From the Guidelines
For a patient undergoing robotic-assisted right anterior hip replacement with this complex medication regimen, Eliquis (apixaban) should be discontinued 48-72 hours before surgery to reduce bleeding risk, with bridging therapy considered if the patient has high thrombotic risk, as suggested by the management approach for new oral anticoagulants 1.
Perioperative Medication Management
The patient's medication regimen includes Eliquis (apixaban), Farxiga (dapagliflozin), Lasix (furosemide), Entresto (sacubitril/valsartan), metoprolol XL (metoprolol succinate), levothyroxine, and atorvastatin.
- Eliquis should be held 48-72 hours before surgery, as the half-life of apixaban is 7-8 hours, and holding it for 2-3 half-lives is recommended for low bleeding risk surgery 1.
- Farxiga should be held 24-48 hours before surgery to prevent perioperative euglycemic diabetic ketoacidosis.
- Lasix should be taken the morning of surgery with a sip of water to maintain volume status while monitoring electrolytes.
- Entresto should be held the day of surgery to avoid intraoperative hypotension.
- Metoprolol XL should be continued through the perioperative period, including the morning of surgery with a small sip of water, to prevent cardiac complications from beta-blocker withdrawal, as recommended by the ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1.
- Levothyroxine should be taken the morning of surgery with minimal water to maintain thyroid homeostasis.
- Atorvastatin should be continued perioperatively, including the day of surgery, as it may provide cardioprotective effects, according to the ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1.
Postoperative Management
Postoperatively, Eliquis can typically be resumed 24-48 hours after surgery when hemostasis is achieved, with mechanical prophylaxis used in the interim. Farxiga should be restarted only after normal oral intake and renal function are confirmed. Blood pressure medications should be restarted based on hemodynamic stability, typically within 24-48 hours. Close monitoring of fluid status, renal function, and electrolytes is essential throughout the perioperative period due to the patient's complex cardiovascular medication regimen.
Risk Stratification
The patient's risk factors, including atrial fibrillation, hypertension, heart failure with preserved EF, history of mitral clip, severe tricuspid regurgitation, and hypothyroidism, should be taken into consideration when managing her perioperative care. The ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery provides recommendations for risk stratification and management of patients with these conditions 1.
From the Research
Perioperative Medication Management
The patient's complex medical history, including atrial fibrillation, hypertension, heart failure, and severe tricuspid regurgitation, requires careful consideration of perioperative medication management. The medications currently being taken by the patient include Eliquis (apixaban), Farxiga (dapagliflozin), Lasix (furosemide), Entresto (sacubitril/valsartan), metoprolol XL (metoprolol succinate), levothyroxine, and atorvastatin.
Medication Hold Recommendations
- Eliquis (apixaban): It is recommended to hold Eliquis 2-3 days prior to surgery, depending on the patient's renal function and the surgeon's preference 2, 3.
- Farxiga (dapagliflozin): There is limited evidence on the perioperative management of Farxiga. However, it is generally recommended to hold SGLT2 inhibitors, including Farxiga, 24 hours prior to surgery due to the risk of acute kidney injury and diabetic ketoacidosis 4.
- Lasix (furosemide): Lasix can be continued up to the day of surgery, but the dose may need to be adjusted based on the patient's volume status and renal function 5, 6.
Risk Stratification
The patient's medical history and current medications require careful risk stratification to minimize the risk of perioperative complications. The patient's atrial fibrillation, heart failure, and severe tricuspid regurgitation increase the risk of cardiac complications, while the use of Eliquis and Farxiga increases the risk of bleeding and acute kidney injury, respectively.
Key Considerations
- The patient's renal function and volume status should be closely monitored perioperatively, especially when holding or adjusting diuretics like Lasix.
- The patient's cardiac function and rhythm should be closely monitored perioperatively, especially when holding or adjusting anticoagulants like Eliquis.
- The patient's blood glucose levels should be closely monitored perioperatively, especially when holding or adjusting SGLT2 inhibitors like Farxiga.
Additional Recommendations
- The patient should be evaluated by a cardiologist and an anesthesiologist prior to surgery to assess the risk of cardiac complications and develop a perioperative management plan.
- The patient's medications should be carefully reviewed and adjusted as needed to minimize the risk of perioperative complications.
- The patient should be closely monitored perioperatively for signs of cardiac, renal, or bleeding complications, and the medical team should be prepared to intervene promptly if any complications arise.