Preparing Your Patient With Rheumatoid Arthritis for Surgery

Slideshow

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  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]

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  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]

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  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]

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  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]

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  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.

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  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]

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  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]

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  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.

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  Management of Medication for Rheumatic Disease

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

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  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]

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  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.