From the Guidelines
For this 59-year-old morbidly obese female with well-controlled type 2 diabetes undergoing right knee replacement, I recommend moderate risk stratification with appropriate perioperative management. The patient's morbid obesity and well-controlled diabetes type 2 require careful consideration of her cardiovascular risk factors, as outlined in the American Heart Association's science advisory on cardiovascular evaluation and management of severely obese patients undergoing surgery 1.
Preoperative Management
Preoperatively, she should continue her diabetes medications until the day before surgery, with the exception of metformin which should be held 24 hours before surgery. Blood glucose should be monitored closely, aiming for levels between 140-180 mg/dL during the perioperative period, as recommended for patients with diabetes undergoing surgery 1.
Risk Stratification
The patient's obesity and surgery type put her at an elevated risk for venous thromboembolism, and she should receive pharmacological prophylaxis with low molecular weight heparin (enoxaparin 40mg subcutaneously daily) starting 12 hours postoperatively and continuing for 10-14 days, as suggested by the American College of Chest Physicians guidelines 1.
Postoperative Care
Early mobilization is crucial, beginning on postoperative day 0-1. Multimodal pain management should include scheduled acetaminophen (1000mg every 6 hours), celecoxib (200mg twice daily if no contraindications), and limited opioids as needed. Her obesity increases her risk for wound complications, respiratory issues, and difficult anesthesia, so optimization of positioning, respiratory support, and careful anesthetic planning are essential, as highlighted in the study on cardiovascular evaluation and management of severely obese patients undergoing surgery 1.
Additional Considerations
Despite her well-controlled diabetes, she should have hemoglobin A1c checked preoperatively to confirm adequate control (target <8%), as poor glycemic control increases infection risk and impairs wound healing after orthopedic surgery, as noted in the study on preoperative evaluation of severely obese patients 1. The patient's age, gender, cardiorespiratory fitness, electrolyte disorders, and heart failure should also be considered as independent predictors for surgical morbidity and mortality, as suggested by the American Heart Association's science advisory 1.
From the Research
Risk Stratification for Right Knee Replacement
The patient in question is a 59-year-old female who is morbidly obese and has well-controlled type 2 diabetes. When considering risk stratification for right knee replacement, several factors come into play, including the patient's diabetes management and obesity.
Diabetes Management
- The patient's well-controlled type 2 diabetes is a positive factor, as tight glycemic control has been shown to prevent microvascular complications 2.
- However, the choice of diabetes medication is also important, as some medications such as dual peroxisome-proliferator-activated receptor agonists and sulfonylurea can worsen cardiovascular disease 2.
- Metformin and insulin are considered the gold standard for diabetes management, and newer classes of medications such as sodium glucose cotransporter 2 (SGLT2) inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, and glucagon-like peptide-1 (GLP-1) analogues have also shown beneficial results 2.
Obesity and Cardiovascular Risk
- Morbid obesity is a significant risk factor for cardiovascular disease, and the patient's obesity should be taken into consideration when assessing cardiovascular risk 3.
- A study on semaglutide, a GLP-1 analogue, has shown promising results in achieving significant weight loss and improving cardiometabolic risk factors in individuals with obesity 4.
- Another study found that metformin was associated with beneficial cardiovascular outcomes in patients with diabetes who had elevated N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) levels, indicating (sub)clinical cardiovascular risk 5.
Psychological Well-being and Obesity
- A cognitive group treatment program that incorporated a non-dieting approach, regular exercise, and alternative coping skills was found to improve psychological well-being and reduce eating-related psychopathology in obese women 6.
- This suggests that interventions aimed at alleviating corollary problems associated with obesity, rather than focusing solely on weight loss, may be beneficial for the patient's overall well-being.