What is the detailed pre‑operative anesthetic plan for a 70‑year‑old man with hypertension, coronary artery disease, chronic obstructive pulmonary disease, dyslipidaemia and possible chronic kidney disease undergoing elective infrarenal abdominal aortic aneurysm repair?

Preoperative Anesthetic Management for Elective Infrarenal AAA Repair in a 70-Year-Old Patient

Proceed with surgery if blood pressure is <180/110 mmHg, optimize cardiac medications including beta-blockers and statins, ensure adequate preoperative hydration to protect renal function, and optimize COPD management with bronchodilators while avoiding prolonged preoperative delays that increase risk. 1, 2

Cardiovascular Assessment and Optimization

Blood Pressure Management

• Measure blood pressure properly: seated position, supported arm, at least 1 minute rest, take 3 readings 1 minute apart, use the lower of the last two readings 1
• Proceed with surgery if BP <180/110 mmHg systolic/diastolic – this threshold accounts for white coat hypertension in the stressful secondary care environment 1
• If BP ≥180/110 mmHg, refer to primary care for concurrent assessment but surgery can still proceed if clinically appropriate 1
• Do not delay surgery to optimize blood pressure below 180/110 mmHg – there is no evidence this reduces perioperative cardiovascular events 1

Cardiac Risk Stratification

• Obtain a 12-lead ECG to evaluate for new ischemic changes, arrhythmias, or prolonged QTc interval (>440 ms) 3
• Calculate the Lee Revised Cardiac Risk Index score; if ≥2 with functional capacity <4 METs, consider cardiology referral for stress testing before major surgery 3
• Assess functional capacity: determine if the patient can climb two flights of stairs or walk four blocks without symptoms 3
• Coronary angiography is not routinely necessary unless the patient has a history of coronary artery bypass graft surgery or very high likelihood of severe CAD 4, 5

Cardiac Medication Optimization

• Continue beta-blockers perioperatively in patients already taking them – sudden withdrawal can precipitate myocardial ischemia 4, 2
• Consider withholding ACE inhibitors and angiotensin receptor blockers on the morning of surgery to reduce risk of intraoperative hypotension, then restart postoperatively once euvolemic 4
• Continue aspirin and statins perioperatively 2
• For patients with atrial fibrillation on anticoagulation, coordinate bridging strategy with intravenous heparin or subcutaneous low-molecular-weight heparin to cover periods of subtherapeutic anticoagulation 4

Pulmonary Assessment and Optimization

COPD Management

• History of smoking and COPD are important predictors of postoperative respiratory complications in aortic surgery patients 4
• Obtain pulmonary function tests and arterial blood gas analyses to risk-stratify patients with COPD 4
• Optimize bronchodilator therapy: ensure the patient is prescribed adequate inhalers – fewer prescribed inhalers is associated with unfavorable outcomes 6
• Administer antibiotics if reversible restrictive disease or excessive sputum production is present 4
• Advise smoking cessation preoperatively 4
• Note: abnormal spirometry and arterial blood gases alone are not predictive of poor outcome – suboptimal COPD management is the key modifiable factor 6

Renal Protection Strategy

• Preoperative renal dysfunction is the most important predictor of acute renal failure after aortic surgery 4
• Ensure adequate preoperative hydration 4
• Avoid hypotension, low cardiac output, and hypovolemia in the perioperative period 4
• If chronic kidney disease is present (serum creatinine >200 μmol/L), this adds 2 points to the EuroSCORE risk assessment 4

Hematologic Optimization

• Correct preoperative anemia: lower hematocrit is associated with unfavorable outcomes in COPD patients undergoing AAA repair 6
• Consider iron, vitamin B12, and folate supplementation if subclinical nutritional anemia is present, ideally at least 28 days before surgery 4

Cerebrovascular Assessment

• Perform duplex imaging of carotid arteries in patients with history of stroke, TIA, or other risk factors for cerebrovascular disease to minimize risk of perioperative stroke 4
• However, the efficacy of treating significant carotid stenosis prior to AAA repair has not been evaluated in randomized trials 4

Geriatric-Specific Considerations

Comprehensive Preoperative Assessment

• Senior geriatrician and senior anesthetist assessment is recommended for high-risk elderly patients 4
• Assess for frailty, cognitive impairment, and functional status – these independently predict perioperative risk 4
• Screen for risk of postoperative delirium (POD): very old age, frailty, cognitive impairment, cerebrovascular disease, and polypharmacy increase risk 4

Nutritional and Functional Optimization

• Avoid prolonged preoperative fasting 4
• Provide oral nutrition and supplementation to counteract poor appetite 4
• Consider "prehabilitation" to maintain functional reserve, though evidence is still emerging 4

Medication Review

• Review all medications for appropriateness and potential perioperative interactions 4
• Be aware that polypharmacy increases risk of postoperative cognitive disorders 4

Anesthetic Planning

Monitoring and Technique Selection

• Tailor anesthetic techniques and monitoring to individual patient needs to facilitate surgical technique and monitor hemodynamics and organ function 4
• Transesophageal echocardiography is reasonable in all open surgical repairs of the thoracic aorta and can be useful in AAA repair for monitoring and procedural guidance 4
• Consider motor or somatosensory evoked potential monitoring when data will guide therapy 4

Intraoperative Hemodynamic Goals

• Maintain blood pressure within 20-30% of preoperative baseline to reduce risk of end-organ injury 1
• Maintain mean arterial pressure ≥60-65 mmHg 1
• Avoid drops >30% below baseline – this threshold is associated with end-organ injury regardless of absolute starting value 1
• In elderly patients with ischemic heart disease, maintain systolic blood pressure within 10% of baseline to reduce risk of postoperative delirium 3

Risk Stratification Tools

• EuroSCORE: Calculate preoperative risk based on age (1 point per 5 years over 60), chronic pulmonary disease (1 point), extracardiac arteriopathy including AAA (2 points), serum creatinine >200 μmol/L (2 points), and other cardiac factors 4
• B-type natriuretic peptide (BNP): Preoperative BNP >385 pg/ml predicts postoperative complications, IABP use, and 1-year mortality 4

Critical Pitfalls to Avoid

• Do not delay surgery for blood pressure optimization below 180/110 mmHg – no evidence supports this practice 1
• Do not routinely obtain coronary angiography – this delays surgery without proven benefit unless specific high-risk features are present 4, 5
• Do not ignore the patient's hypertensive baseline when setting intraoperative targets – patients with preoperative hypertension have higher thresholds for harm 1
• Do not stop beta-blockers abruptly – this can precipitate silent myocardial ischemia 4
• Do not assume abnormal spirometry alone contraindicates surgery – focus on optimizing COPD management instead 6

Postoperative Planning

• Selective ICU admission can be safe: reserve ICU for patients with ejection fraction <30%, FVC or FEV1 <50% predicted, or specific intraoperative complications (prolonged operative time, suprarenal clamping, massive transfusion, hemodynamic instability, cardiac dysfunction) 7
• Plan for close hemodynamic monitoring in recovery, as perioperative myocardial ischemia often occurs postoperatively 3
• Provide multimodal analgesia to reduce sympathetic stress response and myocardial oxygen demand 3
• Monitor for silent myocardial infarction, particularly in diabetic patients with autonomic neuropathy 3