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🧠 Clinical Context

Patients over 65 undergoing inpatient surgery face unique risks. Cognitive impairment, frailty, and increased vulnerability to delirium demand a proactive and nuanced approach to anesthesia and postoperative care.

🔍 Preoperative Priorities

• Age ≥65 and inpatient status should automatically trigger a frailty and cognitive assessment
• Engage a multidisciplinary team early—geriatrics, anesthesia, surgery, and nursing

🛌 Postoperative Delirium: A Common Pitfall

• Use dexmedetomidine in the PACU or ICU setting for sedation/delirium prevention
• Avoid these culprits:
  • Benzodiazepines
  • Antipsychotics
  • Anticholinergics
  • Ketamine
  • Corticosteroids
  • Gabapentin

💡 Practical Strategy

• Optimize environment: quiet, well-lit rooms with clocks and calendars
• Encourage mobility and family engagement
• Hydrate, monitor electrolytes, and manage pain thoughtfully
• Avoid over-sedation and unnecessary polypharmacy

🧩 Clinical Takeaway

Older adults need tailored perioperative management. Screening for frailty and cognition is just as important as lab work and EKGs. Avoid high-risk meds, plan for delirium prevention, and build a team around the patient.

🎯 When it comes to older surgical patients: less is more, and team-based care is everything.

Key Reference: Sieber F et al. 2025 ASA Practice Advisory for Perioperative Care of Older Adults. Anesthesiology. 2025 Jan;142(1):22–51. PMID: 39655991

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🧠 Clinical Context

Hydrochlorothiazide (HCTZ) vs. Chlorthalidone—a classic cardio debate! ALHAT once hinted at chlorthalidone’s superiority, but did a modern head-to-head trial confirm that? Let's break it down.

🧪 Study Snapshot: The HEADS-UP Trial

• Design: Randomized, head-to-head trial
• Population: ~14,000 patients, age ≥65, already on HCTZ 25–50 mg + 1–2 antihypertensives
• Prior CV disease: 15% had MI, stroke, or HF
• Groups:
  • Continue HCTZ
  • Switch to Chlorthalidone 12.5–25 mg daily
• Follow-up: Median 2.4 years

📈 Outcomes

• Primary endpoint: Composite of MI, stroke, HF, urgent revascularization, or non-cancer death
  → Occurred in 10% of both groups
• BP Control: No significant difference
• Hypokalemia:
  • Chlorthalidone: 4.4%
  • HCTZ: 6.0%

💡 What About CKD?

• 23% had GFR <60 at baseline, but…
• No strong data on severely reduced renal function for HCTZ
• In a 12-week placebo-controlled study, chlorthalidone lowered BP in GFR 15–30, but HCTZ didn’t have similar data
• Still, in randomized trials: no difference in mortality or cardiovascular outcomes

⚠️ Surprises & Caveats

• Despite historical bias toward chlorthalidone, outcomes and BP control were equivalent
• Hypokalemia was actually slightly lower with chlorthalidone
• More robust data is still needed for advanced CKD patients

🧩 Clinical Takeaway

Despite all the hype, chlorthalidone isn’t clearly superior. In practice, both meds perform similarly for hypertension control and cardiovascular outcomes in older adults. But if your patient has significantly impaired renal function, chlorthalidone may edge ahead—at least for now.

💬 Bottom line? Choose the thiazide based on patient profile, tolerance, and renal function—not legacy dogma.

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🧠 Clinical Context

GLP-1 receptor agonists have taken center stage for both type 2 diabetes and obesity management, but their gastric side effects are giving anesthesiologists pause. The ASA's recent guidance recommends holding these agents before surgery to reduce risks of gastroparesis, regurgitation, and pulmonary aspiration.

🔬 ASA Guidelines Overview

• Daily Dosing? Hold on the day of surgery
• Weekly Dosing? Hold one week prior
• If asymptomatic and held as above? Proceed as usual

⚠️ But Here’s the Controversy

• There’s no strong evidence that holding GLP-1s as recommended reliably reduces gastric content risk.
• Recent endoscopy studies show no correlation between hold duration and gastric content retention.
• Gastroparesis risk may persist despite withholding the drug, especially in patients with:
  • Diabetes
  • Obesity
  • Opioid use
  • Alcohol, marijuana, or TCA use

🧪 What We Do Know

• Peak delay in gastric emptying appears within the first 12 weeks of therapy.
• Normalization of gastric motility might require holding meds for 5+ half-lives—often impractical.
• Meanwhile, GLP-1s improve glycemic control and may reduce post-op MACE (Major Adverse Cardiac Events).

🧭 Pragmatic Recommendations

• All GLP-1 patients should be considered at elevated aspiration risk, regardless of symptom status or hold duration.
• Use pre-op gastric ultrasound to assess contents.
• Plan anesthesia accordingly:
  • Airway protection
  • Rapid sequence induction
  • Appropriate surgical location

🍽️ Fasting Guidelines? A Gray Area

ASA’s updated fasting guideline (2023) applies to healthy patients without reflux, obesity, diabetes, or delayed emptying—aka, not your typical GLP-1 patient.

Recommendation: Modify fasting guidelines based on judgment. Don’t follow enhanced recovery protocols blindly.

🧩 Clinical Takeaway

Don’t assume that simply holding a GLP-1 agonist clears the gut. Evidence is lacking. Every GLP-1 patient should be approached with caution:

• Assume delayed gastric emptying
• Use tools like ultrasound for verification
• Customize fasting and airway protocols

🔍 Until we have more data, err on the side of protecting your patient’s airway—not just the guideline.

Key Reference: Ushakumari DS, Sladen RN. ASA Consensus-based Guidance. Anesthesiology. 2024 Feb;140(2):346–348. PMID: 37982170

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🧠 Clinical Context

DOACs (Direct Oral Anticoagulants) have revolutionized anticoagulation—goodbye routine INRs, hello convenience. But while they’ve made our lives easier, they’re not always a fit for every scenario. Here's how to navigate the DOAC jungle.

✅ When DOACs Are Preferred

• Venous Thromboembolism (VTE)
• Atrial Fibrillation
  • ⚠️ Exclude patients with:
    • Mechanical heart valves
    • Rheumatic mitral valve disease
       (That’s why cardiologists note “non-rheumatic” AF in their documentation—treatment plan hinges on it.)

⛔ When DOACs Are a No-Go

• Mechanical Heart Valves → Warfarin only
• Rheumatic AF → Warfarin still rules
• Thrombotic Antiphospholipid Syndrome → Warfarin
• Transcatheter Aortic Valve Replacement (TAVR) → Antiplatelet therapy
• Embolic Stroke of Undetermined Source → Antiplatelets preferred

🤔 The Gray Zone: Uncertain Use Cases

These aren’t absolute yes or no. Instead, cue shared decision-making and expert input:

• Pregnancy
  • No strong evidence yet; avoid unless discussed with OB and hematology.
• End-Stage Renal Disease (ESRD)
  • Initially excluded from DOAC trials.
  • Some are doing well, but still a case-by-case basis.
• Others That Require Discussion:
  • Left Ventricular Thrombus
  • Catheter-Associated DVT
  • Splanchnic Vein Thrombosis
  • Cerebral Venous Thrombosis

🧩 Clinical Takeaway

DOACs are game-changers—but they’re not plug-and-play for everyone. For classic AF and VTE? Go for it. For valves, rheumatic disease, or complex syndromes? Tread carefully. And when in doubt, involve the patient in the decision.

🎯 Bottom line: Not every clot deserves a DOAC—some still want warfarin or a platelet plan.

Let me know when you're ready for the next one!

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🧠 Clinical Context:

You're prepping a patient for non-cardiac surgery—what's their cardiovascular risk? Turns out, it’s not always about echo reports or cath results. It starts with a stairs test (sort of).

• Duke Activity Status Index (DASI) and METs >4 can tell you if the heart's got enough reserve.
  • 🚶‍♂️ “Can you walk up a flight of stairs without gasping?” If yes, you’re likely good to go!
• If functional status is poor or unknown, consider labs:
  • BNP, pro-BNP, or troponin — but evidence is weak.
  • Elevated? Time to huddle with a multidisciplinary team (or at least buy time for the patient and lawyer to meet).

🧪 Risk Tools, Not Rituals:

• Stress testing isn’t reflexively helpful anymore.
  • Reserved for high-risk anatomy or major ischemia concerns.
  • Studies show no outcome improvement in most cases.
  • Important caveat: those with severe CAD were excluded from trials!

🧊 Meds to Pause:

• SGLT2 Inhibitors (dapagliflozin, empagliflozin):
  🔴 Stop 3–4 days pre-op to avoid euglycemic ketoacidosis.
• GLP-1 Agonists:
  ⏸️ Hold 1 week before due to risk of delayed gastric emptying, aspiration, and nausea under anesthesia.

🫀 Post-op Cardiac Surveillance:

• Watch for MINS – Myocardial Injury after Noncardiac Surgery
  • Troponin trending may help spot silent ischemia post-op.
  • Elevated levels? 🧠 Consider further cardio eval, especially in high-risk patients.

🧩 Clinical Takeaway:

Modern pre-op cardiac clearance is about functional fitness, thoughtful labs, and smart medication pauses. Don’t just tick boxes—evaluate risk in context. And yes, if grandma can climb stairs without wheezing, she might just be ready for her hip replacement.

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🧠 Trial:

DOAC started at 3 days vs 8–14 days post-stroke in AF patients.

📊 Results:

No ↑ bleeding.

No ↑ ischemic events.

🧩 Clinical Takeaway:

Safe to start within 4 days in mild to moderate stroke.

Still tailor based on infarct size and bleeding risk.

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🧪 Study:

Vitamin K2 (180 mcg) reduced nocturnal leg cramps in elderly.

📉 Results:

Cramps/week ↓ from 3.6 → ~1 over 8 weeks.

Safe and well-tolerated.

🧩 Clinical Takeaway:

Consider a K2 trial in patients with chronic cramps — especially if sleep-disrupting.

Avoid in patients on warfarin.

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🧪 Study:

TXA within 2 hrs of ICH did not reduce hematoma expansion.

No benefit in functional outcome or mortality.

⚠️ Note:

Slight ↑ in thromboembolic events (3% vs 1%).

🧩 Clinical Takeaway:

No routine use for TXA in spontaneous ICH.

Still potential niche use in select trauma cases.

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🧠 Study:

Compared transfusion thresholds of Hgb <8 vs <10 in subarachnoid hemorrhage.

📊 Findings:

No difference in modified Rankin Score at 12 months.

Fewer transfusions, fewer complications in <8 group.

🧩 Clinical Takeaway:

Restrictive transfusion strategy is safe in neuro ICU.

Less exposure = better outcomes.

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🧪 Trials:

RESHAPE-HF2: ↓ HF hospitalizations with transcatheter edge-to-edge repair vs medical therapy.

MATTR: Transcatheter approach non-inferior to surgical repair.

🧩 Clinical Takeaway:

Game-changing for patients too high risk for surgery.

Less peri-op risk, faster recovery — mitral repair is heading the way of TAVR.