Canadian Journal of Anesthesia, Vol 10, 567-583, Copyright © 1963 by Canadian Anesthesiologists' Society

A Study in Geriatric Anaesthesia—Fractured Neck of the Femur

¹ Department of Anaesthesia, University of Saskatchewan and University Hospital, Saskatoon, Saskatchewan

Two hundred and twelve consecutive hip fractures have been reviewed. There were no anaesthetic deaths in this series and only three patients died within 24 hours of the end of anaesthesia, but from causes not directly related to the anaesthetic management. With an over-all hospital mortality of slightly under 9 per cent this is not a dangerous operation, bearing in mind the frequently very advanced age of these patients and associated major diseases of the cardiorespiratory system.

In terms of functional recovery, hip-pinning seems to be a more satisfactory operation than arthroplasty, even in this series where patients for arthroplasty were selected because of their good general condition and the anticipation of good functional recovery. Although almost 60 per cent of patients left the hospital still in wheelchairs after a stay frequently of many weeks, the large majority of them eventually became ambulatory, many of them without support. Of those who did not become fully ambulatory, there were certainly a few who had not been so before the accident and, therefore, they had been restored really to the preoperative status quo. Obviously no more can be expected from the operation.

Perhaps the most significant finding in this study has been the poor survival in patients operated upon as emergencies, and thus the realization of the benefits of an adequate all-round preparation to improve the general status as much as possible. This, despite the fact that early mobilization of these patients is obviously desirable to prevent cardiovascular and thrombotic complications. On balance, there is no doubt that the risk of an increased incidence of these postoperative complications must be borne for the sake of adequate preparation and the reduction in over-all mortality figures. Although not infrequently many days were spent to improve the general condition of the patient as much as could reasonably be expected, spot checks of blood gases pre-and post-operatively have shown that most of these patients are in a state of atleast compensated metabolic acidosis. No conclusions are being drawn from these findings at the present time since an inadequate number of patients has been studied. This project is now under way and comparisons will be made with geriatric patients who are not acutely ill, in order to determine a baseline for the aged.

Our clinical results have convinced us that it is unnecessary in the large majority of cases to use endotracheal intubation in the anaesthetic management of hip-pinnings, provided a perfect airway can be maintained. This permits a much lighter level of anaesthesia and the surgical stimulation is sufficient to ensure adequate respiratory exchange. These patients should be awake within minutes of the completion of the operation. Results from regional anaesthesia are not superior to those following general anaesthetic techniques, so that it is hardly justified to inflict on these patients the discomfort of positioning for spinal or epidural puncture. The actual choice of anaesthetic agent is of secondary importance as compared with meticulous management.

The postoperative period is characterized by the relatively frequent occurrence of pulmonary emboli, many of which are fatal. Routine trophylactic anticoagulant therapy has not been used in our series. Better results could be obtained if this complication could be prevented effectively. Other complications must be minimized by continuous and intensive postoperative management and supervision.

Note:

Presented at the Annual Meeting of the Canadian Anaesthetists' Society at Montebello, Quebec, May 13–16, 1963.