What are the preoperative management recommendations for a patient with a complex medical history undergoing robotic-assisted right anterior hip replacement surgery?

From the Guidelines

Preoperative management for an 87-year-old female with a complex medical history undergoing robotic-assisted right anterior hip replacement should prioritize a comprehensive medical evaluation, optimization of cardiovascular and metabolic status, and careful medication management, with a focus on minimizing perioperative morbidity and mortality, as recommended by the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1.

Key Considerations

• The patient's medical history, including atrial fibrillation, hypertension, heart failure with preserved EF due to nonischemic cardiomyopathy, history of mitral clip, severe tricuspid regurgitation, and hypothyroidism, should be thoroughly assessed and optimized before surgery.
• Medication management is crucial, with consideration of discontinuing or adjusting medications such as Eliquis, atorvastatin, Farxiga, levothyroxine, metoprolol XL, and Entresto, as necessary, to minimize perioperative risks.
• The patient's anticoagulation therapy with Eliquis should be managed according to the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline, which recommends stopping anticoagulants 5 days preoperatively and bridging with low molecular weight heparin if necessary 1.
• Preoperative laboratory testing should include complete blood count, comprehensive metabolic panel, coagulation studies, and type and screen for possible transfusion.
• Infection prevention measures, such as chlorhexidine gluconate showers and prophylactic antibiotics, should be implemented to minimize the risk of surgical site infections.
• A multimodal pain management protocol, including acetaminophen, celecoxib, and gabapentin, should be initiated preoperatively to reduce postoperative opioid requirements and facilitate early mobilization.

Perioperative Care

• The patient should be closely monitored for signs of cardiovascular instability, such as hypotension or arrhythmias, and managed accordingly.
• The patient's metabolic status, including blood glucose levels, should be closely monitored and managed to minimize the risk of perioperative complications.
• The patient's renal function should be closely monitored, and measures should be taken to minimize the risk of acute kidney injury.

Postoperative Care

• The patient should be closely monitored for signs of postoperative complications, such as bleeding, infection, or respiratory failure.
• The patient's pain should be managed with a multimodal approach, including acetaminophen, celecoxib, and gabapentin, to minimize the risk of opioid-related complications.
• The patient should be mobilized early to minimize the risk of postoperative complications, such as deep vein thrombosis or pulmonary embolism.

From the FDA Drug Label

The clinical evidence for the effectiveness of apixaban is derived from the ADVANCE-1, ADVANCE-2, and ADVANCE-3 clinical trials in adult patients undergoing elective hip (ADVANCE-3) or knee (ADVANCE-2 and ADVANCE-1) replacement surgery In the ADVANCE-3 study, 5407 patients undergoing elective hip replacement surgery were randomized to receive either apixaban 2.5 mg orally twice daily or enoxaparin 40 mg subcutaneously once daily. The efficacy data are provided in Tables 11 and 12 Table 11: Summary of Key Efficacy Analysis Results During the Intended Treatment Period for Patients Undergoing Elective Hip Replacement Surgery Total VTE includes symptomatic and asymptomatic DVT and PE.

The patient is taking Eliquis (apixaban), which is indicated for the prophylaxis of deep vein thrombosis (DVT) following hip or knee replacement surgery.

• The ADVANCE-3 study demonstrated the efficacy of apixaban in patients undergoing elective hip replacement surgery.
• The study showed that apixaban was effective in reducing the risk of total VTE (DVT and PE) compared to enoxaparin.
• However, the study does not provide specific guidance on the management of patients with a complex medical history like the one described.
• Given the patient's medical history of atrial fibrillation, hypertension, heart failure, and severe tricuspid regurgitation, it is essential to consider the potential risks and benefits of continuing or discontinuing apixaban in the perioperative period.
• The decision to continue or discontinue apixaban should be made on a case-by-case basis, taking into account the patient's individual risk factors and the potential risks of bleeding or thromboembolic events 2.

From the Research

Preoperative Management Recommendations

The patient's complex medical history, including atrial fibrillation, hypertension, heart failure preserved EF due to nonischemic cardiomyopathy, history of mitral clip, severe tricuspid regurgitation, and hypothyroidism, requires careful consideration in the preoperative management for robotic-assisted right anterior hip replacement surgery.

• The patient's current medications, including Eliquis, atorvastatin, Farxiga, levothyroxine, metoprolol XL, and Entresto, should be evaluated for potential interactions and risks during surgery 3, 4.
• Preoperative assessment and optimization of patient-specific risk factors are crucial for reducing postoperative morbidity and mortality 4.
• Special attention should be paid to preoperative cardiac, respiratory, and metabolic conditions, and the use of clinical scores to specify the patient's individual perioperative risk according to existing comorbidities 4.
• The patient's anticoagulation therapy with Eliquis should be considered in the context of preventing venous thromboembolism after hip replacement surgery, and the potential benefits and risks of continuing or discontinuing this medication should be weighed 5.
• A thorough history taking and physical examination of the patient before surgery are important for assessing the patient's health and estimating perioperative risk, although the extent of detail required is unclear 6.

Robotic-Assisted Hip Replacement Considerations

• Robotic-assisted total hip arthroplasty (rTHA) has emerged as a method to improve surgical precision and outcomes, with advantages including individualized preoperative planning, intraoperative assistance, and improved accuracy in implantation 7.
• However, rTHA also has disadvantages, such as high costs, the learning curve, and prolonged operation time compared to manual THA, which require careful consideration and efforts for minimization 7.
• The potential benefits and risks of rTHA in the context of the patient's complex medical history should be carefully evaluated, and further research is needed to ensure optimal patient benefits 7.