Hip Fracture in a Patient With Severe Pulmonary Hypertension

Abstract

This case presents a discussion of an 80-year-old woman with severe pulmonary hypertension (PH) on chronic intravenous treprostinil infusion and oxygen therapy who presents with a subcapital hip fracture. Care is closely coordinated by an interdisciplinary team, including her PH specialist, in order to optimize her outcome.

Emergency Department Presentation

The patient is an 80-year-old female who fell on her left side a week prior to her emergency department presentation. She has a history of scleroderma and severe pulmonary hypertension (PH) on chronic intravenous (IV) treprostinil infusion and oxygen therapy. She lives in an apartment and is independent with her activities of daily living (ADLs). On the day of the fall, she was walking around the apartment when she tripped over her small dog, which had been running around her feet. She landed on her left hip, but was then able to get up and bear partial weight. Afterward, she started using a walker for support, along with nonsteroidal anti-inflammatory medications, rest, and extremity elevation, which provided little relief. She reported no dizziness, light-headedness, or weakness prior to the fall, and reports no numbness, muscle weakness, or loss of sensation after the fall. Although she recognized the injury as significant, she had become ambivalent about medical interventions and did not want to go to the hospital. The pain finally became sufficiently intense that she did visit her primary care provider. Radiographs revealed a left hip fracture, but the patient adamantly refused to seek surgical attention because she did not want to be hospitalized, despite repeated contacts from various physicians. Finally, with increasing pain, she agreed for evaluation by an orthopedist affiliated to the PH referral center, 2 hours from her home. She describes her pain as aching and constant, worsened by ambulation. The radiographs done in the emergency department demonstrated a subcapital left hip fracture. A geriatrician on call advised over the phone to hold her chronic diuretics and avoid IV fluids. The PH expert is involved from the beginning and reassures the orthopedic nursing staff regarding the management of her chronic IV treprostinil pump. The orthopedics service is concerned about the platelet inhibition associated with treprostinil following a warning generated by the pharmacy, and the resulting potential increased risk of bleeding if they administer standard low-molecular-weight heparin (LMWH).

Comments

• Egan Allen, MD (Geriatrics, palliative care): The history highlights 2 main dimensions pertaining to this patient, impact on function and the need for a palliative intervention. There is much to suggest an immediate mechanical mechanism for her acute injury. Considering acute cardiovascular or neurologic contributors in the spirit of “completeness” may only lead to further delay in the necessary intervention this patient faces, surgical treatment of her fracture. That said, her complex medical history makes her perioperative management complex; this is not the patient with prototypical geriatric fracture. The impact to this patient’s function is likely to be of critical importance. In geriatric patients in general, and in this patient specifically, independence is often paramount when making decisions with respect to medical care. This patient is being maintained with an unusual treatment for a serious chronic illness and requires oxygen at baseline. As an 80-year-old patient, her statistical 1-year mortality in any circumstance is high. She is described as capable of managing her trepostinil pump which speaks to the likely insight she has in the fragility of her situation. She likely knows that in some sense she could develop something severe and sudden and that could threaten her life and, perhaps even more importantly (as is the case for many geriatric patients), her independence. This fracture and her initial reluctance to engage with the medical establishment may stem in part from this self-realization. In regard to her pain, this patient will need surgical fixation. Moreover, a nonoperative treatment plan would likely guarantee a very poor functional outcome (and a poor prognosis in terms of mortality as well). The pain relief itself will be a benefit. We have lost a lot of time already which means we need to assess her current condition in light of surgery and proceed promptly once deemed optimized. The treprostinil is going to be a detail best approached with specialist guidance and with significant deference to the patient (based on the history of the patient’s knowledge). Although there is no mention of dementia, she has a finite chance for delirium postoperatively and the latter deference may need to yield in that case to the specialist. The management of the pump will obviously have nursing impact and open and thorough communication with the nurse and nurse manager would be important. The patient’s PH should be foremost in our mind postoperatively as she is a venous “pooler.” Her renal function may be quite sensitive to volume loss. This is only made more significant by the platelet inhibiting effects of the treprostinil in the context of deep venous thrombosis prophylaxis with LMWH. I would be ready to transfuse this patient should her urine output, blood pressure, and hematocrit drop. I agree with the holding of her diuretics.

• James White, MD (Pulmonary Medicine, PH specialist): The patient’s reluctance to seek care was chiefly related to a prolonged hospitalization she had had about 8 months prior, triggered initially by a central line infection. Disorientation and delirium substantially prolonged her hospitalization, and she was also very uncomfortable with the blood draws and other aspects of standard medical care including LMWH prophylaxis. In talking with her, I emphasized that repairing her hip fracture should be viewed as palliative and further that we would limit interventions if surgery or postoperative care became complicated.

• James Kellam, MD (Orthopedics): The first issue is the home situation and the problem of having dogs, and so on, to fall over. At some time it is necessary for some health care provider to talk to her about falls prevention and making her home safe. I am amazed that with a hip fracture she can be that mobile for 7 days. Also, I am concerned about the 5 days of potential inactivity, poor hydration, and eating. It is important that she has a discussion that involves the geriatrician and surgeon about the pros and cons of care. The final issue is who will admit this patient. She has stable medical conditions but with 7 days of limited activity she is at risk of major complication and with the fact she is on drugs that are problematic for nurses to handle, I would favor admission to a medical service with orthopedic surgery comanaging.

• Rebecca Stanton, BSN, RN, ONC (Nursing): This patient presents with significant comorbidities. Staying in the general orthopedic unit will require work with the pharmacy, family, patient, providers at all levels, specialists, and staff to ensure proper use of the medication pump. Special orders will be needed to allow the family to continue assisting with the pump. The pharmacy will need to ensure and check the IV treprostinil infusion solution. The staff will have ready reference about the IV treprostinil pump to monitor. The family will be able to stay with her during the stay. The team will need to work closely with the family and the patient.

Past Medical History

Apart from her scleroderma and pulmonary arterial hypertension, her medical history is also notable for arthritis, hypothyroidism, Sjogren syndrome, lumbar vertebral fracture, depression, anxiety, and gastroesophageal reflux disease (GERD). In the past year, she had been hospitalized for a central line infection and then briefly for a transient ischemic attack (TIA) which resolved before arriving at the hospital.

Her medications include tadalafil, treprostinil, furosemide, and spironolactone (all for PH), omeprazole, cevimeline (procholinergic for Sjogren syndrome), levothyroxine, duloxetine, lorazepam as needed, diphenoxylate-atropine, nystatin cream, iron, as needed loperamide, olopatodine ophthalmic eye drops, and oxygen via nasal cannula at 3 L (3.5 L while ambulating).

She is a divorced, retired female, who lives in an apartment attached to her daughter’s ranch-style home. She is remarkably functional and enjoys a good quality of life.

She is independent with her ADLs and cooking, ambulates without any devices, and manages her own affairs including independently taking care of her infusion pump. She depends on her family to assist her with transportation. She has been previously evaluated by higher level of care facilities; however, due to the cost of her medications she has not been accepted. She is a former smoker and denies alcohol intake. On review of systems, she mentions occasional palpitations, occasional dyspnea on exertion, and uncontrolled diarrhea twice a week on average (diarrhea related to treprostinil; uses loperamide as a control medication). She is able to walk around the apartment without significant dyspnea. She becomes symptomatic with extended walking (>5 minutes).

Comments

• Egan Allen, MD (Geriatrics): The patient’s prior lumbar vertebral fracture very strongly suggests osteoporosis in this patient. She will need to have a vitamin D level checked. Further, thyroid-stimulating hormone and intact parathyroid hormone should be checked. Surprisingly, she is not on calcium or vitamin D. The GERD may be a barrier to a bisphosphonate (if considered in the past). Her home situation suggests support by her daughter. The expensive medication list she takes may also figure into decisions regarding skilled rehabilitation posthospital; social work will need to be closely involved. The patient’s management of her own pump may also be a key issue to point out to prospective skilled nursing facilities. The mention of the chronic central-line infection may be concerning. I would want to clarify the prior treatment of it given the upcoming open reduction, internal fixation (prosthesis). The “TIA” is also something I would want to clarify. The way it is described, I am assuming it pertains to the prior hospitalization for the central line infection. This patient has already had a bad outcome of something the medical establishment inserted into her body (the central line) and may be a factor in her present situation as described in the history of present illness. She may have a complex trust/distrust aspect to medical care in general. This may be important when considering how to approach her with the trepostinil management (she must be fearful that mistakes may occur if she loses control with its management).

• James Kellam, MD (Orthopedics): Too many drugs for a simple surgeon to cope with, but worries me as to her postoperative care. She is also on no calcium or vitamin D or any osteoporosis treatment. However, from a surgical standpoint she is independent, alert, functioning in society, and so has an excellent chance of surviving surgery but must be warned that her activity levels will drop for at least a year and most likely more. She and her family should be aware that she may require assisted living as she will be less ambulatory but she still may be able to return home with help from the family. Another issue will be anesthesia and potential for prolonged ventilatory support so a living will and do-not-resuscitate status is an imperative conversation prior to surgery.

• James White, MD (Pulmonary Medicine, PH specialist): I agree with this last comment. I had discussed this with her at length prior to her hospital admission and promised to be involved with these discussions as the case evolved.

• Steven Finkelstein, MD (Anesthesiology): There are several challenging aspects to this patient’s medical history apart from the presenting injury. She is obviously frail from her numerous comorbidities, yet she is still functional. The perioperative care and intraoperative management should aim to minimize physiologic disruption. The most salient feature of her history in my view is the PH. I would be concerned with her ability to handle rapid shifts in intravascular volume if she had right ventricular dysfunction. Keeping in mind both her injury and her chronic intermittent diarrhea, I believe her physical examination should focus on her current state of hydration. The presence of worsening peripheral edema would suggest decompensating right-sided ventricular failure, whereas excessive orthostatic swings in blood pressure would suggest intravascular depletion. A neuraxial anesthetic would not be my first choice for her if she was fluid depleted, and this is also relatively contraindicated due to the coadministration of anticoagulant medication. This is where medical comanagement is crucial to the selection of perioperative monitoring options. Perhaps, monitoring of central venous pressure would help guide appropriate fluid management.

• Rebecca Stanton, BSN, RN, ONC (Nursing): The fact that she is living at home and has a past of not being accepted to a skilled facility for rehabilitation will require social work intervention early. She may need a longer length of stay in hospital to ensure a safe discharge to home. Nursing and home care planning and education on falls prevention (having the small dog could cause a problem) and careful monitoring of any anticoagulation therapy will be needed. Her respiratory status may slow her rehabilitation; she may need shorter therapy sessions to facilitate her tolerance. She should have a pressure-reducing mattress to help prevent skin breakdown.

Initial Examination

On examination, she is a well-nourished and well-developed Caucasian female with no acute distress. She is 160 cm tall and weighs 61 kg (body mass index 24). Temperature is 37°C, heart rate is 86, and blood pressure is 136/69 mm Hg with systolic blood pressure range 90 to 140 mm Hg. She is breathing at a rate of 17 breaths/min with an oxygen saturation of 95% on 3 L nasal cannula. She is alert and oriented ×3. Her head, eyes, ears, nose, and throat examinations are normal. She has decreased breath sounds at bases with scattered rhonchi on lung examination. Regular rate and rhythm and prominent S2 are heard on cardiac auscultation. The tunneled central catheter is clean and dry without erythema.

Her abdomen is soft and nontender. The left lower extremity is without any acute deformity, shortening, or rotation. There is tenderness on palpation of the groin area, worsened by external rotation. There is intact sensation and +2 distal pulses in both the lower extremities. There is decreased strength in 4 out of 5 the hip flexors. There is decreased range of motion due to pain. There is notable lower extremity edema, tender to palpation and equal in both extremities.

Comments

• Egan Allen, MD (Geriatrics): The patient’s examination confirms the history in terms of fracture and lends confidence that she is optimized for surgery. Her pain at rest seems thankfully well controlled. There is reassuringly no outward evidence of a problem with the central line.

• James Kellam, MD (Orthopedics): She does not seem to have acute issues that should delay surgery, and from the description of the leg must have a stable minimally displaced fracture.

Initial Evaluation

The electrocardiogram performed shows sinus rhythm with a rate of 83 beats/min, borderline right axis deviation, and T-wave inversion in leads V1-V3. The tracing looks unchanged when compared to the 1 from 3 years prior. The chest radiograph demonstrates mild reticulonodular opacities bilaterally and diffusely, with a left central line tip in the region of the superior vena cava/right atrium junction (see chest radiograph). Left hip films demonstrate a horizontal subcapital fracture of the left hip, with mild impaction and mild degenerative disease (see hip radiographs). She has an echocardiogram from 8 months prior which shows a normal left ventricular ejection fraction (60%) without significant regional wall motion abnormalities. The right ventricular cavity size and systolic function appear to be within normal limits. The right atrial cavity size appears to be enlarged. The echocardiogram estimates moderate PH with pulmonary artery systolic pressure of 50 mm Hg. She had recently undergone a cardiac catheterization which showed optimization of right and left heart filling pressures with a preserved cardiac output. Laboratory tests are without significant abnormalities with white blood cell count 9700, hematocrit 34%, platelets 2 34 000, international normalized ratio 1.0, creatinine 1.17 (with previously noted range of 1.2-1.5), and blood urea nitrogen 37.

The patient is seen by the geriatrician the morning after admission, who finds her to be very anxious about her medication management. She is considered to be a high-risk surgical candidate. β-Blockers are held due to her blood pressure of 99/59 mm Hg at the time of evaluation. Diuretics are held perioperatively with guidance from the PH consultant. He further reassures the nursing management about her infusion pump, and it is collectively determined that the patient or her son will change the cassette because they do this chronically. In addition, the PH consultant provides reassurance on the use treprostinil with prophylactic doses of LMWH, and the patient is placed on a prophylactic dose of dalteparin. The geriatrician reassures the patient frequently that her care is being coordinated by the interdisciplinary regarding her PH medications.

Comments

• Egan Allen, MD (Geriatrics): The objective data do not reveal anything that would delay surgery. She is optimized (but high risk) for this nonelective surgery. Her laboratory work reveals chronic kidney disease. This should be added to her problem list and only furthers the need to be careful when considering her left-sided circulating volume postoperatively. There is no need for repeating an echocardiogram at this time. Doing so will only delay her surgery and incur unnecessary opportunities for the “errors” this patient desperately fears. I agree with the holding of β-blockers given her relatively low-blood pressure. It is reassuring that the PH specialist has been involved. The reassurance given of an open and collaborative approach to her care was essential. Now that we are likely to proceed with surgery I would also reach out to anesthesia to make sure they are aware of her trepostinil pump and her oxygen requirement. I would reassure them that there are no concurrent acute pulmonary issues presently.

• James White, MD (Pulmonary Medicine, PH specialist): Although treprostinil does inhibit platelet aggregation as part of its therapeutic activity, this is not a contraindication to the use of acute or chronic anticoagulation (particularly not for prophylactic doses of LMWH). In fact, many severe patients with PH are chronically anticoagulated with warfarin (although this patient was not). The electrocardiogram and chest radiographs are relatively inconsequential in her risk assessment. The major determinants in her risk assessment are a relatively recent echocardiogram assessing right ventricular size and function and her recent cardiac catheterization results. As long as her functional status and exercise capacity had been relatively stable since the previous echocardiogram, no further testing is necessary. ¹ This is all the more true since neither large fluid shifts nor blood loss is anticipated.

• James Kellam, MD (Orthopedics): There are 2 surgical options for this fracture. It is an impacted valgus fracture that in light of her past week’s history is stable but painful. It is stated that about 80% will heal with nonoperative care of weight bearing as tolerated with a walker over 12 weeks. The down side is the 20% that will displace and need an arthroplasty of some type-a bigger operation than screw fixation of this fracture in its present position. ² This fracture however has some displacement on the medial neck and I feel is at higher risk for displacement than a normal valgus impacted fracture so would be more in favor of surgical intervention with percutaneous screw fixation. With the surgery, she will be more comfortable and better able to ambulate, with weight bearing as tolerated.

• Steven Finkelstein, MD (Anesthesiology): This is where an anesthetic plan is taking shape: If our patient was otherwise healthy, and after ensuring adequate fluid resuscitation, my preference would be a multimodal anesthetic regimen which incorporates regional and general anesthesia, and IV opioid for postoperative analgesia. In any case, I am hoping for a surgical technique that minimizes blood loss and the need for fluid resuscitation. I feel that a single-shot spinal would be unwise in a patient with a tendency toward right ventricular dysfunction and equivocal hydration status. The LMWH effectively shifts the risk–benefit analysis clearly away from the neuraxial techniques. ³ A lower extremity block may be a useful compromise, provided that systemic analgesia could be appropriately dovetailed as the block wears off. The advantage of a regional anesthetic is 2-fold, the requirement for intraoperative levels of both volatile anesthetic agents and IV opioids may be reduced (thus minimizing the need for compensatory treatment with IV fluid and vasopressors), and the requirements for postoperative opioids may be reduced, at least on the first postoperative day. The real downside is that a femoral nerve block alone may not fully cover the territory affected by the incision, although there are proponents of this strategy. Overall, I would lean toward placing the block before a (gentle) induction of general anesthesia, but not relying solely on the nerve block to provide postoperative analgesia. Regardless, analysis of the long-term benefit of one anesthetic technique over another is equivocal. One more thing, before proceeding my physical examination would focus on her scleroderma, as involvement of her face could seriously complicate her airway management. I am not convinced that any further preoperative workup would affect my anesthetic plan.

• Rebecca Stanton, BSN, RN, ONC (Nursing): Detailed preoperative teaching will be needed to assist in alleviating her fears. Education would include prophylactic antibiotic therapy, pain assessment, and medication, reviewing all the present medication orders, the need for indwelling urinary catheter for 24 to 48 hours, the monitoring of IV fluids, and how the team will work with her and her family for her IV treprostinil infusion. The family will be able to go down to the preoperative holding area with her and stay with her until she is ready to go into the operating room. Making sure they allow her family to visit and stay as they want would also help with this goal.

Surgery

The patient is taken to surgery for a planned left hip femoral neck fracture pinning. She receives general endotracheal anesthesia and a femoral nerve block on the left side. She is placed on the fracture table with the right leg in a well-leg holder and the left leg in gentle axial traction with slight internal rotation. An incision approximately 2 cm in length is made in the lateral aspect of the hip and carried down through subcutaneous tissue to the fascia. A guidewire is then placed through the fascia and underlying muscle against the bone, and under fluoroscopic imaging, 3 guidewires are placed in a parallel fashion into the femoral neck and head area followed by short threaded screws placement. Fluoroscopic imaging demonstrates an excellent fracture reduction with screws optimally positioned. Blood loss is estimated to be 50 cm³. The patient tolerates both the procedure and the anesthesia well. She is transported from the recovery room back to her ward room.

Comments

• Egan Allen, MD (Geriatrics): It is not surprising that the anesthetist chose a femoral block given her pulmonary history. It is also reassuring that she incurred only a small amount of blood loss. I expect more, however, postoperatively. She still has a risk of needing a blood transfusion.

• James Kellam, MD (Orthopedics): All seems appropriate. The femoral nerve block I feel is unnecessary as it only delays the postoperative pain for 12 hours and if pain is not managed properly as the block wears off, the patient will be in agony and all will be lost. In most situations, the patient and the nursing are unable to cope with this. The patient will need analgesia to start as she begins to feel the block wear off which may be difficult for an older person to tell in the postoperative period due to confusion and disorientation.

• Steven Finkelstein, MD (Anesthesiology): Not every anesthesiologist would place the femoral nerve block. Dr Kellam’s point about the regional anesthetic is well taken, and if the end of the nerve block is not anticipated, we may indeed find ourselves having trouble with pain management in the middle of the night. That is why good communication between the anesthesiologist, the orthopedic team, the patient, and the rest of her support team is crucial for a good outcome. I encourage the patient and staff to treat the onset of pain early with oral analgesics or patient-controlled analgesia in order to maximize the benefit of any adjunctive anesthetic technique, otherwise—as Dr Kellam correctly states—the patient will ultimately have more pain than if she had not had the block at all. On the other hand, in an environment where our departments are working together, a multimodal anesthetic will provide adequate analgesia with less opioid, which may be beneficial in an elderly patient with impaired pulmonary function.

• Rebecca Stanton, BSN, RN, ONC (Nursing): Her pain will need to be monitored closely. I would notify the provider if she had poor relief or changes in mental status. Protocol-driven pain assessment and management helps insure adequate pain control. Fall precautions education will be continued for her and her family to ensure understanding for her stay in hospital and home.

Postoperative Course

After fracture reduction, the patient is given gentle IV fluids, dalteparin, and her home medications including diuretics. The patient and her son continue management of the treprostinil infusion pump with peripheral supervision by the PH expert.

Her hematocrit remains adequate without transfusion. She is able to bear weight as tolerated and demonstrates the ability to independently reposition and transfer. She is able to ambulate with a rolling walker and has little postoperative pain using as-needed opioids. Postoperative radiographs show excellent screw and fracture position. She is evaluated by an interdisciplinary team including physical therapy and occupational therapy and discharged home on postoperative day 4 with 24-hour supervision, home therapy, and visiting nursing services.

Comments

• Egan Allen, MD (Geriatrics): It is very reassuring that her pain is well controlled, her volume status remained stable (especially with respect to blood loss), and that her physical and occupational therapy were started promptly and she is meeting expectations in terms of function. Given the resilience of this patient and the family’s reliable participation and advocacy it seems reasonable to have a home discharge plan (with 24 hour supervision, home therapy and visiting nurse support). This is the least common discharge plan in general. Although she is medically fragile, the fact that she did so well with the procedure and the family support makes me more confident that the home care plan makes sense. One note, although not stated her urinary catheter should ideally have been removed on postoperative day 1.

• James Kellam, MD (Orthopedics): Excellent in getting back into a familiar environment, but have we forgotten the vitamin D, calcium, and falls prevention counseling and liaison with her primary care provider?

• Rebecca Stanton, BSN, RN, ONC (Nursing): The fact that she was able to return home and have the support of her family is important. Familiar surroundings allow for a better return to preadmission mental status with home care for rehabilitation therapy. ⁴

Discussion Points

1. This case demonstrates the critical importance of frequent and sustained interdisciplinary coordination of care in a patient with a severe chronic comorbidity. For this patient, that coordination included conversations between patient, family, primary care physician, long-standing PH consultant, geriatrician, orthopedic surgeon, anesthesiologist, social worker, and nursing staff.

2. Necessary surgeries are feasible in stable patients on chronic treprostinil infusions, and patients should be encouraged to seek care.

3. In patients who are medically frail, it is essential to guide care based on the patient’s goals and wishes. In this case, her primary concerns were reduction of pain, maintenance of independence, and avoiding prolonged and complicated hospitalization.

4. The availability of onsite PH expertise in patients with severe PH, especially when they are on continuous infusions, is necessary for optimizing the outcome of the surgery.

5. In patients who are stable on chronic PH infusions, the nursing needs are relatively modest, and so the best nursing setting for the patient’s principal problem is reasonable as long as the prescribing PH expert is available to facilitate nursing management. In this case, it was the geriatric orthopedic unit. Additionally, involvement of patient and family when dealing with a patient who is knowledgeable about his or her pump management can help to preserve the patient’s sense of control in the perioperative period.