McLaughlin et al identified preoperative abnormalities in a patient with hip fracture that are associated with postoperative complications. These can help identify a patient who should have problems corrected prior to surgery. The authors are from Mount Sinai Hospital in New York, Bronx VA Medical Center. University of Arkansas, State University of New York, University of Albany and the Hospital for Joint Diseases in New York.
Patient selection: older adult with hip fracture
Parameters:
(1) blood pressure in mm Hg (systolic or diastolic)
(2) cardiac rate and rhythm (heart rate or tachyarrhythmia or heart block)
(3) infection and/or pneumonia (temperature with or without signs of pneumonia)
(4) chest pain and/or cardiac ischemia
(5) congestive heart failure (CHF)
(6) respiratory function (pulse oximetry or PaO2 to PaCO2)
(7) international normalized ratio for the PT (INR)
(8) electrolyte levels (sodium or potassium or bicarbonate)
(9) glucose
(10) renal function (BUN or creatinine)
(11) anemia (hemoglobin)
|
Parameter
|
Major Problem
|
Minor Problem
|
|
systolic BP
|
<= 90 mm Hg
|
>= 181
|
|
diastolic BP
|
NA
|
>= 111 mm Hg
|
|
heart rate
|
<= 45 beats per minute
|
46 to 50 beats per minute
|
|
tachyarrhythmia
|
AF or SVT >= 121, ventricular tachycardia
|
AT or SVT 101-120; sinus tachycardia >= 121
|
|
heart block
|
third degree
|
NA
|
|
temperature
|
< 35°C; >= 38.5°C AND signs of pneumonia
|
>= 38.5°C OR signs of pneumonia (not major)
|
|
cardiac ischemia or chest pain
|
AMI on ECG; chest pain with abnormal ECG
|
chest pain with normal ECG
|
|
CHF
|
pulmonary edema on chest X-ray; CHF on X-ray AND dyspnea or abnormal exam
|
(dyspnea OR pulmonary rales OR S3) AND normal chest X-ray;
|
|
pulse oximetry
|
< 90%
|
NA
|
|
PaO2
|
< 60 mm Hg
|
NA
|
|
PaCO2
|
>= 55 mm Hg
|
47 to 54 m Hg
|
|
INR
|
> 1.6
|
1.4 to 1.6
|
|
sodium
|
<= 125 or > 155 mmol/L
|
126 to 128 or 151 to 155
|
|
potassium
|
< 2.5 or > 6.1 mmol/L
|
2.5 to 2.9 or 5.6 to 6.0
|
|
bicarbonate
|
< 18 or > 36 mmol/L
|
18 - 19 or 35 - 36 mmol/L
|
|
glucose
|
> 600 mg/dL
|
451 to 600 mg/dL
|
|
BUN
|
> 50 mg/dL
|
41 to 50 mg/dL
|
|
creatinine
|
>= 2.6 mg/dL without history of end stage renal disease
|
2.1 to 2.5 without history of end stage renal disease
|
|
hemoglobin
|
<= 7.5 g/dL
|
7.6 to 8.0 g/dL
|
where:
• An abnormal ECG was defined as an ST depression or elevation. Biochemical markers of myocardial damage (troponin) might also be used.
• Second degree heart block might be added as a minor problem.
A parameter was considered abnormal if >= 1 of its components was abnormal.
total number of major abnormal parameters =
= SUM(number of parameters with one or more major problems in components)
Interpretation:
• minimum number of major abnormal parameters: 0
• maximum number of major abnormal parameters: 11
• The risk for complications was associated with > 1 major abnormality OR failure to correct major abnormalities prior to surgery.
• A patient with minor abnormalities only can proceed to surgery without correction.
