2. CASE PRESENTATION
• A 51 year-old female, known case of long-standing
Rheumatoid Arthritis (RA)
• He is on MTX 17.5mg weekly, Prednisolone 5 mg
daily, Hydroxychloroquine 200 mg twice daily, and
NSAIDs on short term bases.
• She has ulnar deviation deformity in both hands.
Hands’ x-rays show multiple peripheral joint
erosions bilaterally.
• The patient is scheduled for a right total hip
replacement (THR) due to avascular necrosis of the
right hip.
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3. PERI-OPERATIVE
MANAGEMENT PLAN
Pre-operative Assessment of specific Medical Problems
Cervical Spine
Affection
Three types:
- Atlantoaxial C1-C2 instability
- Atlantoaxial subluxation
- Subaxial sublaxation
Higher incidence of cervical affection is found in:
- patients with long-standing diagnosis.
- erosive and deforming disease.
Lateral flexion/extension cervical spine films must be considered to
evaluate atlanto-axial stability if RA patient is undergoing surgery.
Intra-operatively, it is important to avoid sudden movements of the neck.
Fiberoptic intubation shoukd be considered.
PRE-OPERATIVE ASSESSEMNT
OF SPECIFIC MEDICAL
PROBLEMS
PRE-OPERATIVE ASSESSEMNT
OF MEDICAL TREATMENT
- DMARDS
- STEROIDS
- NSAIDS
POST-OPERATIVE
FOLLOW UP
PHYSICAL ACTIVITY
AND REHABILITATION
distance between odontoid process and the posterior
border of the atlas > 3.5mm considered unstable
4. PERI-OPERATIVE
MANAGEMENT PLAN
Pre-operative Assessemnt of specific Medical Problems
Pulmonary
Affection
Mild asymptomatic pulmonary abnormalities
are common in RA patients:
- Fibrosis (IPF)
- Bronchiolitis
- Pleuritis
High Resolution CT Chest (HR CT), and
pulmonary function test (PFT) are
recommended, and allows for earlier
detection of defected pulmonary affection in
RA patients.
4
PRE-OPERATIVE ASSESSEMNT
OF SPECIFIC MEDICAL
PROBLEMS
PRE-OPERATIVE ASSESSEMNT
OF MEDICAL TREATMENT
- DMARDS
- STEROIDS
- NSAIDS
POST-OPERATIVE
FOLLOW UP
PHYSICAL ACTIVITY
AND REHABILITATION
Ground-glass opacity in RA ILD
5. PERI-OPERATIVE
MANAGEMENT PLAN
Pre-operative Assessment of specific Medical problems
Crico-arytenoid Joint
Affection
• Cricoarytenoid arthritis is very common among RA patients
and raises concerns of complicated intubation or obstructed
airway after surgery.
• Most patients are asymptomatic but they may present with
symptoms like hoarseness, sore throat, or difficult inspiration.
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PRE-OPERATIVE ASSESSEMNT
OF SPECIFIC MEDICAL
PROBLEMS
PRE-OPERATIVE ASSESSEMNT
OF MEDICAL TREATMENT
- DMARDS
- STEROIDS
- NSAIDS
POST-OPERATIVE
FOLLOW UP
PHYSICAL ACTIVITY
AND REHABILITATION
6. PERI-OPERATIVE
MANAGEMENT PLAN
Pre-operative Assessment of Medical Treatment
Synthetic DMARDs
Methotrexate
Continue MTX for most surgeries.
Consider temporary stop for:
- renal insufficiency
- complex surgical interventions
- risk of infection
MTX may be stopped the week before and the week after surgery.
MTX should be continued as soon as the patient is stable postoperatively.
Toxicity include bone marrow suppression (managed with Folic acid or
Folinic acid, PO or IV).
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PRE-OPERATIVE ASSESSMENT
OF SPECIFIC MEDICAL
PROBLEMS
PRE-OPERATIVE ASSESSMENT
OF MEDICAL TREATMENT
- DMARDS
- STEROIDS
- NSAIDS
POST-OPERATIVE
FOLLOW UP
PHYSICAL ACTIVITY
AND REHABILITATION
7. PERI-OPERATIVE
MANAGEMENT PLAN
Pre-operative Assessment of Medical treatment
Synthetic DMARDs
Leflunomide
Continue LEF for most surgeries.
But there is opposite conclusions regarding wound healing issues, so
consider stopping 2-4 weeks before surgery if large wound is expected.
Hydroxychloroquine – no reason to stop HCQ
May be protective against infection
Serve as postop anticoagulant
Sulfasalazine – no reason to stop SSZ
7
PRE-OPERATIVE ASSESSMENT
OF SPECIFIC MEDICAL
PROBLEMS
PRE-OPERATIVE ASSESSEMNT
OF MEDICAL TREATMENT
- DMARDS
- STEROIDS
- NSAIDS
POST-OPERATIVE
FOLLOW UP
PHYSICAL ACTIVITY
AND REHABILITATION
8. PERI-OPERATIVE
MANAGEMENT PLAN
Pre-operative Assessment of Medical treatment
Biologic DMARDs
Anti TNF Drugs:
Hold drug based on half-life.
Hold at least 2 half lives before
surgery.
Restart 14 days postop. - if there is
no evidence of infection, and wound
healing is satisfactory
Suggest holding for moderate to
intense procedures.
Continue drug for minor procedures.
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PRE-OPERATIVE ASSESSMENT
OF SPECIFIC MEDICAL
PROBLEMS
PRE-OPERATIVE ASSESSMENT
OF MEDICAL TREATMENT
- DMARDS
- STEROIDS
- NSAIDS
POST-OPERATIVE
FOLLOW UP
PHYSICAL ACTIVITY
AND REHABILITATION
Etanercept – half life 3 -5 days
Adalimumab – half life 10 - 20 days
Infliximab – half life 9 days
Certolizumab– half life 14 days
Golumimab – half life 14 days
9. PERI-OPERATIVE
MANAGEMENT PLAN
Pre-operative Assessment of Medical Treatment
Biologic DMARDs
Tocilizumab:
Hold 11 to 13 days before surgery, based on the drug half-life.
Restart 14 days after surgery if there is no evidence of
infection, and wound healing is satisfactory
Tofacitinib (JAK Inhibitors)
Hold 7 days before surgery.
Restart 14 days after surgery if there is no evidence of
infection, and wound healing is satisfactory
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PRE-OPERATIVE ASSESSMENT
OF SPECIFIC MEDICAL
PROBLEMS
PRE-OPERATIVE ASSESSMENT
OF MEDICAL TREATMENT
- DMARDS
- STEROIDS
- NSAIDS
POST-OPERATIVE
FOLLOW UP
PHYSICAL ACTIVITY
AND REHABILITATION
10. PERI-OPERATIVE
MANAGEMENT PLAN
Pre-operative Assessment of Medical Treatment
Steroids
For doses less than 15mg/day of Prednisolone –
or minor procedures, there was no need to screen for
suppression of her hypothalamic-pituitary-adrenal
axis, nor to administer stress doses of steroids. The
current dose is continued perioperatively.
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PRE-OPERATIVE ASSESSMENT
OF SPECIFIC MEDICAL
PROBLEMS
PRE-OPERATIVE ASSESSMENT
OF MEDICAL TREATMENT
- DMARDS
- STEROIDS
- NSAIDS
POST-OPERATIVE
FOLLOW UP
PHYSICAL ACTIVITY
AND REHABILITATION
11. PERI-OPERATIVE
MANAGEMENT PLAN
Pre-operative Assessment of Medical Treatment
Steroids
For moderate to high stress procedures, it is a good practice to
provide STRESS DOSE of steroids:
1- Intra-operatively: Hydrocortisone 50 mg intravenously.
2- Postoperative day 1: Hydrocortisone 20 mg intravenously
every 8 hours for 3 doses.
3- Postoperative day 2: return to preoperative Glucocorticoid
dose or parenteral equivalent.
The glucocorticoid target is 50 to 75 mg per day of
Hydrocortisone for 1 or 2 days.
Then return to pre-operative dose on post-operative day 2.
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PRE-OPERATIVE ASSESSMENT
OF SPECIFIC MEDICAL
PROBLEMS
PRE-OPERATIVE ASSESSMENT
OF MEDICAL TREATMENT
- DMARDS
- STEROIDS
- NSAIDS
POST-OPERATIVE
FOLLOW UP
PHYSICAL ACTIVITY
AND REHABILITATION
12. PERI-OPERATIVE
MANAGEMENT PLAN
Pre-operative Assessment of Medical Treatment
NSAIDs
NSAIDs & ASA puts patient at
risk for intra-operative bleeding
and post-operative GI bleeding.
Recommendation is to stop
NSAIDs 5 half-lives before
surgery (1-3 Days).
Restart them 2–3 days
postoperatively for pain relief.
ASA should be stopped 10 -14
days before surgery.
12
PRE-OPERATIVE ASSESSMENT
OF SPECIFIC MEDICAL
PROBLEMS
PRE-OPERATIVE ASSESSMENT
OF MEDICAL TREATMENT
- DMARDS
- STEROIDS
- NSAIDS
POST-OPERATIVE
FOLLOW UP
PHYSICAL ACTIVITY
AND REHABILITATION
2 to 6 h
(ibuprofen, ketoprofen,
indomethacin)
7–15 h
(celecoxib, naproxen)
> 20 h
(meloxicam, piroxicam)
13. PERI-OPERATIVE
MANAGEMENT PLAN
Post-operative Assessment of Medical Treatment
• Careful follow up for signs of infection and signs of
anemia.
• Antibiotic prophylaxis is needed for RA patients who will
be undergoing long procedures especially patients with
joint replacement and prosthetic joints to prevent surgical
site infections.
• Careful follow up should be obtained for patients with RA
assessing the risk of venous thrombosis and pulmonary
embolism as they have greater risk for the development of
these complications postoperatively.
13
PRE-OPERATIVE ASSESSMENT
OF SPECIFIC MEDICAL
PROBLEMS
PRE-OPERATIVE ASSESSMENT
OF MEDICAL TREATMENT
- DMARDS
- STEROIDS
- NSAIDS
POST-OPERATIVE
FOLLOW UP
PHYSICAL ACTIVITY
AND REHABILITATION
14. PERI-OPERATIVE
MANAGEMENT PLAN
Physical Activity and Rehabilitation
Patient Education
The overall goal of patients’ education in rheumatologic
diseases is to enable the patient to:
• Understand the disease and the different treatment
modalities, control active inflammation and other
symptoms, prevent disabilities, improve patient’s functional
and psychosocial wellbeing.
• Postoperative exercises.
• Post-operative pain management.
• Possible drug-drug and/or drug-food interactions of new
medication regimens.
• The importance of early mobilization.
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PRE-OPERATIVE ASSESSMENT
OF SPECIFIC MEDICAL
PROBLEMS
PRE-OPERATIVE ASSESSMENT
OF MEDICAL TREATMENT
- DMARDS
- STEROIDS
- NSAIDS
POST-OPERATIVE
FOLLOW UP
PHYSICAL ACTIVITY
AND REHABILITATION
15. PERI-OPERATIVE
MANAGEMENT PLAN
Physical Activity and Rehabilitation
Physical Activity and Rehabilitation
• Patients should undergo physical therapy since physical
activities are necessary for patients with rheumatologic
disease to prevent disabilities, restore function and relive pain.
• These activities should be evaluated preoperatively to
determine consistency with treatment goals which are greatly
enhanced by prescribed therapeutic exercises and functional
activities.
• For patients with active inflammatory joint or soft tissue
diseases, the therapeutic exercises should be balanced with
essential rest periods for a successful treatment, which aims
usually at preserving or increasing functional level, decrease
pain and joint inflammation, and increase ROM and strength.
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PRE-OPERATIVE ASSESSMENT
OF SPECIFIC MEDICAL
PROBLEMS
PRE-OPERATIVE ASSESSMENT
OF MEDICAL TREATMENT
- DMARDS
- STEROIDS
- NSAIDS
POST-OPERATIVE
FOLLOW UP
PHYSICAL ACTIVITY
AND REHABILITATION
16. IN CONCLUSION
FOR OUR FEMALE RA PATIENT
She was screened for C1-2 subluxation by Xray cervical spine lat. complete
flexion and extension views. Intraoperatively, it is important to avoid
sudden movements of the neck and body to prevent injury. High resolution
CT chest and PFT was indicated to screen for pulmonary fibrosis.
She was instructed to stop MTX 1 week before and after surgery.
Hydroxychloroquine was suggested to continue, with no risk.
With regards to Prednisolone, as the patient had only been taking 5mg/day
of Prednisolone daily, there was no need to screen for adrenal suppression,
nor to administer stress doses of steroids. The current dose was continued
perioperatively.
Prophylactic perioperative antibiotics should be considered.
Early ambulation was advised for DVT prophylaxis. 16
