Perioperative fluid volume optimization following proximal femoral fracture

Proximal Femoral Fracture (PFF) or 'hip fracture' is a frequent injury, and adverse outcomes are common. Many patients are elderly, with significant comorbidity. Several factors suggest the importance of developing appropriate 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.

To determine the optimal method of fluid volume optimization for adult patients undergoing surgical repair of hip fracture. Comparisons of fluid types (e.g. crystalloid vs. colloid) or of blood transfusion strategies or of other pharmacological interventions (e.g. inotropes) are not considered in this review.

Randomized controlled trials (RCTs) since 1985 were identified by searching MEDLINE, EMBASE, the Cochrane Library, the Cochrane Anaesthesia Group's specialized Controlled Trials Register and bibliographies of retrieved articles. Relevant journals and conference proceedings were handsearched.

RCTs comparing a fluid optimization intervention with normal practice (control) or with another fluid optimization intervention, in patients following PFF undergoing surgery of any type under anaesthesia of any type.

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 was sought. Study quality was assessed using a ten-point instrument and studies were excluded if they did not meet the study criteria or if results were likely to be biased. Due to a lack of consistency in reporting, combination of data was not generally possible.

Searches identified only 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 during the intraoperative period only. One study randomized patients to 'normal care' or optimization using oesophageal Doppler; the second study randomized patients to 'normal care', oesophageal Doppler or central venous pressure monitoring. In each study, invasive monitoring led to a significant increase in volume of fluid infused and a reduction 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 (for example return to previous accommodation). No serious complications were reported to be directly attributable to the monitoring interventions. There were no studies of protocol-guided fluid optimization or of advanced non-invasive techniques.

Invasive methods of fluid optimization during surgery may shorten hospital stay, but their effects on other important, patient-centred, longer-term outcomes are uncertain. An adverse effect 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 given the high incidence and frequently adverse outcome of PFF. More research is needed.