Anaesthesia 2014, 69 (Suppl. 1), 70–80 doi:10.1111/anae.

12492

Review Article
Emergency surgery: the big three – abdominal aortic aneurysm,
laparotomy and hip fracture
M. Stoneham,1 D. Murray2 and N. Foss3

1 Consultant Anaesthetist and Honorary Senior Clinical Lecturer, Nuffield Division of Anaesthetics, Oxford University
Hospitals NHS Trust, Oxford, UK
2 Consultant Anaesthetist, James Cook University Hospital, Middlesbrough, UK
3 Consultant Anaesthetist, Associate Professor, Head of Gastrointestinal & Orthopaedic Anaesthesia, Department of
Anaesthesia, Hvidovre University Hospital, Copenhagen, Denmark

Summary
National reports recommended that peri-operative care should be improved for elderly patients undergoing emer-
gency surgery. Postoperative mortality and morbidity rates remain high, and indicate that emergency ruptured aneu-
rysm repair, laparotomy and hip fracture fixation are high-risk procedures undertaken on elderly patients with
limited physiological reserve. National audits have reported variations in care quality, data that are increasingly being
used to drive quality improvement through professional guidance. Given that the number of elderly patients present-
ing for emergency surgery is likely to rise as the population ages, this review summarises the evidence on which such
guidance is based, and provides information about how anaesthetists might participate in audit and research aimed
at improving local and national outcomes for these most vulnerable of patients.
.................................................................................................................................................................
Correspondence to: Nicolai Foss
Email: nbfoss@gmail.com
Accepted: 1 October 2013

In the UK, national reports have consistently and
repeatedly recommended that peri-operative care
should be improved for elderly patients undergoing
emergency surgery [1–3]. Over the last decade, postop-
erative mortality and (costly) morbidity rates have
remained unacceptably high in comparison with rela-
tive improvements in outcome after similar procedures
undertaken electively. For example, postoperative in-
hospital or 30-day mortalities are ~38%, ~15% and
8.2% after emergency open ruptured aortic aneurysm
repair [4], laparotomy [5] and hip fracture [6] fixation,
compared with ~5%, ~6% and 1.2% after elective open
surgery for abdominal aortic aneurysm (AAA) [4],
colorectal cancer [7] and primary total hip replace-
ment (aged > 80 years) [8]. Emergency ruptured aneu-
rysm repair, laparotomy and hip fracture fixation are
high-risk procedures [9] undertaken primarily on
elderly patients who have limited physiological reserve
and co-morbidities, are often frail and take numerous
medications. However, compared with younger
patients, the elderly are less likely to be admitted for
critical care postoperatively [10].
More recently, national audits have reported sev-
eral-fold variations in the care of elderly emergency
surgical patients in the UK [4–6], and importantly,
these data are beginning to be used to drive quality
improvement [11] through professional guidance
[12–14] that advocates early, focused, multidisciplinary

70 © 2013 The Association of Anaesthetists of Great Britain and Ireland

Stoneham et al. | Abdominal aortic aneurysm, laparotomy and hip fracture
care, and targeted research. This review summarises
the evidence on which such guidance is based.
Emergency abdominal aortic aneurysm
repair
In the UK in 2008–9, approximately 9000 patients
were admitted to hospital with AAA, of which one
third had ruptured [15]. Overall mortality for ruptured
AAA remains at ~75%, with half the patients never
reaching hospital and nearly half of those that do
reach hospital dying as a result. However, as a result
of improvements in surgical technique, peri-operative
anaesthetic management and postoperative intensive
therapy over the last 50 years, there have been modest
improvements in 30-day postoperative patient survival
of approximately 2.5% per decade [16].
Historically, many district general (local) hospitals
in the UK undertook emergency AAA surgery, but
health regions in the UK now centralise vascular
resources at a single tertiary hospital, because outcome
for aortic surgery is better in high-volume compared
with low-volume vascular centres [17]. Concomitant
increases in the transfer time to hospital faced by
patients with ruptured AAA do not appear to affect
mortality adversely. In 2005, the National Confidential
Enquiry into Patient Outcome and Death (NCEPOD)
report Abdominal Aortic Aneurysm: a Service in Need
of Surgery? [2] identified 264 AAA ruptures, with a
30-day mortality of 36% (94/264); the survival of
patients transferred was better (30-day mortality 28%),
implying that being considered fit enough to survive
an ambulance ride conveys a survival benefit. How-
ever, mortality increased markedly with increasing age
(Fig. 1).
Indeed, age is an independent risk factor for post-
operative mortality after AAA rupture in the two most
commonly used scoring systems used to predict hospi-
tal mortality – the Hardman index [18] and the Glas-
gow Aneurysm Score [19]. The former is calculated by
scoring 1 point for each of age > 76 years, creatinine
> 0.19 mmol.l 1, loss of consciousness after arrival,
haemoglobin concentration < 90 g.l 1 and any electro-
cardiographic evidence of ischaemia. The latter is cal-
culated from the sum of weighted variables (age in
years, + 17 if shocked, + 7 if myocardial disease pres-
ent, + 10 if cerebrovascular disease present, + 14 if
© 2013 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia 2014, 69 (Suppl. 1), 70–80
Figure 1 Survival following surgery for ruptured
abdominal aortic aneurysm stratified according
to patient age (reprinted with the permission of
NCEPOD).
renal disease present). In-hospital mortality increases
in proportion to score (area under receiver operator
characteristic curves ~0.75), with a Hardman index
≥ 3 or Glasgow aneurysm score > 85 currently the best
predictors of postoperative mortality. Unfortunately,
no predictive scoring systems for patients with rup-
tured AAA have 100% specificity and sensitivity, and
patients scored as high-risk can still survive, so should
not be denied surgery based on the scoring system
alone [20].
Two recent interventions may help reduce the
mortality from ruptured AAA in the future, namely
abdominal ultrasound screening and endovascular
aneurysm repair (EVAR). Approximately 95% of rup-
tured AAAs occur in men, who are six times more
likely than women to develop an aneurysm. From
2013, implementation of the NHS Abdominal Aortic
Aneurysm Screening Programme (NAAASP) will offer
every 65-year-old UK male an abdominal ultrasound
scan, and referral to a vascular surgeon if their aortic
diameter is 5.5 cm or above, with the aim of reducing
the rate of premature death from ruptured AAA in
this age group by up to 50% [21].
Endovascular aneurysm repair has become increas-
ingly available in the UK for ruptured AAA, and is pre-
ferred to open repair in some hospitals. Compared with
open repair, EVAR may offer significant survival bene-
fits in elective surgery patients aged over 80 years (risk
ratio 3.87, 95% CI 3.19–4.68) and a lower prevalence of
complications [22, 23]. A large randomised controlled
trial (the IMPROVE trial) comparing EVAR and open
repair for ruptured AAA is currently recruiting partici-
pants in the UK, and is due to report in 2014/15 [24].
71
Anaesthesia 2014, 69 (Suppl. 1), 70–80 Stoneham et al. | Abdominal aortic aneurysm, laparotomy and hip fracture
The management of patients undergoing elective
AAA repair was recently overhauled by the Abdominal
Aortic Aneurysm Quality Improvement Program
(AAAQIP) (http://www.aaaqip.com), a collection of
best practice protocols and standards initiated follow-
ing a grant from the Health Foundation to help
achieve a 4% absolute reduction (from 7.5% to 3.5%)
in the mortality associated with elective AAA surgery
by 2013. Whilst the AAAQIP did not specifically
address the management of patients with ruptured
AAA, there are likely to be improvements in care
resulting from new surgical techniques (EVAR or open
repair), the availability of interventions such as cell sal-
vage, and a reduction in ‘cold’ rupture, occurring in
patients who have not been previously assessed by a
vascular multidisciplinary team.
The seniority and expertise of surgeons and anaes-
thetists providing out-of-hours peri-operative care for
ruptured AAA remain contentious. There is recent evi-
dence that the presence of a vascular anaesthetist
improved outcome in 1000 patients undergoing elec-
tive vascular surgery [25], although the numbers for
emergency vascular surgery were smaller and did not
achieve significance. Despite this, few, if any, hospitals
in the UK maintain a vascular anaesthetist on-call rota,
the majority of patients being cared for by ‘general’
anaesthetists. However, the Vascular Society expects
out-of-hours emergency vascular surgery to become
less common after the introduction of both AAA
screening and the provision of more daytime operating
lists in dedicated vascular ‘hubs’ (personal communica-
tion, Mr Mike Wyatt, Honorary Secretary).
The anaesthetic management of open ruptured
AAA repair has not changed appreciably in the last
five years. Important principles of treatment continue
to include limited fluid resuscitation until the aortic
cross-clamp is applied [26], adequate vascular access,
intra-arterial blood pressure monitoring before induc-
tion of anaesthesia, some form of non-invasive car-
diac output monitoring, and careful induction of
anaesthesia in the operating theatre after the patient
has been draped for surgery, a urinary catheter has
been inserted and the surgeon is ready to start.
Twenty-four-hour access to intra-operative cell salvage
should be a standard of care in vascular centres. Peri-
operative point-of-care testing of acid-base balance,
72
haemoglobin concentration and coagulation status
(thrombelastography) facilitate appropriate clinical
decisions about fluid therapy and administration of
blood products. Tranexamic acid may be of use in
the treatment of fibrinolysis-dominant disseminated
intravascular coagulopathy associated with AAA [27].
Specific problems that may develop include signifi-
cant blood loss requiring transfusion of red cells and
other blood products [28], acidosis due to blood loss
and prolonged aortic cross-clamping, and hypothermia
due to environmental exposure and administration of
cold intravenous fluids pre-operatively. Peri-operative
death usually results from either failure to prevent
haemorrhage by proximal cross-clamping or cardiac
arrest, with early postoperative mortality more related
to multiple organ failure. Postoperatively, it is rarely
possible to extubate the patient’s trachea immediately
due to hypothermia, acidosis and haemodynamic
instability, and a period of controlled ventilation on an
intensive care unit is common. Epidural analgesia is
rarely, if ever, indicated due to pre-operative time con-
straints and concerns about coagulation status.
For the patient undergoing emergency EVAR, the
initial and most crucial part of the operation, in which
a balloon is placed above the site of rupture of the
aorta to achieve haemostasis, is commonly performed
under local anaesthesia, with general anaesthesia
induced once the patient has become haemodynami-
cally more stable [29, 30].
In conclusion, survival rates of elderly patients
presenting with acute ruptured AAA have made mod-
est improvements over the last 50 years. The postoper-
ative risk of death increases significantly with age.
Further reductions in mortality may result from aortic
screening programme, advances in endovascular tech-
niques, national audit and, most importantly, vascular
teamwork, involving standardisation of care pathways
and treatments (similar to the AAAQIP for elective
AAA repair), together with the familiarisation of the-
atre and ward personnel that results from the central-
isation of expertise.
Emergency laparotomy
The elderly patient may require emergency laparotomy
for a variety of underlying pathologies. Diverticular dis-
ease affects approximately half of the population aged
© 2013 The Association of Anaesthetists of Great Britain and Ireland
Stoneham et al. | Abdominal aortic aneurysm, laparotomy and hip fracture
over 80 years, and patients may require emergency sur-
gery for diverticular abscess, perforation or fistulae [31].
The incidence of ulcerative colitis and Crohn’s disease
has a secondary age peak in the eighth decade, and
patients may present debilitated due to chronic disease
and long-term steroid use [32]. Delayed presentation for
emergency surgery after failure of medical treatment for
acute colitis is often associated with systemic sepsis.
Colorectal cancer is approximately four times more
common amongst 80-year olds than 60-year olds and
may require emergency surgery for haemorrhage or
obstruction [33]. Although the prevalence of peptic
ulcer disease has decreased significantly with increased
prescription of proton pump inhibitors, failure of endo-
scopic ligation often results in the presentation of
patients moribund and hypovolaemic for emergency
gastroduodenal surgery.
Outcomes
Outcomes following emergency laparotomy in the
elderly are poor when compared with younger
patients, and do not appear to have improved signifi-
cantly over the last 15 years. Cook and Day reported
an in-hospital postoperative mortality among elderly
emergency laparotomy patients aged ~80 years of 44%
in 1998 [34] and 42% in 2007 [35], similar to other
recent studies in the UK (21% 30-day aged over
70 years [36]) and USA (32% for emergency colorectal
surgery in octogenarians [37]). In a prospective audit
of almost 1900 patients undergoing emergency laparot-
omy, the UK Emergency Laparotomy Network
reported a direct relationship between age and 30-day
mortality; for patients in their 50s, mortality was
~10%, increasing by ~5% per decade, such that
patients in their 80 s had a 30-day mortality of 24.4%
and in their 90 s, 32% [5].
Compared with elective laparotomy, postoperative
complication rates after emergency surgery are also
higher in the elderly (88% vs 39%, respectively), with
discharge home considerably less likely (69% vs 6.5%)
[37].
Several factors are associated with poorer outcome.
Some, such as age, urgency of surgery and surgical
pathology are less amenable to interventions that
improve outcome [35, 38]. Thirty-day mortality fol-
lowing emergency small bowel resection, for example,
© 2013 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia 2014, 69 (Suppl. 1), 70–80
is 21% compared with 8.8% for emergency right hemi-
colectomy [39]. However, targeting other factors relat-
ing to the delivery of high-quality clinical care in a
timely fashion, including haemorrhage and sepsis man-
agement, may yield improvements in postoperative
mortality and morbidity. It has been appreciated since
1990, for example, that pre-operative delay of more
than 24 h is associated with in-hospital mortality of
45% among octogenarians undergoing emergency lapa-
rotomy, compared with 6% if surgery is expedited
before 24 h [40], figures which are similar to the five-
fold increase in in-hospital mortality if emergency
surgery for perforated peptic ulcer is delayed in octo-
genarians beyond 12 h from hospital admission [41].
In the presence of sepsis, there is clear evidence that
early administration of antibiotics is associated with
improved survival, and in the context of a surgical
source of sepsis, this is augmented by early source
control [42].
The provision of postoperative critical care also
affects outcome, mainly by reducing attendant compli-
cations. A recent analysis of high-risk emergency gen-
eral surgical admissions recorded by the NHS Hospital
Episode Statistics database found that hospital Trusts
with low 30-day mortality provided significantly more
intensive care beds per 1000 hospital beds [43]. The
concept of ‘failure to rescue’ high-risk patients has
been recognised as an important cause of postoperative
morbidity and mortality, with a 38% in-hospital mor-
tality rate occurring among patients discharged to a
standard ward before critical care admission, compared
with 30% for patients admitted directly to intensive
care from the operating theatres [10].
The occurrence of a major complication within
30 days of surgery has been found to be more impor-
tant than pre-operative or intra-operative factors in
determining survival after major surgery [44]. How-
ever, the development of a major complication does
not automatically increase mortality, and hospitals
have been found to have mortality rates independent
of their similar prevalence of major complications
[45].
Pre-operative management
Given the likelihood of sepsis, patients should receive
prompt antibiotic administration, as this is associated
73
Anaesthesia 2014, 69 (Suppl. 1), 70–80 Stoneham et al. | Abdominal aortic aneurysm, laparotomy and hip fracture
with immediate improvements in survival [42].
Although the patient may benefit from a period of
pre-operative resuscitation, this should not unduly
delay surgery. Multidisciplinary input by senior clini-
cians is important in deciding the most appropriate
treatment, guided ideally by pre-operative computer-
ised tomography, reported by a consultant radiologist
specialising in gastrointestinal imaging.
Endoscopic stent insertion as a ‘bridge to surgery’
allows for patient stabilisation before non-emergency
surgery, and is associated with higher primary anasto-
mosis and lower overall stoma rates, with no signifi-
cant difference in complications or mortality [46, 47].
In some cases, a defunctioning or loop ileostomy/
colostomy as a palliative procedure to relieve symp-
toms may be more appropriate.
Assessment of the risks and benefits of emergency
surgery in an elderly patient with significant co-
morbidities presents challenges. Although data from
the Emergency Laparotomy Network audit suggest that
~70% of patients aged over 90 survive at least 30 days
after surgery, the Scottish Audit of Surgical Mortality
found that the most common ‘adverse event’ was a
concern that, in retrospect, the operation should not
have been carried out [48], emphasising the impor-
tance of multidisciplinary decision-making.
Intra-operative management
There is a lack of research providing specific evidence
of best practice for emergency laparotomy in the
elderly patient [49, 50]. Therefore, anaesthetic manage-
ment is extrapolated from data on younger patients,
adjusted for reduced physiological reserve [51], and
includes fluid therapy guided by appropriate monitor-
ing aimed towards treating critically ill patients with
signs of sepsis.
Invasive arterial blood pressure monitoring
should be utilised in elderly patients due to the high
prevalence of co-morbidity and anticipated physio-
logical derangement caused by surgery and sepsis,
and its use has increased since early NCEPOD
reports [1, 3]. It also facilitates near-patient testing
of haemoglobin concentration acid/base status and
oxygen exchange, the latter two parameters being
important in deciding on postoperative destination.
The use and method of goal-directed fluid therapy
74
in elderly patients (particularly) undergoing emer-
gency surgery is controversial [52, 53]. NCEPOD
highlighted hypovolaemia as a major contributor to
hypotension during the peri- and postoperative per-
iod, particularly after emergency abdominal surgery [1,
3]. However, a recent Cochrane review concluded that
goal-directed therapy does not reduce mortality, but
suggested that postoperative complications (renal and
respiratory failure, and wound infection) and length of
stay were reduced, although evidence was lacking about
use in emergency surgery [54]. The use of epidural anal-
gesia should balance the potential risks of hypotension
and epidural sepsis [55] against the proven benefit of
reducing respiratory complications [56]. There is early
evidence suggesting that peri-operative opioids may be
linked to recurrence after cancer surgery [57].
Core temperature should be measured and appro-
priate warming instituted [58].
Postoperative management
‘Care Bundles’ standardise the provision of care, and
have been shown to increase the reliability of key steps
of care, for example, by reducing the prevalence of
ventilator-associated pneumonia [11, 59]. Recent guide-
lines recommend that the need for postoperative critical
care is based on an assessment of risk of mortality and
morbidity, with admission to critical care for all
patients with a predicted mortality greater than 10%
[12, 60]. Given that all elderly patients have an
expected hospital mortality rate above 15%, there would
seem to be a strong argument in favour of admitting all
elderly patients to a critical care facility postoperatively.
Ongoing postoperative care should include routine
input from a senior specialist in elderly medicine.
National Emergency Laparotomy Audit
Many of the issues discussed above have been the sub-
jects of national reports and guidelines, dating as far
back as 1999 [1, 3, 61]. Despite this, there is little evi-
dence that outcomes have improved [5, 35, 37, 62].
However, the National Emergency Laparotomy Audit
has been recently established in the UK, with the aim
of improving outcome after emergency laparotomy
[63]. NELA will publish named hospital risk-adjusted
outcomes for patients, and inform quality improvement
programmes designed to disseminate best practice
© 2013 The Association of Anaesthetists of Great Britain and Ireland
Stoneham et al. | Abdominal aortic aneurysm, laparotomy and hip fracture Anaesthesia 2014, 69 (Suppl. 1), 70–80

identified in the hospitals with the lowest mortality, Hip fracture

measuring care provision against published standards Hip fracture patients epitomise the hazards of emer-
(summarised in Table 1) [12, 60]. gency surgery for the frail elderly. The global preva-
lence of hip fracture has been forecast to rise in line
Table 1 National Emergency Laparotomy Audit stan- with demographic changes in population, and the
dards of care for patients undergoing emergency lapa- median age at which patients present is currently ris-
rotomy.
ing in Northern Europe (by about 1 year of age every
5 years) [64]. In addition to high peri-operative mor-
Risk assessment tality and morbidity, hip fracture is associated with
High-risk patients identified as those with predicted extensive, expensive rehabilitation and loss of indepen-
mortality > 10% should receive surgery under the direct
supervision of consultant in anaesthesia and surgery dence, and more commonly if patients experience
In addition to objective risk calculation, the following delay before surgery, inadequate analgesia, blood loss,
patients also have a > 10% mortality:
dehydration, unsympathetic anaesthesia, surgical stress,
● Patients aged > 65 years
● Patients with shock of any cause, any age group malnourishment and hypoxia, or secondary complica-
Pre-operative tions, such as delirium, pneumonia, cardiac failure,
Prompt surgical review required with assessment of risk thromboembolism and wound infection [65]. Uncom-
(P-POSSUM recommended)
If sepsis present – sepsis bundle with early antibiotics < 1– plicated, expedited recovery requires multidisciplinary
3h intervention and multimodal peri-operative rehabilita-
Appropriate imaging to define pathology (computerised
tion programmes [13, 66].
tomography recommended)
Adequate communication between consultant surgeon
and anaesthetist Pre-operative optimisation
Access to theatres according to surgical urgency:
● ongoing haemorrhage – immediate surgery Hip fracture most commonly occurs after a simple fall
● septic shock – surgery within three hours of the from standing height in patients with a high preva-
decision to operate
lence of co-morbidities, which may be complicated by
● severe sepsis (with organ dysfunction) – surgery
within six hours to minimise deterioration into septic an acute medical problem, such as a chest infection.
shock Traditionally, surgery was postponed until patients had
Intra-operative recovered from any acute illness and were deemed ‘fit’
Antibiotic therapy in line with specific hospital policy
Goal-directed fluid therapy for anaesthesia and surgery, resulting in pre-operative
Ensure normothermia delay. There is now very strong evidence that delay
Assessment of base excess and serum lactate
from hospital admission to surgery increases mortality,
Effective analgesia
lengthens hospital stay and delays functional recovery
End of surgery care bundle
Reassess risk in light of operative findings: P-POSSUM [67, 68]. Delays normally relate to either organisational
recommended (51%) or medical (44%) problems, both of which are
Within 30 min of the end of surgery, assess:
● lactate/base excess amenable to managed reduction [69]. The majority of
● PO2/FIO2 ratio early deaths after hip fracture surgery are attributable
Admission to critical care if: to pneumonia, myocardial ischaemia or heart failure
● High-risk patient (e.g. any elderly patient)
[70], but there is no evidence to support pre-operative
● > 10% predicted mortality (P-POSSUM)
● Lactate > 4 mmol.l 1 delay for medical treatment as a method of reducing
● PO2/FIO2 ratio < 40 mortality, possibly excepting severe (but rapidly treat-
● Hypothermia < 36 °C
able) derangements of physiology [13]. Improving
Assess neuromuscular blockade
Prescribe antibiotics and fluids for the postoperative patient care pathways towards facilitating ward admis-
period sion from the emergency room and early corrective
Multidisciplinary care surgery are probably of more benefit [67, 70]. Rando-
In the elderly, continuing care/rehabilitation with
mised controlled studies of the effectiveness of specific
assistance from consultant in medicine for the care of
older people pre-operative optimisation in reducing postoperative
mortality and morbidity are urgently needed.

© 2013 The Association of Anaesthetists of Great Britain and Ireland 75

Anaesthesia 2014, 69 (Suppl. 1), 70–80 Stoneham et al. | Abdominal aortic aneurysm, laparotomy and hip fracture
Hip fractures can be associated with severe pain
in the pre-operative period, particularly on movement
[71]. Peripheral neural blockade of the lumbar plexus
in the form of a femoral nerve or fascia iliaca block
has been shown to reduce pain and opioid consump-
tion in the pre-operative period [72], but the effect
on outcome is less certain [72, 73]. Epidural analge-
sia, although out of favour currently in the UK [6],
provides very effective pain control in the pre-
operative period, and reduces the number of cardiac
events [74].
At hospital admission, hip fracture patients are
often anaemic, due to fracture haemorrhage, and hy-
povolaemic, secondary to dehydration and worsened
by subsequent pre-operative fasting, potentiating intra-
operative hypotension. Research is required to calcu-
late how much pre-operative fluid resuscitation is
required to improve peri-operative outcome [75, 76].
Intra-operative management
It remains uncertain whether general or neuraxial
anaesthesia is associated with better outcomes after hip
fracture surgery, although evidence currently points
towards neuraxial anaesthesia as the best technique for
reducing postoperative morbidity (if not necessarily
mortality) [77–79], as reflected in professional guid-
ance [13].
However, direct research comparison of ‘regional’
vs ‘general’ anaesthesia is a complex issue [80], and
many questions remain unanswered, for example, such
as whether general anaesthesia should involve intuba-
tion/mechanical ventilation, co-administration of
peripheral nerve blockade and age-adjusted adminis-
tration of inhalational/intravenous agents, or whether
intrathecal/epidural anaesthesia should be administered
after peripheral nerve blockade or sedation [81] or at
lower doses [82].
Hip fracture patients lose the equivalent of
~25 g.l 1 haemoglobin peri-operatively, from the frac-
ture site, surgery, haemodilution and postoperative
haemorrhage, most of which is unobserved [83] and
which is potentiated by co-administered anticoagulant
drugs. Regional anaesthesia and anti-fibrinolytic agents
(tranexamic acid) potentially reduce intra-operative
bleeding [77, 84], but their effect on outcome linked
specifically to anaemia and/or transfusion is unknown.
76
A recent Cochrane review of (cardiac output-)
guided fluid therapy was inconclusive due to lack of
evidence, but appears to show reduced postoperative
complication rates and length of stay [85]. If only
intra-operative goal-directed therapy is used, patients
could arrive in theatre after a prolonged pre-operative
period of reduced oxygen transport secondary to hypo-
volaemia and/or anaemia, at which point, intervention
might very well be too little or too late to affect post-
operative outcome.
Postoperative care
The goal of hip fracture surgery is to return patients to
their pre-fracture level of function (or better). Delayed
ambulation obstructs this goal, and peri-operative
anaesthetic management should aim to optimise the
chance of ambulation, as one facet of early postopera-
tive, multidisciplinary rehabilitation [65, 86]. Strategies
include the implementation of prescriptive postoperative
care bundles (detailing fluid therapy, analgesia, and
management of anaemia, for example) [11], provision
of critical care facilities and physiotherapy, and the
avoidance of delirium [87].
Postoperatively, profound pain on movement may
persist even though the fracture is fixed, and can con-
tribute to postoperative delirium along with dehydra-
tion, infection and hypoxia, delaying rehabilitation.
Opioid analgesia can contribute to delirium, so non-
opioid methods are preferable, possibly involving sin-
gle-shot but not continuous femoral nerve blocks, as
the latter have shown almost no effect on pain or post-
operative morbidity [88]. Epidural analgesia provides
excellent analgesia both at rest and during movement,
and seems to facilitate physiotherapy [89]. No data
support large volume, low-dose local infiltration anal-
gesia in hip fractures at present [90]. All patients
should have prescribed regular paracetamol [13]
and, cautiously, short courses of non-steroidal anti-
inflammatory drugs [91]. It should be noted, however,
that ~36% of hip fracture patients present with at
least moderate renal dysfunction, which can potentiate
the adverse effects of both opioid and non-steroidal
analgesia [92].
The effect of moderate peri-operative anaemia
(haemoglobin concentration 80–100 g.l 1) on outcome
after hip fracture surgery remains contentious. The
© 2013 The Association of Anaesthetists of Great Britain and Ireland
Stoneham et al. | Abdominal aortic aneurysm, laparotomy and hip fracture
only study of hip fracture patients randomised to
either liberal or restrictive transfusion thresholds in
the intra- and immediate postoperative phase reported
reduced mortality and cardiovascular morbidity when
a liberal transfusion threshold (100 g.l 1) was used
[93]. This contrasts with the FOCUS trial, in which
60-day mortality and independent walking rates were
not found to be significantly different between hip
fracture patients randomly assigned to either liberal or
restrictive transfusion thresholds in the rehabilitative
postoperative phase (postoperative days 2–3) [94]. A
recent Cochrane review concluded that restrictive
transfusion thresholds (transfusion trigger haemoglo-
bin concentration < 80 g.l 1) are associated with sta-
tistically significant reductions in hospital mortality,
functional recovery, length of stay and complications
compared with liberal transfusion triggers, and sup-
ported the use of restrictive transfusion triggers in
patients with pre-existing cardiovascular disease [95],
even though the evidence base for these was heavily
influenced by the FOCUS study. Until comprehensive
randomised studies of transfusion thresholds in the
acute peri-operative phase are reported, restrictive
transfusion thresholds should be used with caution in
the hip fracture population. Future studies need to
evaluate the impact of both transfusion timing and
ambulation/rehabilitation outcomes within formalised
peri-operative care pathways, involving either intracap-
sular or extracapsular fracture populations.
Peri-operative thromboprophylaxis with acetylsali-
cylic acid, low-molecular weight heparin and fondapar-
inux have all been found to reduce the incidence of
venous thromboembolic events after hip fracture sur-
gery, but the effect on mortality is unresolved [96–98].
Studies have been prone to selection bias, excluding
the frailest and those with increased risk of peri-opera-
tive bleeding, and so may not be representative of out-
comes in the general hip fracture population.
Poor outcomes after hip fracture care may indeed
be related to the age and physical status of the
patients sustaining injury, but there has undoubtedly
been a historic contribution resulting from apathy
towards developing and implementing high-quality
care for those affected. Generalist orthopaedic depart-
ments have traditionally provided surgery, anaesthesia
and rehabilitation for hip fracture patients. However,
© 2013 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia 2014, 69 (Suppl. 1), 70–80
multidisciplinary, specialist care programmes have the
potential both to improve functional outcome and to
reduce mortality [99], and should become the stan-
dard of care in all hospitals.
Readers will have noticed several common themes
repeating throughout this review – more elderly
patients are undergoing emergency major surgery, but
continue to have poor but expensive postoperative out-
comes. Whilst the elderly might be expected to have a
worse outcome compared with younger patients due to
limited physiological reserve and co-morbidity, this
alone does not account for the significant variation in
outcomes that is currently seen. Many of the issues
discussed above have repeatedly been the subject of
national reports and guidelines that have dated back
over almost 15 years. The key to improving this situa-
tion is through participation in continuous quality
improvement programmes, accompanied by further
research to expand the evidence on which care is
based. Given that the number of elderly patients pre-
senting for emergency surgery is only estimated to
continue rising, we encourage fellow anaesthetists to
engage urgently in national audit and research pro-
grammes, with the aim of improving care for these
vulnerable patients.
Competing interests
DM founded the Emergency Laparotomy Network, is
National Clinical Lead for the National Emergency
Laparotomy Audit, and is member of the clinical trial
advisory group for two multicentre research trials
involving emergency laparotomy patients, but for
which he does not receive any remuneration. No other
external funding or competing interests declared.
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