Please enable JavaScript.
Coggle requires JavaScript to display documents.
NOF (Intraop (Surgical considerations (Extracapsular (50%) (Increased…
NOF
Preop
Assessment
Commonly mechanical fall
Rule out other fall causes (arrhythmia, valve heart dx, post hypotension)
Other injuries
IHD?
Fluid resus
Analgesia
Timing of LMWH
Consent
ANZCA guidelines
In order for consent to be valid
Threshold - voluntariness, capacity
Information - details procedure, risk/benefit, alternatives, confirm understanding
Consent - Decision, authorisation
In this age gp. the ability to assimilate info and communicate decisions may be poor - steps to overcome this
If patient lacks capacity, need to consult with relatives about treatment decisions and ascertain whether patient has been appointed EPOA
Timing
Guidelines recommend repair within 24hrs of admission (reduced morbidity and mortality)
Special cases
AF - should have a ventricular rate<100
Anticoagulation - Clopidogrel is generally not stopped (esp if drug eluting stents). Surgery should not be delayed but expect increased blood loss. Warfarin should be reversed to INR <1.4.
Chest infection - Prompt Abx, 02, Physio, expedited surgery under spinal preferred
Diabetes - do not delay surgery unless ketotic and/or dehydrated
Murmurs - Postponing surg pending echo is controversial. Majority would proceed to surgery with GA and invasive BP monitoring, with echo in early post op period
NFR orders
Questions in providing anaesthesia to these patients
What if the arrest was not directly related to underlying condition?
What if it was due to reversible SE of drug?
What if patient already has IV access, airway protection and monitoring
Principle
Importance of communication
Explanation - GA involves IV access, airway protection and admin of drugs to protect haemodynamics. Cant do anaesthesia without this
Clarification of patient wishes - informed consent for NFR order (If NFR is part of Advanced care directive, did it have provision for unforseen surgery? Is patient's condition now the same as when NFR signed?)
Informed consent - including consent to manage reversible anaesthetic SEs. If patient refuses, then it may not be possible to provide anaesthesia for the procedure
Reassurance - Resus attempts will not be prolonged, irrespective of cause
Document - preference for limitation of resus from any cause
Intraop
Abx at induction
Technique
GA and PNB - Advantages: Control over duration, depth and HD parameters, complete control of airway and vent, preferable if CIs to regional. Disadvantage: risks of GA
Spinal and PNB - Advantages: Reduced blood loss, DVT/PE, systemic complications and PONV, Cochrane review suggests RA may reduce postop confusion. Disadvantages: Risk block failure, may run out of time, Spinal risks, less control over haemodynamics
Monitoring: Given high incidence of comorbidities, low threshold for ART line
Position
Fixation: supine on 'hip table' (groin prop with table supporting upper body only, feet tied into shoe supports and raised table),
Hemiarthroplasty: lateral or supine on ordinary table
Pressure care: Care with removing dressings or diathermy plates, and when moving the patient
Thermoregulation: Active warming should always be employed (e.g. fluid warmer, Bair hugger)
Surgical considerations
Intracapsular (50%) - minimal blood loss
undisplaced (screws - quick, non-invasive, minimal blood loss) or DHS (more pain)
Displaced (risk of AVN - hemiarthroplasty - longer, more pain)
Extracapsular (50%)
Increased blood loss
Intertrocanteric (DHS)
Subtrocanteric (IM nail)
Revision surgery (longer and more blood loss)
Postop - analgesia for early mobilisation