Pre-Operative Management

Physical activity


Sitting reading/watching television


Washing and dressing


Walking slowly on flat


Gentle housework


Walking a small dog (3 km//h)


Light static cycling/Bowling




Walking quickly (5 km/h)




Climb flight of stairs without stopping




Playing tennis/racquet sports


Those with low levels of activity may have asymptomatic underlying cardiovascular disease or may be limited by musculoskeletal disorders including arthritis, osteoporosis with kyphosis, sarcopenia or indeed obesity. Cardiovascular Disease

Patients with a history of ischaemic heart disease are clearly at risk of peri-operative cardiac events. Cardiovascular risk factors should also be considered including the presence of diabetes, hypertension and smoking.

The Goldman cardiac risk index [15] or the Revised Cardiac risk index [16] may be used to identify high-risk patients and predict likelihood of perioperative cardiac event or death.

A baseline electrocardiogram may give indications of asymptomatic cardiac disease with left bundle branch block or evidence of q waves or poor r wave progression in the anterior leads.

An echocardiogram will give an indication of regional wall abnormalities from myocardial infarction, an estimate of left ventricular function and an indication of underlying valvular heart disease. This information can assist with risk stratification but should not delay surgery.

Patients with suspected coronary artery disease should be discussed with an anaesthetist. Those already on beta-blockers should continue their usual dose pre-operatively unless there is significant bradycardia or hypotension. Attention to haemoglobin levels is important as peri-operative anaemia may increase cardiac strain and increase the risk of a cardiac event.

Valvular Heart Disease

Cardiac murmurs are often present in older people; insignificant aortic sclerosis or mild mitral regurgitation are the most common. A large retrospective study showed that 6.9 % of patients with hip fracture had previously undiagnosed significant aortic stenosis [17]. This may influence the type of anaesthetic and the need for invasive cardiac monitoring. Significant aortic stenosis is suspected if the patient has an ejection systolic murmur in the aortic area in combination with a history of angina on exertion, unexplained syncope or near syncope, a slow rising pulse clinically in the brachial artery, an absent 2nd heart sound or LVH on the ECG without hypertension. Patients with significant aortic stenosis require careful fluid balance and are at high risk of pulmonary oedema.

Heart Failure

Many older patients will have a history or symptoms in keeping with poor ventricular function on a background of hypertension, ischaemic heart disease, valvular heart disease or atrial fibrillation. The mainstays of medical treatment are diuretics, ACE inhibitors, angiotensin receptor blockers, beta-blockers, aldosterone antagonists and a combination of hydralazine and nitrates. Increasingly, therapies for heart failure include electrophysiological interventions such as cardiac resynchronization therapy (CRT), pacemakers with or without implantable cardioverter-defibrillators (ICDs). Severity can usually be gauged from the history, symptoms and required medication.

Those who are euvolaemic should undergo early surgery omitting heart failure medication until 48–72 h post-operatively. Caution should be observed with administering intravenous fluid. Anaemia should be managed proactively to maintain haemoglobin levels above 100 g/l. Once able to transfer out of bed medication can be slowly re-introduced. These patients often develop increasing peripheral oedema 5–7 days post operatively and may require an increased dose of diuretics for a period of time.

Patients with decompensated heart failure and fluid overload at presentation need careful attention. Those with acute left ventricular failure need stabilising before theatre. This is often associated with an acute ischaemic event. Antiplatelet and anticoagulant therapy may cause increased blood loss at the fracture site and should only be started with caution for acute cardiac ischaemia. Discussion with cardiologists regarding appropriate intervention and an individualised decision about timing of surgery should be made.

Those with poor right ventricular function and fluid overload need high dose diuretics with close monitoring of peripheral oedema levels, weight and renal function. This is often associated with hyponatraemia, hypotension and renal impairment and requires close observation. Correction to achieve a euvolaemic state often takes 5–10 days. It is usually better to proceed with surgery and manage the decompensated heart failure in the post-operative period. Significant peripheral oedema in the thigh however may increase the risk of wound breakdown.

Pacemakers and Implantable Cardiac Defibrillators (ICD)

Pacemakers have become increasingly sophisticated and a basic knowledge of different devices and their indications is required to aid the acute management of patients with fragility fracture. All patients with pacemakers have routine annual checks and a pre-operative check is only required if there is concern about malfunction or if it has not been checked within the previous 12 months.

It is important to understand the reason for the device and whether the patient is pacemaker-dependent. External pacing equipment and a defibrillator must be available during surgery.

The use of surgical diathermy/electrocautery can give rise to electrical interference and this can present additional risks when used in patients with pacemakers and ICDs. Energy can also be induced into heart lead systems causing tissue heating at lead tips through high frequency current [18]. The manufacturers recommend avoiding surgical diathermy if surgery is occurring within 50 cm from the device. If diathermy is deemed essential then the use of Bipolar diathermy with short bursts of energy minimises the risk. Where available, the use of a harmonic scalpel should be considered.


If a cardiac technician is available then an ICD device can be turned onto monitor only mode to prevent shock delivery during surgery. Otherwise, ICDs should be turned off by placing a magnet over the device, and securing it with micropore tape. Any sustained VT or VF intraoperatively should be managed with external defibrillation. Post-operatively the magnet should be removed and the patient monitored until the device has been checked.

Atrial Fibrillation

Public campaigns such as ‘know your pulse’ have increased public awareness of the risk of stroke from atrial fibrillation. Patients with AF and a controlled ventricular rate should continue with rate control medication (usually a beta-blocker, dioxin or verapamil) pre-operatively with their usual dose administered on the day of surgery. A history of atrial fibrillation may be permanent (AF) or paroxysmal (PAF). Amiodarone, Flecanide or beta-blockers are often used to maintain sinus rhythm and prevent PAF. Peri-operative AF is common in these patients.

Those with new AF, persistent AF or PAF with a fast ventricular rate need review. Tachycardia may be due to pain, a cardiac event or sepsis and clinical review with a 12 lead ECG, measurement of lactate and inflammatory markers is advised. Those with no evidence of inter-current illness may simply have new AF or poor rate control. If the rate is persistently above 110 bpm then urgent rate control is required pre-operatively. Digoxin and beta-blockers (iv metoprolol) may take 24 h to establish rate control. The most effective method is with intravenous Amiodarone. This is usually administered with a slow bolus of 300 mg over 1 h followed by a 24-h infusion of 0.5 mg/kg/h (450 mg in 500 ml Normal Saline). This must be administered through a large bore cannula and ideally into a central line with cardiac monitoring. Cardiology advice may be required for complex patients. Anticoagulants and Anti-platelets

Antiplatelet drugs are mainly used for secondary prevention of stroke, in peripheral vascular disease and following cardiac events. Antiplatelet agents cause irreversible platelet dysfunction and recovery only occurs with production of new platelets over 7–10 days or by platelet transfusion given more than 6–8 h after the last dose. Aspirin is usually of little consequence for patients with hip fracture and does not influence anaesthetic technique or appear to increase risk of complications. Two recent small studies have shown no significant increase in complications in patients who went to theatre on clopidogrel [19]. The AAGBI recommends avoiding spinal anaesthesia for patients on clopidogrel if possible as there is a small risk of epidural haematoma.

Around 5 % of patients presenting with hip fracture are anticoagulated requiring a clear understanding of the different drugs on the market and locally agreed protocols on management. The AAGBI have produced useful guidelines for regional anaesthesia in patients with abnormalities of coagulation [20] that give advice as to when it would be considered safe to proceed with a spinal anaesthetic. For many, general anaesthesia is an acceptable alternative and surgery should proceed when the surgical bleeding risk is felt to be acceptable. This is not a straightforward decision and should be made on an individual basis depending upon type of anticoagulant, renal function, the type of surgery required, anticipated blood loss, pain control and risk of immobility. Table 5.2 gives details of suggested management for different medications.

Table 5.2
Antiplatelets and anticoagulants in patients with fragility fracture


Elimination half-life


Acceptable to proceed with spinal


4–5 days

5 mgs vitamin K intravenously and repeat INR after 2 h. This can be repeated or consider Beriplex for immediate reversal

If INR <1.4


Irreversible effect on platelets

Proceed with surgery with General Anaesthetic

Monitor for blood loss

Consider platelet transfusion if concerns regarding bleeding

7 days or post platelet transfusion (at least 6 h post last dose)

Unfractionated iv heparin

1–2 h

Stop iv heparin 2–4 h pre-op

4 h

Low molecular weight heparin sub-cutaneous prophylactic dose

3–7 h

Last dose 12 h pre-op

12 h

Low molecular weight heparin sub-cutaneous

Treatment dose

3–7 h

Last dose 12–24 h pre-op.

Monitor for blood loss

24 h


8–12 h

Proceed with surgery with General Anaesthetic

Monitor for blood loss

Consider platelet transfusion if concerns regarding bleeding

5 days or post platelet transfusion at least 6 h post last dose


Irreversible effect on platelets

Proceed with surgery



7–10 h

May be partially reversed with Beriplex

Consider surgery 18–24 h after last dose

Review renal function

18–48 h


12–24 h

Consider surgery 24–48 h after last dose

Review renal function

Consider Pradaxibind for immediate reversal

48–96 h or post Pradaxibind


12 h

Consider surgery 12–18 h after last dose

24–48 h

Understanding the reason for antiplatelet/anticoagulant medication is essential in managing peri-operative risk of thromboembolic events. Patients with cardiac stents are at high risk of thrombosis and cardiac events and antiplatelet medication should either continue or be stopped for the shortest possible time.

Patients with mechanical heart valves (particularly mitral valves), known AF with recent stroke, and recent DVT or PE are at high risk of peri-operative thromboembolic complications and bridging strategies should be considered. Treatment dose subcutaneous low molecular weight heparin can be given until 24 h before surgery or intravenous unfractionated heparin until 2–4 h before surgery. The latter requires careful monitoring with 4–6 hourly APTT levels to ensure correct dosing.

Temporary insertion of an inferior vena cava filter should be considered for those with recent proximal DVT or PE.

Tranexamic acid has been shown to reduce the need for transfusion in a small study of patients with hip fracture with no difference in 3-month mortality [21] but, in another similar small study, there appeared to be a significant increased risk of thromboembolic events [22]. There is a meta-analysis underway with results eagerly awaited.

Use of reversal agents needs to be weighed up against potential risk of thromboembolic events. Anaemia

Anaemia on admission is an independent predictor of poor outcome and is present in about 10–12 % of those presenting with hip fracture [23]. It often reflects underlying disease such as malignancy, chronic kidney disease or poor nutrition. It is important to send blood for haematinics pre-transfusion to aid diagnosis and subsequent management. Macrocytic anaemia should not be transfused without an understanding of the cause and in liaison with haematologists. Although the evidence is controversial, most clinicians would aim for a pre-operative haemoglobin of at least 100 g/dl.

It is possible to predict blood loss depending upon the type of fracture; intracapsular fractures lose about 1000 ml, extracapsular about 1200 ml and intertrochanteric or subtrochanteric up to 1600 ml [24]. This may be greater in those on antiplatelet therapy or anti-coagulants.

The FOCUS study is a large randomised controlled trial comparing liberal transfusion with restrictive transfusion in patients following hip fracture, which showed no difference in mortality, ability to walk across a room at 60 days or length of hospital stay [25]. However, a decision about transfusion trigger should be made on an individual basis pre-operatively taking into account frailty, cardiorespiratory reserve and levels of function. Usual practice is to keep haemoglobin above 80 g/dl for those who are well and to aim for a haemoglobin of above 100 g/dl for those with poor cardiorespiratory reserve. Diabetes

Poor glycaemic control in the peri-operative period can lead to dehydration and poor wound healing with prolonged hyperglycaemia. Hypoglycaemia can also have serious consequences contributing to delirium, falls and seizures.

In the pre-operative period, patients with fragility fracture are often reluctant to eat due to pain, immobility and side effects of analgesia. Immobility may lead to reduced calorie requirements but pain and stress result in hyperglycaemia.

It is important to review diabetes medication pre-operatively and to monitor the blood sugar levels regularly. The AAGBI have produced comprehensive guidelines for peri-operative management of diabetes [26]. Patients who have been taking long-acting oral hypoglycaemics or long-acting insulin need close monitoring and may need slow 5 % glucose infusion if being kept nil by mouth for surgery.

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Aug 29, 2017 | Posted by in ORTHOPEDIC | Comments Off on Pre-Operative Management
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