Effect of an Optimized Clinical Pathway Protocol Including Fascia Iliaca Compartment Block on Delirium and Postoperative Complications in Elderly Hip Fracture Patients
Abstract
1. Introduction
2. Materials and Methods
2.1. Study Population
2.2. Optimized Clinical Pathway Protocol
- o
- In patients receiving warfarin, treatment was discontinued, and vitamin K was administered. Spinal anesthesia was allowed provided that the International Normalized Ratio (INR) was <1.5.
- o
- Direct oral anticoagulants (DOACs):
- For patients taking apixaban, edoxaban, or rivaroxaban, spinal anesthesia was permitted after a cessation period equivalent to at least two elimination half-lives of the respective drug.
- For patients on dabigatran, a minimum withholding period of 48 h post-last dose was required before spinal anesthesia could be administered.
- In individuals with renal insufficiency, these drug cessation intervals were adjusted according to the degree of renal impairment.
- o
- Antiplatelet medication was discontinued upon hospital admission except aspirin
- o
- Surgical procedures were not delayed due to antiplatelet therapy cessation and the use of general anesthesia was encouraged.
- o
- Avoid psychotropic drugs, opioids, anticholinergics, and antihistamines.
- o
- Transfusion was considered when hemoglobin (Hb) levels fell to 8–9 g/dL. For patients with cardiac disease, a higher transfusion threshold of 9–10 g/dL was generally advised.
- o
- Actively prevent hypothermia.
- o
- Treat hypotensive events promptly.
- o
- Furthermore, the protocol stipulated the administration of tranexamic acid and the avoidance of routine urinary catheterization.
2.3. Control Group
2.4. Data Collection and Outcomes
2.5. Outcomes
2.6. Statistical Analysis
2.7. Sample Size
2.8. AI-Assisted Manuscript Preparation
3. Results
Postoperative Management and Complications
4. Discussion
Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Clinical Pathway N = 117 | Control N = 144 | p | |
---|---|---|---|
Age (yr) | 83.40 ± 9.9; 86 [78.5–90.0] | 84.2 ± 9.5; 86 [80.0–90.0] | 0.43 |
Older than 90 years; n (%) | 33 (28.2) | 42 (29.2) | 0.86 |
Weight | 63 ± 13 | 62.6 ± 13.8 | 0.79 |
Height | 159.1 ± 9.26 | 159.96 ± 8.65 | 0.49 |
Body mass index (kg/m2). | 24.89 ± 4.56 | 24.63 ± 4.76 | 0.65 |
ASA; n (%) | |||
I | 1 (0.9) | - | 0.25 |
II | 24 (20.5) | 30 (20.8) | |
III | 84 (71.8) | 95 (66) | |
IV | 8 (6.8) | 19 (13.2) | |
Sex; n (%) | |||
Female | 83 (70.9) | 105 (72.9) | 0.72 |
Male | 34 (29.1) | 39 (27.1) | |
Comorbidity; n (%) | 116 (99.1) | 138 (95.8) | 0.1 |
Origin; n (%) | 0.63 | ||
Domicile | 100 (85.5) | 120 (83.3) | |
Residence | 17 (14.5) | 24 (16.7) | |
Diabetes; n (%) | 28 (23.9) | 34 (23.6) | 0.95 |
Diabetes treatment; n (%) | |||
Oral antidiabetics | 16 (59.3) | 12 (61.8) | 0.12 |
Insulin | 5 (18.5) | 11 (32.4) | |
No treatment | 6 (22.2) | 2 (5.9) | |
Glucose (g/dL) | 122 [101.0–142.0] | 117 [98.0–144.0] | 0.63 |
Hemoglobin (mg/dL) | 12.5 [11.35–13.45] | 12.7 [11.40–13.67] | 0.59 |
Hypertension; n (%) | 82 (70.1) | 102 (70.8) | 0.89 |
Hypertension treatment; n (%) (ACE-I or ARAII) | 50 (57.5) | 63 (48.1) | 0.17 |
Asthma/COPD; n (%) | 17 (14.5) | 11 (7.6) | 0.07 |
OSAHS; n (%) | 5 (4.3) | 2 (1.4) | 0.15 |
Active smoker; n (%) | 12 (10.4) | 11 (7.9) | 0.48 |
Chronic kidney failure; n (%) | 17 (14.5) | 17(11.8) | 0.51 |
Serum creatinine (mg/dL) | 0.87 [0.74–1.13] | 0.8 [0.68–1.07] | 0.075 |
Estimated GFR; mL.min −1.1.73 m−2 | 47 [33.0–61.0] | 50 [36.0–62.0] | 0.26 |
Liver disease | 6 (5.1) | 6 (4.2) | 0.71 |
Coronary artery disease | 10 (8.5) | 13 (9) | 0.89 |
Heart failure | 18 (15.4) | 22 (15.3) | 0.98 |
Valvular heart disease | 16 (13.7) | 18 (12.5) | 0.77 |
Atrial Fibrillation | 26 (22.2) | 36 (25) | 0.60 |
Cerebrovascular disease | 14 (12) | 17 (11.8) | 0.96 |
Urinary tract infection; n (%) | 2 (1.7) | 5 (3.5) | 0.38 |
Antiplatelet therapy | 21 (17.9) | 34 (23.6) | 0.26 |
Anticoagulation therapy | 30 (25.6) | 38 (26.4) | 0.89 |
Chronic benzodiazepines treatment | 45 (38.5) | 65 (45.1) | 0.27 |
Admission timing | |||
From Monday to Thursday | 80 (68.4) | 79 (54.9) | |
On Fridays | 13 (11.1) | 24 (16.7) | 0.08 |
On weekends | 24 (20.5) | 41 (28.5) | |
Type hip fracture; n (%) | |||
Subcapital femoral fracture | 49 (41.9) | 72 (50) | 0.001 |
Pertrochanteric femoral fracture | 47 (40.2) | 70 (48.6) | |
Basicervical femoral neck fracture | 3 (2.6) | 0 | |
Subtrochanteric femoral fracture | 12 (10.3) | 3 (1.4) | |
Persubchanteric femoral fracture | 5 (4.1) | 0 | |
Other fractures | 1 (0.9) | 0 | |
Type of surgical operation; n (%) | |||
Hemiarthroplasty | 48 (41) | 66(43.8) | |
Short intramedullary nail fixation | 45 (38.5) | 57 (39.6) | 0.19 |
Long intramedullary nail fixation | 21 (17.9) | 15 10.4) | |
Cannulated or compression screws | 3 (2.6) | 9 (6.3) | |
Cemented implant (yes) *; n (%) | 45 (93.75) | 51 (77.27) | 0.02 |
Surgery duration (min) | 66.21 ± 28.77; | 60.23 ± 24 | 0.07 |
60 [46.5–83.5] | 56 [45.0–70.0] |
Clinical Pathway N = 117 | Control N = 144 | p | |
---|---|---|---|
Delirium status; n (%) | 18 (15.4) | 27 (18.8) | 0.47 |
Dementia; n (%) | 39 (33.3) | 64 (44.4) | 0.11 |
GDS scale; n (%) | |||
1: No cognitive decline | 77 (65.8) | 81 (56.3) | 0.40 |
2: Very mild cognitive decline | 5 (4.3) | 2 (1.4) | |
3: Mild cognitive decline | 9 (7.7) | 15 (10.4) | |
4: Moderate cognitive decline | 5 (4.3) | 7 (4.9) | |
5: Moderately severe cognitive decline | 10 (8.5) | 16 (11.1) | |
6: Severe cognitive decline | 10 (8.5) | 20 (13.9) | |
7: Very severe cognitive decline | 1 (0.9) | 3 (2.1) | |
Barthel index; n (%) | |||
<20: total dependency | 6 (5.1) | 13 (9) | 0.61 |
20–60: severe dependency | 26 (22.2) | 33 (22.9) | |
61–90: moderate dependency | 41 (35) | 51 (35.4) | |
>90: mild dependency | 44 (37.6) | 47 (32.6) | |
Clinical Frailty Scale *; n (%) | |||
1: very fit | 7 (6) | 10 (6.9) | |
2: Well | 20 (17.1) | 24 (16.7) | 0.008 |
3: Well, with treated comorbid disease | 23 (19.7) | 19 (13.2) | |
4: Apparently vulnerable | 25 (21.4) | 21 (14.6) | |
5: Mildly frail | 23 (19.7) | 16 (11.1) | |
6: Moderately frail | 17 (14.5) | 45 (32.6) | |
7: Severely frail | 2 (1.7) | 9 (6.5) |
Clinical Pathway N = 117 | Control N = 144 | Effect Size (95%CI) | p | |
---|---|---|---|---|
Time to preoperative assessment (hours) | 32.86 ± 28.97; 21 [14.0–44.0] | 49.14 ± 56.15; 36 [19.0–62.0] | –8.56 [–15 to –3] | 0.002 |
Time to surgery (days) | 2.68 ± 1.87; 2 [2.0, 3.0] | 3.44± 2.44; 3 [2.0–4.0] | –1 [–1 to 0] | 0.001 |
Time to surgery (hours) | 66.50 ± 45.49; 52.46 [41.75–76.50] | 79.23 ± 55.41; 69 [44.0–99.75] | -–9.5 [–19.5 to –1.52] | 0.02 |
Surgery within 48 h | 49 (41.9) | 43 (29.9) | 1.69 [1.01 to 2.82] | 0.043 |
Time to surgery in patients on antiplatelet or anticoagulants therapy (days) | 2.76 ± 1.42; 2.5 [2.0–4.0] | 4.03 ± 2,8; 3 [2.0–5.0] | –1 [–1 to 0] | 0.006 |
Time to surgery in patients on antiplatelet or anticoagulants therapy (hours) | 66.22 ± 33.8; 59.5 [41.87–87.51] | 90.86 ± 62.12; 76 [49.0–114.75] | –16.41 [–29 to –2.45] | 0.016 |
Time to surgery in patients on anticoagulants (days) | 2.77 ± 1.17; 2 [2.0–4.0] | 4.73 ± 3.23; 4 [3.0–5.5] | –1 [–2 to –1] | 0.002 |
Time to surgery in patients on anticoagulants (hours) | 67.42 ± 30.35; 58 [41.5–98.0] | 106.13 ± 68.71; 92 [66.0–122.0] | –26 [–47 to –9.49] | 0.005 |
Preoperative complications | 20 (17.1) | 47 (32.6) | 0.42 [0.23 to 0.77] | 0.004 |
Delayed surgery due to medical complication; n (%) | 8 (6.8) | 17 (11.8) | 0.50 [0.14 to 1.27] | 0.17 |
Clinical Pathway N = 117 | Control N = 144 | Effect Size (95%CI) | p | |
---|---|---|---|---|
Orthopedic Anesthesiologist; n (%) | 47 (40.2) | 38 (26.6) | 1.85 [1.09 to 3.13] | 0.02 |
Type of anesthesia; n (%) | ||||
Spinal | 109 (94) | 136 (95.1) | 0.8 [0.27 to 2.37] | 0.68 |
General | 7 (6) | 7 (4.9) | ||
Surgical drains; n (%) | 18(15.4) | 39(27.1) | 0.49 [0.26 to 0.91] | 0.023 |
Urinary catheters | 17 (14.5) | 21 (14.6) | 0.99 [0.49 to 1.9] | 0.99 |
Hypothermia prevention; n (%) | 62 (53.8) | 69 (47) | 1.26 [0.76 to 2.09] | 0.35 |
Spinal opioids; n (%) | 83 (76.1) | 88 (66.7) | 1.59 [0.90 to2.82] | 0.10 |
Intravenous opioids; n (%) | 25 (21.7) | 52 (37.1) | 0.47 [0.26 to 0.82] | 0.008 |
Benzodiazepine sedation; n (%) | 22(19) | 42 (29) | 0.55 [0.30 to 0.99] | 0.047 |
PONV prophylaxis; n (%) | 66 (56.4) | 51 (35.4) | 2.36 [1.41 to 3.89] | 0.001 |
Intraoperative fluid volume crystalloid (mL) | 622.97 ± 243.99 500 [500.0–750.0] | 613.21 ± 287.67 500 [500.0–700.0] | 0 [–50 to 100] | 0.18 |
Intraoperative fluid volume colloid (mL) | 394.44 ± 121.13; 475 [250.0–500.0] | 373.33 ± 137.40 400 [250.0–500.0] | 0 [0 to 0] | 0.81 |
RBC transfusion; n (%) | 11(9.4) | 13 (9) | 1.04 [0.45 to 2.42] | 0.91 |
RBC transfusion units (total) | 1.6 ± 0.69; 1 [2.0–2.0] | 1.25 ± 0.45 1 [1.0–1.0] | 0 [0 to 1] | 0.20 |
Tranexamic administration; n (%) | 20 (17.5) | 4 (2.9) | 7.44 [2.4 to 22.48] | 0.001 |
Intraoperative complications; n (%) | 28 (24.1) | 64 (45.7) | 0.37 [0.22 to 064] | 0.001 |
Intraoperative hypotension; n (%) | 23 (20) | 51 (36.4) | 0.43 [0.24 to 0.77] | 0.004 |
Administration of vasopressors; n (%) | 23 (20) | 57 (40.7) | 0.36 [0.20 to 0.64] | 0.001 |
Arrythmia; n (%) | 2 (1.7) | 9 (6.4) | 0.25 [0.05 to 1.2] | 0.053 |
Clinical Pathway N = 117 | Control N = 144 | Effect Size (95%CI) | p | |
---|---|---|---|---|
Postoperative care unit stay (h) | 2.68 ± 1.19; 2.4 [2.0, 3.0] | 2.94 ± 1.70; 2.5 [2.0–3.1] | 0 [–4 to 0] | 0.16 |
Standardized analgesic protocol; n (%) | 109 (93.2) | 38 (26.4) | 38 [16.94 to 85.25] | 0.001 |
Early mobilization; n (%) | 87 (74.4) | 59 (41.3) | 4.12 [2.42 to 7.28] | 0.001 |
Time to mobilization (hours) | 31.2 ± 29.3 21 [18.0–38.0] | 37.14 ± 23 24 [22.0–47.0] | –5.7 [–8 to –3] | 0.001 |
Time to ambulation (hours) | 78.4 ± 62.4; 65 [39.0–115.0] | 88.6 ± 51.7 72 [48.0–120.0] | –14 [–26 to –2] | 0.028 |
Early food and drink intake; n (%) | 102 (87.2) | 91(63.6) | 3.49 [1.86 to 6.56] | 0.001 |
Glucose control; n (%) | 96 (82.1) | 140 (97.2) | 0.13 [0.04 to 0.39] | 0.001 |
Blood transfusion; n (%) | 50 (42.7) | 64 (44.4) | 0.95 [0.58 to 1.56] | 0.78 |
Composite of 30-day mortality or major complications; n (%) | 17 (14.5) | 37 (25.7) | 0.49 [0.26 to 0.92] | 0.02 |
Postoperative delirium; n (%) | 34 (29.3) | 63 (43.8) | 0.52 [0.31 to 0.88] | 0.015 |
Wound infection, n (%) | 3 (2.5) | 1 (0.69) | 3.79 [0.39 to 36.9] | 0.21 |
Urinary tract infection; n (%) | 15 (12.8) | 16 (11.1) | 1.18 [0.56 to 2.51] | 0.65 |
Ileus; n (%) | 35 (29.9) | 42 (29.2) | 1.04 [0.61 to 1.79] | 0.86 |
Need for reoperation; n (%) | 7 (6) | 5 (3.5) | 2.56 [0.75 to 8.75] | 0.33 |
Readmission; n (%) | 10 (8.8) | 8 (5.7) | 2.04 [0.76 to 5.45] | 0.33 |
Length of hospital stay; (days) | 15.50 ± 11.26; 13 [10.0–17.0] | 14.34 ± 9.6 12 [9.0–16.0] | 1 [–1 to 2] | 0.32 |
30-day mortality; n (%) | 5 (4.3) | 12(8.3) | 0.49 [0.16 to 1.43] | 0.18 |
1-year mortality; n (%) | 24 (20.5) | 28 (19.4) | 1.17 [0.64 to 2.16] | 0.83 |
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Corbella-Giménez, C.; Monge-Cid, E.; Gallo-Carrasco, A.; Barros García-Imhof, J.; Sánchez-Rodríguez, F.; Díaz-García, J.; Vasserot, I.; Anadon-Baselga, M.J.; Zaballos, M. Effect of an Optimized Clinical Pathway Protocol Including Fascia Iliaca Compartment Block on Delirium and Postoperative Complications in Elderly Hip Fracture Patients. J. Clin. Med. 2025, 14, 5284. https://doi.org/10.3390/jcm14155284
Corbella-Giménez C, Monge-Cid E, Gallo-Carrasco A, Barros García-Imhof J, Sánchez-Rodríguez F, Díaz-García J, Vasserot I, Anadon-Baselga MJ, Zaballos M. Effect of an Optimized Clinical Pathway Protocol Including Fascia Iliaca Compartment Block on Delirium and Postoperative Complications in Elderly Hip Fracture Patients. Journal of Clinical Medicine. 2025; 14(15):5284. https://doi.org/10.3390/jcm14155284
Chicago/Turabian StyleCorbella-Giménez, Carmen, Elena Monge-Cid, Alba Gallo-Carrasco, Jorge Barros García-Imhof, Francisco Sánchez-Rodríguez, Jesús Díaz-García, Ignacio Vasserot, Maria José Anadon-Baselga, and Matilde Zaballos. 2025. "Effect of an Optimized Clinical Pathway Protocol Including Fascia Iliaca Compartment Block on Delirium and Postoperative Complications in Elderly Hip Fracture Patients" Journal of Clinical Medicine 14, no. 15: 5284. https://doi.org/10.3390/jcm14155284
APA StyleCorbella-Giménez, C., Monge-Cid, E., Gallo-Carrasco, A., Barros García-Imhof, J., Sánchez-Rodríguez, F., Díaz-García, J., Vasserot, I., Anadon-Baselga, M. J., & Zaballos, M. (2025). Effect of an Optimized Clinical Pathway Protocol Including Fascia Iliaca Compartment Block on Delirium and Postoperative Complications in Elderly Hip Fracture Patients. Journal of Clinical Medicine, 14(15), 5284. https://doi.org/10.3390/jcm14155284