Perioperative Management of Elderly Patients with Comorbidities

Preoperative Optimization

The American College of Surgeons recommends proceeding 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
Administer regular paracetamol immediately unless contraindicated, and 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, 3
Use opioids cautiously only after reviewing renal function, as 40% of hip fracture patients have renal dysfunction (GFR <60 mL/min) 1, 3, 2
Avoid NSAIDs entirely given likely renal dysfunction in elderly patients 1, 3

The American Heart Association recommends continuing ramipril on the morning of surgery with a 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 9, 6, 7
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 9, 6, 7

Regional anesthesia (spinal or epidural) is strongly preferred for this patient with IHD and comorbidities, as it reduces sympathetic hyperactivity, allows for early mobilization, improves postoperative pain control, and reduces DVT risk 1, 4, 2
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 cemented prosthesis) 5, 4

Many patients are hypovolaemic before surgery—prescribe pre-operative IV fluids routinely, and cardiac output-guided fluid administration reduces hospital stay and improves outcomes 5, 4
Use goal-directed fluid therapy with cardiac output monitoring, maintain adequate hydration to reduce DVT risk, and avoid both hypovolaemia and fluid overload given cardiac history 5

Supplemental oxygen for at least 24 hours (elderly patients at risk of postoperative hypoxia), continue regular paracetamol, and add carefully prescribed opioids as needed 10
Monitor for postoperative cognitive dysfunction (occurs in 25% of hip fracture patients), and early oral fluid intake; remove urinary catheter ASAP to reduce UTI risk 10
Early mobilization is critical—improves oxygenation and respiratory function, and coordinate with physiotherapy and occupational therapy 10

Calculate the Nottingham Hip Fracture Score to predict 30-day mortality and facilitate informed consent discussions with the patient/family 3, 2
Document discussion of perioperative risks given multiple comorbidities, and approximately 8.4% of patients die within 30 days; up to 15-30% within one year 3, 10