From the Guidelines
Assessment and Plan for Hematology Clearance
The patient requires immediate and careful assessment for hematology clearance for neurosurgery due to their high risk of thromboembolic events and potential for bleeding, considering their history of C1 fracture and recent pulmonary embolism 1.
Patient Profile
- Age and Frailty: At 83 years old, with frailty and limited mobility, the patient is at an increased risk for venous thromboembolism (VTE) and other complications.
- History of C1 Fracture and Pulmonary Embolism: These conditions indicate a high risk for thromboembolic events, necessitating careful anticoagulation management.
- Symptoms: Foot drop and progressive weakness suggest neurological involvement that may require urgent neurosurgical intervention.
Anticoagulation Therapy
Given the patient's high risk for thromboembolic events, anticoagulation therapy is crucial. A low molecular weight heparin such as enoxaparin 40mg subcutaneously once daily may be considered, but it may need to be held 24 hours prior to surgery to minimize bleeding risks 1.
Prophylactic Measures
- Mechanical Prophylaxis: Intermittent pneumatic compression devices and graduated compression stockings should be considered to reduce the risk of VTE, especially given the patient's limited mobility and high risk profile 1.
- Pharmacological Prophylaxis: The decision to use pharmacological prophylaxis should be based on the patient's risk assessment, considering both the risk of VTE and the risk of bleeding. Low molecular weight heparin (LMWH) is generally preferred over unfractionated heparin due to its higher effectiveness in preventing DVT 1.
Preoperative Preparation
- Coagulation Profile: A thorough assessment is necessary to guide anticoagulation management.
- Complete Blood Count and Renal Function: These tests are essential for evaluating the patient's overall condition and potential risks associated with surgery and anticoagulation.
- Medication Review: Careful review and management of the patient's current medications, including anticoagulants, antiplatelets, and other relevant drugs, are critical perioperatively.
Multidisciplinary Approach
A multidisciplinary team involving neurosurgery, hematology, and anesthesia is essential for optimal management and to minimize risks associated with the patient's condition and planned surgery 1.
Risks and Considerations
- Bleeding and Thrombosis: The patient is at risk for both bleeding and thrombotic events, requiring careful balance of anticoagulation therapy.
- Neurological Deficits: The patient's neurological condition, including foot drop and progressive weakness, necessitates careful consideration to avoid worsening of neurological deficits during surgery.
From the Research
Assessment and Plan for Hematology Clearance
The patient's history of C1 fracture and pulmonary embolism, along with frailty, limited mobility, progressive weakness, and foot drop, necessitate a comprehensive assessment and plan for hematology clearance for neurosurgery.
- The patient's frailty status should be assessed using a validated index, such as the Clinical Frailty Scale (CFS) 2.
- A comprehensive geriatric assessment should be administered to identify potential risks and develop targeted interventions 3.
- Nursing interventions, including nutrition, polypharmacy, adherence to treatment, falls, exercise, and mood and cognitive intervention, should be implemented as part of a multidisciplinary plan 4.
- Prehabilitation programs, including elements of exercise, nutrition, and psychosocial counseling, may be beneficial in improving operative outcomes in frail surgical patients 5.
Considerations for Neurosurgery
- Frailty has been strongly associated with postoperative mortality and morbidity in cardiac surgery, and similar considerations may apply to neurosurgery 6.
- The evaluation of functional status in the emergency department could predict the risk of in-hospital death, and frail patients have an increased risk of death and major complications 2.
- Nonsurgical management should be considered in the case of severely frail and comorbid patients aged ≥80 years needing neurosurgery 2.
- A multidisciplinary team approach, including geriatricians, nurses, and other healthcare professionals, is essential in developing and implementing a comprehensive plan for hematology clearance and neurosurgery 3, 4, 6.