Analgesia and delirium prevention
›Pain and delirium bundle
›Nonopioid baseline
›Acetaminophen PO 1 g every 6 hours
›Maximum 4 g per day
›Lower maximum with liver disease or heavy alcohol use
›NSAID option only if low renal and bleeding risk
›Ibuprofen PO 400 mg every 6 to 8 hours
›Avoid in CKD, active bleeding, high GI risk
›Regional anesthesia
›Fascia iliaca block
›Ropivacaine 0.2% to 0.375% 30 to 40 mL total volume
›Maximum local anesthetic dose per kg and product label
›If anticoagulated, procedural bleeding risk assessment
›Femoral nerve block
›Bupivacaine 0.25% 15 to 20 mL
›Continuous catheter pathway if available
›Opioid rescue
›Morphine IV 2 mg increments every 5 to 10 minutes
›Hold if respiratory rate low or sedation increasing
›Antiemetic option for nausea
›Hydromorphone IV 0.2 mg increments every 5 to 10 minutes
›Avoid stacking doses in frail older adults
›Continuous pulse oximetry if repeated dosing
Perioperative optimization
›Medical optimization targets
›Fluids and perfusion
›Balanced crystalloid bolus if hypovolemia
›Avoid fluid overload in CHF
›Oxygenation
›Supplemental oxygen to maintain target saturation per COPD status
›Incentive spirometry planning for admission
›Temperature and comfort
›Active warming for hypothermia
›Shivering reduction to limit oxygen demand
›Diabetes management
›Sliding scale insulin per local protocol
›Avoid hypoglycemia during NPO periods
Anticoagulation and bleeding management
›Anticoagulation and reversal
›Warfarin
›Vitamin K IV 1 to 2 mg for elevated INR with planned surgery
›PCC dosing per INR and weight for urgent reversal
›DOACs
›Last dose timing documentation
›Renal function based clearance estimate
›If life-threatening bleeding, specific reversal agent per DOAC type and local protocol
›Antiplatelets
›Aspirin continuation commonly acceptable for hip fracture surgery
›P2Y12 inhibitor coordination with surgery and anesthesia
Infection prophylaxis and wound care
›Surgical prophylaxis
›Cefazolin IV 2 g within 60 minutes of incision
›Cefazolin IV 3 g if weight based threshold met per local protocol
›Redose interval per operative duration
›Severe beta-lactam allergy alternative
›Clindamycin IV 900 mg
›Vancomycin IV weight based dosing per local protocol
›Open fracture adjuncts
›Broad spectrum coverage per open fracture grade
›Tetanus status update
›Thromboprophylaxis plan
›Mechanical prophylaxis
›Intermittent pneumatic compression if not contraindicated
›Early mobilization planning
›Pharmacologic prophylaxis
›Enoxaparin 40 mg SC daily
›Enoxaparin 30 mg SC daily if renal impairment per local threshold
›Hold timing around neuraxial anesthesia per anesthesia protocol
›Alternative agent if LMWH contraindicated
›Unfractionated heparin 5000 units SC every 8 to 12 hours
›DOAC prophylaxis only if explicitly chosen by surgical service
Operative management overview
›Definitive management principles
›Early surgery target
›Surgery within 24 to 48 hours associated with improved outcomes
›Delay only for reversible life-threatening medical issues
›Femoral neck fracture approach
›Nondisplaced fracture options
›Percutaneous internal fixation
›Weight-bearing plan per surgeon
›Displaced fracture options in older adults
›Hemiarthroplasty
›Total hip arthroplasty in selected patients
›Intertrochanteric fracture approach
›Cephalomedullary nail for many unstable patterns
›Sliding hip screw for selected stable patterns
›Subtrochanteric fracture approach
›Cephalomedullary nailing common
›Plate fixation in selected cases