What are the preoperative considerations for an elderly patient with a femur fracture?

Preoperative Management of Elderly Patients with Femur Fracture

Elderly patients with femur fractures require immediate multidisciplinary optimization with surgery performed within 48 hours of admission, as delays beyond this timeframe significantly increase mortality, morbidity, and hospital length of stay. 1

Immediate Resuscitation Protocol

Implement a standardized resuscitation protocol immediately upon hospital admission, addressing: 1

• Monitoring: Pulse oximetry, respiratory rate, continuous ECG, non-invasive blood pressure, core temperature, and pain scores (both static and dynamic) 1
• Pain management: Provide analgesia before diagnostic investigations; nerve blocks significantly reduce acute pain and should be prioritized 1
• Intravenous access and fluid therapy: Many patients are hypovolaemic preoperatively; cardiac output-guided fluid administration reduces hospital stay and improves outcomes 1
• Thermoregulation: Active warming strategies to prevent hypothermia 1
• Pressure care: Position patients carefully to prevent pressure ulcers 1

Comprehensive Preoperative Assessment

Conduct systematic evaluation without unnecessarily delaying surgery: 1

• Laboratory investigations: Full blood count, clotting studies, blood type and cross-match, renal function, electrolytes (sodium, potassium), glucose 1
• Cardiac evaluation: ECG, chest X-ray 1
• Nutritional status: Screen for malnutrition 1
• Cognitive baseline: Assess for dementia and delirium, as 25% have moderate-to-severe cognitive impairment and 15-25% have mild impairment 1
• Medication review: Identify patients with cardiac devices (pacemakers, ICDs) requiring cardiology consultation for perioperative management 1

Surgical Timing: The Critical 48-Hour Window

Surgery must be performed within 48 hours of admission; delaying beyond this increases mortality, pressure sores, pneumonia, and thromboembolic complications. 1, 2

Acceptable Reasons to Delay Surgery: 1

• Hemoglobin <8 g/dL
• Severe electrolyte abnormalities (sodium <120 or >150 mmol/L; potassium <2.8 or >6.0 mmol/L)
• Uncontrolled diabetes
• Acute or uncontrolled left ventricular failure
• Correctable cardiac arrhythmia with ventricular rate >120/min
• Chest infection with sepsis
• Reversible coagulopathy

Unacceptable Reasons to Delay Surgery: 1

• Lack of facilities or theatre space
• Awaiting echocardiography
• Unavailable surgical expertise
• Minor electrolyte abnormalities

There is no evidence that delaying surgery for physiological stabilization improves outcomes; expedited surgery reduces mortality. 1, 2

Orthogeriatric Comanagement

Implement immediate orthogeriatric comanagement involving geriatricians, anesthetists, surgeons, nursing staff, and physiotherapists to reduce mortality, hospital stay, and improve functional outcomes. 1

The joint care model on dedicated orthogeriatric units demonstrates: 1

• Shortest time to surgery
• Shortest inpatient stay
• Lowest inpatient and 1-year mortality rates

Specific Medication Considerations

Pain Management: 1

• Regular paracetamol: Continue throughout perioperative period
• Opioids: Use with extreme caution in renal dysfunction; reduce dose and frequency by half; avoid oral formulations
• Avoid codeine: Causes constipation, emesis, and postoperative cognitive dysfunction
• NSAIDs: Use with extreme caution; contraindicated in renal dysfunction

Thromboprophylaxis: 1

• Fondaparinux or low molecular weight heparin: Administer between 18:00-20:00 to minimize bleeding risk with neuraxial anesthesia on daytime trauma lists
• Mechanical prophylaxis: Thromboembolism stockings or intermittent compression devices intraoperatively
• Anticoagulant patients: Require careful monitoring as they have increased 6-month mortality risk (OR=2.0) and delayed time to surgery 3

Antibiotics: 1

• Administer within one hour of skin incision per hospital protocols

High-Risk Patient Identification

Patients at highest risk for 6-month mortality include: 3

• Males (OR=1.82)
• Age >85 years (OR=5.26)
• Charlson comorbidity index ≥7 (OR=2.13)
• Dementia (OR=2.2)
• Peripheral artery disease (OR=2.9)
• Anticoagulant therapy (OR=2.0)
• Postoperative hemoglobin drop >2 g/dL (OR=1.9)

Consent and Capacity Assessment

Evaluate decision-making capacity in all patients, recognizing that 40-50% have some degree of cognitive impairment: 1

• Assess ability to understand, retain, and use information to make decisions
• Address barriers: poor vision, hearing, or speech
• If lacking capacity, proceed under best interests doctrine, consulting relatives about prior wishes and advance directives
• Document thoroughly

Common Pitfalls to Avoid

• Never delay pain management waiting for imaging or laboratory results 1
• Do not postpone surgery for minor electrolyte abnormalities or to await echocardiography 1
• Avoid excessive immobilization as it increases thromboembolism, pressure ulcers, and pneumonia risk 1
• Do not use opioids as first-line without considering renal function and fall risk 1
• Never assume normal renal function in elderly trauma patients; approximately 40% have moderate renal dysfunction 1