Pre-emptive holding of antihypertensives in the first three days after neck of femur fracture surgery: a study in an orthogeriatric ward

Introduction:

Elderly patients undergoing surgery for neck of femur (NOF) fractures are at high risk of post-operative hypotension due to reduced physiological reserve. Hypotension in this context is associated with an increased risk of cardiovascular events and impaired recovery. Therefore, senior clinicians often pre-emptively hold angiotensin-converting enzyme inhibitors (ACE-Is) and calcium channel blockers (CCBs) for 48 hours post-operatively, but this practice is inconsistently followed by resident doctors. We audited the prevalence and impact of this practice, and introduced an intervention to improve consistency.

Methods:

A two-cycle audit was conducted on an orthogeriatric ward. Inclusion criteria were patients aged >65 requiring surgery for NOF fractures. Data collected included antihypertensive use on admission, whether antihypertensives were held post-operatively, systolic blood pressure on post-operative days (POD) 1–3, episodes of moderate (90–100 mmHg) and severe (<90 mmHg) systolic hypotension, and potential confounders (haemoglobin drop, fluid resuscitation, age). Ethical approval was waived.

After the first cycle, an intervention was introduced: (1) an induction teaching session for resident doctors and (2) a revised post-op proforma prompting holding of ACE-Is and CCBs.

Results:

Twenty-four patients were included pre-intervention and 25 post-intervention. 75% of patients were taking at least one antihypertensive on admission. Already in the first cycle, patients in whom antihypertensives were held pre-emptively had significantly fewer days of severe hypotension in POD 1-3 (0.36 vs. 0.64 days, p=0.03).

Prior to the intervention, antihypertensives were appropriately held in 40% of cases. Post-intervention, this rose to 88% (p=0.04). The average number of days with severe hypotension decreased from 0.62 to 0.28 (p=0.03), and hypotension incidence fell from 35% to 28% (p=0.01).

Conclusion:

Pre-emptively withholding ACE-Is and CCBs post-operatively for 48 hours in elderly patients reduces the incidence and duration of hypotension. Teaching and documentation prompts can embed this practice into routine care and improve post-operative outcomes.