DRAFT
Orthopedics Hip Fracture Pre-operative power plan
References:
1. Fleisher LA, et. al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation. 2007; 116: e418-e500. (insert link here)
2. Stone ME, Salter B, and Fischer A. Perioperative management of patients with cardiac
implantable electronic devices. British Journal of Anaesthesia. 107 (S1): i16–i26 (2011). (insert link here)
Patient care
Consider for use in patients:
-With hip fracture and have a planned orthopedics operative procedure
Please complete each of the sections and order appropriate items for each section.
Section 1: Pre-operative assessment (based on 2007 ACC/AHA perioperative guidelines, have links to flow chart and to METs chart and to full document here).
Assume intermediate risk surgery (orthopedic surgeries are all intermediate risk).
Assess for active cardiac conditions
If active cardiac conditions:
Consult Cardiology
If no active cardiac conditions: proceed to functional capacity assessment.
Assess functional capacity
If > 4 METs: proceed to clinical risk factor assessment.
If < 4 METs:
Transthoracic echocardiogram (TTE)
Assess for clinical risk factors (Ischemic heart disease, Compensated or prior heart failure, Diabetes mellitus, Renal insufficiency, and Cerebrovascular disease)
If less than 3 clinical risk factors present and functional capacity > 4 METs: no additional diagnostic testing required.
If 3 or more clinical risk factors present:
Transthoracic echocardiogram (TTE)
Section 2: Other pre-operative assessments and diagnostics.
Assess for active pulmonary symptoms
If active pulmonary symptoms present:
CXR
X EKG
Labs STAT, drawn 0500 on day of surgery
X CBC
X Chem7
X PT/INR
X aPTT
X 25-OH vitamin D level
Goal PT/INR 1.5 pre-operatively.
If INR > 1.5:
Follow anticoagulation reversal power plan (Embed anticoagulation reversal power plan here)
Section 3: Diet and Medications
X NPO at midnight except medications
X Adjust administration time for all morning medications to 0530 on the day of surgery
Most medications should be continued on the day of surgery, including most anti-hypertensives, statins, inhalers, and chronic narcotic pain medications including a fentanyl patch. Basal insulin doses should be continued, as well as correctional sliding scale. Aspirin (ASA) should be continued in patients using it for secondary prevention; a risk-benefit analysis for continuing or stopping should be conducted in all other cases.
The following exceptions apply:
X HOLD any ACE inhibitor/ARB the day of surgery
X HOLD any anticoagulant within 24 hours of surgery
X HOLD Plavix (unless bare metal stent placed <1 month or drug-eluting stent placed <12 months)
X HOLD any nutritional doses of short-acting insulin while NPO
Section 4: For patients with pacemakers or implantable cardiac defibrillators (have link to flow chart and to full article here).
Devices should be interrogated pre-operatively.
Consult Cardiology Electrophysiology for device interrogation pre-operatively.
Assume there will be a source of electromagnetic interference (e.g. electrocautery) present.
Pacemakers should be reprogrammed to asynchronous mode (via programmer or magnet).
Implantable Cardiac Defibrillators (ICDs) should be deactivated (via programmer or magnet).
Section 5: For hemodialysis patients.
Attempt to adjust hemodialysis schedule so that patient receives hemodialysis the day prior to planned surgery (and not on the day of surgery) if possible.
Consult Nephrology for inpatient hemodialysis.
Section 6: Consult Anesthesia
Consult Anesthesia for pre-op evaluation