Perioperative care of patients with hip and major fragility fractures during the COVID-19 pandemic
A consensus statement from the Faculty of Intensive Care Medicine, Intensive Care Society, Association of Anaesthetists and Royal College of Anaesthetists
11 May 2020
This document provides principles, recommendations and comments on the care given to patients with hip fracture, but these can be extended to the care of patients with fragility fractures at other sites.
Key principles
Despite changes resulting from the management of the COVID-19 pandemic that have substantially decreased operating theatre capacity and activity, the medical and surgical management of patients with hip fracture should, as far as possible, remain unchanged from that offered before the pandemic:
Hip fractures should continue to be primarily managed surgically to reduce pain, restore mobility and improve survival.
Non-operative management of hip fractures should only be considered on an individual patient basis, as before the pandemic. It should not be favoured as an option in order to decrease demand on local resources.
Consider transferring patients to other hospitals if resources are inadequate locally to provide surgical care when it would usually be appropriate.
Patients should be appropriately medically optimised without delaying surgery [1].
Surgery should continue to be completed within 36 hours after hip fracture [2].
Multidisciplinary perioperative team meetings should routinely identify individual patient’s risks of coronavirus infection, their resuscitation status and the ceiling to their treatment [3].
Hip fracture surgery should be performed by consultant or SAS surgeons and anaesthetists working with theatre teams fully familiar with fragility fracture surgery.
In order to maximise the efficiency of surgery, we make the following recommendations:
Surgery should not be delayed for the result of a coronavirus swab test.
Consider giving a fascia iliaca or femoral nerve block on the ward to reduce pain on transfer and minimise theatre time [1].
Local policies compliant with Public Health England guidance should be followed with regard to infection control and the wearing of personal protective equipment (PPE) [4].
Use the pre-operative briefing to agree appropriate PPE to be worn during the operating list.
Consider the use of two operating theatres for one trauma list to minimise the time taken for decontamination, cleaning, recovery and set-up between cases. It may be possible to wear PPE on a sessional basis, including between the two theatres.
Use spinal anaesthesia when possible with fascia iliaca or femoral nerve blocks, and avoid the use of intrathecal opioids to prevent respiratory compromise, postoperative nausea and vomiting, and neurocognitive impairment.
Minimise or avoid intraoperative sedation.
Use the debrief after the theatre list to discuss ways of increasing efficiency without compromising patient or staff safety.
The following comments are of relevance to the efficient use of theatre time and wearing of PPE:
Spinal and other forms of regional anaesthesia are not aerosol-generating procedures (AGPs). There is therefore no need to leave any time period between induction of regional anaesthesia and entry into the room by other team members, or to restrict their presence during spinal anaesthesia.
Fragility fracture surgery involves high-speed devices such as bone drills and saws, which are currently classed as AGPs [4].
Diathermy is not considered an AGP associated with coronavirus infection [4].
Pulsed lavage is currently considered to be an AGP, but manual irrigation is not.
The choice between the use of a tracheal tube or supraglottic airway (SGA) to maintain the airway during general anaesthesia should be made as it would be before the pandemic and need not be affected the patient’s COVID-19 status or infection control precautions [5].
After an AGP has been performed, >86% of airborne virus particles are cleared in five minutes from operating theatres with ventilation systems delivering >24 air exchanges per hour. Public Health England guidance therefore recommends that once vacated by staff following an AGP, an operating theatre should be left empty for only five minutes before cleaning can begin [6]. Laminar flow operating theatres function at >300 air exchanges per hour [7].
Patients can leave the operating theatre immediately after the end of surgery and anaesthesia; the aerosolised particles remain in the room and do not travel with the patient.
Matthew Checketts, Tim Cook, Nicholas Freeman, William Harrop-Griffiths, Dom Hurford, Richard Griffiths, Amy Mayor, Iain Moppett, Stuart White
References
Management of Proximal Femoral Fractures. Association of Anaesthetists. Anaesthesia 2012; 67: 85-98 https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline_management_proximal_femoral_fractures_2011_final.pdf?ver=2018-07-11-163755-037&ver=2018-07-11-163755-037 (accessed 8/5/20).
The management of hip fracture in adults. National Institute for Health and Care Excellence Clinical Guideline Centre (CG124) 2011: Updated 2017. https://www.nice.org.uk/guidance/cg124/ (accessed 8/5/20).
Clinical guide for management of fragility fractures during the coronavirus pandemic. https://icmanaesthesiacovid-19.org/guidance-on-perioperative-management-of-patients-with-fragility-fractures (accessed 8/5/20).
Covid 19 Personal Protective Equipment. Updated 27 April 2020. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe#ppe-guidance-by-healthcare-context (accessed 8/5/20).
Use of supraglottic airways during the COVID-19 pandemic. https://icmanaesthesiacovid-19.org/use-of-supraglottic-airways-during-the-covid-19-pandemic (accessed 8/5/20).
Reducing the risk of transmission of Covid-19 in the hospital setting – section 9.2. Updated 27 April 2020. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/reducing-the-risk-of-transmission-of-covid-19-in-the-hospital-setting (accessed 8/5/20).
Current Evidence for the Use of Laminar Flow in Reducing Infection Rates in Total Joint Arthroplasty. Open Orthopaedic Journal 2015; 9: 495-8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4645891/ (accessed 8/5/20).