patients could arrive in theatre after a prolonged pre-operative period of reduced oxygen transport secondary to hypovolaemia and/or anaemia, at which point, intervention might very well be too little or too late to affect postoperative outcome.

Postoperative care

The goal of hip fracture surgery is to return patients to their pre-fracture level of function (or better). Delayed ambulation obstructs this goal, and peri-operative anaesthetic management should aim to optimise the chance of ambulation, as one facet of early postoperative, multidisciplinary rehabilitation [65, 86]. Strategies include the implementation of prescriptive postoperative care bundles (detailing fluid therapy, analgesia, and management of anaemia, for example) [11], provision of critical care facilities and physiotherapy, and the avoidance of delirium [87].

Postoperatively, profound pain on movement may persist even though the fracture is fixed, and can contribute to postoperative delirium along with dehydration, infection and hypoxia, delaying rehabilitation. Opioid analgesia can contribute to delirium, so non-opioid methods are preferable, possibly involving single-shot but not continuous femoral nerve blocks, as the latter have shown almost no effect on pain or postoperative morbidity [88]. Epidural analgesia provides excellent analgesia both at rest and during movement, and seems to facilitate physiotherapy [89]. No data support large volume, low-dose local infiltration analgesia in hip fractures at present [90]. All patients should have prescribed regular paracetamol [13] and, cautiously, short courses of non-steroidal anti-inflammatory drugs [91]. It should be noted, however, that ~36% of hip fracture patients present with at least moderate renal dysfunction, which can potentiate the adverse effects of both opioid and non-steroidal analgesia [92].

The effect of moderate peri-operative anaemia (haemoglobin concentration 80–100 g.l−1) on outcome after hip fracture surgery remains contentious. The only study of hip fracture patients randomised to either liberal or restrictive transfusion thresholds in the intra- and immediate postoperative phase reported reduced mortality and cardiovascular morbidity when a liberal transfusion threshold (100 g.l−1) was used [93]. This contrasts with the FOCUS trial, in which 60-day mortality and independent walking rates were not found to be significantly different between hip fracture patients randomly assigned to either liberal or restrictive transfusion thresholds in the rehabilitative postoperative phase (postoperative days 2–3) [94]. A recent Cochrane review concluded that restrictive transfusion thresholds (transfusion trigger haemoglobin concentration < 80 g.l−1) are associated with statistically significant reductions in hospital mortality, functional recovery, length of stay and complications compared with liberal transfusion triggers, and supported the use of restrictive transfusion triggers in patients with pre-existing cardiovascular disease [95], even though the evidence base for these was heavily influenced by the FOCUS study. Until comprehensive randomised studies of transfusion thresholds in the acute peri-operative phase are reported, restrictive transfusion thresholds should be used with caution in the hip fracture population. Future studies need to evaluate the impact of both transfusion timing and ambulation/rehabilitation outcomes within formalised peri-operative care pathways, involving either intracapsular or extracapsular fracture populations.

Peri-operative thromboprophylaxis with acetylsalicylic acid, low-molecular weight heparin and fondaparinux have all been found to reduce the incidence of venous thromboembolic events after hip fracture surgery, but the effect on mortality is unresolved [96-98]. Studies have been prone to selection bias, excluding the frailest and those with increased risk of peri-operative bleeding, and so may not be representative of outcomes in the general hip fracture population.

Poor outcomes after hip fracture care may indeed be related to the age and physical status of the patients sustaining injury, but there has undoubtedly been a historic contribution resulting from apathy towards developing and implementing high-quality care for those affected. Generalist orthopaedic departments have traditionally provided surgery, anaesthesia and rehabilitation for hip fracture patients. However, multidisciplinary, specialist care programmes have the potential both to improve functional outcome and to reduce mortality [99], and should become the standard of care in all hospitals.

Readers will have noticed several common themes repeating throughout this review – more elderly patients are undergoing emergency major surgery, but continue to have poor but expensive postoperative outcomes. Whilst the elderly might be expected to have a worse outcome compared with younger patients due to limited physiological reserve and co-morbidity, this alone does not account for the significant variation in outcomes that is currently seen. Many of the issues discussed above have repeatedly been the subject of national reports and guidelines that have dated back over almost 15 years. The key to improving this situation is through participation in continuous quality improvement programmes, accompanied by further research to expand the evidence on which care is based. Given that the number of elderly patients presenting for emergency surgery is only estimated to continue rising, we encourage fellow anaesthetists to engage urgently in national audit and research programmes, with the aim of improving care for these vulnerable patients.

Competing interests

  1. Top of page
  2. Summary
  3. Emergency abdominal aortic aneurysm repair
  4. Emergency laparotomy
  5. Hip fracture
  6. Competing interests
  7. References

DM founded the Emergency Laparotomy Network, is National Clinical Lead for the National Emergency Laparotomy Audit, and is member of the clinical trial advisory group for two multicentre research trials involving emergency laparotomy patients, but for which he does not receive any remuneration. No other external funding or competing interests declared.

References

  1. Top of page
  2. Summary
  3. Emergency abdominal aortic aneurysm repair
  4. Emergency laparotomy
  5. Hip fracture
  6. Competing interests
  7. References