Hip Fracture Surgery in Geriatric Patients: Anesthetic Implications

Hip fractures (proximal femur fractures) pose a significant public health issue among the elderly. The global age-standardized incidence rate for hip fractures among older adults was estimated at 948.81 per 100,000 in 2021.1 Surgical fixation is the preferred treatment and is typically recommended within 24–48 h of injury to lower complications and enhance outcomes. Elderly patients with hip fractures often have serious medical comorbidities and reduced physiological reserve, which increases perioperative risk. Frailty is a key factor influencing postoperative outcomes in older surgical patients. Frailty makes individuals more vulnerable to complications after surgery and has been linked to higher rates of postoperative delirium, complications, longer hospital stays, and increased mortality.2 Anesthesiologists play a crucial role in managing patients during the perioperative period. Proper anesthetic planning, careful hemodynamic control, and effective pain management are essential for reducing the risk of complications. In this issue, Harde et al. present an audit of anesthesia techniques for hip fracture surgery in patients aged 60 years or older at their center and compare hemodynamic parameters, complications, and postoperative outcomes.3 Frailty is a condition characterized by increased vulnerability to stressors resulting from declining function across multiple physiological systems. Cardiovascular reserve is often diminished because of impaired myocardial compliance and decreased autonomic function responsiveness.4 Respiratory function may be affected by reduced lung compliance, weakened respiratory muscles, and impaired cough reflex.5 Frailty is also closely associated with postoperative delirium. Delirium occurs in about 30%–50% of elderly patients undergoing hip fracture surgery and results in longer hospital stays and reduced functional recovery.6 Frail patients also tend to have poor nutritional status and sarcopenia, which slows down recovery and raises the risk of death. Frailty independently predicts postoperative complications and mortality in elderly surgical patients.7 Most elderly patients with femoral fractures have multiple comorbidities such as ischemic heart disease, heart failure, hypertension, diabetes mellitus, chronic kidney disease, and chronic obstructive pulmonary disease. These conditions increase the risk of perioperative cardiovascular and respiratory complications.8 Many elderly individuals are on antiplatelet or anticoagulant medications, such as aspirin, clopidogrel, warfarin, or direct oral anticoagulants.9 These medications can impact the timing and safety of neuraxial anesthesia. Patients often present with dehydration and blood loss associated with the fracture. A femoral fracture can cause significant blood loss, and surgery may increase that loss. Hypovolemia can raise the risk of severe hypotension during anesthesia induction or after neuraxial blockade.10 Proper fluid therapy must balance the risks of hypovolemia and fluid overload, especially in patients with heart problems. Elderly patients have impaired baroreceptor responses and cardiac reserves. Both general and neuraxial anesthesia can lead to hypotension through vasodilation and myocardial depression.11 Careful titration of anesthetic agents and vigilant monitoring are essential. General anesthesia is commonly used for surgeries on femoral fractures. It allows for rapid induction and is especially helpful when neuraxial anesthesia is unsuitable, offering reliable airway management. However, general anesthesia is associated with more hemodynamic instability, postoperative lung issues, and delirium.12 Current anesthetic strategies focus on using short-acting agents, multimodal pain management, and opioid-sparing methods to reduce postoperative complications. Spinal anesthesia is commonly used for hip and femoral fracture surgeries and is associated with fewer thromboembolic complications, better postoperative pain control, and fewer lung problems.13 Severe pain from femoral fractures often makes positioning for spinal anesthesia difficult. Difficult positioning also poses a technical challenge for administering spinal anesthesia. Preoperative regional analgesia, such as a femoral nerve block or fascia iliaca block, can significantly reduce pain and ease positioning.14 Spinal anesthesia can cause significant hypotension due to sympathetic blockade. Care should be taken to limit the amount of local anesthetic administered, especially in frail patients, to minimize hemodynamic instability. Combined spinal–epidural anesthesia provides the benefit of a quick onset from the spinal part, permits dosage adjustment through the epidural catheter, and offers the option for postoperative pain relief. However, the technique is more technically demanding and may not always be ideal in an urgent fracture surgery.15 Multimodal analgesia is recommended for managing postoperative pain. It generally includes paracetamol, regional anesthesia, and carefully titrated opioids when necessary.16 Femoral nerve and fascia iliaca blocks are common regional anesthesia techniques used to reduce opioid requirements and improve patient comfort. The pericapsular nerve group (PENG) block targets the articular branches supplying the hip joint and has shown promising results in providing effective pain relief for hip fracture surgery.17 Effective pain control is crucial for promoting early recovery. In certain high-risk patients with severe heart and lung disease, hip surgery can be done using a peripheral nerve block with light sedation. Techniques such as the PENG or lumbar plexus block provide targeted anesthesia, avoid intubation, improve hemodynamics, and enable quicker, more comfortable recovery.18 Supportive measures include preventing hypothermia, as older patients are more vulnerable to perioperative hypothermia due to impaired thermoregulation and a decreased metabolic rate. Hypothermia raises the risk of coagulopathy, wound infection, and cardiac events.19 Delirium prevention strategies include effective pain management, avoiding benzodiazepines, maintaining normal sleep patterns, and promoting early mobilization.20 Early mobilization and physiotherapy are essential to prevent complications such as deep vein thrombosis, pneumonia, pressure sores, and muscle wasting. Chemical thromboprophylaxis is advised to prevent deep vein thrombosis. Both general and neuraxial anesthesia are suitable options, and the choice should be tailored to the patient’s characteristics, anticoagulation status, and surgical factors. Regional anesthesia techniques are essential in perioperative pain management and can decrease opioid use and postoperative complications. A multidisciplinary team, including anesthesiologists, surgeons, geriatricians, and physiotherapists, is vital for improving outcomes in this vulnerable population. Authors’ contributions This manuscript has only one author who is responsible for the entire work.