What is the medical optimization plan for an elderly patient with hypertension (HTN), diabetes mellitus (DM), and ischemic heart disease (IHD) presenting with a femoral fracture?

Medical Optimization Plan for Elderly Patient with HTN, DM, and IHD Presenting with Femoral Fracture

Proceed to surgery within 36-48 hours without delay for "optimization" of chronic conditions, as delaying surgery beyond 48 hours significantly increases mortality, pneumonia, pressure sores, and thromboembolic complications. 1, 2

Immediate Actions Upon Admission

Pain Management (First Priority)

• Administer regular paracetamol immediately unless contraindicated 1
• Strongly implement femoral nerve block or fascia iliaca block for superior pain control, which reduces anxiety and sympathetic hyperactivity—particularly important given this patient's IHD 1, 2
• Use opioids cautiously only after reviewing renal function, as 40% of hip fracture patients have renal dysfunction (GFR <60 mL/min) 1, 2
• Avoid NSAIDs entirely given likely renal dysfunction in elderly patients 1
• Document pain scores at rest and with movement before and after analgesia 1

Resuscitation Protocol

• Establish IV access and initiate fluid resuscitation immediately 1, 2
• Institute continuous monitoring: pulse oximetry, respiratory rate, ECG, non-invasive blood pressure, core temperature 1
• Implement warming measures to prevent hypothermia 1
• Begin pressure care protocols 1
• Initiate thromboprophylaxis with fondaparinux or LMWH (administer between 18:00-20:00 to minimize bleeding risk with neuraxial anesthesia) 1

Essential Investigations (Order Immediately)

Mandatory Tests

• Full blood count: Check hemoglobin—if Hb <9 g/dL or <10 g/dL with IHD history, consider pre-operative transfusion 1, 2
• Urea and electrolytes: Identify hypokalaemia (risk for atrial fibrillation), hyperkalaemia (possible rhabdomyolysis), hyponatraemia 1
• Blood glucose: Assess current diabetic control 1, 2
• ECG: Required in all elderly hip fracture patients 1, 3
• Chest radiograph: Only if clinically indicated (new heart failure or pneumonia suspected) 1, 3

Do NOT Order

• Routine chest X-ray without clinical indication 3, 2
• Echocardiography unless specific indications present (see below) 3

Cardiovascular Optimization (IHD Management)

Blood Pressure and Heart Rate

• Do not delay surgery for elevated BP/HR—this is likely pain and anxiety-related; adequate analgesia often normalizes vital signs 2
• If atrial fibrillation develops, ensure ventricular rate <100/min by treating precipitants: hypokalaemia, hypomagnesaemia, hypovolaemia, sepsis, pain, hypoxaemia 1
• If rate control needed despite treating precipitants, use metoprolol or verapamil 1

Medication Management

• Continue ramipril on morning of surgery with sip of water—no evidence supports withholding ACE inhibitors in urgent hip fracture surgery 2
• Continue aspirin if prescribed for unstable angina or recent TIA; otherwise may withhold during inpatient stay 1
• If on clopidogrel (common with IHD/stents), do not stop—especially with drug-eluting stents; surgery should not be delayed, expect marginally greater blood loss 1

Echocardiography Indications (Do NOT Delay Surgery)

Echocardiography should NOT delay surgery 3, 2. Consider only if:

• Patient breathless at rest or minimal exertion (assess LV function) 1, 3
• Ejection systolic murmur in aortic area with ≥2 of: angina on exertion, unexplained syncope, slow-rising pulse, absent second heart sound, LVH on ECG without hypertension 1, 3
• If echocardiography cannot be obtained without delay, proceed to surgery with general anesthesia and invasive blood pressure monitoring 1, 3

Intraoperative Cardiac Monitoring

• Invasive arterial blood pressure monitoring given IHD and limited LV function 1
• Consider cardiac output monitoring (transoesophageal Doppler or LiDCO) for fluid optimization 1
• Consider cerebral oxygen saturation monitoring to reduce postoperative cognitive dysfunction 1

Diabetes Management

Preoperative Assessment

• Check current glucose control and assess for diabetic complications: nephropathy, neuropathy, retinopathy 2
• Follow hospital-specific perioperative diabetes protocols 1
• Hyperglycemia alone does not delay surgery unless patient is ketotic and/or dehydrated 1

Perioperative Glucose Control

• Target glucose control during perioperative period to reduce complications 4
• Adjust insulin regimen for NPO status per hospital protocol 1

Anesthetic Planning

Preferred Technique

• Regional anesthesia (spinal or epidural) is strongly preferred for this patient with IHD and comorbidities 1, 2
• Benefits include: reduced sympathetic hyperactivity, early mobilization, improved postoperative pain control, better cooperation with physiotherapy, reduced DVT risk 1, 2
• Regional anesthesia particularly advantageous for diabetic patients 2

If General Anesthesia Required

• Use invasive blood pressure monitoring 1
• Consider BIS monitoring to optimize depth and avoid cardiovascular depression 1
• Increase inspired oxygen concentration at time of cementation (if cemented prosthesis) 1

Fluid Management

Preoperative Optimization

• Many patients are hypovolaemic before surgery—prescribe pre-operative IV fluids routinely 1
• Cardiac output-guided fluid administration reduces hospital stay and improves outcomes 1
• Optimize fluid therapy to reduce morbidity 1

Intraoperative Management

• Use goal-directed fluid therapy with cardiac output monitoring 1
• Maintain adequate hydration to reduce DVT risk 1
• Avoid both hypovolaemia and fluid overload given cardiac history 1

Timing of Surgery

Target surgery within 36-48 hours of admission 1, 3, 2. The evidence is clear:

• Delaying beyond 48 hours increases: prolonged hospital stay, pressure sores, pneumonia, thromboembolic complications, and mortality 1, 3, 2
• No evidence supports delaying surgery for physiological stabilization 1, 2
• Balance risks of untreated acute conditions against surgical delay 1

Risk Stratification and Communication

• Calculate Nottingham Hip Fracture Score to predict 30-day mortality and facilitate informed consent discussions with patient/family 1, 2
• Document discussion of perioperative risks given multiple comorbidities 1
• Approximately 8.4% of patients die within 30 days; up to 15-30% within one year 1

Postoperative Management Plan

Immediate Postoperative Care

• Supplemental oxygen for at least 24 hours (elderly patients at risk of postoperative hypoxia) 1
• Continue regular paracetamol; add carefully prescribed opioids as needed 1
• Monitor for postoperative cognitive dysfunction (occurs in 25% of hip fracture patients) 1
• Early oral fluid intake; remove urinary catheter ASAP to reduce UTI risk 1

Mobilization and Rehabilitation

• Early mobilization is critical—improves oxygenation and respiratory function 1
• Coordinate with physiotherapy and occupational therapy 1
• Multidisciplinary input from orthogeriatricians essential 1

Monitoring for Complications

• Assess for: chest infection, silent myocardial ischemia, urinary tract infection, pressure sores 1
• Optimize analgesia, nutrition, hydration, electrolyte balance, bowel function 1
• Continue thromboprophylaxis 1

Critical Pitfalls to Avoid

• Do NOT delay surgery for "cardiac clearance" or "medical optimization" of chronic stable conditions 1, 3, 2
• Do NOT withhold ACE inhibitors perioperatively 2
• Do NOT stop clopidogrel if patient has coronary stents 1
• Do NOT order routine echocardiography that would delay surgery 3, 2
• Do NOT use NSAIDs given renal dysfunction risk 1
• Do NOT transfuse prophylactically unless Hb <9 g/dL or <10 g/dL with cardiac disease 1, 2
• Do NOT use codeine (constipating, emetic, associated with cognitive dysfunction) 1