203

XII

Chapter 30

Perioperative Management of the Patient with Rheumatologic Disease

Elizabeth Kaplan

GENERAL PRINCIPLES Patients with rheumatologic disease, e.g., rheumatoid arthritis (RA) and systemic lupus erythematosus, should receive the same preopera-tive cardiovascular, pulmonary, and other risk assessment as other patients.

Evaluate the preoperative status of the patient’s rheumatologic ■

disease. In general, surgery during active fl ares of disease should be avoided. Make note of any hypercoagulable states, especially in patients ■

with systemic lupus erythematosus (SLE). Assess recent history of and current steroid use, including pulse ■

of steroids within the last year, even if the patient is no longer taking steroids (see Chap. 22 ). Determine the level of immune suppression. ■

Recommend coordinated care with patient’s rheumatologist. ■

RHEUMATOID ARTHRITIS PREOPERATIVE EVALUATION: HISTORY TAKING FOR PATIENTS WITH RA

Length of disease (disease duration is associated with more ■

joint damage, particularly neck involvement) Current functional status ■

Speci fi c joints affected ■

Current medications ■

C.J. Wong and N.P. Hamlin (eds.), The Perioperative Medicine Consult Handbook, DOI 10.1007/978-1-4614-3220-3_30, © Springer Science+Business Media New York 2013

204 THE PERIOPERATIVE MEDICINE CONSULT HANDBOOK

Previous and current use of steroids ■

Extra-articular manifestations of disease ■

Previous complications associated with surgery ■

SPECI FI C PERIOPERATIVE CONCERNS FOR PATIENTS WITH RA [ 1 ] :

Cardiovascular disease: Patients with RA are at increased risk ■

of cardiovascular disease, particularly those with poorly con-trolled or long-standing disease. Cardiovascular risk strati fi cation is not necessarily different with respect to the cur-rent ACC/AHA algorithm, but particular attention should be paid to possible cardiac symptoms in patients with RA. Pulmonary disease: Patients with RA may have a variety of dif- ■

ferent pulmonary complications of their disease including fi brosis, bronchiolitis, and pleuritis. Depending on their sever-ity, these complications may impact the patient’s pulmonary status in the perioperative period. Preoperative evaluation should include a thorough history of these conditions, if pres-ent, and consideration of workup if the patient has undiag-nosed pulmonary symptoms at the time of the preoperative evaluation. Cricoarytenoid arthritis: Up to 75% of patients with RA may ■

have arthritis of the cricoarytenoid joints. Arthritis of these joints may lead to dif fi culties with intubation or postoperative airway obstruction (due to irritation from ET tube). History of hoarseness, sore throat, and trouble with inspiration may be a clue to its presence although most patients are asymptomatic. This entity should be considered in a postoperative patient who is having respiratory dif fi culty [ 1 ] . Cervical spine disease: Underlying C1–C2 subluxation, atlanto- ■

axial impaction, or subaxial disease can put patients at risk for cervical spine injury when a patient’s neck is manipulated dur-ing surgery (for intubation or positioning). Consider cervical spine fi lms fl exion/extension if the patient is undergoing ortho-pedic surgery speci fi cally for his/her rheumatologic disease (suggests more severe overall disease), has had disease for >5 years, or has any neurologic abnormality corresponding to the cervical spine on exam. If plain fi lms are abnormal, then it is recommended to discuss with the patient’s rheumatologist and anesthesiologist prior to the surgery, and consider further evaluation with an MRI.

205CHAPTER 30: PERIOPERATIVE MANAGEMENT OF THE PATIENT…

XII

PREOPERATIVE EVALUATION: STUDIES TO CONSIDER IN PREOPERATIVE EVALUATION FOR PATIENTS WITH RA

CBC to look for leukopenia related to drugs, anemia related to ■

drug-associated duodenal irritation, and/or bone marrow suppression. LFTs, renal function (because of effects some RA drugs can ■

have on these systems). Walking O ■ 2 sat if history or suspicion of pulmonary complica-tions of RA. Consider cervical fi lms as discussed above. ■

PERIOPERATIVE MANAGEMENT OF ANTIRHEUMATIC AGENTS (TABLE 30.1 ) Note that dosing of medication should be con fi rmed with the patient’s pharmacy and/or rheumatologist.

SYSTEMIC LUPUS ERYTHEMATOSUS

Patients with SLE have a higher risk for CAD at a relatively ■

younger age and the presence of antiphospholipid antibodies confers a higher risk for both heart valve disease as well as thrombosis. There is a two- to sevenfold higher mortality rate for SLE ■

patients undergoing both nonelective and elective hip and knee surgery compared to RA patients and controls independent of major medical co-morbidities [ 7 ] . Important perioperative issues are medication management, ■

thromboembolic disease, hematologic abnormalities, renal dis-ease, immune dysfunction, and increased risk of CAD. Reduce risk of perioperative MI and thrombosis by addressing ■

traditional risk factors such as smoking, use of oral contracep-tive pills (OCPs), and having good blood pressure and lipid con-trol in the preoperative setting. In patients with established thromboembolic disease and ■

antiphospholipid antibody syndrome (APS), bridging therapy for anticoagulation is recommended (see Chap. 23 ). If the patient has Raynaud’s phenomenon, cooling periopera- ■

tively should be limited to avoid digital ischemia.

206 THE PERIOPERATIVE MEDICINE CONSULT HANDBOOK

TA

BL

E 3

0.1

PER

IOPE

RAT

IVE

MA

NA

GEM

ENT

OF

AN

TIR

HEU

MAT

IC A

GEN

TS

Met

hot

rexa

te

■ U

sual

ly g

iven

on

ce w

eekl

y ■

A p

rosp

ecti

ve r

and

omiz

ed t

rial

of

pat

ien

ts w

ith

RA

un

der

goin

g el

ecti

ve o

rth

oped

ic s

urg

ery

show

ed f

ewer

com

pli

cati

ons,

in

fect

ion

s, a

nd

fl ar

es i

n t

he

grou

p t

hat

con

tin

ued

met

hot

rex-

ate

rath

er t

han

dis

con

tin

uin

g it

[ 2 ]

■

Gen

eral

con

sen

sus

is t

o co

nti

nu

e it

un

less

su

rger

y is

bei

ng

don

e fo

r a

seri

ous

infe

ctio

n.

Rea

son

s to

con

sid

er s

top

pin

g m

edic

atio

n i

ncl

ud

e p

ost-

op i

nfe

ctio

n, r

isin

g cr

eati

nin

e,

pro

lon

ged

NP

O s

tate

, pat

ien

t ov

er a

ge 7

0 ■

Rec

omm

end

dis

cuss

ing

wit

h t

he

pat

ien

t’s r

heu

mat

olog

ist

Le fl

un

omid

e (A

rava

® )

■ C

onsi

der

sto

pp

ing

in p

atie

nts

in

wh

om la

rge

wou

nd

s ar

e an

tici

pat

ed. T

her

e is

no

clea

r d

ata

for

man

agem

ent

of le

fl u

nom

ide,

an

d d

iscu

ssio

n w

ith

th

e p

atie

nt’s

rh

eum

atol

ogis

t is

usu

ally

w

arra

nte

d

■ O

ne

tria

l sh

owed

no

dif

fere

nce

in

wou

nd

hea

lin

g in

ort

hop

edic

su

rger

y p

atie

nts

[ 3 ]

; h

owev

er a

sec

ond

tri

al s

how

ed t

hat

it

did

aff

ect

wou

nd

hea

lin

g ■

Not

e th

at lo

ng

hal

f-li

fe (

~2

wee

ks)

may

mak

e co

mp

lete

dis

con

tin

uat

ion

pro

ble

mat

ic

Su

lfas

alaz

ine

■ G

ener

ally

acc

epta

ble

to

con

tin

ue

[ 4 ]

Aza

thio

pri

ne

■ M

ay b

e co

nti

nu

ed f

or m

inor

pro

ced

ure

s an

d h

eld

for

a f

ew d

ays

for

maj

or p

roce

du

res,

al

thou

gh n

o cl

ear

dat

a to

su

gges

t th

at t

his

is

nec

essa

ry [

4 ]

Hyd

roxy

chlo

roqu

ine

(Pla

quen

il ® )

■ G

ener

ally

acc

epta

ble

to

con

tin

ue

■ O

ne

retr

osp

ecti

ve s

tud

y sh

owed

no

dif

fere

nce

in

pos

top

erat

ive

wou

nd

hea

lin

g or

in

fect

ion

s [ 4

]

207CHAPTER 30: PERIOPERATIVE MANAGEMENT OF THE PATIENT…

XII

TN

F-a

lph

a in

hib

itor

s—in

fl ix

imab

(R

emic

ade ®

), a

dal

i-m

um

ab (

Hu

mir

a ® ),

et

aner

cep

t (E

nb

rel ®

)

■ S

ome

smal

l stu

die

s ( n

= 3

1 or

less

) h

ave

not

sh

own

a d

iffe

ren

ce i

n o

rth

oped

ic s

urg

ery,

b

ut

wer

e li

kely

un

der

pow

ered

[ 4–

6 ]

■ O

ne

grou

p r

ecom

men

ds

for

“ste

rile

” si

te s

urg

ery

to h

old

in

fl ix

imab

for

1 m

onth

, ad

ali-

mu

mab

for

3–4

wee

ks, a

nd

eta

ner

cep

t fo

r 1–

2 w

eeks

, an

d f

or “

sep

tic”

en

viro

nm

ent

or r

isk

surg

ery

(ab

dom

inal

su

rger

y, jo

int

rep

lace

men

t) t

o st

op t

hes

e ag

ents

for

tw

ice

as lo

ng

[ 4 ]

■ P

osto

per

ativ

ely

it i

s re

com

men

ded

to

rest

art

thes

e ag

ents

on

ce w

oun

d h

eali

ng

is

com

ple

te a

nd

th

ere

is n

o ev

iden

ce o

f in

fect

ion

usu

ally

not

ear

lier

th

an 1

0–14

day

s p

osto

per

ativ

ely

[ 4 ]

■ W

e re

com

men

d d

iscu

ssio

n w

ith

th

e p

atie

nt’s

rh

eum

atol

ogis

t an

d s

urg

eon

reg

ard

ing

the

use

of

th

ese

agen

ts i

n t

he

per

iop

erat

ive

per

iod

■

If d

ecis

ion

is

to h

old

th

e d

rug

(wh

ich

is

mos

t li

kely

th

e ca

se f

or m

oder

ate

to i

nte

nse

pro

ce-

du

res)

, hol

d b

ased

on

½ li

fe a

nd

hol

d a

t le

ast

two

hal

f-li

ves.

Hal

f-li

ves

are

list

ed b

elow

: ■

Eta

ner

cep

t (E

nb

rel ®

): 3

.5–5

.5 d

ays

■ A

dal

imu

mab

(H

um

ira ®

): 1

0–20

day

s ■

In fl

ixim

ab (

Rem

icad

e ® ):

9.5

day

s ■

Cer

toli

zum

ab (

Cim

zia ®

): 1

4 d

ays

■ G

olu

mim

ab (

Sim

pon

i ® ):

14

day

s

An

akin

ra (

Kin

eret

® ),

R

itu

xim

ab, A

bat

acep

t (O

ren

cia ®

)

Rec

omm

end

dis

cuss

ion

wit

h t

he

pat

ien

t’s r

heu

mat

olog

ist

NS

AID

s (S

ee C

hap

. 4 , p

erio

per

ativ

e m

edic

atio

n m

anag

emen

t)

208 THE PERIOPERATIVE MEDICINE CONSULT HANDBOOK

OTHER RHEUMATOLOGIC DISEASES

Consider involving the patient’s rheumatologist. ■

REFERENCES 1. Bandi V, Munnur U, Braman SS. Airway problems in patients with rheumatologic disorders.

Crit Care Clin. 2002;18(4):749–65. 2. Grennan DM, Gray J, Loudon J, et al. Methotrexate and early postoperative complications in

patients with rheumatoid arthritis undergoing elective orthopaedic surgery. Ann Rheum Dis. 2001;60(3):214–7.

3. Tanaka N, Sakahashi H, Sato E, et al. Examination of the risk of continuous le fl unomide treat-ment on the incidence of infectious complications after joint arthroplasty in patients with rheumatoid arthritis. J Clin Rheumatol. 2003;9:115–8.

4. Pieringer H, Stuby U, Biesenbach G. Patients with rheumatoid arthritis undergoing surgery: how should we deal with antirheumatic treatment? Semin Arthritis Rheum. 2007;36(5):278–86. Epub 3 Jan 2007.

5. Bibbo C, Goldberg JW. Infectious and healing complications after elective orthopaedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy. Foot Ankle Int. 2004;25:331–5.

6. Giles JT, Bartlett SJ, Gelber AC, et al. Tumor necrosis factor inhibitor therapy and risk of serious postoperative orthopedic infection in rheumatoid arthritis. Arthritis Rheum. 2006;55:333–7.

7. Domsic RT, Lingala B, Krishnan E. Systemic lupus erythematosus, rheumatoid arthritis, and postarthroplasty mortality: a cross-sectional analysis from the nationwide inpatient sample. J Rheumatol. 2010;37(7):1467–72.