PRE-OPERATIVE USE OF ECHOCARDIOGRAM IN PATIENTS WITH FRACTURED NECK OF FEMUR. IS IT JUSTIFED?

Abstract

Echocardiograms are requested in patients presenting with hip fractures and the finding of a cardiac murmur. The opinion amongst anaesthetists in our department is that general anaesthetic (GA) is safer in patients with significant aortic stenosis, mitral regurgitation, or left ventricular impairment compared to spinal anaesthetic (SA).

A retrospective review was carried out and data on fifty patients were collected, who had presented with fractured neck of femur with the finding of a heart murmur and required an echocardiogram pre-operatively.

Our results demonstrated :

1. Focussed history and examination was rarely performed;

2. Thirty five percent of echocardiograms influenced choice of anaesthetic. Of these 100% had abnormal ECG’s;

3. Fifty seven percent of patients with GA had no abnormality on echocardiogram, whereas 31% of patients with SA had abnormality;

4. The average admission to theatre time with an echocardiogram was 4.31 days, compared to 1.6 days in patients without echocardiogram.

Our audit suggests that many echocardiograms are ordered unnecessarily. Effective use of clinical skills and investigations are rarely utilised by orthopaedic doctors, in requesting an echocardiogram. There is delayed operating times, cost implications and increased workload for the cardiology department. There is no indication that the results of these echocardiograms significantly influences anaesthetic choice.

A second audit cycle was performed prospectively with the use of a proforma. An echocardiogram was not ordered if a recent echocardiogram (within last the last year) was normal or if the history, examination and ECG findings in a patient were all insignificant. This demonstrated a reduction in ordering of echocardiograms by 40%. Local guidelines have been implemented in our department.