Dr Micheal Looney Consultant Anaesthetist Connolly Hospital Blanchardstown To Delay or Not to Delay Hip Fracture Surgery
"You may delay, but time will not, and lost time is never found again." Benjamin Franklin
Reasons for Delay > 48 Hours
ASA Classification of Patients
Acceptable Reasons for Delay
Acceptable Reasons for Delay
Anaemia
Anaemia ~ 40% patients have anaemia Hb conc decreases 2.5g/dL perioperative period Adhere to a restrictive transfusion strategy Consider transfusion if Hb 8 g/dl or less Transfuse if symptomatic of anaemia or if patient has stable cardiovascular disease
Severe Electrolyte Imbalance
Severe Electrolyte Imbalance Hyponatraemia why should we treat it preoperatively? Increase in subsequent peri-operative complications Hypernatraemia assoc with increased mortality after surgery
Uncontrolled Diabetes
Uncontrolled Diabetes Patients who manifested a serum glucose greater than 220 mg/dl (12 mmol/l) had a 25% infection rate including: wound infections pneumonia urinary tract infections bacteraemia or severe sepsis Perioperative glucose levels greater than 220 mg/dl (12mmol/L) increased the likelihood of infection by a factor of seven in orthopaedic trauma patients even with no known history of DM
Uncontrolled / Acute Left Ventricular Failure An echocardiogram is indicated for anyone with: suspicious systolic murmur, dyspnoea of unknown cause worsening CCF If echo is delayed, surgery should proceed with relevant anaesthetic precautions and monitoring in place Bedside echocardiography may be useful tool to stratify surgical risk and optimize patients by assessing a patient s: intravascular volume status myocardial contractility/ventricular ejection fraction valvular heart disease in the peri-operative period Aortic Stenosis - echocardiography is indicated if it has not been performed recently
Correctable Cardiac Arrhythmia, Ventricular Rhythm > 120bpm
Correctable Cardiac Arrhythmia, Ventricular Rhythm > 120bpm Normal atrial activity accounts 10% ventricular filling up to 40% fast ventricular heart rates Elderly more dependent atrial activity due reduced elasticity ventricles Adverse effects AF more profound elderly and those underlying cardiovascular disease
Correctable Cardiac Arrhythmia, Ventricular Rhythm > 120bpm
Chest Infection With Sepsis
Chest Infection and Sepsis Prevalence preoperative pneumonia 1.2% Independent risk factor mortality and adverse events Underweight BMI assoc w higher mortality within 30 days Time from admission to surgery not assoc adverse events
Reversible Coagulopathy Drug Class Drug Name SAB Surgery Anti-platelet Clopidogrel (Plavix) Not recommended within 7 days of taking last dose of 75mg/day of clopidogrel. Low Molecular Weight Heparin Enoxaparin (Clexane) Avoid SAB if prophylactic dose administered within the last 12 hours. 1 & 4 Avoid SAB if therapeutic dose administered within the previous 24 hours. 1 & 4 Note these intervals are extended in renal impairment. If surgery is required within 48 hours of last dose it is suggested that platelets (2 pools) be ordered and in the hospital prior to surgery Unfractionated Heparin Heparin infusion Cease infusion 4 hours before surgery
Reversible Coagulopathy Drug Class Drug Name SAB Surgery Coumadins Warfarin INR should be 1.3 prior to placement of SAB Direct Thrombin Inhibitors Dabigatran (Pradaxa) 2 4 days after last dose depending on creatinine clearance INR normally takes 5 days to return to normal after cessation of warfarin. INR < 2. If surgery is required before this, emergency reversal of warfarin can be performed. 2 4 days after last dose depending on creatinine clearance * Can reverse with idarucizumab Factor Xa Inhibitors Rivaroxaban (Xarelto) Avoid SAB for three days after last dose taken Proceed with Sx 48 hours after last dose taken Apixaban (Eliquis) Avoid SAB for three days after last dose taken Proceed with Sx 48 hours after last dose of taken
Conclusions Delays due to medical optimisation of patients could be improved AAGBI clear guidelines on appropriate delays surgery NOACs problematic cause delays until cost effective antidotes