Intended for healthcare professionals


Hyponatraemia after orthopaedic surgery

BMJ 1999; 319 doi: (Published 21 August 1999) Cite this as: BMJ 1999;319:514

Failsafe system is needed

  1. Andrew M Severn, council member, Age Anaesthesia Association (,
  2. Chris Dodds, council member, Age Anaesthesia Association
  1. Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster LA1 4RP
  2. Department of Anaesthesia, South Cleveland Hospital, Middlesbrough TS4 3BW
  3. St James's University Hospital, Leeds LS9 7TF
  4. Alexandra Hospital, Redditch, Worcestershire B98 7UB
  5. Coventry and Warwickshire Hospital, Coventry CV1 4FH
  6. Department of Pathology, Faculty of Medicine, Kuwait University, PO Box 24923, Safat, Kuwait
  7. Wellington Hospital, London NW8 9LE
  8. University Department of Surgery, Royal Free and University College Medical School, London NW3 2QG
  9. Department of Neurochemistry, Institute of Neurology, London WC1N 3BG

    EDITOR—There are errors and omissions in Lane and Allen's editorial about hyponatraemia1 and the subsequent responses in the eBMJ.2 The assumption that orthopaedic patients are badly managed has been robustly criticised by those who are insulted about allegations of poor care in this specialty.

    What is it about the patients that may put them at risk? Firstly, orthopaedic patients probably represent the largest group of elderly patients undergoing major and emergency surgery. Secondly, many take non-steroidal anti-inflammatory drugs. Thirdly, the use of spinal anaesthesia may result in too much intravenous fluid being given to counteract the effects of sympathetic block. The discussion about the role of the angiotensin-renin system, though interesting, is not relevant to the pathogenesis of hyponatraemia in these circumstances An old patient who takes non-steroidal anti-inflammatory drugs and receives too much free water while the adrenal axis is affected by a spinal block will probably have problems with sodium balance. The tragedy is that it takes a clinical disaster and an editorial to spell this out.

    The adverse outcome that prompted the editorial was an example of a failed system. There are always several steps in a critical incident that lead to adverse outcomes. The solution is to have a failsafe system We believe that protocols in fluid management have a role, and unless the junior medical staff understand fluid management (and recent changes in training can only make this harder to obtain) the job could be done by specialist nurses acting under the authority of senior medical staff. The issue then is which specialty these senior medical staff should be in: surgical, anaesthetic, or geriatric medicine?

    Frail old women are nursed on busy surgical wards. They have their broken hips mended late in the evening and return to the wards when many of the …

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