Elective Hernia Repair in a Patient With a Recent Coronary Stent and an Infected Incision Site
Mrs. R is a 68-year-old woman with a BMI of 33, type 2 diabetes (A1c 9.4%), hypertension, and a drug-eluting coronary stent placed 5 months ago after NSTEMI. She is scheduled in 10 days for elective laparoscopic ventral hernia repair with mesh. Her medications are aspirin 81 mg daily, clopidogrel 75 mg daily, metformin 1 g twice daily, empagliflozin 10 mg daily, lisinopril 20 mg daily, and atorvastatin 40 mg daily. She reports two hypoglycemic episodes in the past month and has a 2-cm umbilical ulcer with purulent drainage at the planned incision site. The surgeon plans mesh placement and asks you, the RNFA, to complete the preoperative assessment. Cardiology gave telephone clearance but did not address antiplatelet therapy, and the anesthesia team has not yet seen her.
1. Identify the preoperative risk factors that must be addressed before this elective operation and explain how each changes the plan.
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Four issues dominate. First, the stent is only 5 months old and she is on dual antiplatelet therapy. Elective surgery within 6 months of a drug-eluting stent carries a catastrophic stent-thrombosis risk, so the case should be deferred until at least 6 months if it is truly elective, with cardiology agreeing on the antiplatelet plan. Second, an A1c of 9.4% plus two recent hypoglycemic episodes signals poor glycemic control. Hyperglycemia increases surgical-site infection and wound failure, so endocrinology should optimize glucose before a prosthetic mesh is implanted. Third, the umbilical ulcer with purulent drainage is an active infection at the planned incision. Mesh must not be placed through infected skin. The infection needs treatment and the case should be rescheduled. Fourth, BMI 33, hypertension, and lisinopril are modifiable but lower priority. The RNFA should document these findings, notify the surgeon, and request formal cardiology and endocrinology input rather than relying on a telephone clearance that did not address antiplatelet therapy.
2. State the perioperative medication instructions you would recommend and the reasoning for each.
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Continue aspirin 81 mg. Do not stop it without cardiology because of stent risk. Clopidogrel should be managed by cardiology. If surgery cannot be deferred, many patients continue dual antiplatelet therapy and accept bleeding risk, but the decision must be documented. Hold empagliflozin for at least 3 days before surgery because SGLT2 inhibitors can cause euglycemic diabetic ketoacidosis perioperatively. Hold metformin on the day of surgery and restart when renal function is stable and oral intake has resumed. Hold lisinopril on the morning of surgery to reduce intraoperative hypotension, and restart when the patient is hemodynamically stable. Continue atorvastatin. Give clear written instructions, a contact number, and sick-day rules, and confirm the patient understands them. Check glucose on admission and consider an insulin plan. Because the wound is infected, the entire regimen should be coordinated with the rescheduled date, not the original 10-day window.
3. The surgeon says, 'You are the RNFA, just document that she is cleared.' How do you respond, and what are the scope and documentation issues?
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Scope of practice does not include independent medical clearance. The RNFA can complete a focused history and physical, identify risk factors, order tests per protocol, and document findings, but final surgical clearance is the surgeon's responsibility and anesthesia clearance belongs to anesthesia. I would say: 'I can document my assessment and the unresolved issues, but I cannot clear her. Cardiology needs to address the antiplatelet plan and the stent timing, and the active wound infection needs treatment.' I would notify the surgeon in writing, request a formal cardiology consult, and document the conversation, the patient's understanding, and the plan. If the surgeon insists on proceeding, I would escalate to the OR director or risk management and follow facility policy. Witnessing informed consent does not mean providing clearance. The consent discussion must include stent thrombosis, bleeding, infection, and mesh complications.