Guideline for the management of hip fractures 2020

Abstract

Summary We convened a multidisciplinary Working Party on behalf of the Association of Anaesthetists to update the 2011 guidance on the peri‐operative management of people with hip fracture. Importantly, these guidelines describe the core aims and principles of peri‐operative management, recommending greater standardisation of anaesthetic practice as a component of multidisciplinary care. Although much of the 2011 guidance remains applicable to contemporary practice, new evidence and consensus inform the additional recommendations made in this document. Specific changes to the 2011 guidance relate to analgesia, medicolegal practice, risk assessment, bone cement implantation syndrome and regional review networks. Areas of controversy remain, and we discuss these in further detail, relating to the mode of anaesthesia, surgical delay, blood management and transfusion thresholds, echocardiography, anticoagulant and antiplatelet management and postoperative discharge destination. Finally, these guidelines provide links to supplemental online material that can be used at readers' institutions, key references and UK national guidance about the peri‐operative care of people with hip and periprosthetic fractures during the COVID‐19 pandemic.

Regional anaesthesia in patients at risk of bleeding

“…The AoA has recently produced new guidance on the anaesthetic management of patients with hip fractures. 22 It is recognised that 30e40% of patients with hip fractures take anticoagulant medications, VCH is an extremely rare complication and that the elevated risk in a patient who is anticoagulated is unquantifiable but likely small. Therefore, this new AoA guidance argues that in some patients taking anticoagulant medications, the risk of VCH may be assessed as being considerably lower than the risks of GA or delaying surgery beyond 24e48 h.…”

Anaesthesia for hip fracture repair

“…More recent guidelines by the Association of Anaesthetists and Fragility Fracture Network have addressed these inconsistencies and harmonised best practice recommendations, nationally and internationally. 6,7 Although early mortality has improved in the past decade, less is known about restoring function and reducing morbidity, and the long-term effects on patients. However, national data collection has started to address this.…”

“…Although there is little evidence to favour either mode of anaesthesia, accumulating evidence suggests that the aims and techniques of anaesthesia (of either mode) are important in hip fracture repair. 6…”

“…Both should be used with caution, particularly in the context of renal dysfunction. 6,7 The lateral cutaneous nerve of the thigh (LCNT) should be blocked for surgery, as it supplies the skin that is incised, although additional local anaesthetic infiltration is required if a posterior surgical approach (sometimes used for total hip replacement) is used (Table 3). Blockade of the LCNT can be achieved either directly or as part of the FICB.…”

“…The Association of Anaesthetists advises that peripheral nerve blocks for hip fracture patients can be repeated after 6 h. It is therefore often appropriate to provide an FICB in the perioperative period even if it has been undertaken earlier, to reduce quadriceps femoris muscle spasm, facilitate positioning for anaesthesia and provide postoperative pain relief. 6…”