Preoperative Assessment and Optimization for Urgent Hip Fracture Surgery

Immediate Priorities

• Delaying surgery beyond 48 hours increases mortality, pneumonia, pressure sores, and thromboembolic complications, therefore, surgery should proceed within 36-48 hours without unnecessary delay 1

Pain Management

• Administer multimodal analgesia immediately, including regular paracetamol and cautious opioids, after reviewing renal function, as 40% of hip fracture patients have renal dysfunction 2
• Strongly consider femoral nerve block or fascia iliaca block for superior pain control and anxiety reduction, which can be administered by trained emergency or anesthetic staff 2

Essential Investigations

• Order full blood count, urea and electrolytes, blood glucose, ECG, and chest radiograph (if clinically indicated) immediately, as these tests are essential for preoperative assessment 3
• Pre-operative anemia occurs in 40% of patients; if Hb <9 g/dL or <10 g/dL with cardiac history, consider pre-operative transfusion 3

Cardiovascular Assessment

• The elevated BP and HR require assessment but not delay, as this hypertension is likely pain and anxiety-related; adequate analgesia often normalizes vital signs 2
• Continue ramipril on the morning of surgery, as there is no evidence that withholding ACE inhibitors improves outcomes in urgent surgery 2

Diabetes Management

• Follow hospital-specific perioperative diabetes protocols, and check current glucose control and assess for diabetic complications (nephropathy, neuropathy, retinopathy) 1, 4
• Hyperglycemia alone does not delay surgery unless ketotic or dehydrated 1, 4

COPD Optimization

• Assess current respiratory status, and check SpO2, as expedited surgery under regional anesthesia is preferred for COPD patients, enabling early mobilization and better cooperation with postoperative physiotherapy 8, 4

Medication Review

• Continue ramipril 5mg on the morning of surgery with a sip of water, as no evidence supports withholding ACE inhibitors in urgent hip fracture surgery 2
• Review for polypharmacy, as 20% of patients over 70 take >5 medications; 80% of adverse drug reactions are potentially avoidable 2

Pre-operative Optimization Protocol

• Implement standardized resuscitation immediately, including IV access and fluid resuscitation, continuous monitoring, warming measures, pressure care, and thromboprophylaxis 1, 8

Risk Stratification

• Calculate Nottingham Hip Fracture Score to predict postoperative mortality and facilitate informed consent discussions with patient/family 3, 2

Anesthetic Planning

• Regional anesthesia is preferred, as it reduces sympathetic hyperactivity and may improve outcomes in diabetic patients with COPD, and allows early mobilization and better postoperative pain control 8, 4

Critical Pitfalls to Avoid

• Do not delay surgery for "optimization" of chronic conditions, as there is no evidence that delaying improves outcomes, and delay beyond 48 hours increases mortality 1
• Do not withhold ramipril, as continue ACE inhibitors perioperatively 2
• Do not order routine chest X-ray unless clinically indicated 3
• Do not transfuse prophylactically unless Hb <9 g/dL or <10 g/dL with cardiac disease 3