8.1 Pain relief

Many drugs used for pain relief and methods of administration are available and it is not possible in the context of this guideline to discuss specific techniques. The provision of good pain relief for postoperative patients is generally associated with reduced cardiovascular, respiratory and gastrointestinal morbidity. Good analgesia is thought to enhance early mobilisation and may be associated with early discharge from hospital.

Studies have shown a reduction in postoperative opioid requirements when peripheral nerve blocks were used but have not shown any clinical benefits as a result of this reduction.⁶⁴ Evidence level 1++

The analgesic requirements of patients with fractured hip and the adequacy of current analgesic practice have not been fully evaluated. Adequate assessment of analgesia and pain in the confused elderly patient remains a major challenge.

The Royal College of Surgeons of London recommends regular assessment and formal charting of pain scores as this can help in the management of pain.¹⁵⁵ Evidence level 4

Regular assessment and formal charting of pain scores should be adopted as routine practice in postoperative care.

Pain management in elderly patients should be supervised by practitioners with appropriate specialised experience.

8.2 Oxygen

One RCT and an observational study have shown that hypoxaemia can persist until the fifth postoperative day.^90,91 Evidence level 1+, 2+

Continuous ECG monitoring has shown that episodes of myocardial ischaemia occur in postoperative patients with known ischaemic heart disease in the early hours of the morning and are most common on the second postoperative day.¹⁰¹ Hypoxaemia can be detected by using pulse oximetry regularly to check oxygen saturation levels. Not surprisingly, it has been shown that monitoring oxygen saturation using pulse oximetry reduces the incidence of hypoxaemia.¹⁵⁶ Providing supplementary oxygen increases the mean oxygen saturation, but does not completely prevent episodic desaturation/hypoxaemia in the postoperative period.¹⁵⁷ Evidence level 2+

Oxygen saturation should be monitored routinely to reduce the incidence of hypoxaemia and continued for as long as the tendency to hypoxaemia exists.

Supplementary oxygen is recommended for at least six hours after general or spinal/epidural anaesthesia, at night for 48 hours postoperatively and for as long as hypoxaemia persists as determined by pulse oximetry.

8.3 Fluid and electrolyte balance

Electrolyte imbalances, particularly hyponatraemia and hypokalaemia, are common in the postoperative period¹⁵⁸ and reflect the limited renal reserve of these patients. Evidence level 1+

The situation may be made worse by diuretics and inappropriate composition of maintenance intravenous fluids. Fluid management in elderly patients is often poor⁵³ and elderly women appear particularly at risk of developing hyponatraemia in the perioperative period.⁸⁹ Evidence level 4

Fluid and electrolyte management in elderly patients should be monitored regularly.

Fluid and electrolyte management should begin in A&E (see section 4).

8.4 Early mobilisation

Early mobilisation may prevent complications such as pressure damage and deep vein thrombosis.^58,159 Early mobilisation in combination with pre- and postoperative physiotherapy may be of value in reducing pulmonary complications.¹⁶⁰

If the patient's overall medical condition allows, mobilisation and multidisciplinary rehabilitation should begin within 24 hours postoperatively.

Weight bearing on the injured leg should be allowed.

8.5 Constipation

Prevention of constipation should be considered in the early management of hip fracture patients. Use of opioid analgesics, even in low doses, dehydration, decreased fibre in the diet and lack of mobility can all lead to constipation. The following options should be considered in constipated patients:¹⁶¹

• laxatives
  (as recommended in the British National Formulary for drug-induced constipation)
• increase fluid intake
• increase fibre in diet
• increase mobility.

Prevention of constipation should be considered.

8.6 Urinary catheterisation

The guideline development group found no good quality evidence on urinary catheterisation in hip fracture patients.

In general catheterisation should be avoided, except in the following specific circumstances:

• in the presence of urinary incontinence
• on a long journey
• where there is concern about urinary retention
• when monitoring renal/cardiac function.

In patients with a catheter, good management includes:

• maintaining adequate fluid balance
• ensuring adequate pain relief.

Urinary catheters should be avoided except in specific circumstances.

When patients are catheterised in the postoperative period, prophylactic antibiotics should be administered to cover the insertion of the catheter.