What are the pre-operative optimization strategies for an elderly patient with a history of diabetes mellitus (DM) on insulin therapy, ischemic heart disease (IHD) with previous myocardial infarction (MI) and percutaneous coronary intervention (PCI), significant smoking history, and multiple medications including clopidogrel, carvedilol, lisinopril, carbamazepine, and latanoprost, presenting with a femoral fracture?

Pre-operative Optimization for Elderly Diabetic Patient with Femoral Fracture

Proceed to surgery within 36-48 hours without delay—delaying surgery beyond 48 hours significantly increases mortality, pneumonia, pressure sores, and thromboembolic complications, and there is no evidence that "optimizing" chronic conditions improves outcomes. 1, 2

Immediate Pain Management

• Administer regular paracetamol immediately unless contraindicated 1, 2
• Implement femoral nerve block or fascia iliaca block immediately—this provides superior pain control, reduces anxiety and sympathetic hyperactivity (critical given this patient's IHD history), and can be administered by trained anesthetic staff 1, 2
• Use opioids cautiously and only after reviewing renal function, as approximately 40% of hip fracture patients have renal dysfunction (GFR <60 mL/min/1.73m²) 3, 1
• Avoid NSAIDs entirely given the high likelihood of renal dysfunction in elderly patients and existing renal impairment risk 3

Cardiovascular Optimization

• Continue lisinopril on the morning of surgery with a sip of water—there is no evidence that withholding ACE inhibitors improves outcomes in urgent hip fracture surgery 1, 2
• Continue clopidogrel without interruption—do not stop clopidogrel, especially in patients with prior MI and PCI (likely has coronary stents); surgery should not be delayed, and platelets should not be administered prophylactically, though marginally greater blood loss should be expected 3, 1
• Continue carvedilol (beta-blocker) on the morning of surgery—beta-blockers reduce perioperative cardiac events in patients with IHD 3
• Ensure ventricular rate control if atrial fibrillation develops perioperatively (target heart rate <100 bpm) 3

Diabetes Management

• Continue insulin on the morning of surgery following your hospital's perioperative diabetes protocol—hyperglycemia alone is not a reason to delay surgery unless the patient is ketotic and/or dehydrated 3
• The HbA1c of 9.4% indicates suboptimal chronic control, but this does not delay surgery 3
• Adjust insulin dosing perioperatively based on blood glucose monitoring—insulin requirements may be altered during surgical stress 4
• Monitor for hypoglycemia closely, as early warning symptoms may be blunted in patients with long-standing diabetes and neuropathy (this patient has neuropathic pain requiring carbamazepine) 3, 4
• Screen for diabetic complications that affect perioperative risk: assess for gastroparesis (delayed gastric emptying increases aspiration risk), cardiac autonomic neuropathy (orthostatic hypotension, silent myocardial ischemia), and nephropathy 3

Essential Pre-operative Investigations

• Order immediately: full blood count, urea and electrolytes, blood glucose, and ECG 3, 2
• Check hemoglobin—pre-operative anemia occurs in 40% of hip fracture patients; if Hb <10 g/dL with cardiac history (this patient has IHD), consider pre-operative transfusion 2
• Review electrolytes carefully—hypokalaemia is associated with new onset rapid ventricular rate atrial fibrillation perioperatively, and hyperkalaemia may indicate rhabdomyolysis if the patient was immobilized after falling 3
• Do not order routine chest radiograph unless there are new clinical findings suggesting heart failure or pneumonia 3, 2
• Platelet count is not routinely needed unless planning neuraxial anesthesia with clopidogrel on board 3

Respiratory Optimization for COPD

• Assess current respiratory status and confirm SpO2 is adequate 2
• Regional anesthesia (spinal or epidural) is strongly preferred for this patient with COPD, IHD, and multiple comorbidities—it reduces sympathetic hyperactivity, allows early mobilization, improves postoperative pain control, and enables better cooperation with postoperative physiotherapy 3, 1, 5
• If chest infection is present, administer prompt antibiotic therapy along with supplemental oxygen, intravenous fluids, and physiotherapy, but still proceed with expedited surgery under regional anesthesia 3

Medication Management

• Continue carbamazepine for neuropathic pain perioperatively 3
• Continue latanoprost for glaucoma—no contraindication to continuing eye drops perioperatively 3
• Review for polypharmacy interactions, as elderly patients frequently take multiple medications with potential drug-drug interactions 2

Fluid Management and Resuscitation

• Many hip fracture patients are hypovolemic before surgery—prescribe pre-operative IV fluids routinely 1
• Use goal-directed fluid therapy with cardiac output monitoring intraoperatively—this reduces hospital stay and improves outcomes 1
• Maintain adequate hydration to reduce DVT risk, but avoid fluid overload given cardiac history 1

Anesthetic Planning

• Regional anesthesia (spinal or epidural) is the preferred technique—it provides reliable surgical anesthesia, blocks the lateral cutaneous nerve of thigh, femoral, obturator, sciatic, and lower subcostal nerves, and reduces DVT risk 1, 5
• If general anesthesia is required, use invasive blood pressure monitoring, consider BIS monitoring to optimize depth and avoid cardiovascular depression, and increase inspired oxygen concentration at the time of cementation if a cemented prosthesis is used 1
• Neuraxial anesthesia can be performed safely with clopidogrel on board, though the risk-benefit must be carefully weighed—a platelet count of 50-80 × 10⁹/L is a relative contraindication to neuraxial anesthesia 3

Risk Stratification and Communication

• Calculate the Nottingham Hip Fracture Score to predict 30-day mortality based on age, sex, number of comorbidities, cognitive function, hemoglobin, and malignancy 3, 1, 2
• Document discussion of perioperative risks with the patient or family—approximately 8.4% of patients die within 30 days, and up to 15-30% within one year 1
• This patient has multiple high-risk features: elderly age, diabetes with poor control, IHD with prior MI, COPD with significant smoking history, and polypharmacy 3, 1

Postoperative Management Planning

• Supplemental oxygen for at least 24 hours postoperatively, as elderly patients are at risk of postoperative hypoxia 1
• Continue regular paracetamol and add carefully prescribed opioids as needed for breakthrough pain 1
• Monitor for postoperative cognitive dysfunction, which occurs in 25% of hip fracture patients 1
• Early mobilization is critical—coordinate with physiotherapy and occupational therapy immediately postoperatively 1
• Remove urinary catheter as soon as possible to reduce UTI risk 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, 2
• Do not stop clopidogrel—continue it perioperatively, especially in patients with drug-eluting stents 3, 1
• Do not withhold lisinopril—continue ACE inhibitors perioperatively 1, 2
• Do not delay surgery for hyperglycemia unless the patient is ketotic or dehydrated 3
• Do not order routine chest X-ray unless clinically indicated 3, 2
• Do not transfuse prophylactically unless Hb <10 g/dL with cardiac disease 2