INTRAOPERATIVE INTRAVASCULAR VOLUME OPTIMIZATION AND LENGTH OF HOSPITAL STAY AFTER REPAIR OF PROXIMAL FEMORAL FRACTURE - RANDOMIZED CONTROLLED TRIAL

Objectives: To assess whether intraoperative intravascular volume opti misation improves outcome and shortens hospital stay after repair of p roximal femoral fracture. Design: Prospective, randomised controlled t rial comparing conventional intraoperative fluid management with repea ted colloid fluid challenges monitored by oesophageal Doppler ultrason ography to maintain maximal stroke Volume throughout die operative per iod. Setting: Teaching hospital, London. Subjects: 40 patients undergo ing repair of proximal femoral fracture under general anaesthesia. Int erventions: Patients were randomly assigned to receive either conventi onal intraoperative fluid management (control patients) or additional repeated colloid fluid challenges with oesophageal Doppler ultrasonogr aphy used to maintain maximal stroke volume throughout the operative p eriod (protocol patients). Main outcome measures: Time declared medica lly fit for hospital discharge, duration of hospital stay (in acute be d; in acute plus long stay bed), mortality, perioperative haemodynamic changes. Results: Intraoperative intravascular fluid loading produced significantly greater changes in stroke Volume (median 15 ml (95% con fidence interval 10 to 21 ml)) and cardiac output (1.2 l/min (0.1 to 2 .3 l/min)) than in the conventionally managed group (-5 ml (-10 to 1 m i) and -0.4 l/min (-1.0 to 0.2 l/min)) (P < 0.001 and P < 0.05, respec tively). One protocol patient and two control patients died in hospita l. In the survivors, postoperative recovery was significantly faster i n the protocol patients, with shorter times to being declared medicall y fit for discharge (median 10 (9 to 15) days v 15 (11 to 40) days, P < 0.05) and a 39% reduction in hospital stay (12 (8 to 13) days v 20 ( 10 to 61) days, P < 0.05). Conclusions: Proximal femoral fracture repa ir constitutes surgery in a high risk population. Intraoperative intra vascular volume loading-to optimal stroke volume resulted in a more ra pid postoperative recovery and a significantly reduced hospital stay.