What is the perioperative management for a patient with hypertension, hyperlipidemia, and hypothyroidism undergoing arthrodesis when outpatient management of chronic conditions is optimized prior to admission?

Perioperative Management for Arthrodesis in a Patient with Hypertension, Hyperlipidemia, and Hypothyroidism

For a patient with optimized hypertension, hyperlipidemia, and hypothyroidism undergoing arthrodesis, continue antihypertensive medications through the day of surgery, maintain levothyroxine therapy without interruption, and ensure intraoperative mean arterial pressure remains ≥60-65 mmHg to reduce perioperative cardiovascular complications.

Preoperative Management

Hypertension Management

• Continue most antihypertensive medications up to and including the morning of surgery 1, 2
• Consider withholding ACE inhibitors/ARBs 24 hours before surgery to reduce intraoperative hypotension risk (Class IIb recommendation, Level B-R) 1, 2
• For patients with grade 1-2 hypertension (SBP <180 mmHg and DBP <110 mmHg), proceed with surgery without delay 1
• For patients with grade 3 hypertension (SBP ≥180 mmHg or DBP ≥110 mmHg), consider postponing elective surgery until better control is achieved, especially in those with cardiovascular risk factors 1, 2
• Beta-blockers should be continued if the patient is already taking them chronically 1, 2

Hypothyroidism Management

• Continue levothyroxine therapy without interruption 3
• Administer levothyroxine on an empty stomach, one-half to one hour before breakfast with a full glass of water 3
• Do not administer levothyroxine within 4 hours of agents that can decrease absorption (iron, calcium supplements, antacids) 3
• Ensure thyroid function is optimized preoperatively as hypothyroidism can affect cardiovascular function and drug metabolism 4

Hyperlipidemia Management

• Continue statin therapy throughout the perioperative period 1
• No need to delay surgery based on lipid levels 1
• For patients on combination therapy (statin plus fibrate), consider the cardiovascular risk profile when determining whether to continue both medications 5

Intraoperative Management

Blood Pressure Management

• Maintain intraoperative mean arterial pressure (MAP) ≥60-65 mmHg or systolic blood pressure ≥90 mmHg (Class I recommendation, Level B-NR) 1, 2
• Be prepared to treat significant blood pressure fluctuations with appropriate IV medications 2
• Monitor for exaggerated hypotensive responses, particularly if the patient has chronic hypertension with altered autoregulation 2

Fluid Management

• Pay careful attention to volume status as high-volume infusion is often needed intraoperatively 1
• Monitor for fluid overloading which may cause decompensation of heart failure 1

Postoperative Management

Medication Resumption

• Restart antihypertensive medications as soon as clinically reasonable (Class I recommendation, Level C-EO) 1, 2
• Resume levothyroxine at the same dose as preoperatively 3
• Monitor for signs of hypothyroidism if levothyroxine resumption is delayed 4
• Continue lipid-lowering medications postoperatively 5

Blood Pressure Control

• Treat postoperative hypotension (MAP <60-65 mmHg or SBP <90 mmHg) promptly to limit cardiovascular, cerebrovascular, and renal events (Class I recommendation, Level B-NR) 1, 2
• Before administering antihypertensive medication, assess for reversible causes such as pain, anxiety, urinary retention, hypoxemia, hypothermia, volume overload, and medication withdrawal 2
• Use the patient's home antihypertensive medications when possible for postoperative hypertension 2

Special Considerations and Pitfalls

Potential Complications to Monitor

• Cardiovascular: Patients with hypothyroidism may have diastolic hypertension and dyslipidemia, which can promote atherosclerosis 6, 4
• Hemodynamic: Hypothyroidism reduces cardiac oxygen consumption and may affect response to vasoactive medications 4
• Metabolic: Monitor glucose levels closely, especially if the patient is receiving glucocorticoids perioperatively 1
• Wound Healing: Hypothyroidism may impair wound healing; ensure adequate thyroid replacement 7

Common Pitfalls to Avoid

• Abrupt discontinuation of beta-blockers or clonidine can cause rebound hypertension 2
• Overaggressive fluid administration can lead to postoperative heart failure 1
• Delayed resumption of chronic antihypertensive medications may increase 30-day mortality risk 1, 2
• Failure to monitor thyroid function postoperatively, as surgical stress may affect thyroid hormone requirements 4

By following these evidence-based recommendations, perioperative cardiovascular complications can be minimized in patients with hypertension, hyperlipidemia, and hypothyroidism undergoing arthrodesis.