Perioperative Care of the Patient with Rheumatic Disease

Ronald C. MacKenzie

Nigel Sharrock

INTRODUCTION

Patients with rheumatic disease frequently require surgery for problems arising in the course of their chronic condition or in the acute setting of trauma or bone fracture. Therefore, rheumatologists, internists, and primary care physicians are often asked to evaluate patients in the perioperative setting. This chapter reviews the basic concepts that underlie perioperative medical care and management, emphasizing problems that are relatively specific to the patient with rheumatic disease.

The purpose of the preoperative medical and subsequent perioperative management are as follows:

Identification of comorbid conditions that may affect perioperative clinical decision-making.
Assessment of risk (both in magnitude and type).
Anticipation of potential postoperative complications.

COMPONENTS OF A PREOPERATIVE MEDICAL EVALUATION

The preoperative evaluation should take place, whenever possible, in the office setting several weeks before surgery. Although not always possible (e.g., as in the setting of acute injury requiring immediate surgical intervention), such anticipatory evaluation allows for sufficient time for discourse with other physicians involved in the patient’s care, for additional consultation and further investigation and, if necessary, for the institution of therapy directed at optimizing the patient’s medical status prior to the contemplated surgery. The preoperative evaluation should serve as a focal point of an up-to-date medical assessment and communication among all members of the medical team who will be caring for the patient.

I. MEDICAL EVALUATION

No consensus exists regarding what constitutes the optimal preoperative medical evaluation. The nature and extent of the preoperative evaluation of the patient depends on such factors as age, functional capacity, existing comorbidity, the type of anesthesia, and the type of surgery to be performed. However, some general guidelines as given here can provide a useful framework for such evaluations.

History and physical examination. Except for young patients and those undergoing only minor surgical procedures, most other patients should undergo a complete medical history and physical examination immediately prior to the surgical procedure.
Laboratory studies. Although it has never been demonstrated that preoperative laboratory testing improves surgical outcome, a number of investigations may be considered appropriate and are commonly performed on patients prior to major surgical procedures. Depending on the nature of the problem and the magnitude of surgery required to correct it, as well as the nature and severity of coexisting diseases, such testing might include the following:
- Complete blood count.
- Urinalysis and culture (for those patients undergoing total joint arthroplasty).
- Complete blood chemistries.
- Prothrombin [international normalized ratio (INR)] and partial thromboplastin time (while these are not demonstrated to be of value as preoperative
  investigations, they are of reasonable value in patients requiring anticoagulants after surgery, i.e., total joint arthroplasty).
- A 12-lead electrocardiogram (ECG).
- Chest radiograph (particularly in the elderly patients and those undergoing major joint or spine surgery).

II. COORDINATION OF CARE

At times, it is necessary to bring together the internist, orthopedist, and anesthesiologist preoperatively in a conference setting to address the conditions of very high-risk patients such as those undergoing bilateral joint procedures or extensive and prolonged spine surgery. This type of approach can often prevent significant cardiac, pulmonary, and neurologic problems, as well as problems with clotting postoperatively. This “ounce of prevention” usually pays off handsomely.

ASSESSMENT OF SURGICAL RISK

A primary purpose of the preoperative medical evaluation is the identification of patients who are at higher risk for postoperative complications. Although the standard history and physical examination remain the principal screening method for the detection of conditions likely to affect the outcome of surgery, there are two rating systems that are useful in identifying patients who are most likely to develop postoperative complications.

The best known and most widely used is the American Society of Anesthesiologists’ (ASA) Physical Status Scale, which has a high correlation with the patient’s postoperative course. The ASA consists of five levels of risk, which are based on the presence of a systemic disturbance; absent (I), mild (II), moderate (III), severe (IV), and virtually certain to cause death (V); the subdesignation E denotes emergency surgery.
A second system, focused on the risk of cardiac complications after surgery, is the Goldman Cardiac Risk Index (or subsequent modifications of the index). This system is somewhat more complex, emphasizes recent myocardial infarction and decompensated congestive heart failure as risk factors, and is the foundation upon which much of the current perioperative cardiac risk assessment is based.

ANESTHESIA IN PATIENTS WITH RHEUMATIC DISEASE

A variety of issues, which include airway considerations, the site and anticipated duration of surgery, existing comorbidity, and the patient’s emotional state are important determinants for the type of anesthesia to be used, to decide whether invasive monitoring will be necessary, and to determine the length of time the patient will spend in the recovery room after surgery.

I. TYPE OF ANESTHESIA

Both general and regional anesthesia are commonly used in the surgical treatment of patients with rheumatic disease. General anesthesia with endotracheal intubation may present a particular danger in patients with rheumatoid arthritis or ankylosing spondylitis in which cervical spine and/or cricoarytenoid disease may be present. In patients with cervical spine instability or a rigid airway, fiberoptic intubation may be required. Regional anesthesia may take the form of limited local anesthesia for minor procedures, peripheral nerve block for surgery of the upper and lower extremity, and epidural/spinal anesthesia for arthroplasty in the lower extremity.

II. MONITORING TECHNIQUES

Patients undergoing major surgical procedures should have continuous electrocardiographic and pulse oximeter monitoring intraoperatively. At the discretion of the anesthesiologist, central venous pressure, arterial pressure, and Swan-Ganz catheter monitoring may be helpful in select patients. Such monitoring is often employed in patients undergoing bilateral joint replacement surgery and in those with a history of prior cardiac disease.

III. POSTOPERATIVE ANALGESIA

A number of options exist for the control of postoperative pain, including the traditional intravenous or intramuscular routes (systemic) versus the administration of epidural analgesia. Patient-controlled analgesia via an epidural route of administration is a very effective method of pain control
postoperatively and often facilitates postoperative physical therapy, which is important in the restoration of range of motion in patients undergoing orthopedic surgery. This technique also reduces the systemic absorption of analgesics, thereby minimizing the problem of narcotic-induced respiratory depression, sedation, or cognitive problems in the elderly patients, or bowel problems such as ileus. Parenterally administered nonsteroidal anti-inflammatory drugs (NSAIDs), such as ketorolac (Toradol), are a useful alternative to traditional analgesia after surgery and can be used to reduce the requirement of narcotics after major surgery. These drugs should not be given to patients with the usual contraindications to NSAIDs such as peptic ulcer disease, renal disease, and the concomitant use of anticoagulants.

PERIOPERATIVE MANAGEMENT OF COMORBID MEDICAL CONDITIONS

The following discussion addresses the important comorbidities encountered in the perioperative setting. Table 60-1 summarizes medication concerns and reminders related to comorbid conditions.

I. CARDIAC DISEASE AND HYPERTENSION

Coronary artery disease

Introduction. The presence and extent of cardiovascular disease in assessing the risk of noncardiac surgery cannot be overstated and is, fortunately, the most investigated and well-documented arena of perioperative medicine. A large subset of patients who undergo orthopedic procedures such as joint replacements and hip fracture repair are older individuals, or have a systemic joint disease such as rheumatoid arthritis. Both the older individuals and patients with rheumatoid arthritis have an increased incidence of coronary artery disease, the former because of age-related phenomena and the latter because of the inflammatory state itself.

Practical guidelines for the physicians involved in the assessment and care of patients with cardiac disease are widely recognized. The predictive value of the routine clinical assessment, including medical history, physical examination, ECG, and chest x-ray is well established, at least with respect to the identification of the presence of pre-existing cardiac disease. However, it is also important to define disease severity and stability, as well as prior treatment received. The factors that work in concert with other clinical characteristics and ultimately define postoperative risk include the following:
- Age.
- Functional capacity (as determined by simple activity questionnaires).
- Comorbidity (particularly diabetes mellitus, peripheral vascular disease, and chronic pulmonary disease).
- Type of surgery to be performed (major orthopedic procedures tend to be of intermediate risk).
- A series of factors may predict postoperative myocardial infarction, congestive heart failure, and death after orthopedic surgery.
Major predictors of increased perioperative cardiac risk are as follows:
- Recent myocardial infarction (<30 days).
- Unstable or severe angina.
- Poorly compensated congestive heart failure.
- Significant arrhythmias.
- Severe valvular disease.

Intermediate predictors of increased perioperative cardiac risk are as follows:

Mild angina.
Prior myocardial infarction determined from history or by pathologic Q waves.
Compensated or prior congestive heart failure.
Diabetes.

Table 60-1 Perioperative Evaluation and Care

Category	Medications	Reminders
Cardiac	Continue medications through surgery May have to change to transdermal, intravenous, or sublingual equivalents Avoid abrupt withdrawal Avoid rapid diuresis before surgery	Bacteremia during surgery may seed endocardium Consider whether β-blockers should be used Stop clopidogrel (Plavix) 10 d before surgery
Hypertension	Continue most medications through surgery, using nonoral forms if necessary Change ganglionic blockers and MAOIs to other agents	Only severe (diastolic higher than 110) or malignant hypertension needs control preoperatively in most cases
Endocrine	Diabetes: Stop oral hypoglycemics 1 d before surgery; discontinue chlorpropamide and glyburide 3 d before surgery For insulin users, halve the usual insulin dose before surgery with dextrose and water and sliding scale insulin; for prolonged NPO or brittle diabetes, insulin drip Thyroid disease: Continue thyroid supplements during surgery Reduce L-thyroxine dose by 20% for long-term parental use Corticosteroids: Stress doses if used regularly within a Y of surgery, tapering over 3-4 d to maintenance after surgery	Even young patients with diabetes have autonomic insufficiency Prolonged anesthetic effect after surgery may suggest hypothyroidism
Gastrointestinal and Hepatic	Cimetidine may precipitate confusion, delirium in the older individuals Malabsorption, dysmotility of bowel, hepatic dysfunction may significantly alter pharmacodynamics of perioperative medications, including anesthetic	Nutritional assessment, vitamins History of risk factors for hepatitis B or C History of alcohol use Watch for bleeding diathesis Theophylline clearance may be decreased by cimetidine, erythromycin, ciprofloxacin
Renal	Caution with nephrotoxins, including acetaminophen	Don’t feed too quickly for fear of ileus
Rheumatologic	NSAIDs: stop 5–7 d before surgery (reversible platelet function) Hold anti-TNF biologics 1–2 wk preoperative and start again 1–2 wk postoperative when wound is clean and healing	Cervical spine disease may compromise safe intubation RA patients with cervical spine disease should wear cervical collar to the OR Treat asymptomatic bacteriuria in patients undergoing total joint arthroplasty Patients with severe sicca syndrome require
Hematology	Hold cytotoxic or immunosuppressive drugs before surgery	Consider autologous blood transfusion requirements well in advance of surgery
Neurology	Continue anticonvulsant therapy	Phenothiazines may lower seizure threshold Atropine may precipitate delirium in Parkinson’s disease
Geriatrics	Polypharmacy common in the older individuals; continue medications only if indicated	Nutritional assessment Delirium may be caused by sundowning, infection, ischemia, drug effect (sedatives especially), alcohol withdrawal, electrolyte imbalance, hypoxia Discharge planning essential preoperatively Advance directives should be discussed well before surgery
Miscellaneous	Ask about nonprescription drugs and supplements Alcohol and illicit drug use should be considered possible	HIV risk factors Patient may be unaware of pregnancy Patient fears and expectations Vaccination status
HIV, human immunodeficiency virus; MAOIs, monoamine oxidase inhibitors; NPO, nothing by mouth; NSAIDs, nonsteroidal anti-inflammatory drugs. Adapted from MacKenzie CR, Sharrock NE. Perioperative medical considerations with rheumatoid arthritis. Perioperative medical considerations in patients with rheumatoid arthritis. Rhem Dis Clin North Am. 1998; 24(1):1–17, with permission.

Table 60-2 Recommendations for the Use of Perioperative β-blockers

Perioperative β-blockers should be used in patients with any of these criteria:

Ischemic heart disease, defined as:
1. –History of myocardial infarction or Q waves on ECG
2. –History of angina pectoris
3. –Positive stress test
4. –History of angioplasty or coronary artery bypass graft
Cerebrovascular disease, defined as history of transient ischemic attack or cerebrovascular accident
Diabetes mellitus requiring insulin therapy
Chronic renal insufficiency, defined as baseline creatinine ≥2.0

Perioperative β-blockers should be used in patients meeting any two of the following criteria:

Age 65 or older
History of hypertension (treated or untreated)
Current smoker
History of hypercholesterolemia (treated or untreated)
Diabetes mellitus not requiring insulin therapy

Possible contraindications for β-blockade (often such patients may still cautiously receive β-blockade on a case-by-case basis):

Bradycardia, defined as a heart rate <60
Congestive heart failure if uncontrolled
Asthma/COPD history, especially if severe and/or uncontrolled
History of intolerance of β-blockers

COPD, chronic obstructive pulmonary disease; ECG, electrocardiogram.
From Auerbach AD, Goldman L. Beta blockers and reduction of cardiac events in noncardiac surgery: scientific review. JAMA. 2002;287:1435–1444, with permission.

Minor predictors of increased perioperative risk are as follows:
- Advanced age.
- Abnormal ECG.
- Rhythm other than sinus rhythm.
- Low functional capacity.
- Prior stroke.
- Poorly controlled hypertension.
- Prior cardiac revascularization, currently asymptomatic.
Cardiac testing. The indications for preoperative exercise stress testing with or without nuclear scanning or ambulatory electrocardiography (Holter monitoring) are not clear. Ultimately, the decision will depend on the physician’s estimates of the effectiveness, risk, and costs of such evaluations. Feasibility also may come into play in patients with chronic rheumatic diseases and orthopedic conditions, given the functional compromise that is attendant to such conditions. This is also an issue when there is the need to perform relatively urgent surgery, as in the case of fracture. Nonetheless, guidelines have emerged from a large body of clinical data.

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