Patient taken to OR

1. Goal time to OR is <24 hours as a hip fracture needs urgent surgical repair.  Getting to the OR within 24 hours is associated with improved health outcomes including decreased post-operative complications (pneumonia, hypoxia, arrhythmias, UTIs, PE), lowered mortality, improved pain and decreased rates of delirium shorter length of stay.

2. Orthopedic On-call chief notifies attending on-call and covering trauma attending as well as University Service Chief and Intern

3. Orthopedic chief discusses all hip fractures admitted overnight or planned for surgery each day with E1 in the morning. This discussion will include any relevant co-morbidities that may affect surgical planning.

4. Patients are optimized by 11AM if they present overnight, ASAP if they present during the day, but no later than 11AM the following day

                                i.Statement to be placed in chart when optimized

1. “This surgery is urgent and patient is medically optimized for the proposed procedure and requires no further medical evaluation at this time.   Please discuss with anesthesia that spinal anesthesia is preferred if appropriate and safe.”

Anesthesia

1. Neuraxial strongly preferred in all patients

                                 i.INR < 1.3

                                ii.Must provide adequate paralysis for fracture reduction

2. Contraindications or neuraxial + regional anesthesia: Refer to:   http://medctrpharm.ucsf.edu/system/files/documents/UCSF%20Antithrombotics%20%20Neuraxial%20Intervention%20July%202015.pdf

1. GETA for patients with INR > 1.3 but able to go to surgery otherwise
2. Basic Preoperative Workup

                                i.CBC, Chem 10, Coags

                               ii.Chest radiograph if clinically indicated (hx of heart or lung problems or sx)

                              iii.ECG if clinically indicated (hx of heart problems or new sxs)

     3. Standard Preoperative antibiotics as a weight based dose of Cefazolin

                                i.Vancomycin for Cephalosporin allergic patients

                                ii.Vancomycin for penicillin allergic patients if the allergy was anaphylaxis

    4.Tranexemic Acid 10mg/kg IV at the beginning and end of the case

                               i.Any specific concerns for contraindications to be discussed between attendings

Surgery

1. Coverage

                               i.The Trauma Attending of the Day covers the case from 1PM until 7PM start time

                              ii.If the case can go after 7PM the general on-call attending covers

                              iii.If the case requires a total hip arthroplasty the arthroplasty attending on call or arthroplasty fellow will cover depending on availability.                                                             If the on-call attending or fellow is not available and the case can go then any arthroplasty faculty available will cover.

   2.Standard Preoperative antibiotics as a weight based dose of Cefazolin

                                i.Vancomycin for Cephalosporin allergic patients

                                ii.Vancomycin for penicillin allergic patients if the allergy was anaphylaxis

   3.Tranexemic Acid 10mg/kg IV at the beginning and end of the case

   4.INR 1.5-1.8, give one unit FFP on call to OR

   5.Hip Fracture Booking

                                i.All cases that will be going for ORIF will be booked as: HIP FRACTURE ORIF (HIPT3045)

                                ii.All cases that will be going for CRPP will be booked as HIP FRACTURE CRPP (HIPT3205)

                                iii.All cases requiring a Hemiarthroplasty or Total Hip Arthroplasty will be booked as: HIP FRACTURE HEMIARTHROPLASTY (HIPT3044)

                                iv.In order to search for the appropriate booking code type in the alias “thundercat” and the three above codes will appear.

                                v.ONLY BOOK WITH THESE CODES

1. Continue Aspirin at all doses
2. Warfarin

                                 i.Hold Warfarin, give Vitamin K 5mg PO x 1 ASAP

                                 ii.Type and cross for 2 units FFP

                                 iii.Goal INR for OR is 1.5 or less for surgery, Goal INR for neuraxial anesthesia is 1.3 or less

                                iv.Re-check INR 12 hours after vitamin K dose

                                v.Can proceed with surgery if INR 1.8 or less and patient can get FFP on the way to the OR (patient will receive GETA)

3. Clopidogrel, prasugrel, ticagrelor, cilostazol

                                 i.Continue any Acute Coronary Syndrome (treated medically or with stent) within last 12 months

                                 ii.Continue if drug-eluding stent in last 6 months (in non-ACS)

                                 iii.Continue if bare metal stent within last 1 month (in non-ACS)

                                iv.No need to delay surgery (patient will receive GETA)

4. NOACs (dibigatran, rivaroxaban, apixiban, edoxaban)

                                i.Hold, record time of last dose taken clearly. Clearance dependent on renal function.

                                ii.Generally hip fracture surgery with general anesthesia only can be undertaken 24 hours after last dose for all medications and normal renal                                                       function (48 hours for Dabigatran and Apixiban and high risk of bleeding). Risks and benefits should be weighed by teams (ortho,                                                          medicine, geriatrics, and anesthesia) for delaying surgery more than 24 hours.

5. Bridging

                                 i.Bridging therapy with heparin indicated if any of the very high risk conditions below:

                                ii.Very high risk conditions

1. Mechanical heart valve
   1. Mitral prosthesis
   2. Caged ball/tilting aortic prosthesis
   3. Stroke/TIA within 6 months
2. Atrial Fibrillation
   1. CHADS-VASC score 7-9  + absence of additional bleeding risk
   2. Stroke/TIA or systolic embolism within 3 months
3. VTE
   1. VTE within 3 months
   2. Severe thrombophilia
   3. History of VTE during discontinuation of anticoagulation

Co-morbidities:  Only unstable conditions should delay going to the  OR (Active ACS, Unstable Arrhythmia, Decompensated CHF and Known Moderate/Severe Aortic or Mitral stenosis [a-d]) below:

1. Active Acute Coronary Syndrome (ischemic EKG changes or elevated troponin)

                                i.Cardiology consult and OR delay until optimized

2. Unstable Arrhythmia (hypotension or significantly uncontrolled)

                                i.Cardiology consult and OR delay until optimized

3. Decompensated CHF with new symptoms:  see “Patients requiring an echo”

                                i.New symptoms or severe decompensation needs an echo before OR

4. Known Mod/Severe AS or Mod/Severe MS with no echo in the past 12 months

5. Pulmonary Compromise

               a. COPD/Asthma- continue inhaled bronchodilators/steroids. If acute, serious exacerbation--consider delaying surgery 24-48 hours with steroid treatment

               b. Acute bronchitis/PNA: Assess for sepsis/SIRS/bactermia and treat as necessary

    6. Anemia

                                i.Transfusion trigger is Hgb < 8

7. Diabetes/Elevated blood sugar

                                i.Goal  blood sugar 100-180 (too low increases falls, too high impedes repair)

Patients Requiring an Echo

1. A recent Echo is defined as in the last 12 months
2. Only patients with the following conditions require a new echo

                                i.CHF with new symptoms/signs of decompensation

                                ii.Mod/severe aortic stenosis or mitral stenosis

     3. With new severe symptoms or new oxygen requirement

     4. If no echo in last 12 months

     5. Coordinate with cardiology to have echo done within 12 hours of admission (before 11 am next day)

Cardiac Anesthesia

a.Only a requirement at the discretion of the anesthesia service (Medicine, Cardiology, or Geriatrics should NOT recommend)