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Anesthetic Management: 65-year-old Male with Irregularly Treated Hypertension + History of Atrial Fibrillation for Inguinal Hernia Repair

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CASE SUMMARY / PROBLEM IDENTIFICATION

1. Irregularly treated hypertension - end-organ damage risk, hemodynamic lability
2. History of atrial fibrillation (AF) - rate/rhythm control status unknown, anticoagulation status, stroke risk
3. Elective inguinal herniorrhaphy - intermediate-to-low risk surgery, highly amenable to regional anesthesia

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I. PREOPERATIVE EVALUATION

A. History

• Duration, severity, compliance with medications, current drugs (ACEI/ARB/CCB/beta-blocker/diuretic)
• Symptoms of end-organ damage: headache, visual changes (hypertensive retinopathy), dyspnea, chest pain, nocturia, ankle edema
• History of hypertensive crisis

• Type: paroxysmal / persistent / permanent
• Current rate control status (target resting HR < 80 bpm)
• Anticoagulation: warfarin (INR), DOAC (last dose), or no anticoagulation
• CHA₂DS₂-VASc score (to guide thromboembolism risk stratification)
• Last echo: LV function, valvular disease (especially mitral stenosis)

• Functional capacity (METs) - can the patient climb 2 flights of stairs or walk on level ground at 4 mph?
• History of coronary artery disease, stroke, heart failure, diabetes, CKD
• Drug history: diuretics (electrolyte imbalance), digoxin toxicity, anticoagulants
• Prior anesthesia: any difficult airway, adverse reactions

B. Physical Examination

• Vital signs: BP both arms, HR (rate and rhythm), SpO₂, weight/BMI
• Cardiovascular: JVP, carotid bruits, heart sounds (irregular rhythm = AF still present?), signs of heart failure (basal crepitations, ankle edema)
• Airway assessment: Mallampati, mouth opening, neck extension, thyromental distance
• Neurological: baseline deficit assessment (especially if on anticoagulants and regional anesthesia planned)
• Spine assessment for regional anesthesia (deformity, infection, prior surgery)

C. Investigations

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II. PREOPERATIVE OPTIMIZATION

Hypertension

• Do NOT cancel surgery if BP < 180/110 mmHg - mild-moderate uncontrolled hypertension alone is not an independent predictor of major perioperative adverse cardiac events (Goldman & Caldera; Miller's Anesthesia 10e)
• Cancel/postpone if diastolic BP > 110 mmHg or SBP > 180 mmHg - optimize before proceeding
• Continue all antihypertensives on the morning of surgery with a sip of water, EXCEPT:
  • ACE inhibitors and ARBs - consider withholding on the day of surgery (they blunt the renin-angiotensin axis response and can cause refractory hypotension under anesthesia, especially with neuraxial blocks). This remains controversial; discuss with the surgical team
  • Diuretics - withhold on the morning of surgery to avoid hypovolemia
• Check potassium - hypokalemia from diuretics increases arrhythmia risk in an already AF-prone heart

Atrial Fibrillation

• Rate control: Ensure adequate ventricular rate control (HR < 80 bpm at rest). Continue rate-controlling agents (beta-blockers, digoxin, diltiazem) perioperatively
• Anticoagulation management (critical exam point):
  • If on Warfarin: Stop 5 days before surgery. Check INR - proceed if INR < 1.5 for spinal anesthesia. Per the BRIDGE trial (NEJM 2015), bridging anticoagulation with LMWH is NOT routinely needed for AF patients with no mechanical valves - it increases bleeding without reducing thromboembolic events. Barash Clinical Anesthesia 9e confirms this
  • If on DOAC: Stop 24-48 hours (apixaban/rivaroxaban) or 48-72 hours (dabigatran) before surgery based on renal function
  • Resume anticoagulation 24-48 hours postoperatively once hemostasis is confirmed
• CHA₂DS₂-VASc scoring: Age 65 = 1 point; Hypertension = 1 point; minimum score ≥ 2 in this patient - warrants anticoagulation

Medication Reconciliation Summary

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III. ANESTHETIC PLAN

Choice of Technique: Regional Anesthesia is PREFERRED

1. Spinal anesthesia (subarachnoid block) - technique of choice
2. Epidural anesthesia
3. Local infiltration / ilioinguinal-iliohypogastric nerve block (with or without sedation)
4. General anesthesia (if regional contraindicated or patient refuses)

• Avoids airway manipulation, systemic anesthetics, and intubation hemodynamic response (critical in a hypertensive patient)
• Better intraoperative and postoperative hemodynamic stability
• Avoids general anesthetic-induced myocardial depression
• Lower risk of postoperative nausea, vomiting, and delayed emergence
• Allows detection of transient ischemia or hemodynamic changes in an awake patient
• Spinal anesthesia is well-established for inguinal hernia (requires T10 sensory level)

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A. SPINAL ANESTHESIA (Preferred Technique)

• Tablet alprazolam 0.25 mg or tablet diazepam 5 mg (oral) the night before if anxious - use cautiously given age
• IV access established; crystalloid preloading 10-15 mL/kg (important to prevent hypotension, but avoid fluid overload in a hypertensive patient)

• Hyperbaric bupivacaine 0.5%: 2.5-3 mL (12.5-15 mg) - provides T10 level block sufficient for inguinal hernia
• Additives:
  • Fentanyl 25 mcg intrathecal - prolongs analgesia, reduces bupivacaine requirement
  • Clonidine 15-30 mcg - prolongs block, improves quality (avoid in hypotensive patients)

• Adequate IV preloading
• Have vasopressors ready: Ephedrine 5-10 mg IV bolus (first-line; has both alpha and beta effects, maintains CO which is important in AF patients) or Phenylephrine 50-100 mcg IV (pure alpha, but can cause reflex bradycardia which is a concern in AF)
• Mephentermine 6-12 mg IV (common in South Asia) is also appropriate

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B. GENERAL ANESTHESIA (if Regional is Contraindicated)

Preoperative

• Antacid prophylaxis: Tab ranitidine 150 mg / pantoprazole 40 mg night before and morning of surgery
• Metoclopramide 10 mg IV 30 min before induction

Induction

• Pre-oxygenation: 100% O₂ for 3 minutes via tight-fitting mask
• IV fentanyl 1-2 mcg/kg (blunts intubation response - critical in hypertensive patient)
• Propofol 1.5-2 mg/kg IV (induction agent of choice - but titrate carefully; can cause significant hypotension in hypertensives; consider slower administration)
  • Alternative: Etomidate 0.2-0.3 mg/kg - more hemodynamically stable (preferred if LV dysfunction)
• Vecuronium 0.1 mg/kg or Atracurium 0.5 mg/kg (muscle relaxant)
• Attenuating the laryngoscopy and intubation response (critical in hypertension + AF):
  • IV lignocaine 1.5 mg/kg 90 seconds before intubation
  • Esmolol 0.5-1 mg/kg IV 2 min before intubation
  • Deepening anesthesia with additional fentanyl or higher propofol dose

Maintenance

• Volatile anesthetic: Isoflurane or sevoflurane in O₂:N₂O or O₂:air mixture
  • Sevoflurane preferred - smoother hemodynamics, less arrhythmogenic
  • Avoid halothane (sensitizes myocardium to catecholamines, worsens AF risk)
  • Target MAC 1.0-1.2
• TIVA option: Propofol infusion 4-12 mg/kg/hr + remifentanil/fentanyl
• Ventilation: IPPV with TV 6-8 mL/kg, RR 12-14/min, ETCO₂ 35-40 mmHg

Monitoring

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IV. INTRAOPERATIVE CONCERNS AND MANAGEMENT

1. Hemodynamic Goals

• Maintain BP within 20% of baseline preoperative values
• Avoid tachycardia (increases O₂ demand, reduces diastolic filling time - especially critical in AF with a rate-dependent cardiac output)
• Target HR: 60-80 bpm

2. Intraoperative Hypertension

• Rule out and treat the cause first
• Deepen anesthesia
• IV esmolol 0.5 mg/kg bolus (rapid onset, short-acting, safe in AF)
• IV labetalol 5-10 mg bolus (alpha + beta blockade)
• IV NTG infusion or hydralazine 5-10 mg IV if persistent
• Sodium nitroprusside (SNP) 0.25-5 mcg/kg/min infusion for hypertensive emergency (Morgan & Mikhail 7e)

3. Intraoperative Hypotension

• IV fluid bolus (250-500 mL crystalloid)
• Ephedrine 5-10 mg IV (preferred in AF - raises CO via beta effect without reflex bradycardia)
• Reduce volatile agent concentration
• Phenylephrine 50-100 mcg IV (use cautiously - can cause reflex bradycardia worsening AF hemodynamics)

4. Atrial Fibrillation Considerations

• Continue rate-controlling medications perioperatively
• Avoid:
  • Tachycardia (increases AF response rate)
  • Hypokalemia and hypomagnesemia (arrhythmogenic) - check and correct preoperatively
  • Hypothermia (precipitates arrhythmia)
  • Excessive volatile anesthetics causing hypotension
• If new-onset rapid AF intraoperatively:
  • Correct reversible causes: hypoxia, hypercapnia, electrolyte imbalance, hypovolemia
  • Rate control: IV metoprolol 2.5-5 mg slow IV or diltiazem 0.25 mg/kg
  • If hemodynamically unstable: synchronized DC cardioversion
• Note: Halothane and high-dose catecholamines should be avoided as they sensitize the myocardium and can precipitate arrhythmias

5. Fluid Management

• Avoid over-hydration (hypertensive patients are at risk for pulmonary edema)
• Target euvolemia - balanced crystalloids (PlasmaLyte / Ringer's Lactate)
• Avoid hypotonic saline (worsens hypertension)

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V. POSTOPERATIVE MANAGEMENT

Recovery Room (PACU)

• Continue ECG monitoring (detect postoperative AF or arrhythmias)
• Monitor BP every 5-15 minutes; target within 20% of preoperative baseline
• Resume all antihypertensive medications as soon as oral intake tolerated
• Resume rate-controlling medications (IV if oral not tolerated)

Analgesia (Multimodal)

• Tab paracetamol 500-1000 mg 8-hourly (safe, avoids NSAIDs which can cause renal impairment and fluid retention in hypertensives and worsen AF)
• NSAIDs (diclofenac/ketorolac) - use with caution in elderly hypertensive with possible renal impairment; short courses acceptable
• Ilioinguinal + iliohypogastric nerve block with bupivacaine 0.25-0.5% (excellent for inguinal hernia - reduces opioid requirement)
• Wound infiltration with local anesthetic by surgeon
• Opioids (tramadol/morphine) - reserve for moderate-severe pain, titrate carefully

Anticoagulation Restart

• Resume anticoagulants 24-48 hours postoperatively once hemostasis is assured
• For warfarin: restart warfarin at usual dose; bridge not required for AF (BRIDGE trial evidence)
• DOACs: restart at 24-48 hours

Monitoring

• Watch for hypertensive surge on emergence (ensure adequate analgesia, antiemetics, smooth extubation)
• Observe for postoperative AF, bradycardia, or heart block if on multiple nodal agents
• Adequate hydration; early mobilization

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VI. SPECIAL POINTS FOR THE EXAMINER

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ANESTHETIC CLASSIFICATION (ASA Status)

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Anesthetic Management: 65M, Irregularly Treated Hypertension + History of Atrial Fibrillation, Posted for Inguinal Herniorrhaphy

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CASE ANALYSIS AT A GLANCE

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I. PREOPERATIVE EVALUATION

A. Detailed History

• Duration of hypertension, compliance with treatment, current drugs (ACEI/ARB/CCB/beta-blocker/diuretic)
• Symptoms of end-organ damage: headache, visual disturbance, chest pain, dyspnea on exertion, nocturia
• History of hypertensive urgency or emergency
• History of stroke or TIA

• Type: paroxysmal / persistent / long-standing persistent / permanent
• Current ventricular rate at rest - is it controlled? (target < 80 bpm)
• Anticoagulation status: warfarin (INR values), DOAC (drug and last dose), or no anticoagulation
• CHA₂DS₂-VASc score (see box below)
• Last echocardiogram: LV function (EF), valvular disease (especially mitral stenosis, which changes the risk category significantly)
• Symptoms of heart failure: PND, orthopnea, bilateral ankle edema

CHA₂DS₂-VASc in this patient:

• Age 65-74 = 1 point
• Hypertension = 1 point
• Minimum score = 2 → Annual stroke risk ~2.2% → anticoagulation indicated
• Score may be higher if diabetes, prior stroke, vascular disease, or female sex also present

• Functional capacity in METs - can the patient climb 2 flights of stairs, walk uphill, or do heavy housework? If YES → > 4 METs → adequate functional capacity → no additional noninvasive cardiac testing needed
• History of coronary artery disease, diabetes, CKD
• Previous anesthesia: awareness, difficult airway, adverse drug reactions
• Drug history: digoxin (toxicity signs), diuretics (electrolyte imbalance), anticoagulants

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B. Physical Examination

• Vital signs: BP in both arms, HR (rate AND rhythm assessment), SpO₂, BMI
• Cardiovascular: JVP, carotid bruits, apex beat character/position, heart sounds (S3/S4 gallop, murmurs suggesting mitral valvular disease), signs of heart failure (bilateral basal crepitations, pitting ankle edema)
• Airway: Mallampati grade, mouth opening (>3 cm), neck extension, thyromental distance (>6.5 cm), dentition
• Neurological: Baseline neurological status - important before regional anesthesia (document any pre-existing deficits)
• Spine: Deformity, infection, mobility, prior surgery - relevant for spinal anesthesia

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C. Investigations

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II. PREOPERATIVE OPTIMIZATION

1. Blood Pressure Optimization

• SBP > 180 mmHg OR DBP > 110 mmHg (Stage 3 hypertension) → postpone and optimize
• Evidence note: Goldman & Caldera demonstrated that mild-to-moderate hypertension alone is NOT an independent predictor of major perioperative cardiac events; however, diastolic > 110 mmHg is the widely accepted threshold for postponement

• BP < 180/110 mmHg → proceed with optimization of antihypertensives
• Ensure patient has been compliant with medications for at least 2-4 weeks preoperatively

2. Medication Management (Critical Exam Point)

3. Anticoagulation Bridging Decision (High-Yield Exam Point)

• Bridging anticoagulation with LMWH was NOT superior to placebo for arterial thromboembolism prevention
• Bridging significantly increased major bleeding
• Conclusion: Perioperative bridging is UNNECESSARY for non-valvular AF

Exception: Bridging is appropriate for patients with mechanical heart valves (especially mitral) or very high CHA₂DS₂-VASc score with recent stroke/TIA.

4. Correct Electrolytes

• Potassium: target 3.5-5.0 mEq/L (hypokalemia is pro-arrhythmic and must be corrected before surgery in an AF patient)
• Magnesium: target 1.8-2.4 mg/dL (hypomagnesemia worsens AF)

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III. ANESTHETIC PLAN

Choice of Technique: REGIONAL ANESTHESIA IS STRONGLY PREFERRED

• Avoids hemodynamic surge of laryngoscopy and intubation (critical in hypertension)
• Avoids systemic anesthetic agents that depress myocardium
• Provides excellent operating conditions for inguinal hernia (T10 level required)
• Awake patient allows early detection of cardiac events
• Superior postoperative analgesia; less postoperative nausea/vomiting
• Reduces opioid requirement
• Faster recovery and discharge

1. Spinal anesthesia (SAB) - preferred
2. Epidural anesthesia
3. Combined spinal-epidural (CSE)
4. Ilioinguinal + iliohypogastric nerve block ± sedation
5. General anesthesia (if regional contraindicated)

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IV. SPINAL ANESTHESIA (Technique of Choice)

Preoperative Preparation

• Informed consent - explain procedure, risks (PDPH, hypotension, failure, neurological)
• Premedication: Tab alprazolam 0.25-0.5 mg oral the night before (use cautiously in elderly; age-related reduced hepatic metabolism)
• IV line: Establish 18G cannula; start IV fluid (Ringer's Lactate or PlasmaLyte) 10-15 mL/kg preloading or co-loading
  • Caution: Do not over-hydrate (risk of pulmonary edema in hypertensive with possible diastolic dysfunction)
• Empty bladder
• NIBP, ECG, SpO₂ monitoring established before block
• Vasopressors drawn and ready before administering spinal

Technique

• Position: Left lateral decubitus (L3-L4 level) or sitting position
• Level: L3-L4 interspace (well below conus medullaris at L1)
• Needle: 25G or 27G pencil-point (Whitacre or Sprotte) - reduces PDPH incidence significantly in this 65-year-old
• Identification: Free flow of CSF confirms correct placement

Drug and Dose

• Pinprick test (loss of sharp sensation)
• Cold sensation test
• Motor block: Bromage scale Grade 3 (complete motor block) at lower limbs

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CRITICAL POINT: Spinal Hypotension in Hypertensive Patient

• Adequate preloading / co-loading with IV crystalloid
• Avoid aortocaval compression (left lateral tilt if applicable)
• Slow injection of local anesthetic

• Ephedrine 5-10 mg IV bolus - PREFERRED in AF patients
  • Mixed alpha + beta agonist
  • Increases HR + CO + SVR
  • Does NOT cause reflex bradycardia
  • Important: maintains cardiac output, which in AF is rate-dependent
• Phenylephrine 50-100 mcg IV - pure alpha agonist, causes reflex bradycardia → can worsen AF hemodynamics
• Mephentermine 6-12 mg IV (commonly used in South Asia)
• IV fluid bolus 250-500 mL
• If unresponsive: norepinephrine infusion

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V. GENERAL ANESTHESIA (If Regional Contraindicated or Refused)

Contraindications to Regional (must check)

• Patient refusal
• INR > 1.5 / therapeutic anticoagulation
• Infection at puncture site
• Severe uncorrected coagulopathy
• Raised intracranial pressure
• Severe aortic stenosis (relative contraindication)

Premedication

• Tab pantoprazole 40 mg + tab metoclopramide 10 mg - night before and morning of surgery
• Tab alprazolam 0.5 mg oral - night before (anxiolysis)
• Glycopyrrolate 0.2 mg IM (antisialagogue if needed)

Induction Sequence

• Vecuronium 0.1 mg/kg (cardiovascular neutral, non-depolarizing)
• Atracurium 0.5 mg/kg (safe in renal impairment; histamine release at higher doses)
• Succinylcholine 1.5 mg/kg if rapid sequence required

1. IV lignocaine 1.5 mg/kg IV 90 seconds before laryngoscopy
2. IV esmolol 0.5-1 mg/kg 2 minutes before laryngoscopy (short-acting, titratable)
3. IV fentanyl 2 mcg/kg (adequate opioid pretreatment)
4. Deepen anesthesia before laryngoscopy
5. Use LMA instead of ETT where possible - avoids tracheal stimulation entirely; acceptable for inguinal hernia repair

• Direct laryngoscopy with ETT OR
• LMA ProSeal / Classic - appropriate for inguinal hernia (supine, short procedure, non-aspiration-prone patients)
• Videolaryngoscopy if difficult airway anticipated (obesity, limited neck extension)

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Maintenance of Anesthesia

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VI. INTRAOPERATIVE MONITORING

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VII. INTRAOPERATIVE PROBLEMS AND MANAGEMENT

1. Intraoperative Hypertension

• Inadequate depth of anesthesia (most common)
• Inadequate analgesia / pain
• Hypercapnia (inadequate ventilation)
• Hypoxia
• Urinary retention / distended bladder
• Pre-existing uncontrolled HTN
• Drug effect (e.g., vasopressor overshoot)

• Deepen anesthesia (increase volatile agent, supplement opioid)
• Treat the underlying cause
• IV esmolol 0.5-1 mg/kg bolus (first choice: short-acting, titratable, useful in AF for rate control simultaneously)
• IV labetalol 5-10 mg bolus (alpha + non-selective beta block)
• IV NTG (nitroglycerin) 0.5-1 mcg/kg/min infusion (for ischemia-associated HTN)
• IV hydralazine 5-10 mg slow bolus (15-20 min onset; use for persistent HTN)
• IV sodium nitroprusside (SNP) 0.25-5 mcg/kg/min infusion (for hypertensive emergency; requires intraarterial monitoring; can cause cyanide toxicity at high doses > 3 mcg/kg/min for prolonged periods)
• IV phentolamine if suspected pheochromocytoma (never use pure beta-blocker alone without alpha block)

2. Intraoperative Hypotension

• IV fluid bolus 250-500 mL (avoid excess)
• Reduce volatile agent concentration
• Ephedrine 5-10 mg IV (preferred in AF - preserves CO via beta effect, avoids reflex bradycardia)
• Phenylephrine 50-100 mcg IV (pure alpha; use with caution - reflex bradycardia can worsen AF hemodynamics)
• Norepinephrine infusion for refractory hypotension

3. Atrial Fibrillation - Intraoperative New-Onset Rapid Response

• Correct hypoxia (FiO₂ ↑)
• Correct hypercapnia (adjust ventilation)
• Correct hypovolemia
• Correct hypokalemia/hypomagnesemia (IV MgSO₄ 1-2 g over 10-15 min)
• Correct hypothermia
• Reduce sympathetic stimulation (deepen anesthesia)

• IV metoprolol 2.5-5 mg slow IV (titrate to response)
• IV diltiazem 0.25 mg/kg over 2 min (good rate control, also reduces SVR)
• IV digoxin 0.25-0.5 mg slow IV (slower onset, useful maintenance)
• IV amiodarone 150 mg over 10 min then infusion (if above fail, or if conversion to sinus rhythm also desired)

• Synchronized DC cardioversion immediately: start at 100-200 J biphasic

Note: Avoid cardioversion if the patient has been in AF for > 48 hours and is not adequately anticoagulated (risk of embolic stroke).

4. Bradycardia

• Occurs with high spinal, excessive beta-blockade, vagal stimulation
• IV atropine 0.6 mg (first-line)
• IV ephedrine 5-10 mg
• IV glycopyrrolate 0.2 mg (longer-acting, less CNS penetration)
• Reduce volatile agent
• If complete heart block: transcutaneous pacing

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VIII. EMERGENCE AND EXTUBATION

• Ensure full reversal of neuromuscular blockade: neostigmine 0.05 mg/kg + glycopyrrolate 0.01 mg/kg
• Monitor TOF ratio (train-of-four) > 0.9 before extubation
• Smooth emergence is critical - rough emergence causes coughing, straining, and a hypertensive surge
  • Adequate analgesic coverage before extubation
  • Consider IV lignocaine 1.5 mg/kg 1-2 minutes before extubation to blunt reflex
  • Dexmedetomidine 0.5-1 mcg/kg infusion over 10 minutes before extubation (attenuates extubation response; also useful if rate control is needed)
• Extubation criteria: awake, obeying commands, adequate spontaneous ventilation (RR 12-16, TV > 5 mL/kg), SpO₂ > 96%, hemodynamically stable
• Do NOT extubate in deep anesthesia in this patient (increased risk of aspiration and loss of airway control)

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IX. POSTOPERATIVE MANAGEMENT

Monitoring (PACU)

• Continue ECG monitoring for minimum 1-2 hours (arrhythmia detection)
• NIBP every 5-15 minutes initially
• SpO₂ monitoring; supplemental O₂ via face mask if SpO₂ < 95%
• Temperature monitoring (warm if hypothermic)

Analgesia (Multimodal - Exam High-Yield)

Antihypertensive Restart

• Resume ALL oral antihypertensives as soon as oral intake is tolerated
• IV substitutes if oral route not available:
  • IV labetalol for beta-blocker
  • IV hydralazine for HTN control
  • IV diltiazem for rate control in AF

Anticoagulation Restart

• Resume anticoagulation 24-48 hours postoperatively once surgical hemostasis is confirmed
• Warfarin: restart at usual dose; no bridging required (BRIDGE trial)
• DOACs: restart at 24-48 hours

Fluid Management

• Target euvolemia; restrict if any signs of pulmonary congestion
• Avoid hypotonic IV fluids (exacerbate hypertension)

Postoperative AF

• Anticoagulation recommended for patients with postoperative AF following noncardiothoracic surgery until full assessment is completed (Miller's Anesthesia 10e)

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X. SUMMARY ALGORITHM

PREOPERATIVE
├── BP < 180/110? → Proceed | BP ≥ 180/110? → Postpone, optimize
├── AF rate controlled (HR < 80)? → Confirm + continue meds
├── INR < 1.5? → Safe for spinal | INR > 1.5? → Wait / postpone
├── Electrolytes normal? → Correct K⁺, Mg²⁺
└── RCRI score 0-1, functional capacity > 4 METs → No further cardiac testing

INTRAOPERATIVE
├── Spinal anesthesia (preferred)
│    ├── Hyperbaric bupivacaine 0.5% 12.5-15 mg + fentanyl 25 mcg
│    ├── Target T10 block
│    └── Ephedrine ready for hypotension
└── General anesthesia (if regional contraindicated)
     ├── Propofol + fentanyl + vecuronium
     ├── Attenuate laryngoscopy response (lignocaine + esmolol)
     └── Maintain with sevoflurane (avoid halothane)

POSTOPERATIVE
├── Multimodal analgesia (paracetamol + nerve block + NSAID PRN)
├── Resume all cardiac medications ASAP
└── Restart anticoagulation at 24-48 h (no bridging in AF)

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XI. KEY EXAM TAKE-HOME POINTS

1. Spinal anesthesia is the technique of choice for inguinal herniorrhaphy in a hypertensive + AF patient - avoids hemodynamic surges of intubation and systemic anesthetic effects on myocardium
2. Hypertensives are MORE susceptible to spinal hypotension - pre-load with IV fluids; have ephedrine drawn
3. Never stop beta-blockers abruptly perioperatively - rebound ischemia and tachycardia
4. ACEI/ARB held on morning of surgery - risk of refractory intraoperative hypotension
5. Statins continued - perioperative withdrawal worsens cardiovascular outcomes (Class I recommendation)
6. No bridging anticoagulation for non-valvular AF - BRIDGE trial 2015 proved it is harmful
7. INR must be ≤ 1.5 before spinal anesthesia
8. Ephedrine over phenylephrine for hypotension in AF - preserves heart rate and cardiac output
9. Sevoflurane over halothane - halothane sensitizes myocardium, worsens arrhythmia
10. Correct hypokalemia and hypomagnesemia preoperatively - both are pro-arrhythmic in AF
11. Blunting laryngoscopy response (lignocaine + esmolol + fentanyl) is mandatory if GA used
12. Functional capacity > 4 METs + low-risk surgery = no additional cardiac testing needed (2024 ACC/AHA)

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