Clinics in geriatric medicine
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Because most older adults with hip fractures require urgent surgical intervention, the preoperative medical evaluation focuses on the exclusion of the small number of contraindications to surgery, and rapid optimization of patients for operative repair. Although many geriatric fracture patients have significant chronic medical comorbidities, most patients can be safely stabilized for surgery with medical and orthopedic comanagement by anticipating a small number of common physiologic responses and perioperative complications. In addition to estimating perioperative risk, the team should focus on intravascular volume restoration, pain control, and avoidance of perioperative hypotension.
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Clin. Geriatr. Med. · May 2014
ReviewVenous thromboembolism and postoperative management of anticoagulation.
Deep venous thrombosis and pulmonary embolism are common after fragility fracture surgery, although the incidence is decreasing over time. Prophylaxis is important, because it is effective; additionally, the consequences are significant. Several medications are available for prophylaxis, and the choice of agent should be determined based on patient and surgery characteristics, and balancing of venous thromboembolism (VTE) and bleeding risk. A comprehensive approach to VTE prophylaxis includes consideration of a pharmacologic agent and nonpharmacologic management.
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Clin. Geriatr. Med. · May 2014
ReviewPreoperative management of anticoagulation and antiplatelet agents.
This article describes current literature and treatment plans for managing anticoagulation and antiplatelet agents in patients presenting with hip fractures. Indications for anticoagulation and antiplatelet agents are discussed, and management techniques for when patients present with hip fractures are reviewed.
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Clin. Geriatr. Med. · May 2014
ReviewManagement of postoperative complications: cardiovascular disease and volume management.
Postoperative cardiovascular complications are common, predictable, and typically treatable in geriatric patients who have sustained fractures. Although intervention-specific data are sparse, observational evidence from high-performing geriatric fracture centers coupled with an understanding of geriatric principles can serve as a basis for treatment guidelines. Many patients can be safely and effectively managed with close attention to intravascular volume status, heart rate control, and minimization of other physiologic stresses, including pain and delirium. Many chronic cardiovascular therapies may be harmful in the immediate postoperative period, and can usually be safely omitted or attenuated until hemodynamic stability and mobility have been restored.
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Anemia is extremely common following hip fracture. Consistent data from randomized trials show that transfusion of less blood, with a transfusion threshold around 8 g/dL hemoglobin concentration, is preferable to a traditional threshold of 10 g/dL. ⋯ The most common complication of transfusion is circulatory overload. Future research may elucidate the optimal transfusion threshold for these elderly patients and address the specific needs of subgroups of patients, including those with acute coronary syndrome or chronic kidney disease.