Pre-operative Medical Assessment and Optimisation

Excerpt

One-third of patients presenting with hip fracture are active and independent without significant comorbidities that impact on their daily living. For them, the risk of surgery and post-operative complications is low. However, the challenge arises for those with markers of frailty, and it is important to consider that a quarter of patients are likely to be in their last year of life.

The pre-operative assessment of patients with frailty is complex. It requires time and skills in information gathering, an understanding of the implications of each co-morbidity, knowledge of pharmacology and pharmacodynamics and an awareness of the likely impact of trauma, anaesthesia and surgery on organs with limited physiological reserve.

Pre-operative management of patients with frailty involves a focused 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 through which goal-driven interventions may be agreed.

Optimisation of medical conditions, medication review and adjustment in the peri-operative period, predicting likely complications and implementing preventative strategies form the basis of pre-operative medical management. In some, complications will inevitably occur, and pre-operative management should 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 medical management is essential to support a smooth intra-operative and post-operative course which should then enable the best possible outcome for the patient.