What are the pre-operative clearance requirements for a 72-year-old patient with a history of atrial fibrillation (A-fib), cerebrovascular accident (CVA), mood disorder, anemia, benign prostatic hyperplasia (BPH) with obstruction, and dystonia, who is taking Eliquis (apixaban), aspirin, Lipitor (atorvastatin), metoprolol, omeprazole, and Flomax (tamsulosin) and is scheduled for inguinal hernia repair?

From the Guidelines

For a 72-year-old patient with multiple comorbidities scheduled for inguinal hernia repair, comprehensive preoperative clearance is essential, and Eliquis (apixaban) should be discontinued 48 hours before surgery due to bleeding risk, as suggested by the management approach for new oral anticoagulants 1. This patient should undergo cardiac evaluation including an ECG and possibly an echocardiogram to assess cardiac function given the history of atrial fibrillation. Anticoagulation management is critical, and the decision to discontinue Eliquis is based on the patient's renal function and the type of surgery, with the goal of minimizing bleeding risk while also considering the risk of thromboembolic events. Aspirin should also be managed according to the patient's specific risk factors, and the latest guidelines suggest continuing aspirin around the time of surgery instead of stopping it 7 to 10 days before surgery for patients undergoing CABG surgery 1. However, for this patient, aspirin management should be individualized based on the risk of bleeding and thrombosis. The patient should continue metoprolol to maintain heart rate control, and Lipitor, omeprazole, and Flomax can generally be continued through the perioperative period. Laboratory tests should include a complete blood count to evaluate anemia, basic metabolic panel, coagulation studies, and possibly liver function tests. A neurology consultation may be warranted given the history of CVA and dystonia to assess stroke risk and optimize management. The patient's mood disorder should be evaluated to ensure stability before surgery. Pulmonary function testing might be considered depending on the anesthesia plan. The patient should be instructed to take permitted medications with a small sip of water on the morning of surgery and to follow standard NPO guidelines. This comprehensive approach addresses the patient's complex medical history while minimizing perioperative risks, and is in line with recommendations for the management of patients with atrial fibrillation 1.

Some key considerations for this patient include:

• Cardiac evaluation to assess the risk of cardiac complications during surgery
• Anticoagulation management to balance the risk of bleeding and thrombosis
• Management of aspirin therapy based on individual risk factors
• Continuation of metoprolol and other medications as necessary to maintain heart rate control and manage other medical conditions
• Laboratory tests to evaluate anemia, renal function, and coagulation status
• Neurology consultation to assess stroke risk and optimize management
• Evaluation of the patient's mood disorder to ensure stability before surgery
• Pulmonary function testing as needed to inform anesthesia planning.

Overall, the goal of preoperative clearance for this patient is to minimize perioperative risks while also ensuring that the patient's complex medical needs are met.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Pre-Operative Clearance Requirements

To determine the pre-operative clearance requirements for a 72-year-old patient with a history of atrial fibrillation (A-fib), cerebrovascular accident (CVA), mood disorder, anemia, benign prostatic hyperplasia (BPH) with obstruction, and dystonia, who is taking Eliquis (apixaban), aspirin, Lipitor (atorvastatin), metoprolol, omeprazole, and Flomax (tamsulosin) and is scheduled for inguinal hernia repair, the following steps should be considered:

• Cardiac evaluation: The patient's history of A-fib and CVA indicates a need for careful cardiac evaluation prior to surgery 2. This may include assessment of cardiac function, evaluation of the risk of cardiac complications, and consideration of strategies to reduce this risk.
• Management of anticoagulation: The patient is taking Eliquis (apixaban), a direct oral anticoagulant (DOAC), which will need to be managed peri-operatively to minimize the risk of bleeding or thromboembolic complications 3.
• Optimization of medical therapy: The patient's medical therapy, including beta-blockers (metoprolol) and antihypertensive drugs, should be optimized prior to surgery to reduce the risk of cardiac complications 4.
• Anemia management: The patient's anemia should be evaluated and managed prior to surgery to reduce the risk of peri-operative complications.
• Mood disorder and dystonia management: The patient's mood disorder and dystonia should be evaluated and managed prior to surgery to reduce the risk of peri-operative complications.

Specific Considerations

• The patient's history of A-fib and use of anticoagulation therapy (Eliquis) will require careful consideration to minimize the risk of thromboembolic complications 3.
• The patient's use of aspirin and Eliquis will require careful management peri-operatively to minimize the risk of bleeding complications.
• The patient's history of CVA and use of antihypertensive drugs (metoprolol) will require careful consideration to minimize the risk of cardiac complications 4.
• The patient's anemia and BPH with obstruction should be evaluated and managed prior to surgery to reduce the risk of peri-operative complications.

Key Recommendations

• A thorough pre-operative cardiac evaluation should be performed to assess the patient's cardiac risk and develop strategies to reduce this risk 2.
• The patient's anticoagulation therapy should be managed carefully peri-operatively to minimize the risk of bleeding or thromboembolic complications 3.
• The patient's medical therapy should be optimized prior to surgery to reduce the risk of cardiac complications 4.
• The patient's anemia, mood disorder, and dystonia should be evaluated and managed prior to surgery to reduce the risk of peri-operative complications.