The evidence for much of how we anaesthetise patients with hip fracture is limited. As a result, there is no consensus on how anaesthesia should best be administered for patients with hip fracture. The evidence-based standards listed here have been developed by consensus among several UK experts, to provide a baseline from which further research can develop. The rationale behind each standard is explained, along with a list of supporting publications.

Click the Standard buttons below to find information on the rationale for, and evidence behind, each standard.

Standard 1

Spinal anaesthesia should be selected in preference to general anaesthesia.

 

Standard 2

A nerve block should be administered before spinal anaesthesia.

 

Standard 3

Low dose spinal anaesthesia should be used:

<=1.8mls (9mg) 0.5% hyperbaric (heavy) bupivacaine for total hip replacement
<=1.5mls (7.5mg) 0.5% hyperbaric (heavy) bupivacaine for all other procedures

 

Standard 4

The use of intrathecal opioids should be restricted to <=25mcg fentanyl.

 

Standard 5

Sedation should be avoided with spinal anaesthesia. If necessary for patient comfort, sedation should be restricted to <=40mg propofol.

 

Standard 6

General anaesthesia should be adjusted for age and depth, using a depth of anaesthesia monitor or nomogram.

 

Standard 7

A nerve block should be co-administered with general anaesthesia (femoral, fascia iliaca, psoas compartment block or local anaesthesia infiltration).

 

Standard 8

The systolic blood pressure fall should be maintained within 25% of pre-induction or pre-spinal levels and the mean arterial pressure maintained at more than 60mmHg.

 

Standard 9

A bone cement implantation syndrome (BCIS) protocol should be followed when patients are scheduled to receive a cemented prosthesis.

 

Standard 10

An end of surgery care bundle should be completed for all patients.

 

An audit tool to remind colleagues about these standards (and to identify any difficulties following them) can be found here.

 

What are the aims of standardised anaesthesia?

Anaesthesia can help re-enable patients after hip fracture. Re-enabling patients involves immediate/early postoperative analgesia, mobilisation and toiletting, nursing care, eating and drinking, respiratory function and cognitive recovery.

Ideally, in the recovery room after anaesthesia for hip fracture, patients should be sitting up, pain free, not connected to oxygen, not connected to intravenous fluids, drinking tea and eating a biscuit, and talking coherently.

There may be valid reasons why patients do not look like this after hip fracture surgery (eg cognitively impaired, chest infection etc) BUT in the absence of these, anaesthetists should always aim to understand why, and aim to improve care for future patients accordingly

 

 A schematic timeline of how anaesthesia affects postoperative re-enablement.

 

Reenablement

The blue line represents traditional anaesthesia care. The patient’s functional condition has been declining for some time, until they fall and break their hip (‘X’), at which point they become entirely dependent. They are taken to hospital but receive minimal care until surgery, and so experience no functional improvement. Intraoperatively, the fracture is fixed, analgesia, fluids/blood are given, the blood pressure monitored, and the patients functional status improves, which continues into the immediate postoperative period. However, perhaps the patient develops delirium or feels too nauseous to remobilize for several days in the early postoperative period, as a result of reliance on postoperative opioid analgesia. They recover function over the next few days, but then develop pressure sores and suffer a pulmonary embolism related to their prolonged bedrest, and their functional recovery is delayed again. Eventually, they recover, not quite to their pre-fracture level of function but enough to be discharged from hospital. However, their relatives report that the patient ‘was never quite the same’ after this episode, with a slow ongoing decline in function after discharge (dotted lines).

Instead, proactive multidisciplinary care (red line) aims to return patients quickly to their pre-fracture functional status. Simple resuscitation (analgesia, fluids, food) decreases the relative decline in function after fracture, and may indeed begin to improve function pre-operatively. The patient undergoes surgery sooner and for a shorter period, during which resuscitation and normalization of function continues using standardized anaesthesia. The patient’s functional status rapidly returns to prefracture levels, there are no immobilizing complications, the patient is discharged from hospital sooner and remains ‘well’ after discharge.