The pre-operative assessment of frail older patients is complex. It requires time and skills in information gathering. An understanding of the implications of each co-morbidity, a recognition of frailty, knowledge of pharmacology and pharmacodynamics are essential, together with an awareness of the likely impact of trauma, anaesthesia and surgery on an individual.
Pre-operative management involves comprehensive geriatric assessment (CGA) or geriatric evaluation and management (GEM). This is both interdisciplinary and multidimensional, recognising medical conditions in the context of functional impairment, environmental and social issues. This approach generates a problem list for which goal-driven interventions may be agreed.
Predicting likely complications and implementing preventative strategies form the basis of pre-operative medical management. In some, complications will inevitably occur, so pre-operative assessment should also include setting expectations and appropriate ceilings of care and ensuring these are agreed and understood by all the healthcare professionals involved, the patient and their families and carers.
Predicting likely functional outcome, care needs and support enables pre-operative discussion about likely length of hospitalisation and early identification of requirements for discharge planning.
Excellent pre-operative management is essential to support a smooth intra-operative and post-operative course that should then enable the best possible outcome for the patient.
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Brady M, Kinn S, Stuart P (2003) Preoperative fasting for adults to prevent peri-operative complications. Cochrane Database Syst Rev (4):CD004423Google Scholar
NICE (2011) NICE clinical guideline 124. Hip fracture: the management of hip fracture in adults. Guidance.nice.org.uk/cg124Google Scholar
Craig M, Jeavons R, Probert J et al (2012) Randomised comparison of intravenous paracetamol and intravenous morphine for acute traumatic limb pain in the emergency department. Emerg Med J 29(1):37–39CrossRefPubMedGoogle Scholar
Morrison R, Magaziner J, McLaughlin MA et al (2003) The impact of post-operative pain on outcomes following hip fracture. Pain 103(3):303–311CrossRefPubMedGoogle Scholar
Foss NB, Kristensen BB, Bundgaard M et al (2007) Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anesthesiology 106(4):773–778CrossRefPubMedGoogle Scholar
Duncan D, Beck S, Hood K et al (2006) Using dietetic assistants to improve the outcome of hip fracture: a randomised trial of nutritional support in an acute trauma ward. Age Ageing 35(2):148–153CrossRefPubMedGoogle Scholar
Marcantonio E, Flacker JM, Wright RJ et al (2001) Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 49(5):516–522CrossRefPubMedGoogle Scholar
Kalisvaart K, de Jonghe J, Bogaards M et al (2005) Haloperidol prophylaxis for elderly hip surgery patients at risk for delirium: a randomised placebo controlled trial. J Am Geriatr Soc 53(10):1658–1666CrossRefPubMedGoogle Scholar
Bellilli G, Morandi A, Daniel H et al (2014) Validation of the 4AT; a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing 0:1–7. doi:10.1093/ageing/afu021Google Scholar
Jette M, Sidney K, Blumchen G (1990) Metabolic equivalents (METS) in exercise testing, exercise prescription, and evaluation of functional capacity. Clin Cardiol 13:555–565CrossRefPubMedGoogle Scholar
Goldman L, Caldera DL, Nussbaum SR et al (1977) Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 297:845–850, 9CrossRefPubMedGoogle Scholar
Lee T, Marcantonio E, Mangione C et al (1999) Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 100:1043–1049CrossRefPubMedGoogle Scholar
McBrien M, Heyburn G, Stevenson M et al (2009) Previously undiagnosed aortic stenosis revealed by auscultation in the hip fracture population- echocardiographic findings, management and outcome. Anaesthesia 64:863–870CrossRefPubMedGoogle Scholar
MHRA Committee on the Safety Devices (CSD) and Heart Rhythm UK (HRUK) London: Medicines and Healthcare Products Regulatory Agency; 2006. Guidelines for the perioperative management of patients with implantable pacemakers, or implantable cardioverter defibrillators where the use of surgical diathermy / electrocautery is anticipated. Accessed from https://www.erbe-med.com/images/uk/Diathermy__Pacemakers-ICDs1.pdf
Doleman B, Moppett I (2015) Is early hip fracture surgery safe for patients on clopidogrel? Systematic review, meta-analysis and met-regression. Injury 46:954–962CrossRefPubMedGoogle Scholar
Harrop-Griffiths W, Cook T, Gill H et al; AAGBI (2013) Regional anaesthesia in patients with abnormalities of coagulation. Anaesthesia 68:966–972Google Scholar
Lee C, Freeman R, Edmondson M et al (2015) The efficacy of tranexamic acid in hip hemiarthroplasty surgery: an observational cohort study. Injury 46(10):1978–1982CrossRefPubMedGoogle Scholar
Zufferey P, Miquet M, Quenet S et al (2010) Tranexamic acid in hip fracture surgery: a randomized controlled trial. Br J Anaesth 104:23–30CrossRefPubMedGoogle Scholar
White S, Moppett I, Griffiths R (2014) Outcome by mode of anaesthesia for hip fracture surgery. An observational audit of 65 535 patients in a national dataset. Anaesthesia 69:224–230. doi:10.1111/anae.12542CrossRefPubMedGoogle Scholar
Foss N, Kehlet H (2006) Hidden blood loss after surgery for hip fracture. J Bone Joint Surg 88-B:1053–1059CrossRefGoogle Scholar
Carson J, Michael M, Terrin L et al; FOCUS investigators (2011) Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 365:2453–2462Google Scholar
Lobo D, Dhatariya K, Levy N et al; on behalf of the ASGBI (2012) The peri-operative management of the patient with diabetes. Accessed from www.asgbi.org.uk/downloads
Arozullah A, Conde M, Lawrence V (2003) Preoperative evaluation for postoperative complications. Med Clin North Am 87(1):153–173CrossRefPubMedGoogle Scholar
Batsis J, Huddlestone J, Melton L et al (2009) Body mass index and risk of non-cardiac postoperative medical complications in elderly hip fracture patients: a population based study. J Hosp Med 4(8):E1–E9CrossRefPubMedPubMedCentralGoogle Scholar
Rosencher N, Vielpeau C, Emmerich J et al (2005) Venous thromboembolism and mortality after hip fracture surgery: the ESCORTE study. J Thromb Haemost 3(9):2006–2014CrossRefPubMedGoogle Scholar
Falls and Fragility Fracture Audit programme National Hip Fracture Database: Anaesthesia Sprint Audit of Practice 2014. Healthcare Quality Improvement PartnershipGoogle Scholar
Moppett I, Parker M, Griffiths R et al (2012) Nottingham hip fracture score: longitudinal and multicentre assessment. Br J Anaesth. Available from doi:10.1093/bja/aes187
The Association of Anaesthetists of Great Britain and Ireland (2009) Do not attempt resuscitation decisions in the peri-operative period. Accessed from www.aagbi.org/sites/default/files/dnar
Neuberger J, Currie C, Tsang C et al (2015) The impact of a national Clinician-led audit initiative on care and mortality after hip fracture in England. Med Care 53(8):686–691. Accessed from http://researchonline.Ishtm.ac.uk/2242004
Harari D, Hopper A, Dhesi J et al (2007) Proactive care of older people undergoing surgery (POPS): designing, embedding, evaluating and funding a comprehensive assessment service for older elective surgical patients. Age Ageing 36(2):190–196CrossRefPubMedGoogle Scholar
Griffiths R, Alper J, Beckingsale A et al (2012) Management of proximal femoral fractures. Association of Anaesthetists of Great Britain and Ireland. Anaesthesia 67(1):85–98CrossRefPubMedGoogle Scholar