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Introducing a clinical pathway in fluid management.


Proximal femoral neck fracture is the most common orthopaedic emergency and reason for admission in the UK. There are 50,000 fractured neck of femurs (NOF) in the UK each year (McMorran et al 2005). There is a high incidence of mortality in this group of patients for many reasons. Firstly, patients are often frail, with poor nutritional reserves. Secondly, patients may be dehydrated from having fallen and been immobilised, which may be associated with acute (or acute on chronic) renal failure. Thirdly, patients often have several co-morbidities, including cardio-respiratory disease, exposing them to an increased anaesthetic risk and predisposing to postoperative complications. Patients may be taking medication which may have contributed to a fall, or caused dehydration. Hypovolemia in the elderly could be caused by blood loss of up to 1,500ml (Madore & Davenport 2006), lying on the floor after a fall (insensible losses), diuretics or being nil by mouth due to immobility following a fall or anxiety about incontinence.

The NCEPOD report, Extremes of Age (NCEPOD 1999), found that there was poor fluid management and fluid chart documentation in this group of patients, and the incidence of perioperative hypotension in this group was 17% (Figure 1). The report concluded that: 'Fluid management in the elderly is often poor; it should be accorded the same status as drug prescription. Multidisciplinary reviews to develop good local working practice are required' (NCEPOD 1999, pxix).

The report emphasised the importance of adequate fluid resuscitation in all patients, but especially in the elderly, and that the multidisciplinary team needs to interact to ensure this occurs and that ongoing education of doctors and nurses is vital to reduce mortality.

Patients and methods

Following the publication of the NCEPOD report a baseline audit was undertaken. Between February and September 2000, the notes of 79 patients admitted with fractured NOF to the A&E department at our hospital were examined retrospectively. Perioperative hypotension was measured from the anaesthetic record as a 50% or greater reduction in systolic blood pressure from the admission value. The incidence of factors contributing to hypotension, and fluid management during the admission, was assessed.

From a medical perspective it was found that:

* only 28% of patients were given three litres of crystalloid in the first 24 hours

* a 37% incidence of perioperative hypotension occurred.

From a nursing perspective and from the fluid charts, only one patient had name, date and hospital number recorded and only 15% of the sample had their output accurately recorded on the fluid chart.

These results indicated that fluid management in this group of patients could be improved. Thus a multidisciplinary (MDT) pathway was designed and introduced in February 2002. The pathway development was by Caroline Pillbeam, Orthopaedic Coordinator. The audit tool was developed by Dr R Griffin in association with the Clinical Effectiveness Unit at St Richard's Hospital, Chichester. The fluid management section of the pathway was developed after discussion between the Anaesthetic, Orthopaedic and Medical Directorates, A&E consultants and Dr R Griffin. It was aimed at:

* improving adequate fluid prescribing preoperatively

* improving fluid chart completion

* reducing intraoperative hypotension.

The pathway includes:

* an intravenous fluid regimen of three litres of sodium chloride 0.9%

* space for preoperative medical review

* all MDT notes together in one booklet (medical, operative, physiotherapy and nursing notes)

* data easily available and used to re-audit 2002, 2003, 2005.

The original audit was then repeated in 2002 (43 patients), 2003 (64 patients) and 2005 (100 patients).

Data collection was performed by Dr J Davidson and Dr R Griffin. The data was then summated and analysed using Microsoft Excel. Statistical analysis was used to compare the values of incidence of perioperative hypotension, the incidence of fluid prescribed and the accurate completion of output on fluid charts. This was done by manual calculations using the [chi square] test.



Statistical analysis of hypotension, fluid given and completion of fluid charts Using the [chi square] test, the incidence of perioperative hypotension between the years 2000 and 2005 was compared. The value from 2000 was deemed to be the expected value and from 2005, the observed value. The result was 15.2 with p<0.05 (123.23 (degrees of freedom=99)), thus the difference between the two years is statistically significant.

The [chi square] test was also used to compare the percentage of patients who were prescribed fluids. The value was 120.1 so using the same significance value as above (p<0.05), this is also a statistically significant result. Mortality incidence in the six months following fractured NOF was also examined, and was found to be unchanged over the five year period. Length of stay reduced over the years but as there were many contributing variables, these would need to be controlled in a future study, to assess any associations with preoperative management more accurately. The mean hospital lengths of stay were 20 days in 2000, 22 days in 2002 and 17 days in 2005. There was no significant difference between these years.


From an initial notes audit of patients admitted to our A&E Department in 2000, a protocol-driven pathway was developed to improve fluid management in orthopaedic trauma patients. The initial audit highlighted that only a third of admitted patients were given an adequate fluid prescription and that a third of these patients experienced perioperative hypotension, which was higher than the national average (NCEPOD 1999).

Since the introduction of this protocol-driven pathway, fluid management of patients admitted with fractured NOF has improved and the incidence of perioperative hypotension has decreased significantly. In 2000, 28% of patients were given three litres of fluids and the incidence of perioperative hypotension was 37%. More recently, in 2005, 86% of patients were given adequate fluid replacement, and the incidence of perioperative hypotension was found to be 8%.

The key reason for developing this protocol-driven pathway was as a result of the NCEPOD report in 1999. Since this time a Cochrane review has been published (Price et al 2004) which recommended that patients admitted with a proximal femoral fracture should be given a volume of fluid in excess of that normally given (i.e. on the assumption that they are dehydrated). However, the authors noted that there was insufficient evidence to prove or disprove the effect of the various outcomes of this intervention and that more randomised controlled trials were required to verify any interventions.

There are many reasons for ensuring patients are medically optimised prior to surgery. Optimisation measures include adequate rehydration and identification of medical conditions, including any pre-existing cardiac and respiratory conditions. Admission to ITU may be necessary to allow early accurate assessment of cardiovascular function, for example, using oesophageal Doppler or central venous pressure monitoring. It has been shown that optimised oxygen delivery to the tissues preoperatively improves tissue viability intra and postoperatively and starts with adequate fluid delivery (Tote & Grounds 2006). Early invasive monitoring also allows accurate assessment of physiological parameters which can be quite variable in the elderly patient, especially in those who are at high risk of mortality and morbidity (acute renal failure, over 70 years of age, surgery performed in an emergency setting).

Price et al (2004) noted that adequate rehydration benefits the patient throughout their hospital admission. Preoperative benefits include: treating acute or acute on chronic renal failure, correcting a reversible cause of delirium (Barsoum et al 2006) and correcting electrolyte imbalances. Intraoperative benefits include: maintenance of blood pressure (Charuluxananan et al 2006), good hydration of tissues (Tote & Grounds 2006) and adequate oxygenation of tissues (Charuluxananan et al 2006). Postoperative benefits include reduction in the incidence of thromboembolic disease, chest and urinary tract infections, side effects of anaesthesia and mortality (Tornetta et al 1999), also improved healing and improvement of postoperative mobilisation (Sinclair et al 1997). A prospective RCT assessing intraoperative intravascular volume optimisation found that in the control group, lower volumes of fluid were given preoperatively as the clinicians were anxious about precipitating left ventricular failure. However, Sinclair et al (1997) consider that it is much more likely that patients have occult hypovolemia and therefore fluid resuscitation is required.

The protocol-driven pathway was introduced in our A&E and includes space for three litres fluid prescription, initial A&E admission notes, admission blood and radiological results, medical review, operation note, postoperative daily blood results (including urea and electrolytes), daily medical ward round notes, daily nursing notes and physiotherapy notes. The intravenous fluid prescription is for three litres of crystalloid (sodium chloride 0.9% with potassium to be added to the prescription when the admission electrolytes were available). The first litre is prescribed to be infused over six hours, the second and third over eight hours each. Crystalloid was chosen because it is inexpensive, readily available on all wards and colloids have not been shown to reduce fatality in critically ill patients following trauma (Roberts et al 2004). This choice of infusate is supported by the Cochrane review (Price et al 2004), in which the reviewers concluded that, 'it remains possible that the key component of invasive fluid optimisation techniques is the administration of a volume of fluid in excess of that routinely adminisrered. Systematised (protocol-guided) interventions may deliver important benefits and they may be relatively undemanding of resources or technical skill' (p 9).

The suggestions we made after the first audit include: the continuing education of junior doctors, nurses and health care assistants about the pathway to achieve consistency of care for each patient, and using the same fluid charts in A&E, wards and theatres (currently fluids can be prescribed on casualty card, intravenous infusion charts, pathway and anaesthetic record) to ensure accurate fluid balance throughout each patient's admission. In addition to introduction of the pathway, Dr R Griffin gave educational presentations to both the nursing staff on the orthopaedic wards and also the orthopaedic house officers. It would be interesting to know how fluid prescribing is undertaken in other centres and whether there is improved accuracy from using one prescription chart, rather than several charts throughout an admission. Also, it would be interesting to know if any other hospitals have introduced a protocol-driven method for fluid management, as a limited search of electronic databases (PubMed) did not generate any new publications. This highlights an important implication in the surgical management: for example, it has previously been thought that surgery should be undertaken within 24 hours, but there is a growing body of evidence that supports adequate preoperative optimisation of fluid status and medical conditions to reduce morbidity and mortality (Zohman & Lieberman 1995).


Proximal femoral fracture is common in the elderly and is associated with high morbidity and mortality. An MDT pathway that was introduced in 2002 to improve the intravenous fluid management of patients admitted with fractured neck of femur has proven to improve patient care. Combined with targeted education, this repeat audit has shown a statistically significant increase in the prescribing and administration of intravenous fluids and a reduction in the incidence of perioperative hypotension.

* Fluid management is often poor in this group of patients

* A protocol-driven fluid regime has reduced the incidence of hypotension perioperatively


Barsoum WK, Helfand R, Krebs V, Whinney C 2006 Managing perioperative risk in the hip fracture patient Cleveland Clinic Journal of Medicine 73 (Suppl 1) S46-S50

Charuluxananan S, Bunburaphong P, Tuchinda L, Vorapaluk P, Kyokong O 2006 Anaesthesia for Indian Ocean tsunami-affected patients at a South Thailand provincial hospital Acta Anaesthiologica Scandinavica 50 (3) 320-323

McMorran J, Crowther D, McMorran S et al 2005 Epidemiology of hip fractures Available from [Accessed 17 April 2007]

Madore GR, Davenport RM 2006 Fractures, Hip Available from topic198.htm [Accessed 17 April 2007]

National Confidential Enquiry into Perioperative Death1999 Extremes of AgeAvailable from: [Accessed 18 Apr 2007)

Price JD, Sear JW, Venn RM 2004 Perioperative fluid volume optimization following proximal femoral fracture Cochrane Database of Systematic Reviews Issue 1 Chichester, John Wiley & Sons Ltd

Roberts I, Alderson P, Bunn F, Chinnock P, Ker K, Schierhout G 2004 Colloids versus crystalloids for fluid resuscitation in critically ill patients Cochrane Database of Systematic Reviews Issue 4 Chichester, John Wiley & Sons Ltd

Sinclair S, James S, Singer M 1997 Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial British Medical Journal 315 (7113) 909-912

Tornetta P, Mostafavi H, Riina J et al 1999 Morbidity and mortality in elderly trauma patients Journal of Trauma 46 (4) 702-706

Tote SP, Grounds RM 2006 Performing preoperative optimization of the high risk surgical patient British Journal of Anaesthesia 97 (1) 4-11

Zohman GL, Lieberman JR 1995 Perioperative aspects of hip fracture: guidelines for intervention that will impact prevalence and outcome American Journal of Orthopaedics 24 (9) 666-671

Jennifer Davidson


Senior House Officer St Mary's Hospital, Paddington

Richard Griffin


Consultant Physician in Geriatric Medicine St Richard's Hospital, Chichester

Simon Higgs


Clinical Effectiveness Manager St Richard's Hospital, Chichester
Table 1 Demographics of sample

Year    Mean Age    ASA Grade    Deaths within     Mean hospital
         (years)     3/4 (%)      6 months (%)    length of stay

2000       84           38             24               20
2002       86           67             35               22
2003       82           41             27         (not recorded)
2005       81           50             20               17
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Author:Davidson, Jennifer; Griffin, Richard; Higgs, Simon
Publication:Journal of Perioperative Practice
Article Type:Clinical report
Geographic Code:4EUUK
Date:Jun 1, 2007
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