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Chapter 55 Perioperative Care in the Rheumatic Disease Patient

Manual of Rheumatology and Outpatient Orthopedic Disorders

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Chapter 55 Perioperative Care in the Rheumatic Disease Patient

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C. Ronald MacKenzie and Nigel Sharrock

Preoperative evaluation
Assessment of risk
Anesthesia in patients with rheumatic disease
Considerations pertaining to specific chronic conditions
Specific clinical problems

Patients with chronic rheumatologic diseases such as rheumatoid arthritis frequently require orthopedic surgery in the course of their illness . Therefore, the internist or rheumatologist will often be called on to evaluate patients in this setting. This chapter reviews the basic concepts that underlie perioperative medical management, emphasizing problems that are relatively specific to the rheumatic disease patient.

The goals of preoperative medical evaluation and perioperative care are to (a) identify comorbid conditions that might affect surgical and anesthetic decision making or influence preoperative and postoperative care, (b) stratify patients according to surgical risk, and (c) identify potential postoperative problems that can be addressed before surgery to reduce the likelihood of their occurrence.

I. Preoperative evaluation should take place, whenever possible, in the office setting several weeks before the surgical procedure. This allows sufficient time for discussion with other physicians involved in the patient's care, further investigation or consultation, and the institution of therapy directed at optimizing the patient's status before the anticipated surgery. It should serve as a focal point for communication between all the members of the medical team who will be caring for the patient.

There is no consensus regarding what constitutes an optimal preoperative medical evaluation, and the specific needs of a given patient will depend on a variety of factors, including the patient's age, comorbidities, and the type of anesthesia and surgery being planned. Practical guidelines have been suggested and provide a useful framework from which to approach such evaluations.

1. History and physical examination. Except for young patients and those undergoing minor surgical procedures, patients with rheumatic disease should provide the physician with a complete medical history and undergo a physical examination before surgery.
2. Laboratory studies. Although it has never been demonstrated that preoperative laboratory testing improves surgical outcome, a number of investigations seem appropriate for patients undergoing major surgery. These include a complete blood cell count, urinalysis , measurement of electrolytes, biochemical profile, a basic evaluation of clotting (in selected patients), and a urine culture in patients undergoing joint arthroplasty. A 12-lead electrocardiogram and chest radiograph are also helpful, particularly in the elderly and those undergoing major surgery.

II. Assessment of risk. The primary purpose of the preoperative medical evaluation is the identification of patients at high risk for postoperative complications. Although the standard clinical examination remains the best screening method for the detection of diseases likely to affect surgical outcome, rating systems do exist that have proved useful in predicting which patients are most likely to have a complicated postoperative course.

1. The best known of these is the American Society of Anesthesiologists (ASA) Physical Status Scale, which is based on the presence of a systemic disturbance designated as absent (I), mild (II), moderate (III), severe (IV), or virtually certain to cause death (V); the subdesignation E denotes emergency surgery. This system, which has been in widespread use for more than 30 years , has demonstrated a high correlation with a patient's postoperative course.
2. A second system, which focuses primarily on the risk for cardiac complications after surgery, is the Goldman Cardiac Risk Index. Table 55-1 presents the specific risk factors, their relative contribution to the overall index, and the corresponding rates of serious postoperative morbidity and mortality according to the total index score.
   
   

   
   

   Table 55-1. Goldman cardiac risk index

   
   
   

III. Anesthesia in patients with rheumatic disease. A variety of issues, including airway considerations, the site and anticipated duration of surgery, existing comorbidity, and the patient's emotional state, are important determinants of the type of anesthesia to be used, whether invasive monitoring will be necessary, and the length of time the patient will spend in a recovery room after surgery.

1. Type of anesthesia. Both general and regional anesthesia is 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 (see section V ). In patients with cervical spinal 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 .
2. Monitoring techniques. Patients undergoing major surgical procedures should have continuous electrocardiographic and pulse oximeter monitoring intraoperatively. At the discretion of the anesthesiologist, arterial and Swan-Ganz catheter monitoring may be helpful in selected patients. Such monitoring is often employed in patients undergoing bilateral joint replacement surgery and in those with a history of prior cardiac disease.
3. Postoperative analgesia. A number of options exist for the control of postoperative pain, including the traditional IV or IM 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 problems of narcotic-induced respiratory depression. New, parenterally administered nonsteroidal antiinflammatory agents such as ketorolac are a useful alternative to traditional analgesia after surgery and can be used to reduce narcotic requirements after major surgery. These drugs should not be given to patients with the common contraindications to nonsteroidal antiinflammatory drugs (i.e., peptic ulcer disease, concomitant use of anticoagulants, renal disease).

IV. Considerations pertaining to specific chronic conditions

1. Hypertension. The preoperative evaluation should determine whether end-organ damage (cardiac, neurologic, renal) is present, as this would increase the risk of surgery. Blood pressure should be measured with the patient lying down and in a sitting position to determine the maximal orthostatic fall in blood pressure and the degree of control. Patients are then classified as untreated, hypertensive controlled on medication , or hypertensive despite therapy.
   1. Risk of surgery. Controversy exists about whether mild to moderate hypertension increases the risk of surgery. However, patients whose blood pressure is above this range likely are at greater risk and should be stabilized with antihypertensive therapy before surgery.
   2. Drug therapy. Patients on antihypertensive therapy should continue their medication through the morning of surgery, and it should be restarted postoperatively as soon as they resume oral intake. After surgery, owing to bed rest and fluid losses, some patients may temporarily require less antihypertensive medication.

      Generally , patients taking long- term antihypertensive therapy should be maintained on their medications up to the time of surgery. A cautionary note regarding two medications is required. In the rare patient taking guanethidine or a monoamine oxidase inhibitor, these medications must be discontinued and replaced with other antihypertensive agents several weeks before surgery, as they may cause a marked lability in the blood pressure during or following anesthesia.

2. Ischemic heart disease
   1. Risk of surgery. Patients with ischemic heart disease undergoing surgery are at greater risk for perioperative myocardial infarction. This risk is significantly greater in patients with a recent infarction. Stable angina pectoris is not thought to increase the risk of surgery, but unstable angina does. A prior myocardial infarction also increases risk, particularly if the infarction has occurred 3 to 6 months before the surgery. Patients who have undergone coronary revascularization have a substantially lower risk for postoperative myocardial infarction. A number of factors contribute to the risk for postoperative death, including decompensated congestive heart failure, arrhythmias, and obstructive lung disease.
   2. Preoperative testing. The precise role of stress testing, nuclear scanning, and ambulatory electrocardiography in the preoperative setting is not clear. Such testing may be helpful in selected patients, and a decision regarding their utility can be reached in conjunction with cardiology consultation. Nonetheless, patients with unstable angina or a recent myocardial infarction should not undergo elective surgery until their risk can be modified with appropriate medical and surgical management.
   3. Drug therapy. For patients taking long-acting nitrates, the drug should be given on the morning of surgery; cutaneous nitrate preparations can be continued postoperatively until the patient resumes oral intake. Likewise, beta blockers and calcium channel blockers should be restarted as soon as possible postoperatively. Decisions to give cardioactive and vasoactive medication on the day of surgery should be fully discussed and sanctioned by the anesthesiologist.
   4. Postoperative testing. Postoperative surveillance for the development of cardiac ischemia or myocardial infarction is required for patients at high risk for these complications. Although creatine kinase levels are usually elevated in these patients because of the muscle trauma associated with surgery, serial electrocardiograms and determination of creatine kinase isoenzymes are useful in the detection of interval ischemia.
3. Congestive heart failure. Patients with decompensated congestive heart failure and, to a lesser extent, those with a history of cardiac failure are at greatest risk in the postoperative setting. Therefore, it is important to assess the patient's intravascular volume status, and elective surgery should be postponed until any existing cardiac failure is controlled. Patients should be maintained on their usual program of medications, including diuretics and ACE inhibitors , throughout the perioperative period. Digitalization before surgery is reasonable in patients with a known congestive cardiomyopathy, and in patients with a history of atrial fibrillation.
4. Valvular heart disease. The risks of surgery in patients with valvular heart disease depend on the valve affected and on the nature and severity of the valvular lesion. Hemodynamically significant aortic stenosis is the most serious lesion, followed by hypertrophic cardiomyopathy (the latter being considered a relative contraindication to epidural or spinal anesthesia). Mild to moderate mitral lesions or aortic insufficiency is usually well tolerated, although hemodynamically significant valvular disease (New York Heart Association class 3 or 4) of any type creates major risks. When it is present, cardiology consultation and monitoring from 13 to 48 hours is prudent.
5. Pulmonary disease. Chronic obstructive lung disease and asthma are the two forms of pulmonary disease seen most frequently in the preoperative setting.
   1. Risk of surgery. The risk of pulmonary complications can be attributed to various factors, both pulmonary and nonpulmonary. Minor pulmonary complications (atelectasis, bronchitis) are increased in patients who smoke or who have chronic cough or abnormal spirometry values. However, the risk for severe postoperative pulmonary complications (pneumonia, respiratory failure) is increased mainly in those patients with marked impairment in lung function (FEV ₁ <1.5 L). Among the nonpulmonary factors that contribute to the risk for postoperative complications are age, obesity, longer duration of anesthesia, excessive sedation, poor patient effort, and the type of surgery. Respiratory dysfunction is less severe after orthopedic than after intraabdominal or thoracic surgery.
   2. Bronchodilator therapy. Patients who are taking bronchodilators on a long-term basis before surgery should be given their standard dose the night before surgery, and bronchodilator therapy should be administered postoperatively either systemically or by nebulizer.
   3. Incentive spirometry and mobilization are helpful in preventing postoperative atelectasis or pneumonia.
6. Endocrine disease
   1. Diabetes. The most important endocrine disorder encountered in surgical patients is diabetes mellitus. Diabetics appear to be at slightly greater risk for postoperative death, likely because of the greater prevalence of ischemic heart disease in these patients. Several reports also suggest that diabetics with autonomic insufficiency (manifested by postural hypotension, impotence, nocturnal diarrhea) may be at risk for sudden cardiopulmonary arrest postoperatively. Numerous regimens for the management of diabetics in the perioperative setting have been reported . A common method is to give one-half of the patient's usual morning dose of NPH (neutral protamine Hagedorn) on the morning of surgery together with 5% dextrose.

      Supplemental short-acting insulin is then given as dictated by daily fingerstick determination of blood sugars. This approach can be continued until the patient resumes oral intake. For patients on oral hypoglycemic agents, these medications can be taken the day before surgery and resumed when the patient is eating . Chlorpropamide (Diabinese), because of its long half-life, should be discontinued 2 to 3 days before surgery.

   2. Patients on corticosteroids. A relatively common problem in rheumatic disease patients on long-term corticosteroid therapy who are undergoing surgery is prophylaxis against adrenal insufficiency. Patients believed to be at increased risk in this regard include those currently taking a pharmacologic dose of corticosteroid (>20 to 30 mg of hydrocortisone daily, >5 mg of prednisone), those who have taken such doses for longer than 2 weeks in the preceding year, and those who are receiving replacement corticosteroid therapy for known adrenal insufficiency. Such patients undergoing major surgical procedures should receive their usual steroid dose by mouth the day before surgery. On the day of surgery, 100 mg of hydrocortisone should be given IV in the early morning, with a second 100-mg dose administered intraoperatively. Postoperatively, 100 mg is given IV q8h for 24 hours, followed the next day by 50 mg q8h, and on the third day by a single IV dose of 100 mg. At this point, the patient's usual daily dose can be reinstituted. In patients undergoing relatively minor procedures (i.e., surgery of the distal extremities or those requiring only regional or local anesthesia), either the usual dose in a sip of water or a single preoperative dose of 100 mg of hydrocortisone IV is sufficient coverage.
7. Gastrointestinal disease. Gastrointestinal problems, both acute and chronic, may result in significant morbidity in the postoperative period.
   1. Peptic ulcer disease, a common condition in rheumatic disease patients, may be exacerbated during the perioperative period and is particularly problematic in the arthroplasty patient who is to be placed on prophylactic anticoagulant therapy after surgery. Therefore, patients with a history of peptic ulcer disease, gastrointestinal bleeding, or active symptoms of dyspepsia should receive prophylactic histamine ₂ blocker therapy throughout the postoperative period. If clinical suspicion is strong that an active peptic process is ongoing, the surgery should be canceled , a workup performed, and treatment instituted before the surgery is undertaken. In patients at risk for the development of gastrointestinal bleeding after surgery, serial stool guaiac tests are a good approach to surveillance.
   2. Inflammatory bowel disease, an occasional accompaniment to rheumatic disease, poses nutritional problems and also increases the risk for postoperative ileus. Preoperative dietary consultation should be obtained if such patients continue appropriate medications. Postoperatively, the resumption of the patient's oral intake should be careful and slow.
   3. History of diverticulitis.
   4. Patients with chronic constipation. Narcotics taken for pain relief after surgery will greatly aggravate bowel motility in this setting.
8. Genitourinary conditions. Because of the effects of bed rest, the use of narcotics and epidural anesthesia, or the presence of prostatic disease, urinary catheters are frequently placed in patients after major joint and back surgery. Such catheters frequently remain in situ for up to 48 hours after surgery, increasing the risk for urinary tract infection. Urinary catheters should be removed at the earliest possible time after surgery and a surveillance urine culture performed to rule out the development of a urinary tract infection. Prostatic disease leading to urinary outflow obstruction is a common problem in men after orthopedic surgery. In patients with significant symptomatology, a urologic consultation should be obtained before surgery and therapy (including transurethral resection of the prostate) instituted if deemed necessary. In patients with nephrolithiasis, dehydration should be rigorously avoided to avoid the development of acute renal colic.
9. Infection. The risk for infection in a prosthetic joint is of great concern in patients undergoing total joint arthroplasty. Therefore, assiduous efforts directed at the detection and prevention of any infectious process are of the utmost importance in these patients. The skin and urinary tract are sites of specific concern, and infection can be ruled out by a careful physical examination and routine preoperative urine culture. In addition, a formal dental consultation may be appropriate in patients with poor oral hygiene and dentition. Appropriate local and antibiotic therapy should be completed before surgery is performed.
10. Neurologic problems
    1. Confusional states. As a result of a variety of factors arising in the perioperative setting (e.g., sedatives, analgesics, anesthesia, fever , metabolic derangements, the disorienting effects of an unfamiliar environment), elderly patients and those with a history of central nervous dysfunction (e.g., parkinsonism) are particularly prone to the development of confusional states after surgery. Although these are usually a transient phenomenon and multifactorial in etiology , the investigative approach to this problem should focus on the detection and treatment of correctable causes such as metabolic disturbances (hyponatremia, hypoxemia) and infection, the discontinuation of possible offending medications, and the treatment of acute conditions (e.g., respiratory failure, myocardial infarction, cardiac arrhythmias, congestive heart failure, pulmonary and fat embolism syndrome). Occasionally, a formal neurologic consultation and workup are necessary, although the results are generally unrevealing.
    2. Neuropraxias arise particularly after surgery of the upper and lower extremities. These are generally a compression- related phenomenon resulting from prolonged positioning of the extremity during surgery or casting. All persons involved in the postoperative care of orthopedic patients must keep this problem in mind, as early detection is critical to the ultimate recovery of nerve function. Patients with antecedent subclinical neuropathy are prone to the development of these lesions following surgery. Peroneal nerve palsy may occur following complex knee surgery (valgus deformity) and sciatic nerve palsy after revision or complex total hip replacement.

V. Specific clinical problems

1. The rheumatoid neck. Some rheumatoid patients with sufficiently severe joint destruction to necessitate hip or knee replacement surgery may also have significant involvement of the cervical spine. Atlanto- axial or subaxial subluxation should be ruled out on flexion-extension films in patients with neck pain or crepitus on range of motion, radicular symptoms, or arm or leg weakness. These patients are at increased risk for cord compression during intubation or during uncontrolled neck movement while being positioned for surgery. All such lesions should be well-defined preoperatively and discussed with the anesthesiologist and surgeon. These patients should wear a soft cervical collar in the operating room for immobilization and to warn all involved in their care not to manipulate the neck excessively. If possible, epidural or spinal anesthesia should be used.
2. The spondylitic patient. Patients with ankylosing spondylitis may have spinal or peripheral joint involvement and may require surgical intervention in the course of their illness. A variety of problems may arise, primarily as a result of severe spinal involvement. Patients with a rigid or ankylosed cervical spine may present the most challenging cases of endotracheal intubation to anesthesiologists. Fiberoptic techniques can be helpful, even mandatory, in these patients. If the patients are rigid and osteoporotic, there is a risk for spinal fracture and paraplegia with uncontrolled movement. In addition, restrictive lung disease often arises as a consequence of thoracic spinal involvement and increases the potential for postoperative pulmonary complications. Aggressive pulmonary toilet is mandatory in patients with anklyosing spondylitis, irrespective of the type of surgery that they are undergoing. A small percentage of these patients may also have underlying aortic valve disease or conduction abnormalities, which can complicate perioperative management.
3. Fat embolism syndrome. Although generally thought to arise more commonly in young trauma patients, fat embolism syndrome is not uncommon after total joint arthroplasty, particularly in patients undergoing simultaneous bilateral procedures. The time of onset may vary, with hemodynamic instability developing almost immediately (presaged by a rise in pulmonary artery pressure as the prosthesis is cemented) or more insidiously during the first 2 to 3 postoperative days. Postoperatively, patients are moderately to severely hypoxemic, may be hypotensive, and, in the case of the elderly, often become confused .

   Hematologic abnormalities such as transient thrombocytopenia are commonly seen. Frank adult respiratory distress syndrome may develop and become life- threatening . Treatment includes the administration of increased concentrations of inspired oxygen (possibly intubation), prevention of pulmonary hypertension by fluid restriction, use of diuretics and venodilators, and prevention of pain. The use of corticosteroid therapy is not recommended. In high-risk circumstances (i.e., patients undergoing bilateral total joint arthroplasty, those with preexisting cardiopulmonary dysfunction), pulmonary artery catheterization for 24 to 48 hours can be helpful to guide therapy. If the pulmonary artery diastolic pressure is maintained at below 20 mm Hg, respiratory insufficiency is usually prevented.

4. Prophylaxis for thromboembolic disease. The prevention of thromboembolic problems after orthopedic surgery has been extensively investigated clinically, and numerous protocols have documented efficacy. Epidural anesthesia has been demonstrated to reduce markedly the rate of proximal deep venous thrombosis (10% vs. 25%) after total hip replacement; the beneficial effect following total knee replacement in comparison with general anesthesia is less certain. Likewise, pneumatic compression stockings, low-dose warfarin (prothrombin time in the range of 14 to 16 seconds), an international normalized ratio 1.5 to 2 times normal, and adjusted-dose heparin have all been reported to prevent venous thrombosis in patients undergoing total joint arthroplasty. Aspirin alone is of questionable efficacy but is useful when combined with other modalities such as pneumatic compression devices or pneumatic compression plus epidural anesthesia in total hip replacement. An alternative approach is to perform venography on the fifth to seventh postoperative day and treat only those patients with evidence of deep venous thrombosis.
5. Integument
   1. Rheumatic disease. Either as a result of therapy or as a manifestation of the underlying rheumatic disease, skin integrity may be compromised in these patients. In addition to the delayed wound healing and a propensity to infection that may result from chronic corticosteroid and immunosuppressive therapy, an even greater problem in the postoperative period is the potential for the development of decubitus ulceration (particularly heels and buttocks).

      The early institution of measures to combat the development of decubitus ulcers is vital to an uncomplicated postoperative course. Above all, we should strive to prevent bedsores so that we do not have to expend effort in treating them.

   2. Scleroderma. Patients with scleroderma present major challenges both in terms of patient selection for surgery and in wound healing. Whether the use of local or systemic vasodilators plays a short-term role in the maintenance of blood flow to the skin is uncertain .
6. Immunosuppressive therapy. Although few data exist to guide recommendations for immunosuppressive therapy in the perioperative setting, the issue frequently arises in patients taking methotrexate and other immunosuppressive agents. Whether such agents increase the potential for infection or delay wound healing is uncertain, but it seems prudent to discontinue such therapy 1 to 2 weeks before surgery and restart approximately 1 to 2 weeks postoperatively. Acute disease flares resulting from the abrupt discontinuation of antiinflammatory therapy can usually be managed with a short course of corticosteroids.
7. Eye
   1. Medication. In general, patients taking long-term ophthalmic medication should have their eye drops instilled before surgery, especially if prolonged surgery is anticipated. The one exception to this recommendation involves the use of phosphodiesterase inhibitors in the treatment of glaucoma. These agents may prolong the action of the neuromuscular blocker succinylcholine. This is particularly pertinent in patients with Sjgren's syndrome, who require artificial tears to prevent perioperative conjunctival injury .
   2. Risk for injury. Patients in the prone position are at risk for sustaining ocular injury secondary to external pressure. Patients with underlying vasculitis of the optic vessels are at particular risk for ischemic injury to the eye.

Books@Ovid
Copyright 2000 by Lippincott Williams & Wilkins
Stephen A. Paget, M.D., Allan Gibofsky, M.D., J.D. and John F. Beary, III, M.D.
Manual of Rheumatology and Outpatient Orthopedic Disorders

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