1. Discuss the common outcomes following hip fracture repair

Hip fracture is a frequent event in the elderly and is associated with significant mortality, morbidity, and long-term disability. With increasing longevity in the developed world, the incidence of hip fracture is predicted to increase by 10 to 20% by 2030, consuming an ever-larger portion of health-care resources. Recovery times, postoperative morbidity, and long-term outcomes can be improved by early pain management and delirium prevention. Together with multicomponent strategies, regional anesthesia (RA) may contribute to improved outcomes.

Hip fracture is associated with a 30-day mortality of 5 to 10%, increasing to approximately 25% mortality by one year. Postoperative cardiorespiratory complications occur in about 20% of patients. Further, many patients will not return to their pre-fracture level of activities of daily living (ADLs) [1]. Three quarters of the patients will also experience moderate to severe pain and approximately 50% will experience delirium postoperatively [2]. Lifetime risk of hip fracture in 2008 was 12% in females and 4.6% in males [3].

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  Mortality: Advanced age (>85 years), male gender, preoperative cognitive impairment, delirium, poor mobility, and multiple comorbidities are strong preoperative predictors of mortality [4]. Patients with hip fractures have five to eight times greater mortality than patients without fractures within three months of their events [5]. Surgical delay increases mortality [6]. Postoperatively, heart failure and pulmonary infections are associated with a 30-day mortality of 65% and 43%, respectively [7].

  
  
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  Morbidity: Medical complications after hip fracture repair, particularly cardiopulmonary complications, are associated with increased mortality [7]. Patients with multiple complications have the worst prognosis (Table 25.1).

  
  
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  Disability: Compared to matched cohorts, hip fracture is associated with a greater functional decline over two years in ADLs including walking ten feet (3 m), transferring from bed to chair, and grooming. Inability to perform ADLs increases dependency state and transfer to long-term care facilities [8]. It takes six months after surgery to recover the pre-fracture levels of activity and approximately 33% of patients will not recover their function by one year [9]. Patients who returned home without any decreases in ADLs had only a slight reduction in expected life span. In contrast, those with one or more new permanent deficits had a 33% reduction in life span [10].

2. List factors that may improve outcomes

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  Early surgery: Surgery should occur within 48 hours of presentation to the hospital. This both increases survival (19% reduction in 30-day mortality and 45% reduction in one-year mortality) and reduces morbidity. Early surgery also shortens hospital stay and reduces the incidence of decubitus ulcers, deep vein thrombosis, and pneumonia [6].

  
  
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  Preventing delirium: Delirium affects 35 to 65% of patients after hip surgery [2]. Development of delirium is associated with a two times greater mortality, increased postoperative medical complications, decreased quality of life, prolonged hospital stay, and higher risk of transfer to long-term care facilities and persistent cognitive decline. Patients with cognitive impairment are likely to have other coexisting diseases that impact their general health, which in turn may impair rehabilitation. Delirium prevention is associated with decreased mortality and improved functional outcome.

  
  
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  Regional vs. general anesthesia: Regional anesthesia has multiple benefits in this population. In a meta-analysis involving 2,162 patients, RA was associated with reduced one-month mortality and decreased the incidence of deep vein thrombosis, myocardial infarction (MI), and postoperative confusion [11]. Compared to general anesthesia (GA), spinal anesthesia reduced pulmonary complications and in-hospital mortality by 25 to 29% [12]. Mortality was similarly reduced in patients with chronic obstructive pulmonary disease (COPD) undergoing hip fracture repair with RA [13]. A recent retrospective review of 55,000 hip fracture patients showed neuraxial anesthesia decreased length of stay compared with GA [14]. Despite numerous results indicating a decreased mortality with RA for hip fracture surgery [11–12, 15], White et al. found no difference in mortality outcome based on anesthesia type in over 65,000 patients in an observational database study [16].

  
  
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  Treating anemia: Hip fracture patients often present to the hospital with anemia and this increases while awaiting surgery. Preoperative anemia may indicate chronic comorbid disease, poor nutrition, or blood loss. Higher preoperative hemoglobin was found to be associated with a shorter hospitalization and lower risk of death within 60 days [17].

  
  

  An average postoperative drop in hemoglobin of 2.5 g/dl is common following hip fracture surgery. Compared with a restrictive transfusion level of Hgb <8 g/dl, liberal transfusion (Hgb >10 g/dl) does not improve independent ambulation, alter cardiac morbidity in high-risk patients, reduce mortality [18], or reduce delirium incidence or severity [19]. Perioperative transfusion is therefore not recommended for Hgb >8 g/dl unless the patient is symptomatic.

3. Evaluate strategies to decrease the incidence of postoperative delirium

Delirium is felt to be preventable but not necessarily reversible and the cause may not be temporally evident. Patients often emerge from anesthesia lucid but develop delirium on postoperative days 1 to 3. Although predisposing factors are seldom modifiable, some can be mitigated. These include severe pain, electrolyte imbalance, dehydration, malnutrition, sensory deprivation, drug-related causes, cerebral hypoperfusion, and use of urinary catheters or restraints [20]. Strategies should be aimed at prevention.

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  Pain management: Pain management is paramount to preventing delirium. Pain increases the risk for delirium by nine-fold [21]. Pain is often underestimated and undertreated for fear of respiratory depression and delirium from opioids, especially in the non-verbal patient. Notably, avoiding opioids is associated with an increased risk of delirium from pain – except for meperidine, which is associated with increased delirium [21]. However, opioids fail to address dynamic pain [22], and dosages are often limited by nausea, vomiting, and excess sedation.

  
  

  Regional anesthesia may be helpful for pain management. A femoral nerve block (FNB) or a fascia iliaca compartment block (FICB) provides effective opioid-sparing analgesia [23]. The FICB technique significantly reduces rest and dynamic pain while decreasing sedation and hypoxemia [22]. Fascia iliaca compartment block may also reduce the incidence, severity, and duration of delirium in this population [24].

  
  
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  Avoid general anesthesia, anticholinergics, benzodiazepines, and sedatives: RA decreases the risk of confusion compared with GA [11]. General anesthesia has the potential for neurotoxicity whereas RA may decrease surgical stress response and associated inflammation and immunomodulation. Administering RA decreases or avoids the administration of psychotropic anesthetic agents and airway instrumentation, as pulmonary complications are associated with delirium [25]. Despite these compelling advantages, RA has not demonstrated a positive effect on delirium prevention [26]. The inability to demonstrate a difference in outcome by a single intervention is not surprising, as cognition problems are highly heterogeneous and multifactorial with many precipitating factors. Excess sedation under RA, for example, may precipitate delirium. Sieber et al. found that 40% of patients deeply sedated on propofol (BIS ≈ 50) experienced delirium compared to 19% of lightly sedated patients (BIS ≥80) [27].

  
  

  Although the pathophysiology of delirium is incompletely understood, the “final pathway” likely involves the balance between acetylcholine deficiency and dopamine excess [28]. Anticholinergics cause delirium. Common perioperative medications, such as diphenhydramine and meperidine, have anticholinergic properties and are best avoided in this population. Benzodiazepines are also associated with delirium and the risk increases with longer-acting agents and higher doses [29].

  
  
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  Antipsychotics: prophylaxis or treatment?: Meta-analysis on the use of antipsychotic medications, including haloperidol, has shown a significant difference in the incidence of delirium compared to the use of placebo [26]. Subgroup analysis revealed that atypical agents (risperidone and olanzapine) had a greater effect than haloperidol. In the interest of limiting polypharmacy and side effects in the elderly, perhaps antipsychotics should be used for treatment of agitated delirium rather than prophylaxis.

  
  
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  Multicomponent strategies: Prevention of a multifactorial problem requires multicomponent strategies. Implementation of both pharmacological and non-pharmacological interventions by specialized teams [2, 30] significantly reduces the incidence of delirium (Table 25.2).

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