During a preoperative evaluation clinic visit, an internal medicine physician is reviewing the medication list of an individual scheduled for an elective total hip replacement. The patient's past medical history includes heart failure with reduced ejection fraction, type 2 diabetes mellitus, a mechanical aortic valve replacement, and severe osteoarthritis. Match each of the patient's chronic medications to the most appropriate perioperative management strategy based on current clinical guidelines.
- Warfarin therapy (Indication: Mechanical aortic valve)Discontinue 5 days preoperatively and utilize therapeutic low-molecular-weight heparin bridging.
- Lisinopril therapy (Indication: Heart failure with reduced ejection fraction)Omit the scheduled dose on the morning of the surgery to prevent refractory intraoperative hypotension.
- Bisoprolol therapy (Indication: Heart failure and coronary artery disease)Administer as normally scheduled, including on the morning of the procedure, to prevent rebound tachycardia and ischemia.
- Dapagliflozin therapy (Indication: Type 2 diabetes mellitus)Suspend 3 to 4 days prior to the procedure to minimize the risk of perioperative euglycemic ketoacidosis.
Cevap
Warfarin requires bridging with low-molecular-weight heparin; Lisinopril should be held the morning of surgery; Bisoprolol must be continued through the morning of surgery; Dapagliflozin must be stopped 3-4 days prior to surgery.
Optimal perioperative management requires tailoring the handling of chronic medications to balance the risks of underlying disease exacerbation against the risks of anesthesia and surgical stress. Beta-blockers are maintained to prevent ischemia; ACE inhibitors are held to prevent severe vasoplegia; SGLT2 inhibitors are stopped early to avoid ketoacidosis; and warfarin is bridged for high-thrombotic-risk conditions.
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Perioperative Medication Management
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