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

 

Rationale

Older patients with hip fracture are sensitive to the cardiovascular effects of general anaesthesia [1].

Hypotension is more common during general anaesthesia than spinal anaesthesia for hip fracture repair [2].

Reducing the amount of general anaesthesia administered reduces the prevalence of hypotension [3].

Depth of anaesthesia monitoring should be used for all hip fracture patients undergoing GA because it allows for dose reduction, resulting in less prevalent hypotension [4-7].

A Lerou nomogram can also be used to administer agwe-appropriate doses of inhalational anaesthesia [8].

Balanced anaesthesia involving general anaesthesia + nerve block further reduces the MAC/MIC of general anaesthesia.

Inhalational induction of anaesthesia (2% sevoflurane in 100% oxygen) or use of a 10-20mg propofol ‘primer’ before a reduced iv induction dose of propofol are relatively cardiostable induction techniques [9-11].

Research is urgently needed comparing spontaneous ventilation via a laryngeal mask (risking aspiration, hypercarbia) and mechanical ventilation via an endotracheal tube (risking pulmonary complications) in hip fracture patients.

 

Evidence

1. Messina A, Frassanito L, Colombo D, Vergari A, Draisci G, Della Corte F, Antonelli M. Hemodynamic changes associated with spinal and general anesthesia for hip fracture surgery in severe ASA III elderly population: a pilot trial. Minerva Anestesiologica 2013; 79: 1021-9.

2. Royal College of Physicians and the Association of Anaesthetists of Great Britain and Ireland. National Hip Fracture Database. Anaesthesia Sprint Audit of Practice. 2014. http://www.nhfd.co.uk/20/hipfractureR.nsf/welcome?readform (accessed 01/01/2016).

3. Dundee JW, Robinson FP, McCollum JS, Patterson CC. Sensitivity to propofol in the elderly. Anaesthesia 1986; 41: 482–5.

4. Ballard C, Jones E, Gauge N, et al. Optimised anaesthesia to reduce post operative cognitive decline (POCD) in older patients undergoing elective surgery, a randomised controlled trial. PLoS One 2012; 7: e37410.

5. Radtke FM, Franck M, Lendner J, Krüger S, Wernecke KD, Spies CD. Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction. British Journal of Anaesthesia 2013; 110 s1: i98-105.

6. Riad W, Schreiber M, Saeed AB. Monitoring with EEG entropy decreases propofol requirement and maintains cardiovascular stability during induction of anaesthesia in elderly patients. European Journal of Anaesthesiology 2007; 24: 684-8.

7. Punjasawadwong Y, Phongchiewboon A, Bunchungmongkol N. Bispectral index for improving anaesthetic delivery and postoperative recovery. Cochrane Database of Systematic Reviews 2014; 6: CD003843.

8. Lerou JG. Nomogram to estimate age-related MAC. British Journal of Anaesthesia 2004; 93: 288–91.

9. Luntz SP, Janitz E, Motsch J, Bach A, Martin E, Böttiger BW. Cost-effectiveness and high patient satisfaction in the elderly: sevoflurane versus propofol anaesthesia. European Journal of Anaesthesiology 2004; 21: 115-22.

10. Moran AP, Stock K, Jenkins C, et al. Co-induction of anaesthesia with 0.75 mg kg propofol followed by sevoflurane: a randomized trial in the elderly with cardiovascular risk factors. European Journal of Anaesthesiology 2008; 25: 183-7.

11. Reich DL, Hossain S, Krol M, Baez B, Patel P, Bernstein A, Bodian CA. Predictors of hypotension after induction of general anesthesia. Anesthesia and Analgesia 2005; 101: 622-8.