Nightly enteral nutrition support of elderly hip fracture patients: a phase I trial.

OBJECTIVE: This non-blinded randomized controlled trial was the first phase of a planned series of investigations designed to test the efficacy of aggressive post-operative enteral nutrition support to decrease the rate of post-operative complications or improve long-term outcomes in specifically defined subgroups of elderly patients who have sustained a hip fracture requiring surgery. METHODS: Eighteen patients (17 males) were randomized to the treatment (eight male subjects) or control groups. The control group (mean age 76.5+/-6.1 years) received standard post-operative care. Subjects in the treatment group (mean age 74.5+/-2.1 years) received 125 cc/hour of nasoenteral tube feedings over 11 hours each night in addition to standard post-operative nutritional care. RESULTS: Both the treatment and control groups had reduced volitional nutrient intakes for the first 7 post-operative days (3,966+/-2,238 vs. 4,263+/-2,916 kJ/day [948+/-535 vs. 1019+/-697 kcal/day], p=0.815), but the treatment subjects had a greater total nutrient intake (7,719+/-2,109 vs. 4,301+/-2,858 kJ/day [1845+/-504 vs. 1028+/-683 kcal], p=0.012). On average, treatment subjects were tube fed for 15.8+/-16.4 days. There was no difference between the groups (treatment vs. controls) in the rate of post-operative life-threatening complications (25 vs. 30%, p=1.00) or in-hospital mortality (0 vs. 30%, p=0.216). Mortality within 6 months subsequent to surgery was lower in the treatment group compared to the controls (0 vs. 50%, p=0.036). DISCUSSION: We conclude that nightly enteral feedings are a safe and effective means of supplementing nutrient intake. The greatest impact of nutrition support may be to reduce mortality.

The change in serum protein concentration in response to the stress of total joint surgery: a comparison of older versus younger patients.

OBJECTIVE: To investigate whether the physiological response to surgery-induced stress, as measured by changes in serum secretory proteins, is more profound on older than in younger total joint arthroplasty patients. DESIGN: Retrospective study. SETTING: A 267-bed teaching hospital. PARTICIPANTS: A total of 220 ambulatory patients with normal admission serum albumin levels, of whom 106 were 65 years of age or older (mean age 73.3 +/- 6.2 years) and 114 less than age 65 (mean age 48.8 +/- 12.2 years). METHODS: Serum albumin and transferrin levels obtained at admission an on the fifth and tenth postoperative days were compared in the two age groups. RESULTS: In both age groups, admission serum albumins were significantly higher than on the corresponding postoperative Day 5 levels (40.4 +/- 3.7 g/L vs 25.0 +/- 3.3 g/L, P < .0001 and 39.5 +/- 2.5 g/L vs 23.9 +/- 3.1 g/L, P < .001 in older and younger patients, respectively). The drop in the serum concentration of albumin by postoperative Day 5 in the older patients was not significantly different from that of the younger patients (a drop of 15.6 +/- 3.3 g/L in older vs 15.4 +/- 4.4 g/L for the younger, P = .740). Among the 64 patients who remained in the hospital 10 days subsequent to surgery, the average postoperative Day 10 serum albumin concentration was significantly lower in the older patients when compared with the younger (26.2 vs 29.1 g/L P = .016). Similar results were obtained for serum transferrin. CONCLUSIONS: Subsequent to elective arthroplasty, the magnitude of change in serum albumin and transferrin concentrations is similar in older compared with younger, patients, suggesting that this stress response to surgery is nor age dependent. In contrast, the rate of recovery of the serum protein concentrations to preoperative levels may be slower in the older patients. However, this issue needs to be investigated further.

Effect of delayed admission to the hospital on the preoperative prevalence of deep-vein thrombosis associated with fractures about the hip.

Thirteen (10 per cent) of 133 patients who had venography on admission to the hospital for a fracture about the hip had radiographic evidence of deep-vein thrombosis. Only seven (6 per cent) of the 122 patients who were seen at the hospital within two days after the fracture had evidence of thrombosis. However, six of the eleven patients who had a delay of more than two days between the fracture and admission to the hospital had evidence of thrombosis. Although there was no significant difference between these two groups with respect to the mean age, sex distribution, frequency of fracture type, or history of deep-vein thrombosis, there was a significant difference in the prevalence of thrombosis in the patients who had a delay before admission to the hospital compared with those who did not (p<0.001). These results suggest that there is a substantial risk of venous thromboembolic disease in patients who have a fracture about the hip, regardless of whether or not they have had an operation, and that this risk increases if the time to presentation is delayed. Consequently, patients for whom there was a delay between a fracture about the hip and admission to the hospital should be considered to be at high risk for, and should be evaluated for, deep-vein thrombosis preoperatively.