1.4 Preoperative risk assessment and preparation
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1 Introduction
Skilled preoperative assessment and optimization of the geriatric fracture patient directly contributes to excellent outcomes. Although there is a paucity of relevant literature on older adults undergoing urgent surgery, best practices are heavily informed by geriatric principles combined with evidence extrapolated from other populations and settings. The perioperative medical practices supported by much of the existing literature require modification for the physiologies and vulnerabilities of older adults, and geriatric fracture care should not simply replicate practices patterns used for the stable and healthier elective surgery patient.
Medical centers using a standardized geriatric medicine approach to preoperative care have reliably demonstrated improved outcomes in mortality, length of stay and reduction in complications [1–3]. This chapter focuses on the strategies used by many of these centers in the areas of risk assessment and optimization.
Key principles and goals:
Early surgical fixation, particularly for highly frail or comorbid patients
Optimization by a general medical service for surgery in less than 24 hours for most patients, and many in less than 6 hours
Pain control with parenteral opiates and regional nerve block techniques
Anticipation of hypotension in the intra and postoperative period; liberal use of intravascular hydration, and cessation or reduction of most antihypertensive medications
Avoidance of excessive perioperative testing, medical consultation and polypharmacy
2 Unique perioperative aspects
In addition to risk assessment and surgical planning, the perioperative management of older adults is focused on active efforts directed towards pain control, maintenance of hemodynamic stability and avoidance of functional decline. Early surgery is the most important way to achieve these goals, and the preoperative medical assessment needs to prioritize early surgery and early mobility over many other chronic medical issues. For these reasons, high-performing geriatric fracture centers have implemented clinical pathways that emphasize timely transition to operative repair, even in highly comorbid or frail older adults. Many notable comorbidities warranting more intensive preoperative testing and consultation prior to elective surgery are not vigorously pursued in the geriatric fracture setting.
3 Preoperative risk assessment
For almost all patients, the benefits of operative fracture repair, including hemostasis, pain control and mobilization, exceed the risks related to anesthesia and surgery. This is due to both the improved safety of advanced anesthetic and surgical techniques and the excessive morbidity and mortality of hip fracture patients in the absence of surgical repair. Patient-specific risks can be roughly estimated with the careful use of preoperative risk calculators, and may allow for better anticipation of patient-specific outcomes and complications.
3.1 Risk calculators
The Nottingham Hip Fracture Score [4] is the best-validated instrument for predicting 30-day and longer outcomes in the hip fracture population, and incorporates measures of comorbidity burden, functional status (ie, type of residence), cognitive status (ie, mini-mental test score), nutritional status (ie, albumin), and key demographic factors (ie, age, gender). Elements like institutionalization and mini-mental test score are not universally consistent across different international settings, but likely can be approximated and remain useful for estimating perioperative risk and short-term outcomes ( Table 1.4-1 , Table 1.4-2 ).
Variable | Value | Points |
Age, y | 66–85 > 85 | 3 4 |
Gender | Male | 1 |
Admission hemoglobin | ≤ 10 g/dL | 1 |
Admission mini-mental test score | ≤ 6 of 10 | 1 |
Living in an institution | Yes | 1 |
Number of comorbidities | ≥ 2 | 1 |
Malignancy | Yes | 1 |
Nottingham Hip Fracture Score | Estimated 30-day mortality, % |
1 | 1 |
3 | 3 |
5 | 7–10 |
7 | 16–23 |
10 | 45–57 |
A number of additional calculators have been developed in the attempt to provide a reasonable estimate of serious complications in surgical patients; none are validated in older adults undergoing urgent orthopedic surgery. Three calculators that were examined in the most recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines include the Revised Cardiac Risk Index (RCRI) [6], the Myocardial Infarction or Cardiac Arrest calculator [7], and the American College of Surgeons’ National Surgical Quality Improvement Program Surgical Risk Calculator [8]. The key features of the RCRI are summarized in Table 1.4-3 .
Total points | Risk of major cardiac event, % |
1 | 1.0 |
2 | 2.4 |
≥ 3 | 5.4 |
3.2 Other assessments of prognostic importance
Despite the historical emphasis on comorbidity scoring for estimating surgical risk, functional and cognitive impairment have long been recognized in geriatric medicine to predict many clinically significant perioperative complications and mortality [10]. There are several tools to quickly classify cognitive and functional status into meaningful categories; these can be easily incorporated into standard medical, surgical or nursing assessments.
3.2.1 Functional capacity
The Parker Mobility Score is a simple measure of function that has been derived and validated in the hip fracture setting, and evaluated in multiple settings and for multiple important outcomes ( Table 1.4-4 ). More extensive functional status evaluation can be helpful in the rehabilitation phase.
Total (NMS) | 1-year mortality, % |
≤ 3 | 56 |
4–5 | 38 |
> 5 | 15 |
Mobility | No difficulty | With an aid | With assistance | Not at all |
Around house | 3 | 2 | 1 | 0 |
Out of house | 3 | 2 | 1 | 0 |
Shopping | 3 | 2 | 1 | 0 |
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