Create an Epic dot phrase for an 80‑year‑old patient with an acute hip fracture and chronic systolic heart failure on a dobutamine infusion who is hemodynamically stable.

Epic Dot Phrase: 80-Year-Old with Hip Fracture and Heart Failure on Dobutamine

Patient Presentation

• 80-year-old with acute hip fracture
• Chronic systolic heart failure, currently on dobutamine infusion
• Hemodynamically stable

---

Pre-Operative Cardiac Assessment

Current Inotropic Support

• Dobutamine infusion is running at _____ µg/kg/min (typical range 2–20 µg/kg/min) 1
• Indication for dobutamine: low cardiac output state with systolic BP 85–110 mmHg and signs of hypoperfusion 1
• Current hemodynamics: HR _____, BP _____, cardiac index _____ L/min/m² (target >2.0) 1
• Continuous ECG monitoring in place for arrhythmia detection 2
• Arterial line present: Yes/No (mandatory for accurate BP monitoring during cement insertion) 1

Heart Failure Severity

• NYHA functional class: _____
• Left ventricular ejection fraction: _____% (if known)
• Recent echocardiogram findings: _____
• Signs of congestion: pulmonary edema (Yes/No), elevated JVP (Yes/No), peripheral edema (Yes/No) 1
• End-organ perfusion markers: lactate _____ mmol/L (target <2), urine output _____ mL/kg/h (target >0.5), mental status _____ 1

---

Surgical Timing Decision

Surgery should proceed within 36–48 hours of admission despite dobutamine requirement 1

• Delaying surgery beyond 48 hours increases mortality, pressure sores, pneumonia, and thromboembolic complications 1
• There is no evidence that delaying surgery for "cardiac optimization" improves outcomes 1
• The only absolute contraindications to proceeding are: active myocardial infarction, uncontrolled arrhythmia requiring immediate treatment, or severe aortic stenosis requiring urgent echocardiography 1

---

Intra-Operative Anesthetic Plan

Monitoring Requirements

• Invasive arterial line is mandatory (if not already present) for real-time BP monitoring during cement insertion 1
• Set automated BP cuff to "stat" mode as backup during cementation 1
• Continuous ECG telemetry for arrhythmia detection 2
• End-tidal CO₂ monitoring (sudden drop indicates right heart failure/catastrophic CO reduction) 1

Anesthetic Technique

• General anesthesia is preferred over neuraxial in patients with significant aortic stenosis or hemodynamic instability 1
• Target systolic BP within 20% of pre-induction baseline 1
• Avoid hypotension (SBP <85 mmHg) which worsens end-organ perfusion 1

Dobutamine Management Intra-Operatively

• Continue dobutamine infusion throughout surgery without interruption 1
• Have vasopressors prepared and immediately available (norepinephrine 0.2–1.0 µg/kg/min preferred over dopamine) 1
• If additional inotropic support needed, dobutamine dose may be increased up to 20 µg/kg/min 1
• In patients on chronic β-blockers, dobutamine doses may need to reach 20 µg/kg/min to restore inotropic effect 1

---

Bone Cement Implantation Syndrome Prevention

Three-Stage Protocol 1

Stage 1: Pre-Cementation Preparation

• Confirm arterial line functioning and set BP cuff to "stat" mode 1
• Surgeon must announce: "Preparing to insert cement" 1
• Anesthesiologist confirms readiness and awareness 1
• Prepare vasopressors at bedside (norepinephrine or phenylephrine drawn up) 1

Stage 2: Surgical Technique

• Surgeon thoroughly washes and dries femoral canal 1
• Apply cement in retrograde fashion using cement gun with suction catheter and intramedullary plug 1
• Avoid vigorous pressurization of cement in this high-risk patient with cardiovascular compromise 1

Stage 3: Vigilant Monitoring

• Watch for sudden drop in systolic BP (early warning of cardiovascular collapse) 1
• Monitor end-tidal CO₂ (sudden drop indicates right heart failure/reduced cardiac output) 1
• Immediately treat hypotension with vasopressors if SBP drops >20% from baseline 1

---

Post-Operative Management

Dobutamine Weaning Strategy

• Do not abruptly discontinue dobutamine 1
• Gradual tapering essential: decrease by 2 µg/kg/min increments 1
• Simultaneous optimization of oral heart failure therapy (ACE inhibitor, β-blocker, diuretics) 1
• Monitor for signs of decompensation during wean: rising lactate, falling urine output, worsening mental status 1

Hemodynamic Targets Post-Op

• Systolic BP >90 mmHg 1
• Cardiac index >2.0 L/min/m² 1
• Urine output >0.5 mL/kg/h 1
• Lactate <2 mmol/L 1

Pain Management

• Multimodal analgesia to minimize opioid requirements (opioids can depress respiration and worsen heart failure) 1
• Regional analgesia (femoral nerve block) if not contraindicated 1

Mobilization

• Early physiotherapy (within 24 hours) to prevent complications 1
• Gradual mobilization with hemodynamic monitoring 1

---

High-Risk Complications to Monitor

Cardiovascular

• Arrhythmias (atrial fibrillation, ventricular tachycardia)—dobutamine increases risk in dose-dependent manner 2
• Patients with pre-existing atrial fibrillation at highest risk for rapid ventricular response 2
• Myocardial ischemia (dobutamine increases myocardial oxygen demand) 1
• Acute decompensated heart failure 1

Cement-Related

• Bone cement implantation syndrome (hypotension, hypoxia, arrhythmia, cardiac arrest) 1
• Right heart failure from cement/fat embolization 1

General Surgical

• Pressure ulcers (increased risk with prolonged immobility) 1
• Pneumonia 1
• Venous thromboembolism 1

---

Disposition Planning

• ICU/step-down bed post-operatively for continued dobutamine infusion and hemodynamic monitoring
• Cardiology consultation for heart failure optimization and dobutamine weaning plan
• Orthogeriatric co-management throughout hospitalization 1