Pre-operative optimization

Fahad M. Al-Suwayeh
Orthopedic Resident
• To obtain satisfactory results it requires a
careful approach to preoperative preparation
of patients
• Specific patient groups have specific needs
• High risk patients should be identified early
and appropriate measures taken to reduce
complications
• Team approach
– Multi-disciplinary
• Surgeon
• Anesthesiologists
• Consulted service
• Nurses / Therapists
– GOALS:
• Optimize Patient Outcomes after surgery
• early mobilization
• return to preoperative functional status
• pain control
• Mortality
• Delirium
• Medical complications
– Pneumonia
– PE/DVT
– Pressure ulcer
– MI
• Arthroplasty patients??
• Wake forest bundle protocol??
• Check list of patient’s risk factors from the initial
clinic visit >> Formulate a medical optimization plan
• Non-Modifiable Risk • Modifiable Risk Factors
– Poor Dentition
Factors
– BMI > 40
– Metal Allergy – DM (Hemoglobin A1c)
– Inflammatory – Tobacco Abuse
Arthrities – MRSA History
– Previous TJA – History of / Current Open
Wounds
Complication
– Current Anticoagulation
– Progressive – Obstructive Sleep Apnea
Neurological Disease – DVT / PE History
 Modifiable risk factors
• BMI > 40: referral to PCP, Bariatric surgery, or a
dietitian
• Why??
– Higher DVT/PE
– Higher infection rate
– Higher re-admission rate
– Post op morbidity and mortality
 Modifiable risk factors
• HbA1C >7: referral to PCP or endocrinologist
• Why?
– PE
– Infection
– Transfusion requirements
– Prolonged length of stay
– Mortality
 Modifiable risk factors
• Smoking > 0.5 ppd:
– smoking cessation plan

• OSA symptoms/hx
– Sleep study evaluation
Pre operative nutrition assessment
• Albumin <3.5 g/dl
– Most widely recognized
– Simplest to obtain

– Anthropometric measurements
• Indirect gauge of malnutrition
– Body composition
• Calf circumference
• Arm muscle circumference
• Triceps skinfold
 Malnutrition and infection risk
• Impairs wound healing
– Hinders fibroblast proliferation
– Decreases collagen synthesis
• Prolongs inflammation
• Decreases lymphocyte count
– Impairs body’s ability to fight infection
• Bohlet al, Malnutrition and Total Joint Arthroplasty
2016
– Retrospective review of 49,000 TJA patients
– Outcomes compared between patients with and
without hypoalbuminemia
• Albumin < 3.5 g/dL
– 2x increase in surgical site infection
– Increased risk for
• Pneumonia
• Longer length of stay
• Hospital readmission
• “A Bundle Protocol to Reduce the Incidence of
PeriprostheticJoint Infections After Total Joint
Arthroplasty: A Single-Center Experience”
– Results
• 62% reduction in periprosthetic infection rate for THA
(10 of 641 vs 4 of 675)
– Not statistically significant
• 92% reduction in periprosthetic infection rate for TKA
(13 of 908 vs 1of 890)
– Statistically significant
,Thank you