Case Discussion

Abstract

This case presents a discussion of a 92-year-old man with multiple comorbidities, who presents with a subtrochanteric fracture. His course is complicated by large volume blood loss intraoperatively, requiring intensive care unit (ICU) monitoring postoperatively. His course is also complicated by delirium.

Emergency Department Presentation

The patient is a 92-year-old man who lives in a nursing home. He ambulates with a walker at baseline. He has a history of dementia and is in his girlfriend’s room when staff hear him fall and find him on the floor at 7 pm. He has left thigh pain immediately and difficulty bearing weight. He denies chest pain, palpitations, dizziness, or shortness of breath. He has no loss of consciousness or head injury. He is taken to the emergency department where he is diagnosed with a subtrochanteric femur fracture with significant extension down the shaft.

Initial films show a spiral fracture of the left proximal femoral diaphysis, extending into the lesser trochanter, with possible nondisplaced fracture of the greater trochanter (see Figure 1).

Figure 1.

Preoperative femur X-ray.

Comments on Emergency Department Presentation

Colleen Christmas, MD (Geriatric Medicine)—My initial thoughts about this patient start with the biggest picture and then I work my way to the details. A nursing home resident who is demented and already 92 years old may have a limited life expectancy, particularly if his dementia is severe, he is losing weight, or has severe comorbidities. I also wonder about the severity of the dementia in terms of his abilities to cooperate with therapy and thus recover from surgery later on and would not want him to take on the risk of surgery if it appeared he has a very short overall life expectancy, excessive surgical risks, or is unlikely to benefit in terms of functional recovery. So, we need to gather more information to determine whether surgery is the right approach for him. If so, we turn our attention to minimizing surgical risks, or if not, we will need to focus on determining a plan for pain control in a bedridden individual. I want to know how demented he is as the term “dementia” could represent a very wide span of cognitive abilities and prognoses. I also want to know more about his physical functioning at baseline. Additionally, we would want to consider the cause of this fall (was this syncope from an unstable cardiac condition that needs to be addressed prior to surgery?).

Simon Mears, MD, PhD (Orthopedic Surgery)—My initial thoughts are that the patient has some cognitive dysfunction which makes his entire pathway of care more difficult. This raises the risks of delirium and other complications and means that medically we really need to be on our A game.

Surgically, subtrochanteric fractures are always more difficult to fix. Reduction of the proximal fragment can be difficult and right away may take more time or require open reduction. The patient also has significant peripheral vascular disease on the X-ray. With this happening in the evening, I am already hoping that we can get him on the operating room (OR) schedule for tomorrow and get this fracture fixed.

Frederick Sieber, MD (Anesthesiology)—In preparation for the OR, the primary concerns of the anesthesiologist center around medical issues. For one, we would want to know whether reliable nursing home records are available, particularly medications and past medical history. Is there a reliable historian available to provide the patient’s past medical history? Second, it is important to verify the patient has no other associated injuries. We also would like to know whether the patient has sustained an acute cardiovascular or neurologic event. In patients with dementia, capacity to provide consent is always an issue. We would wish to know who has power of attorney and whether or not the patient is able to provide informed consent for any surgical procedure.

Examination of the X-rays suggests this may not be a routine hip fracture repair. The anesthesiologist must keep in mind this may be a complicated procedure with prolonged operating time and larger than usual blood requirements.

Julie Votsis, RN (Nursing)—Given his age and the fact that he lives in a nursing home, I would question whether he really walks independently with a walker only? I would also be on alert because of his dementia—wondering whether he would be combative or delirious. How is his pain? Is he at his baseline mental status? I would wonder what kind of family support he has, what his comorbidities are, and if he is compliant with his health care as needed. I would also do a full assessment for skin breakdown and how alert and oriented he is. I would assume he would be going to the OR, so I would get him ready as much as possible for surgery, by keeping him NPO (nil per os) and making sure a urinary catheter, pain medications, large bore intravenous (IV) line, β-blockers, and antibiotics are ordered.

Ron Wood, DPT (Rehabilitation) —While rehabilitation is not appropriate at this point, there is an opportunity for the team to begin planning. There is some basic information here that gives us an idea about his baseline level of function and that in turn helps us to establish a rehabilitation prognosis. The patient’s age and residence in a skilled nursing facility are both factors, but the soft tissue damage associated with this injury will have a significant impact as well. The distal extension of the fracture would suggest damage to some degree of antigravity muscles in the lower extremity (LE), and these will be critical in recovering function.

Past Medical History

His history is significant for hypertension, gastrointestinal (GI) bleed, anxiety, dementia, osteoporosis, benign prostatic hypertrophy (BPH), coronary artery disease (CAD), vitamin B12 deficiency, and mild chronic obstructive pulmonary disease (COPD). He has a history of a right hip fracture with trochanteric fixation nail in March 2010, old pubic ramus fracture, and a history of a left tibial plateau fracture.

The patient is on omeprazole, calcium and vitamin D, metoprolol, trazodone, citalopram, oxycodone, acetaminophen, aspirin, tamsulosin, vitamin B12, senna, and a multivitamin.

He is a nursing home resident, having transitioned after his right hip fracture the year before. He ambulates with a walker at baseline. He is independent with toileting, independent with eating set-up, and needs assist with bathing. He denies alcohol, tobacco, or other drug use. His advance directives indicate that he is full code. Review of systems is unremarkable.

Comments on Past Medical History

Colleen Christmas, MD (Geriatric Medicine)—We need a bit more information about the status of each condition to understand how we should weigh these factors into our decision making. For example, if his GI bleeding was in 2003, and he had an endoscopy that showed gastritis and has been quiescent ever since, this issue would not weigh into our decision making later about the use of blood thinners to prevent deep venous thrombosis (DVT). I would still check a stool for occult blood, particularly if he is anemic, however. If his GI bleeding is an active issue, the patient becomes more complicated. Again, more details about cognitive functioning would be helpful, but the combination of anxiety, dementia, and polypharmacy all mean this man is very highly likely to become delirious with all of the attendant complications of that syndrome. I would like to understand whether he makes decisions independently or if he has a health care agent we should be talking with. I cannot help but be curious about why a man now on his fourth fracture is not on therapy for osteoporosis to reduce subsequent fracture, however this is an unfortunately common scenario. Likely he has undiagnosed vertebral fractures as well, and if he is kyphotic that may further reduce his lung expansion, along with COPD and increase the risks of postoperative pulmonary complications. I am starting to think about ways we can reduce the most likely postoperative complications for this man: delirium, myocardial infarction, pneumonia, DVT, urinary retention, constipation, pain, skin breakdown, perhaps GI bleeding if that is an active issue, functional decline, and perhaps Clostridium difficile–associated diarrhea, given his use of a proton pump inhibitor and upcoming need for prophylactic antibiotics.

Table 1.

Summary of Discussion Points

1.	A thorough evaluation of baseline mental status helps to plan acute risks, rehabilitation potential, and long-term prognosis.
2.	In patients with previous fractures, it is useful to review the type/types of fractures and course following surgery in order to identify potential ongoing impairments, as well as acute and subacute risks.
3.	It is often appropriate to continue β-blockers in patients on chronic therapy.
4.	Consider alternative methods of pain management such as peripheral nerve blocks in patients with dementia and high risk of delirium.
5.	Assess clinically for hypovolemia preoperatively, particularly in the setting of complex fractures.
6.	This fracture pattern often requires that open reduction be performed promptly with clamps or cables, in order to minimize blood loss. Good communication between surgeon and anesthesiologist is essential in planning and carrying out the surgery.
7.	Consider pain as a contributor to delirium and tachycardia.

Simon Mears, MD, PhD (Orthopedic Surgery)—This gives me the indication that this man is declining. He had a fracture last year and was not able to return to independence. Probably a lot of this is from his cognitive dysfunction. This worries me that this fracture will cause further decline. I would hope we can get him through this without further complications so that he can continue at the present level of function. I would like to know more about his family and what other support he has and who is to make decisions if he cannot.

Frederick Sieber, MD (Anesthesiology)—In a patient with such a complicated medical history, this is an area where our geriatric colleagues have an important role. We would like to know from the consultant geriatrician whether medical management of the hypertension, CAD, and COPD have been optimized. We would also seek assurance that no active GI bleed was occurring. Other issues of import include the previous history of dementia which suggests that the patient may have a greater than average risk of sustaining postoperative delirium. The patient is also on multiple medications, several of which are psychoactive, including omeprazole, trazodone, citalopram, and oxycodone. Multiple medications as well as these particular types of medications suggest once again that this patient is at high risk for postoperative delirium.

Julie Votsis, RN (Nursing)—With a significant orthopedic history like that, it would make me question even more how independent he really is with ambulating in the nursing home. Family support is something to look at as well. I would anticipate some issues with voiding after surgery (after the urinary catheter is removed), not only from his dementia, but from his BPH as well. I would anticipate the need for supplemental oxygen because of his COPD, and I would anticipate a higher level of care postoperatively because of his heavy cardiac history and age and complication of fracture. I would also think of him as high risk for embolism, skin breakdown, and atelectasis. I would use appropriate nursing interventions pre- and postoperatively to minimize those types of complications, but remembering he is a geriatric patient with dementia and more interventions may make him more frustrated and anxious. I would prioritize ambulation, hydration, and elimination. I would forgo any compression stockings, try to discontinue his urinary catheter as early as possible and anticipate giving some kind of medication to calm him when agitated instead of using mitts. I would also apply a bed alarm. I would try to medicate less frequently and use crushed meds in pudding to reduce the patient’s stress about frequent medication. I would try to mimic his usual schedule.

Ron Wood, DPT (Rehabilitation)—The past medical history is significant for 3 orthopedic events which likely involved prolonged periods of reduced activity, recovery, and persistent functional deficits. It is quite possible that his tibial plateau fracture required a period of nonweight bearing, likely resulting in strength impairments of the antigravity muscles in the LE. The uninvolved, right, LE has a recent history of hip fracture and subsequent trochanteric nail fixation. This reduces the potential to shift functional demands away from the newly injured limb. There is evidence that alterations in the distribution of weight bearing persist over the long term following hip fracture,¹ suggesting that his prior fracture may have contributed to this fall and future risk will now be increased that much more. In determining a rehabilitation prognosis, it may be useful to find out what prompted his admission into the skilled nursing facility (SNF). Functional decline or a persistent deficit would be quite limiting. If his dementia was the primary factor, this may have implications on the cognitive aspects of participating in a successful rehabilitation.

Initial Examination

On initial examination, he is in no acute distress. He is alert and oriented to person, place, and time. He is comfortable, awake, and talking. Vital signs show a blood pressure of 105/57, heart rate of 57, respiratory rate of 18, and temperature of 36.6, with oxygen saturation of 97%. His heart is in a regular rhythm without murmurs, lungs are clear, and abdomen is benign. Examination of his bilateral upper extremities and right LE demonstrate no tenderness to palpation and full range of motion of all joints. Examination of his left hip demonstrates tenderness to palpation. This is shortened and externally rotated. He is able to fire his ankle dorsiflexors, plantarflexors, and extensor hallucis longis. His sensation is intact to light touch. His skin is intact. He has less than 2-second capillary refill. He has a hematoma on his left thigh.

Comments on Initial Examination

Colleen Christmas, MD (Geriatric Medicine)—I am relieved to hear the first hints that the dementia may not be a strongly limiting factor, as suggested by his orientation to person, place, and time. I would do a complete mental status test now as a baseline to compare to, should he seem delirious later. I am quite concerned by the low blood pressure in a man who has a history of hypertension so would quickly assess his volume status and assure he has sufficient IV access should he require blood transfusions prior to surgery. He does not have a resting tachycardia as one would expect with hypovolemia, but he takes a β-blocking agent so would be unable to mount this response. His heart examination does not demonstrate a murmur to suggest aortic stenosis or arrhythmia that would have caused the fall or would require addressing prior to surgery. He is not wheezing so his COPD is likely not active at this time. He has no overt other injury though given his history of fall we would keep subdural hematoma on our minds, should he become confused later. I am anxious to see his electrocardiogram (ECG), chest X-ray, and baseline labs.

Simon Mears, MD, PhD (Orthopedic Surgery)—This initial examination is encouraging; there does not seem to be anything obvious that will keep us from early surgery. I would like to know more about his cognitive function. A short Mini-Mental State Examination would give a lot of information. He has a diagnosis of dementia but so far we only know he is alert and oriented × 3.

Frederick Sieber, MD (Anesthesiology)—Given the patient’s blood pressure of 105, which is relatively low for an 85-year-old, and the fact that he has a hematoma on his left thigh, one of the concerns during the perioperative period is that the patient would be coming to the OR in a hypovolemic state and may have sustained significant bleeding around the fracture. Blood must be available prior to going to the OR and adequate IV access must be obtained prior to starting the procedure.

Pain management is an important consideration in a patient with this type of fracture. One wants to try to avoid large doses of narcotics to manage pain as this may interfere with the patient’s mental status. A suitable alternative might be peripheral nerve blocks such as a femoral nerve block, possibly with the placement of a femoral nerve catheter for ongoing local anesthetic administration.

Julie Votsis, RN (Nursing)—The only thing that would concern me here is his bradycardia.

Initial Evaluation

Original ECG shows sinus bradycardia at a rate of 54, with no acute changes. Chest radiograph shows linear atelectatic changes in the lung bases which are otherwise clear and normal cardiac contour.

Pertinent labs include a hematocrit of 30, platelets of 299, and white blood count (WBC) of 13.4. Sodium is 134, potassium 5.3, chloride 98, and CO₂ of 24. Blood urea nitrogen (BUN) is 28 and creatinine is 1.26, up from 25 and 1.05, respectively, 1 month prior. International normalized ratio (INR) is 1.2. Urinalysis has a specific gravity of 1.021, with trace ketones, no white blood cells, and no bacteria.

The patient is seen by Geriatrics the morning after admission and is felt to be at intermediate risk for surgery. They recommend holding his β-blocker due to bradycardia and his tamsulosin due to borderline blood pressure. They also recommend blood transfusion in preparation for surgery.

Comments on Initial Evaluation

Colleen Christmas, MD (Geriatric Medicine)—I am not particularly concerned with heart rate in the 50s and would not have held a β-blocker from someone chronically taking them, with at least moderate-to-high risks of adverse cardiovascular complications postoperatively at this heart rate. He receives 3 points on a modified revised cardiac risk index (2 points for having a history of CAD and 1 point for age).² He appears to be volume depleted and I would have hydrated him more, and the transfusion will surely help provide some oncotic pressure. The exact hematocrit cutoffs for blood transfusions are controversial, but I agree with the geriatricians who treated him in deciding to transfuse him because of his evidence of volume depletion, with concern that his hematocrit will drop with hydration, his CAD, suggesting that we want his hematocrit above 30, and because he is about to undergo surgery that is associated with significant blood loss.

Simon Mears, MD, PhD (Orthopedic Surgery)—Again, this is all encouraging information and I would be trying to get him to the OR as soon as possible. Delay is only going to cause harm.

Frederick Sieber, MD (Anesthesiology)—Once again we suspect that the patient is hypovolemic. The probability of this is increased, given the change in the patient’s BUN and creatinine.

While it is understandable that β-blockers were held due to the patient’s vital signs, an alternative approach might be more aggressive fluid management with both crystalloid and blood, while continuing with the β-blockade. Current literature suggests that it may be advisable to continue β-blockers in those patients who already are on β-blockers, to avoid adverse cardiovascular outcomes.³ Preoperative management of this patient’s volume status is not straightforward by any means.

Julie Votsis, RN (Nursing)—His hematocrit is a little low and his BUN and creatinine are slightly increased. Is he dehydrated? I would be a little concerned with holding his β-blocker. I would confirm that with the doctor and make sure to document in a progress note that I discussed that with the provider. I would also check his family support as well in preparation for postoperative care and make sure all necessary preoperative documentation was done accurately to reflect nursing care.

Surgery

The patient is brought to the OR for placement of a trochanteric fixation nail. Given the significant displacement of the fracture and the inability to achieve a reduction closed, the fracture site is opened. A direct lateral approach is performed to the femur with dissection through the skin and subcutaneous fat down to the vastus. The vastus is elevated superiorly over the top of the bone, exposing the proximal and distal fracture sites. With these fracture sites exposed, the long oblique segments are clamped and, using a combination of traction, elevation, and reduction forceps, satisfactory reduction is achieved. A 360 mm intramedullary device is passed down the femoral shaft. Once this is in appropriate position, the blade is passed up into the femoral head. 2 distal interlocks are placed with a freehand technique, and the wound is copiously irrigated. Estimated blood loss is 1700 cc, and operative time is over 4 hours due to difficulty obtaining an adequate reduction. The patient experiences transient hypotension, with a drop in blood pressure to 78/50 during the procedure, requiring norepinephrine (levophed). Because of the large volume loss, he is transfused with 5 units of packed red blood cells (pRBCs), 2400 cc of IV fluids, and 1 unit of fresh frozen plasma intraoperatively. Upon the completion of the case, radiographs are obtained, verifying appropriate length and rotation as well as fracture reduction. The patient is then taken to the intensive care unit (ICU) for ongoing monitoring.

Comments on Surgery

Colleen Christmas, MD (Geriatric Medicine)—Most of the surgical discussion is like a foreign language to me; I scan the operative notes looking to see whether the fracture was adequately reduced and good alignment achieved (so he can weight bear immediately postoperatively), to see how much blood was lost, and to see whether there are complications or unstable vital signs. He had severe hypotension and required a large volume of blood and crystalloid, even transient pressors, so absolutely he should go to the ICU postoperatively for very close monitoring of his cardiovascular and pulmonary systems, monitoring of his oxygenation, vitals, intake and output, and labs. I anticipate he will have issues with volume management over the next couple of days but hope he will be liberated from the ventilator quickly to reduce the risk of pneumonia, one of the most dreaded postoperative complications in older adults associated with a very high mortality. I would be super-vigilant in the ICU to manage and prevent postoperative complications and to try to get him out of the ICU and out of bed as soon as he possibly can.

Simon Mears, MD, PhD (Orthopedic Surgery)—This is a difficult fracture pattern. When I approach this I have a very short period before I decide that the fracture should be opened. It is important to recognize though that reduction does not have to be perfect for rod fixation. It is important though that the deformity typically created (flexion of the proximal segment) is corrected. Otherwise the fracture will not heal. I would try first with a reduction tool or a Cobb elevator to reduce the fracture. The initial drill hole must be properly aligned with the proximal segment. This is best done by reducing the fracture first before drilling the starting hole. If this cannot be done quickly (15 minutes) I would open the fracture and clamp it.⁴ My surgical goal is to do this quickly so that blood loss can be reduced as much as possible. It is good that the patient was transfused but perhaps this could have been more aggressively done to avoid the hypotensive episode. In this patient with a starting hematocrit of 30, I would have transfused when I knew that the fracture would have to be opened. I think the decision to go the ICU is very wise. This patient may require further transfusion and volume management will probably be a big issue for the next several days. With this amount of fluid on board extubation may be difficult and respiratory status will have to be closely monitored. The alignment of the fracture is excellent and this patient should be allowed to weight bear as tolerated.

Frederick Sieber, MD (Anesthesiology)—Given the complexity of this orthopedic procedure and the age and comorbidity of the patient, it is important that good communication occur between the anesthesia team and surgery team throughout the operation. It is important for the surgeon to be aware when there are significant problems in keeping up with the blood loss. In addition, it is important that the surgeon communicate with the anesthesia team if large blood loss is anticipated. In this manner, fluid and blood management will be optimized. Given the large blood loss, it would be important to monitor urine output to get a better idea of the patient’s fluid status since no invasive monitoring was done during the procedure.

An elderly patient with these comorbidities, having this degree of blood loss, and suffering intraoperative hypotension is a setup for postoperative complications. The physicians involved in his care ensured that he was closely monitored postoperatively by sending him to the ICU.

A patient of this age with the above-mentioned cardiovascular comorbidities is highly likely to have underlying diastolic dysfunction. In patients with diastolic dysfunction, fluid balance is tenuous, such that too much intravascular volume will precipitate congestive heart failure, whereas too little intravascular volume will precipitate hypotension.⁵ I would consider placement of invasive monitoring to assist in fluid management of this patient during the postoperative period. For instance, one might consider placement of an arterial catheter, or a central venous catheter, a Foley catheter, and possibly a transesophageal echo to assess intravascular volume. The patient will require close observation of laboratory values until stabilized. Given the patient’s cardiovascular history, and the fact that β-blockers were discontinued prior to surgery, one should consider not only the aggressive fluid management outlined above but also reinstituting β-blockers.

Julie Votsis, RN (Nursing)—The patient lost a lot of blood, and the surgery was long and complicated so I would assume that he will need ICU or a higher level of care postoperatively. He also received a lot of fluid quickly so I would anticipate the need for future β-blockers and assess his intake and output really accurately. I would assume he would be delirious and noncooperative and if he did have family that they would be frustrated as well and may not understand. The nursing staff would be frustrated as well and might anticipate a 1:1 staff member with him to ensure increased safety for patient and staff.

Ron Wood, DPT (Rehabilitation)—The surgical approach is important when planning rehabilitation post-surgery. We may be able to anticipate impairments associated with the incised tissues. Knowing which muscles were damaged from the fracture and which may have been incised as part of the repair will help us to guide our exercise interventions.

Postoperative Course

Postoperatively, the patient is intermittently agitated and delirious. Mitts are placed in the ICU to prevent pulling at lines and drains. He self-extubates himself on postoperative day (POD) #1 and is weaned to a 50% ventimask. He becomes more agitated, pulling at his urinary catheter. Attempts are made to reorient him without success. A physician assistant orders haloperidol 5 mg, and he is noted to be calmer subsequently.

An internal jugular line is placed on POD #1. He does not require any further pressor support while in the ICU. He receives IV metoprolol twice for tachycardia. Postoperative hematocrit is 35, and 12 hours later it is 26. On POD #2, he receives 2 more units of pRBC for a hematocrit of 22. Troponin curve peaks at 0.05 (normal range 0.0-0.02). ECG shows sinus tachycardia at 112 with nonspecific ST-T wave changes. An echocardiogram is attempted while intubated but is nondiagnostic due to body habitus. He fails an initial bedside swallow evaluation but passes a repeat evaluation on POD#3.

He is progressively weaned to room air over the next 2 days. He had been on fentanyl and midazolam for sedation while intubated, but these are weaned after extubation, and he is restarted on his home doses of citalopram and trazodone.

The wound is stable without oozing and follow-up X-rays are deferred until the patient is able to go to radiology.

Comments on Postoperative Course

Colleen Christmas, MD (Geriatric Medicine)—The delirium does not come as a surprise but nonetheless makes us all worry. I would search aggressively for contributors to his delirium; most pressingly I wonder whether his pain is well controlled. If not, it is likely we are treating tachycardia from pain and hypovolemia with metoprolol and agitation from pain with large doses of haloperidol and that would be unfortunate. This can be a real challenge to distinguish at the bedside in a very confused patient, however, and it is likely his caregivers considered this. I would have given him IV morphine to see whether his tachycardia and agitation improved before reaching for a neuroleptic, and then would have tried a lower dose neuroleptic in an elderly man. As noted above, I would not have stopped the β-blocker; but if it had been stopped, I would restart it now on a standing, not as needed, basis. In addition to his pain, I would search vigorously for an infection, pulmonary edema, and drugs that may be causing the delirium and try to address these, if present. His anemia contributes and deserves aggressive management while monitoring volume status. All the while I am recalling that he had a fall, so a subdural hematoma remains in my differential diagnosis. He has a history of anxiety and that may be contributing as well. I would maximize his sensory input, get him up and out of bed as much as possible during the day, try to minimize interrupting his sleep at night, and try to minimize tubes and tethers, limiting these only to the most medically essential ones. I would remove the foley catheter and if he is unable to urinate, institute intermittent straight catheterizations. If the mitts could be avoided, particularly if a family member could sit with him, that would be strongly preferred. There is dubious utility in doing swallowing studies in delirious individuals.

Simon Mears, MD, PhD (Orthopedic Surgery)—With the patient remaining intubated, delirium is really expected in this patient. The dose of haloperidol seems large, although this is a typical dose when the presentation is so dramatic. Probably a smaller dose would be equally effective with less subsequent rebound. The need for further transfusions is expected. I am very happy that his respiratory status has improved and that he is back to room air. This is very encouraging. Often mobilization is difficult in the ICU setting. The nursing staff and physical therapy (PT) need to be encouraged to get this patient out of bed to help pulmonary toilet and to help get the sleep–wake cycle reset.

Frederick Sieber, MD (Anesthesiology)—Postoperative pain management is an issue in this patient. One might consider peripheral nerve blocks in this individual to try to decrease the amount of opioids administered. It would be best if any additional opioids are administered by the nursing staff and not via patient-controlled analgesia. It appears that the patient’s mental status does not allow for this alternative.

Sedation in the ICU, especially in elderly intubated patients, is a controversial area. Commonly used drugs include narcotics and benzodiazepines, both of which may contribute to cognitive dysfunction. Newer studies suggest dexmedetomidine may be a more appropriate drug for ICU sedation in patients who can tolerate it.⁶ Data demonstrate decreased agitation and delirium in ICU patients when this drug is used.

Issues concerning administration of oral medication in a patient who has failed a trial swallowing test present the specter of an increased risk of aspiration. Any oral medications or meals need to be given with supervision to this individual.

Providing adequate oxygen carrying capacity in this elderly patient in the form of red cell transfusion, while at the same time not triggering congestive heart failure in a patient with probable underlying diastolic dysfunction, is an important consideration. Placement of an internal jugular line was performed to help with fluid management and additional transfusions were given to increase the patient’s oxygen carrying capacity. In addition, careful attention must be paid to the patient’s coagulation status. The clinical scenario suggests there may be ongoing bleeding.

β-blockade was reinstituted, given the patient’s tachycardia, ECG changes, and troponin leak. Control of the heart rate is helpful in attenuating any ongoing cardiac ischemia.

The patient has several precipitating factors for his episode of postoperative delirium. I will leave that discussion to my geriatric colleagues. But as noted above, several areas which may impact delirium include adequate pain management, appropriate sedation, and aggressive management of the patient’s cardiovascular status.

Julie Votsis, RN (Nursing)—The mitts are a mistake—they only make things worse. Haloperidol may not be the right approach, and it might be helpful to consult with the geriatrician (even while the patient is in ICU) for possibly different medication. I would try to discontinue the urinary catheter as early as possible. The patient received a lot of fluid quickly, so I would be concerned about the possible strain on his heart. I would continue assessing his skin and question whether he is bleeding in light of his hematocrit. I would continue to assess family support. He would need nursing postoperative assessments frequently as well as 1:1 coverage for safety of the patient and staff. He would need turning and repositioning as much as possible.

Ron Wood, DPT (Rehabilitation)—Despite the patient’s medical status, there may be an opportunity to initiate PT at this point. There is evidence that bed rest poses a host of consequences⁷ which can be mitigated with early mobilization.⁸ However, this should only come after approval from and a conversation with the medical and surgical team to clarify any precautions that should be taken. Passive range of motion (PROM) may further agitate our patient’s apparent delirium and his cardiopulmonary status may preclude any out-of-bed activities. Conversely, PROM or stretching would help with flexibility, and early activity may help to preserve and improve cardiopulmonary function. Also, the ICU nursing staff may not be entirely familiar with patients after hip fracture, particularly given the variety of hip fractures and surgical procedures to correct them. Cooperation between nursing, PT, and possibly respiratory therapy may help capitalize on a frequently overlooked opportunity to preserve or improve function.

Postoperative Course, Continued

He is transferred from the ICU to the floor on POD #3. On transfer, he is described as sleepy but arouseable, oriented to person, and unable to cooperate with a full neurologic examination. On POD #4, a recommendation is made by the geriatrician to avoid mitts,and to discontinue the Foley catheter, IV lines, and oxygen as possible. His Foley catheter and mitts are discontinued. A recommendation is also made to avoid venous compression devices due to delirium and to avoid anticoagulation due to bleeding. His hematocrit is 28.

Postoperative films are completed on POD # 4 and show satisfactory alignment (Figures 2 and 3). He is full weight bearing as tolerated. He is evaluated by PT on POD # 4.

Figure 2.

Postoperative femur X-ray, proximal.

Figure 3.

Postoperative femur X-ray, distal.

By POD # 5, he is alert and cooperative, able to answer questions appropriately, and to follow commands. He is able to tolerate a mechanical soft diet. Central catheter is removed.

He is discharged back to the nursing home on POD #6, with plans for daily PT. He is scheduled to follow-up with the orthopedic surgeon 10 days after discharge, and he is recommended to receive dalteparin for 6 weeks for anticoagulation.

Comments

Colleen Christmas, MD (Geriatric Medicine)—It sounds like he is out of immediate crisis and now the hard work of trying to restore his cognitive and physical abilities become the primary focus. We also want to consider evaluations to prevent fall and fracture #5. The transition from hospital to nursing home tends to be a risky one and so will require very careful communications across several disciplines to safely coordinate care and follow-up. Ideally, the nursing home team would have been involved and updated throughout the hospital course, which would make the hand off of care more seamless.

Simon Mears, MD, PhD (Orthopedic Surgery)—The postoperative delirium seems to be improving but a lot remains to be done. At the beginning, I was concerned that this fracture could lead to a permanent decrease in the patient’s function and this may still be the case. In terms of next steps, the continued aggressive mobilization of this patient is very important. Close medical management in a rehabilitation center is needed so that the patient’s delirium is not further aggravated.

This points to the need for particular care of the hip fracture patient with cognitive dysfunction. This is the most challenging group of patients who have the highest risks of surgery. In general the treatment team is not as familiar with these patients and is not overall as interested in their care. This makes for particular challenges in trying to get the best outcomes.

Julie Votsis, RN (Nursing)—Discontinue all lines that are possible! The patient and family will need a lot of emotional support—I would consider enlisting help from a volunteer to read to the patient or sit with him to make him feel more normal or safer and maybe be able to avoid more medication. I would see that he ambulates as much as possible! He will need to be turned and repositioned or we would use a motorized lift if the patient is unable to cooperate with PT. The patient will need encouragement/assistance in eating and drinking. It is important in order to decrease anxiety and delirium to make the patient feel safe and have knowledgeable geriatric nurses taking care of the patient and his family. Communication with social work and PT and the provider is a must in order to discharge the patient as safely as possible.

Ron Wood, DPT (Rehabilitation)—Given the clearance for full weight bearing and improved medical status it is time to get to work. The rehabilitation team should be coordinating with nursing to maximize pain control while maintaining good mental status, and activity should be encouraged at every opportunity. This is largely through simple things, such as sitting upright in a chair for a few hours, ankle pumps, LE isometrics at regular intervals, and participation in formal PT sessions. A discussion between PT and nursing should take place to avoid things such as bed pans, or bedside commodes, which make nursing care easier but reduce the patient’s activity. PT can provide nursing with tips for assisting with transfers and gait to reduce the burden on their workload and their risk of injury. The patient also benefits by having the opportunity to move more over the course of the day.

The increased activity should help to mitigate the risk of developing a DVT; particularly relevant given that venous compression devices and anticoagulation medications had to be discontinued. The patient’s mental status will be key in accomplishing this broad goal of increasing activity. The more the patient can participate in his own care the better.

Early resumption of weight bearing activity (ie, ambulation, transfers) should be the overriding rehabilitation goal at this point in his recovery. This is also a time to address the issue of fear associated with mobility. His history lists a hip fracture, tibial plateau fracture, and pelvic fracture. It is likely that each of these came from a fall, reinforcing the potential for fear avoidance and further limiting his mobility. The entire team should be encouraging safe mobility, anticipating the patients concerns, and reassuring him that activity will contribute to his recovery.

As the others have mentioned, there are many factors weighing against our patient and I am very concerned about the overall potential for a permanent loss of function. This makes the patient’s involvement in his care and our efforts to promote that involvement in this period even more important.