What is the optimal perioperative management plan for elderly patients undergoing hip replacement surgery with multiple comorbidities, including impaired cardiac and respiratory function?

Optimal Perioperative Management for Elderly Hip Replacement Patients with Multiple Comorbidities

Elderly patients with impaired cardiac and respiratory function undergoing hip replacement require immediate multidisciplinary assessment by senior geriatricians and anesthetists, with surgery performed within 48 hours while simultaneously optimizing modifiable risk factors rather than delaying surgery for sequential optimization. 1, 2

Pre-operative Assessment and Risk Stratification

Mandatory Senior-Level Evaluation

• Assessment must be conducted by both a senior geriatrician and senior anesthetist with geriatric subspecialty training, as age-related physiological decline, multi-morbidity, and frailty independently increase perioperative risk 1
• Document baseline cognitive function, as 25% have moderate-to-severe cognitive impairment and patients with cardio-/cerebrovascular disease face significantly elevated risk of postoperative delirium (POD) and postoperative cognitive decline (POCD) 1, 2
• Assess frailty using structured tools, exercise tolerance, oxygen requirements, baseline SpO2, and cardiac function given the combination of cardiac and respiratory impairment 3

Critical Laboratory and Clinical Investigations

• Obtain full blood count and urea/electrolytes routinely; additional tests only if clinically indicated 1
• Pre-operative transfusion should be considered if hemoglobin <9 g/dL, or <10 g/dL with ischemic heart disease history, as elderly patients require higher transfusion triggers and fracture-related blood loss typically drops hemoglobin by 2.5 g/dL 1
• Crossmatch 2 units if hemoglobin 10-12 g/dL; grouped sample sufficient if normal 1
• Review renal function carefully, as approximately 40% have at least moderate renal dysfunction (GFR <60 mL/min/1.73m²), which affects opioid dosing 1

Medication Review and Optimization

• Conduct comprehensive medication review for polypharmacy (20% of patients >70 take >5 medications), focusing on cardiac medications, anticoagulation status, bronchodilators, and potential drug interactions 1, 3
• 80% of adverse drug reactions in this population are potentially avoidable 1

Pre-operative Optimization Strategy

Simultaneous Rather Than Sequential Approach

• Optimization and surgery must occur simultaneously rather than consecutively, as pre-operative delay is associated with poorer outcomes in hip surgery 1
• Surgery should be performed within 48 hours of admission, as delays beyond this increase mortality, pressure sores, pneumonia, and thromboembolic complications 2

Target Four Critical Domains

1. Prevent Organ-Specific Ischemia

• Reduce oxygen uptake through analgesia, thermoregulation, and antibiotics 1
• Improve oxygen delivery through supplemental oxygen, fluids, medication review, and strict avoidance of hypotension and severe anemia 1
• The brain and heart have absolute oxygen requirements; perioperative ischemia dramatically increases cardiac and cerebral dysfunction risk 1

2. Optimize Cardiorespiratory Function

• Tailor management to the elderly patient, recognizing that multiple conflicting guidelines may apply 1
• Avoid over-investigation that extends polypharmacy 1
• For patients with atrial fibrillation and severe COPD, avoid beta-blockers and calcium channel blockers for acute rate control 3

3. Reduce Postoperative Delirium Risk

• Identify high-risk patients (very old, frail, cognitively impaired, cardio-/cerebrovascular disease, multimorbidity/polypharmacy) and communicate this throughout the multidisciplinary team 1
• Implement multimodal interventions pre-operatively to reduce POD prevalence, severity, and duration 1
• Strictly avoid medications that precipitate delirium 3

4. Address Malnutrition

• Provide iron, vitamin B12, and folate supplementation for subclinical nutritional anemia at least 28 days before elective surgery, as this reduces postoperative morbidity and mortality 1
• Avoid prolonged pre-operative fasting 1

Intra-operative Management

Hemodynamic Monitoring and Goals

• Arterial line placement is mandatory for continuous blood pressure monitoring, as elderly patients have poorly compliant vasculature making non-invasive measurements unreliable 3
• Maintain systolic blood pressure within 20% of pre-induction values throughout surgery using vasopressors and/or fluids 1
• Ensure adequate hydration before and during anesthesia 1
• Implement cardiac output-guided fluid administration 2

Anesthetic Depth and Dosing

• Use depth of anesthesia monitoring (BIS or entropy) to prevent relative anesthetic overdose, as elderly patients require lower doses but commonly receive standard doses leading to prolonged hypotension 3

Critical Awareness for Cemented Prostheses

• All theatre team members must be aware that adverse cardiovascular events occur in approximately 20% of cemented hip operations (bone cement implantation syndrome) 1
• Risk factors include increasing age, male sex, significant cardiopulmonary disease, and diuretic use 1
• Maintain heightened vigilance once the femoral head is removed and surgeon indicates intent to instrument the femoral canal 1
• Have vasopressors (metaraminol/adrenaline) immediately available for cardiovascular collapse 1

Postoperative Management

Multimodal Analgesia Protocol

• Start with scheduled paracetamol (acetaminophen) as first-line therapy for all patients 3, 2
• Use opioids at 25-50% of standard doses with close monitoring for toxicity (respiratory depression, hypotension, altered mental status) 3
• Avoid codeine entirely 2
• Use low-dose NSAIDs cautiously only if paracetamol ineffective, at lowest dose for shortest duration with proton pump inhibitor protection 3
• Consider single-shot or continuous nerve blocks (femoral/fascia iliaca) 1
• Opioids require extreme caution in patients with renal dysfunction 1

Delirium Prevention Bundle

• Implement multimodal interventions including strictly avoiding deliriogenic medications 3
• Optimize non-pharmacologic factors 3
• Continue multidisciplinary communication about identified risk factors 1

Thromboprophylaxis

• Use fondaparinux or low molecular weight heparin 2
• Implement mechanical prophylaxis with thromboembolism stockings or intermittent compression devices 2

Early Mobilization

• Early mobilization is crucial to reduce deep vein thrombosis risk 4

Decision-Making and Consent

Risk Communication

• Provide information specifically about how the intervention affects both quantity and quality of remaining life, as there may be disparity between what doctors and patients view as "acceptable risk" 1
• Use risk calculators like the Nottingham Hip Fracture Score to predict postoperative mortality based on comorbidities, age, sex, malignancy, cognitive function, residence, and anemia 1
• Discuss nature, purpose, short-term and long-term risks/benefits of the procedure, alternatives, and conservative therapy 1

Capacity Assessment

• Evaluate decision-making capacity in all patients, recognizing that 40-50% have some degree of cognitive impairment 2
• Follow Mental Capacity Act 2005 duties for patients lacking capacity 1
• Consultants must make "best interests" determinations after considering patient's expectations, known wishes, and input from relatives/carers 1

Critical Pitfalls to Avoid

• Never delay surgery beyond 48 hours for sequential optimization - this increases mortality and morbidity 1, 2
• Never use standard opioid doses - elderly patients require 25-50% reductions 3
• Never proceed with high-risk surgery without pre-operative commitment to appropriate postoperative care 1
• Never rely on non-invasive blood pressure monitoring alone - arterial lines are mandatory 3
• Avoid excessive flexion and internal rotation of the non-operative hip during positioning 4