Postoperative Management of Patients with Hip Fracture

Deep Venous Thromboembolism

Patients who have sustained hip fracture are often started on deep venous thromboembolism (DVT) prophylaxis very soon after the fracture occurs and prior to surgery although evidence suggests there is little or no benefit to this approach. High-quality evidence does support the use of DVT prophylaxis following surgery. Medications used include low-dose unfractionated heparin, low-molecular-weight heparin, fondaparinux (Arixtra) and low-dose warfarin (Coumadin). Aspirin alone is insufficient for this purpose.8-10

Ideally, before a patient leaves the hospital, his or her family physician should work with the surgeon to establish a postdischarge plan. Many times, the surgeon will have already prescribed medication to prevent DVT. If that is not the case, the family physician will likely need to do so. Family physicians should know how to balance the risks and benefits of DVT prophylaxis. The most common reason for not initiating prophylactic anticoagulation is related to the amount of bleeding and fear of future bleeding at the surgical site. In patients who are at risk of bleeding, anticoagulants should not be administered for 12 to 24 hours after surgery.8 If the risk of anticoagulation is considered too high by the surgeon and the family physician, pneumatic hose, which are virtually free of side effects and are effective immediately after surgery, may be used to reduce risk of a thrombotic event. Evidence-based guidelines from the American College of Chest Physicians (ACCP) recommend extended DVT prophylaxis for 28 to 35 days after surgery, especially for patients who meet one or more of the following criteria: have a history of venous thromboembolism; are obese; aren’t ambulatory shortly following discharge; are of advanced age; and/or have cancer.8 Once a patient becomes ambulatory, the risk of pulmonary embolism decreases.

Anemia

Surgery and DVT prophylaxis increase the likelihood that anemia will complicate a patient’s recovery and rehabilitation. As such, it’s important to monitor for anemia throughout the recovery process. The family physician should be aware of the patient’s preoperative hemoglobin (Hgb) values so that he or she can appropriately assess the patient’s improvement following surgery. In general, patients who have an Hgb of at least 10 g per dL fare better in terms of ambulating independently than those with a lower count.11,12 For most patients who have a postoperative Hgb value of 8 g per dL or less, a blood transfusion will be necessary prior to hospital discharge. For other patients, however, taking a 325 mg dietary supplement of ferrous sulfate is generally sufficient. It’s important to keep in mind that constipation may already be an issue for the patient, owing to the discomfort that most people experience with using a bedpan while in the hospital. If iron supplementation exacerbates a patient’s constipation, the family physician may also need to prescribe a stool softener.

Pressure Ulcers

From the moment an individual’s hip breaks to the time he or she is ambulatory, the patient is at risk for pressure ulcers. The incidence of pressure ulcers among people who have sustained a hip fracture is reported to be between 10 percent and 40 percent.13 Such ulcers increase the length of hospital stay and the risk of nosocomial infection.

The National Guideline Clearinghouse offers a comparison of recently published evidence-based guidelines for the prevention of pressure ulcers. In summary, successful prevention relies on skin care measures, including inspection, cleansing and moisturizing; appropriate positioning (e.g., frequent turning or changes of position); use of pressure-relieving devices (e.g., air, water or gel mattresses); optimal nutrition (e.g., increased protein and caloric intake); and education of caregivers, including family members and/or nursing home staff.

Urinary Tract Infection

Urinary tract infection (UTI) is a common complication during the immediate postoperative period. Evidence supports removal of indwelling catheters within 24 to 36 hours after surgery to reduce the risk of UTI, even in the presence of transient urinary retention resulting from pain, opioid medications or anesthesia. If retention does not resolve spontaneously, an indwelling catheter can be reinserted for another 24 to 48 hours but should then be withdrawn again.14

Pain, Restlessness and Delirium

Length of hospital stay and the success of short- and long-term recovery are affected by how effectively postoperative pain is managed. Patient-controlled, intravenous delivery of morphine is a good choice for pain management immediately after surgery.15 Meperidine (Demerol) and pentazocine (Talwin), commonly used narcotics for postoperative pain management, should be avoided as they can cause excess confusion in the older patient.16 At the time of hospital discharge, most hip fracture patients will still require regularly scheduled oral pain medication (for example, acetaminophen supplemented with oxycodone).

Restlessness may be a problem for patients during their hospital stay, and addressing it can pose challenges for hospital staff. The family physician’s goal is to help patients get sufficient sleep while also ensuring that they are alert and energetic enough to begin the rehabilitation process. While sedatives may help the patient rest, they can also cause delirium and can have a negative effect on a patient’s willingness and ability to eat. Therefore, low-dose sedatives should be used cautiously (e.g., 5 mg of zolpidem [Ambien] or 25 mg of trazodone [Desyrel]).

Confusion or delirium should not be considered a “normal” side effect of surgery; however, some patients may have already had delirium prior to their hip repair. Evaluating fluid status is important during the postoperative period. Electrolyte and metabolic states can shift quickly in older patients, and a sodium level that is either too high or too low can negatively affect cognitive abilities. Among other things, confusion can cause problems with swallowing, thereby hindering a patient’s ability to take in sufficient calories to fuel recovery. If delirium-induced agitation does develop, management should include provision of a safe environment with a family member or professional sitter to stay with the patient.

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