Preparing Your Patient With Rheumatoid Arthritis for Surgery - Rheumatology Advisor

Preparing Your Patient With Rheumatoid Arthritis for Surgery

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  • 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. [1]

    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. [1]

  • 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. [6]

    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. [6]

  • Increased infection rates, specifically surgical site infections (SSI), are possibly the greatest perceived risk associated with biologic DMARDs, particularly during postoperative care. [9]

    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. [9]

  • The American College of Rheumatology guidelines recommend discontinuing anti-TNF agents 1 to 4 weeks before surgery. [7] Available evidence suggests that methotrexate can be continued throughout the perioperative period. [8]

    Decision to Continue Disease-Modifying Antirheumatic Drugs

    The American College of Rheumatology guidelines recommend discontinuing anti-TNF agents 1 to 4 weeks before surgery. [7] Available evidence suggests that methotrexate can be continued throughout the perioperative period. [8]

  • 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.

    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 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. [10]

  • Preoperative Cervical Radiography

    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. [2]

  • Comprehensive laboratory evaluation is important if blood transfusion is expected, to screen for antirheumatic drug side effects, and to assess medical comorbidities. [3] The results of these tests should be shared with the surgical team to reduce surgical morbidity and mortality.

    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. [3] The results of these tests should be shared with the surgical team to reduce surgical morbidity and mortality.

  • Most patients with RA are taking multiple medications, which must be managed during the perioperative period.

    Management of Medication for Rheumatic Disease

    Most patients with RA are taking multiple medications, which must be managed during the perioperative period.

  • Suppression of the hypothalamopituitary-adrenal axis and the potential risk for adrenal crisis are recognized complications of prolonged glucocorticoid (GC) use. [5] 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. [5]

    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. [5] 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. [5]

  • The inflammatory process associated with RA increases the risk for cardiac morbidity and mortality [4]; therefore, those at risk should undergo preoperative cardiac risk stratification. Further cardiac testing may be indicated as part of this evaluation.

    Cardiac and Pulmonary Risk Stratification

    The inflammatory process associated with RA increases the risk for cardiac morbidity and mortality [4]; 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. 

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References

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.

2.Lopez-Olivo MA, Andrabi TR, Palla SL, Suarez-Almazor ME. Cervical spine radiographs in patients with rheumatoid arthritis undergoing anesthesia. J Clin Rheumatol. 2012;18(2):61-66.
3.Bissar L, Almoallim H, Albazli K, Alotaibi M, Alwafi S. Perioperative management of patients with rheumatic diseases. Open Rheumatol J. 2013;7:42-50.
4.Meune C, Touzé E, Trinquart L, Allanore Y. Trends in cardiovascular mortality in patients with rheumatoid arthritis over 50 years: a systematic review and meta-analysis of cohort studies. Rheumatology (Oxford). 2009;48(10):1309-1313. 
5.Woods CP, Argese N, Chapman M, et al. Adrenal suppression in patients taking inhaled glucocorticoids is highly prevalent and management can be guided by morning cortisol. Eur J Endocrinol. 2015;173(5):633-642.
6.Gribsholt SB, Svensson E, Thomsen RW, et al. Preoperative glucocorticoid use and risk of postoperative bleeding and infection after gastric bypass surgery for the treatment of obesity. Surg Obes Relat Dis. 2015;11(6):1212-1217.
7.Wendling D, Balblanc JC, Brousse A, et al. Surgery in patients receiving anti-tumour necrosis factor alpha treatment in rheumatoid arthritis: an observational study on 50 surgical procedures. Ann Rheum Dis. 2005;64(9):1378-1379.
8.Grennan DM, Gray J, Loudon J, Fear S. Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery. Ann Rheum Dis. 2001;60(3):214-217.
9.den Broeder AA, Creemers MC, Fransen J, et al. Risk factors for surgical site infections and other complications in elective surgery in patients with rheumatoid arthritis with special attention for anti-tumor necrosis factor: a large retrospective study. J Rheumatol. 2007;34(4):689-695. 
10. Pedersen AB, Sorensen HT, Mehnert F, Overgaard S, Johnsen SP. Risk factors for venous thromboembolism in patients undergoing total hip replacement and receiving routine thromboprophylaxis. J Bone Joint Surg Am. 2010;92(12):2156-2164
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