What is the preoperative assessment and optimization for a patient with hypertension, diabetes, and Chronic Obstructive Pulmonary Disease (COPD) scheduled for urgent open reduction and internal fixation of fracture neck of femur, taking ramipril (Angiotensin-Converting Enzyme inhibitor) 5mg once daily, presenting with anxiety, pain, and vital signs showing hypertension, tachycardia, and normal oxygen saturation?

Preoperative Assessment and Optimization for Urgent Hip Fracture Surgery

Immediate Priorities

This patient should proceed to surgery within 36-48 hours without unnecessary delay, as delaying surgery beyond 48 hours increases mortality, pneumonia, pressure sores, and thromboembolic complications. 1 The current hypertension (165/95) and tachycardia are likely secondary to pain and anxiety, not reasons to delay surgery. 1

Pain Management - First Priority

• Administer multimodal analgesia immediately including regular paracetamol and cautious opioids after reviewing renal function (40% of hip fracture patients have renal dysfunction). 1
• Strongly consider femoral nerve block or fascia iliaca block for superior pain control and anxiety reduction, which can be administered by trained emergency or anesthetic staff. 1
• Pain scores should be documented at rest and on movement before and after analgesia. 1
• NSAIDs are relatively contraindicated given likely renal impairment in this population. 1

Essential Investigations

Order these tests immediately: 1

• Full blood count: Pre-operative anemia occurs in 40% of patients; if Hb <9 g/dL or <10 g/dL with cardiac history, consider pre-operative transfusion. 1
• Urea and electrolytes: Check for hypokalaemia (risk of new-onset atrial fibrillation), hyperkalaemia (suggests rhabdomyolysis from prolonged immobilization), or hyponatraemia (17% incidence, may indicate infection). 1
• Blood glucose: Hyperglycemia is not a reason to delay surgery unless the patient is ketotic and/or dehydrated. 1
• ECG: Mandatory in all elderly hip fracture patients to assess for ischemia, arrhythmias, or silent myocardial infarction. 1
• Chest radiograph: Only if clinically indicated (new heart failure or pneumonia suspected), not routine. 1

Cardiovascular Assessment

The elevated BP (165/95) and HR (95) require assessment but not delay: 1

• This hypertension is likely pain and anxiety-related; adequate analgesia often normalizes vital signs. 1
• Continue ramipril on the morning of surgery - there is no evidence that withholding ACE inhibitors improves outcomes in urgent surgery. 1
• Assess for cardiac autonomic neuropathy given diabetes: check for orthostatic hypotension, which predicts perioperative hemodynamic instability. 1
• Review ECG for signs of silent myocardial infarction (common in diabetics), prolonged QTc, or ischemia. 1
• Do not delay surgery for echocardiography unless the patient has severe aortic stenosis symptoms (angina, syncope, slow-rising pulse, absent second heart sound). 1

Diabetes Management

Follow hospital-specific perioperative diabetes protocols: 1

• Check current glucose control and assess for diabetic complications (nephropathy, neuropathy, retinopathy). 1
• Screen for cardiac autonomic neuropathy: decreased respiratory heart rate variability predicts perioperative hemodynamic instability. 1
• Hyperglycemia alone does not delay surgery unless ketotic or dehydrated. 1
• Plan intraoperative glucose monitoring and insulin sliding scale if needed. 1

COPD Optimization

Assess current respiratory status: 1

• Check SpO2 (currently 96% on room air - acceptable). 1
• If chest infection suspected: start antibiotics, supplemental oxygen, IV fluids, and physiotherapy immediately. 1
• Expedited surgery under regional anesthesia is preferred for COPD patients, enabling early mobilization and better cooperation with postoperative physiotherapy. 1
• Ensure bronchodilators are continued perioperatively. 1

Medication Review

Ramipril management: 1

• Continue ramipril 5mg on the morning of surgery with a sip of water. 1
• No evidence supports withholding ACE inhibitors in urgent hip fracture surgery. 1

Review for polypharmacy: 1

• 20% of patients over 70 take >5 medications; 80% of adverse drug reactions are potentially avoidable. 1
• Check for aspirin (can continue), clopidogrel (do not stop, expect slightly more bleeding), or warfarin (requires reversal if INR >2). 1

Pre-operative Optimization Protocol

Implement standardized resuscitation immediately: 1

• IV access and fluid resuscitation: Correct dehydration from immobilization. 1
• Continuous monitoring: Pulse oximetry, respiratory rate, ECG, non-invasive BP, temperature, and pain scores. 1
• Warming measures: Prevent hypothermia with active warming devices. 1
• Pressure care: Assess skin condition and implement pressure relief measures. 1
• Thromboprophylaxis: Start mechanical prophylaxis immediately (pneumatic compression devices). 1

Risk Stratification

Calculate Nottingham Hip Fracture Score to predict postoperative mortality and facilitate informed consent discussions with patient/family. 1

Anesthetic Planning

Regional anesthesia is preferred: 1

• Spinal or epidural anesthesia reduces sympathetic hyperactivity and may improve outcomes in diabetic patients with COPD. 1
• Allows early mobilization and better postoperative pain control. 1
• Facilitates cooperation with physiotherapy in COPD patients. 1

Critical Pitfalls to Avoid

• Do not delay surgery for "optimization" of chronic conditions - there is no evidence that delaying improves outcomes, and delay beyond 48 hours increases mortality. 1
• Do not withhold ramipril - continue ACE inhibitors perioperatively. 1
• Do not order routine chest X-ray unless clinically indicated. 1
• Do not transfuse prophylactically unless Hb <9 g/dL or <10 g/dL with cardiac disease. 1