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 most recent guidelines 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, necessitates a thorough cardiovascular evaluation and optimization of cardiac function before surgery.
• Medication management is crucial, with consideration of continuing beta-blockers and statins through the perioperative period, while potentially holding ACE inhibitors and ARBs on the day of surgery to prevent intraoperative hypotension, as suggested by recent guidelines 1.
• The use of anticoagulants, such as Eliquis, should be carefully managed, with consideration of bridging therapy if necessary, to minimize the risk of perioperative bleeding or thromboembolic events.
• Preoperative laboratory testing should include a complete blood count, comprehensive metabolic panel, coagulation studies, and type and screen for potential transfusion, as recommended by recent guidelines 1.
• Infection prevention measures, including chlorhexidine showers and prophylactic antibiotics, should be implemented to minimize the risk of surgical site infections.

Perioperative Pain Management

• The use of a multimodal analgesic regimen, including paracetamol and a non-steroidal anti-inflammatory drug or a cyclo-oxygenase-2-selective inhibitor, is recommended for postoperative pain management, as suggested by recent guidelines 1.
• Opioids should be reserved as rescue analgesics in the postoperative period, with careful consideration of the patient's individual needs and risk factors for opioid-related adverse events.

Conclusion is not allowed, so the response continues with the next section

Additional Recommendations

• Preoperative exercise and education are recommended to improve outcomes and reduce the risk of perioperative complications, as suggested by recent guidelines 1.
• A single intra-operative dose of intravenous dexamethasone 8–10 mg is recommended for its analgesic and anti-emetic effects, as suggested by recent guidelines 1.
• A single-shot fascia iliaca block or local infiltration analgesia is recommended for postoperative pain management, as suggested by recent guidelines 1.

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 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 preventing DVT in patients undergoing elective hip replacement surgery.

• The study showed that apixaban 2.5 mg orally twice daily was superior to enoxaparin 40 mg subcutaneously once daily in reducing the risk of total VTE (venous thromboembolism) and all-cause death.
• The efficacy profile of apixaban was generally consistent across subgroups of interest, including age, gender, race, body weight, and renal impairment.

Given the patient's complex medical history, including atrial fibrillation, hypertension, heart failure, and severe tricuspid regurgitation, it is essential to carefully manage their anticoagulation therapy. The patient is currently taking Eliquis (apixaban), which should be continued as directed, and the dose should not be adjusted without consulting the prescribing physician 2.

It is crucial to note that the patient's medical history and current medications should be carefully evaluated to ensure that they are adequately prepared for the robotic-assisted right anterior hip replacement surgery. The patient's cardiovascular risk factors should be optimized, and their anticoagulation therapy should be carefully managed to minimize the risk of thromboembolic events.

The patient's hypothyroidism should also be well-controlled, and their levothyroxine dose should be adjusted as necessary to maintain a euthyroid state. The patient's metoprolol XL and Entresto should be continued as directed to manage their heart failure and hypertension.

In summary, the patient's preoperative management should focus on optimizing their cardiovascular risk factors, carefully managing their anticoagulation therapy, and ensuring that their hypothyroidism is well-controlled. The patient should be closely monitored for any signs of thromboembolic events or other complications, and their medications should be adjusted as necessary to minimize their risk. 2

From the Research

Preoperative Management Recommendations

For an 87-year-old female with a complex medical history undergoing robotic-assisted right anterior hip replacement surgery, several factors need to be considered:

• Atrial fibrillation, hypertension, heart failure preserved EF due to nonischemic cardiomyopathy, history of mitral clip, severe tricuspid regurgitation, and hypothyroidism require thorough evaluation and management before surgery 3, 4.
• Medications such as Eliquis, atorvastatin, Farxiga, levothyroxine, metoprolol XL, and Entresto should be reviewed and optimized preoperatively to minimize risks and ensure the best possible outcomes 5.

Preoperative Assessment and Optimization

Preoperative assessment typically focuses on evaluating and accepting the patient's condition, but it is essential to move towards preoperative optimization to improve patient outcomes 3.

• A collaborative preoperative clinic can help achieve this goal by identifying and managing modifiable risk factors, such as cardiac complications, thromboembolism, and glycemic control 4.
• Early identification of significant medical and nonmedical issues allows for complete evaluation and planning, decreasing the likelihood of delays, cancellations, and complications.

Role of History and Physical Examination

A thorough history taking and physical examination are crucial in preoperative evaluation, although the extent of detail required is unclear 6.

• These assessments can help identify potential risks and guide further testing or optimization strategies.
• However, routine testing for all surgical patients before operation has limited benefits and is not advocated.

Robotic-Assisted Total Hip Arthroplasty

Robotic-assisted total hip arthroplasty (rTHA) has emerged to improve surgical precision and outcomes, offering advantages such as individualized preoperative planning and improved accuracy in implantation 7.

• However, high costs, the learning curve, and prolonged operation time compared to manual THA are critical drawbacks that require careful consideration.
• Further research is needed to ensure optimal patient benefits and evaluate the long-term outcomes of rTHA.