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Perioperative Medical Comorbidities in the Orthopaedic Patient

Dr. Bushnell is Chief Resident, Department of Orthopaedic Surgery, University of North Carolina Hospitals, Chapel Hill, NC. Dr. Horton is Hospitalist, TeamHealth, Greenville, SC. Dr. McDonald is Assistant Professor, Department of Internal Medicine/Pediatrics, University of North Carolina Hospitals, Chapel Hill. Dr. Robertson is Cardiology Fellow, Department of Cardiology, University of Alabama–Birmingham Hospitals, Birmingham, AL.

None of the following authors or a member of their immediate families has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Bushnell, Dr. Horton, Dr. McDonald, and Dr. Robertson.

Reprint requests: Dr. Bushnell, Department of Orthopaedic Surgery, University of North Carolina Hospitals, CB #7055, Bioinformatics Building, Chapel Hill, NC 27599-7055.

Evaluation and management of medical comorbidities in the perioperative period can help improve surgical morbidity and mortality. Perioperative evaluation essentially is risk assessment and minimization. Patients undergoing orthopaedic treatment may benefit from temporizing measures to reduce systemic complications associated with some procedures. Patients at increased risk of cardiac ischemia should undergo risk stratification to determine possible perioperative interventions. Use of perioperative medications and/or consultation with specialists can help to address heart murmurs, bacterial endocarditis, prior stenting, heart failure, and hypertension. Patients with severe or unstable chronic obstructive pulmonary disease require the involvement of pulmonary care specialists. Renal failure can require nephrology consultation, particularly in cases of worsening renal function or urinary outflow obstruction. Hematologic considerations include bleeding and clotting. Prophylaxis should be used in patients with risk factors for peptic ulcer, as well as respiratory failure and hypotension. Nutritional status and liver disease also must be monitored and treated preoperatively. Orthopaedic diabetic patients should be placed on modified oral hypoglycemic or insulin regimens; recalcitrant cases merit consultation. Effective communication among all members of the patient’s caregiving team is paramount.

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