From the Guidelines
For a 59-year-old morbidly obese female with well-controlled type 2 diabetes undergoing right knee replacement, I recommend a comprehensive perioperative approach, prioritizing blood glucose control and cardiovascular risk assessment, as outlined in the most recent guidelines 1.
Preoperative Management
- Preoperatively, a risk assessment should be performed to identify potential cardiac risks, particularly in patients with high-risk features such as autonomic neuropathy or renal failure 1.
- The patient's diabetes medications should be managed carefully, with metformin held on the day of surgery and other oral glucose-lowering agents held the morning of surgery 1.
- The target preoperative HbA1c should be <8% to minimize complications, as recommended by the latest standards of care in diabetes 1.
Intraoperative Management
- Intraoperatively, blood glucose levels should be maintained between 100-180 mg/dL, using insulin infusion if needed, to minimize the risk of complications 1.
- Close monitoring of the patient's cardiovascular status is crucial, given the increased risk of cardiac complications in obese patients undergoing surgery 1.
Postoperative Management
- Postoperatively, the patient's home diabetes regimen should be resumed once she is eating regularly, with close glucose monitoring every 4-6 hours for the first 48 hours 1.
- Multimodal analgesia, including preoperative celecoxib, acetaminophen, and gabapentin, followed by scheduled acetaminophen and opioids as needed, can help manage pain and reduce the risk of complications.
- Early mobilization within 24 hours is crucial to reduce thromboembolic risk, and extended thromboprophylaxis with enoxaparin 40mg daily for 28 days post-discharge should be considered, given the patient's increased risk of venous thromboembolism.
Key Considerations
- Obesity increases the risks of wound complications, infection, and implant failure, while well-controlled diabetes is favorable but still requires vigilant glucose management to prevent surgical site infections and promote healing.
- Nutritional optimization and physical therapy both before and after surgery can improve outcomes and reduce the risk of complications.
- The patient's cardiovascular status should be closely monitored, given the increased risk of cardiac complications in obese patients undergoing surgery, and any signs of cardiac dysfunction should be promptly addressed.
From the Research
Patient Profile
- 59-year-old female
- Morbidly obese
- Well-controlled diabetes type 2
- Undergoing right knee replacement
Relevant Studies
- A study published in 2024 2 found that patients with diabetes taking sodium-glucose cotransporter-2 inhibitors (SGLT2i) had higher odds of postoperative adverse events, but lower odds of transfusion, after total knee arthroplasty.
- Studies comparing apixaban and enoxaparin for thromboprophylaxis after knee replacement found that apixaban was as effective as enoxaparin in preventing deep vein thrombosis and had a lower risk of bleeding 3, 4, 5.
- A study published in 2003 6 found that patients with diabetes had higher knee scores and pain scores after total knee replacement, but also had a higher revision rate and incidence of deep infections.
Considerations for Knee Replacement
- Patients with diabetes may be at higher risk for postoperative complications, such as deep infections and revision surgery 6.
- SGLT2i may increase the risk of postoperative adverse events, but may also reduce the risk of transfusion 2.
- Apixaban may be a suitable alternative to enoxaparin for thromboprophylaxis after knee replacement, with a lower risk of bleeding and similar efficacy in preventing deep vein thrombosis 3, 4, 5.