Techniques, for detecting when patients undergoing surgery for hip fracture need more fluid, may reduce hospital stay, but more research is needed.

Price JD, Sear JJW, Venn RRM

Published Online:

October 8, 2008

Hip fracture is common, and the outcome may be poor. Many patients need more fluid, but clinicians find it difficult to tell how much is needed. Protocols (formal guidance) or advanced monitoring techniques (such as central venous pressure monitoring) may help guide fluid therapy. This review of trials found no evidence about the value of protocols. Some small trials suggest that advanced monitoring techniques shorten the duration of hospital care and have few adverse effects, but more research is needed.

Abstract (click to read)

Background:

Proximal Femoral Fracture (PFF) or 'hip fracture' is a frequent injury, and adverse outcomes are common. Several factors suggest the importance of developing techniques to optimize intravascular fluid volume. These may include protocols that enhance the efficacy of clinicians' assessments, invasive techniques such as oesophageal Doppler or central venous pressure monitoring, or advanced non-invasive techniques such as plethysmographic pulse volume determination.

Objectives:

To determine the optimal method of fluid volume optimization for adult patients undergoing surgical repair of PFF. Comparisons of fluid types, of blood transfusion strategies or of pharmacological interventions are not considered in this review.

Search strategy:

We searched CENTRAL (The Cochrane Library, issue 4, 2003), MEDLINE (1985 to 2003), EMBASE (1985 to 2003), and bibliographies of retrieved articles. Relevant journals and conference proceedings were handsearched.

Selection criteria:

Randomized controlled studies comparing a fluid optimization intervention with normal practice or with another fluid optimization intervention, in patients following PFF undergoing surgery of any type under anaesthesia of any type.

Data collection and analysis:

Searches and exclusion of clearly irrelevant articles were performed by one reviewer. Two reviewers examined independently the remaining studies, extracting study quality and results data. A wide range of short- and long-term outcome data were sought. Studies were excluded if they did not meet selection criteria or if results were likely to be biased. Due to inconsistent data reporting, combination of data was not generally possible.

Main results:

Searches identified four trials, of which two studies, randomizing a total of 130 patients, were of adequate quality and addressed the review question. Both studies were of invasive advanced haemodynamic monitoring, either oesophageal Doppler ultrasonography or central venous pressure monitoring, during the intraoperative period only. In both, invasive monitoring led to significant increases in fluid volumes infused and reductions in length of hospital stay. The pooled Peto odds ratio for in-hospital fatality was 1.44 (95% confidence interval 0.45-4.62). Neither study followed patients beyond hospital discharge or assessed functional outcomes. No serious complications were directly attributable to the interventions. There were no studies of protocol-guided fluid optimization or of advanced non-invasive techniques.

Authors' conclusions:

Invasive methods of fluid optimization during surgery may shorten hospital stay, but their effects on other important, patient-centred, longer-term outcomes are uncertain. Adverse effects on fatality cannot be excluded. Other fluid optimization techniques have not been evaluated. The lack of randomized studies of adequate quality addressing this important question is disappointing. More research is needed.

This record should be cited as:

Price JD, Sear JJW, Venn RRM. Perioperative fluid volume optimization following proximal femoral fracture. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD003004. DOI: 10.1002/14651858.CD003004.pub2

Assessed as up to date:

November 10, 2003

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Primary Review Group:

Anaesthesia Group

Health topics:

Anaesthesia & pain control > Peri-anaesthetic/peri-operative care > Fluid management

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Techniques, for detecting when patients undergoing surgery for hip fracture need more fluid, may reduce hospital stay, but more research is needed.

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