History and Physical Examination
A thorough patient history and physical examination can reveal important information regarding joint mobility and range of motion. For example, patients with rheumatoid arthritis (RA) may have cervical spine involvement, with instability arising from atlantoaxial or subaxial subluxation. Involvement of the temporomandibular joint may limit jaw opening, and therefore may influence the choice of airway management. 
Mitigation of Bleeding Risk
The increased bleeding risk associated with glucocorticoids must also be balanced against the risk for bleeding associated with other agents, including aspirin and cyclooxygenase-2 (COX-2) inhibitors. 
Disease-Modifying Antirheumatic Drugs and Risk of Surgical Site Infection
Increased infection rates, specifically surgical site infections (SSI), are possibly the greatest perceived risk associated with biologic DMARDs, particularly during postoperative care. 
Decision to Continue Disease-Modifying Antirheumatic Drugs
The American College of Rheumatology guidelines recommend discontinuing anti-TNF agents 1 to 4 weeks before surgery.  Available evidence suggests that methotrexate can be continued throughout the perioperative period. 
Minimizing Long-Term Interruptions of Disease-Modifying Antirheumatic Drug Therapy
It is necessary to balance the risk for postoperative infection with continued DMARD use against the risk for disease flare and progression when DMARDs are withheld.
Total Joint Arthroplasty and Risk of Venous Thromboemolism
Total joint arthroplasty, especially in patients with pulmonary hypertension, is considered a risk factor for postoperative venous thromboembolism. This finding should allow clinicians to better stratify patients having total hip replacement and target specific thromboprophylaxis modalities. 
Preoperative Cervical Radiography
Currently, there is no consensus regarding the role of plain x-rays in the evaluation of cervical spine instability in those with RA, despite that between 17% and 86% of those with RA have evidence of cervical spine disease 5 years after diagnosis. 
Preoperative Laboratory Evaluation
Comprehensive laboratory evaluation is important if blood transfusion is expected, to screen for antirheumatic drug side effects, and to assess medical comorbidities.  The results of these tests should be shared with the surgical team to reduce surgical morbidity and mortality.
Management of Medication for Rheumatic Disease
Most patients with RA are taking multiple medications, which must be managed during the perioperative period.
Glucocorticoids and Delayed Wound Healing
Suppression of the hypothalamopituitary-adrenal axis and the potential risk for adrenal crisis are recognized complications of prolonged glucocorticoid (GC) use.  Use of GCs may suppress the normal increase in endogenous cortisol that occurs in response to stress or surgery. GCs are also known to delay wound healing. 
Cardiac and Pulmonary Risk Stratification
The inflammatory process associated with RA increases the risk for cardiac morbidity and mortality ; therefore, those at risk should undergo preoperative cardiac risk stratification. Further cardiac testing may be indicated as part of this evaluation.
The optimal perioperative management of those with rheumatic diseases begins with careful review of the patient’s clinical condition through history and physical examination, and continues by identifying presenting comorbidities and assessing joint mobility and risks.
|To Continue Reading about the perioperative management of rheumatic disease Click Here|
1.Partridge JS, Harari D, Martin FC, Dhesi JK. The impact of pre-operative comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery: a systematic review. Anaesthesia.2014;69(Suppl 1):8-16.