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Perioperative

Perioperative management of Patients with Rheumatic Disease

* General Principles

Problem Work-up
Intubation Approach C-spine dynamogram, open mouth
Medication Prescription
Disease specific issue
- Disease activity / Cardiac risk		 Physical examination

** Appropriate management of anti-rheumatic medication and underlying disease in the perioperative period may provide an important opportunity to mitigate risk.

1. Intubation approach

1. Atlantoaxial Subluxation

1. Definition and major symptoms

  • Erosion of the odontoid process or the transverse ligament of C2
  • The odontoid process to slip posteriorly & cause myelopathy/cord compression
  • Neck pain: 40~88% in RA
  • Sx: Posterior neck pain, headache, dizziness, tinnitus
  • Neuropathy Sx: weakness, clumsiness, coordination disturbances

2. Measurement

  • Atlantodental distance
  • Anterior
    • 2~4mm: suggest
    • 7mm: instability
    • 2~9mm: risk for cord compression
  • Posterior
    • < 14 mm: Indication of surgery (fixation)
  • Image
  • Flexion-extension을 찍는다.
  • Open mouth view : loosening이 발생하면 양쪽 side 간격이 asymmetric하게 된다.

3. Intubation technique

  • Flexible fiberoptic inbutation

2. Medication

1. Glucocorticoid

1. Cortisol secretion in Stress condition

  • Normal basal secretion: 8-10mg/d
  • Minor surgery or illness: 25-50mg/d
  • Surgical stress: 75-150mg/d
  • Severe stress (major trauma): 200-500mg/d

2. HPA axis

  • Normal HPA axis
  • Any dose of glucocorticoid for < 3 weeks
  • <= 5mg/d prednisolone daily
  • <=10mg/d prednisolone every other day
  • HPA axis suppression
  • => 20mg/d prednisolone (=>3 weeks)
  • Clnical Cushing's syndrome

3. Glucocorticoid replacement

Risk Example Replacement
Minor surgery
Moderate surgical stress
Major surgical stress

** Continue the current daily dose in patients with RA, SpA, or SLE who are receiving prednisolone <=15 mg/day undergoing THA or TKA, rather than administering perioperative "stress dosing”

2. NSAIDs

  • 3~5 times the half life
  • celecoxib는 bleeding 측면에서는 크게 걱정하지 않아도 된다.

3. DMARD & Immunosuppressant

  • Medication of patients with TKA & THA
  • Biologics- 46% of RA
  • DMARDs - 67% of RA
  • lmmunosuppressants - 75% of SLE

1. DMARDs

  • Conventional DMARDs : Continue the current dose of MTX, LFN, HCQ, and/or SSZ
  • Biologic DMARDs : Withhold all current biologic agents prior to surgery, plan the surgery at the end of the dosing cycle
  • Tofacitinib : Withhold tofacitinib for at least 7 days prior to surgery
  • Tocilizumab : suppress fever and increase of CRP after surgery
  • Restart Biologics : The wound shows evidence of healing (~14 days), all sutures/staples are out, there is no significant swelling, erythema, or drainage, and there is no clinical evidence of non-surgical site infections

2. Immunosuppressant

  • Severe SLE : continue the current dose of MTX, MMF, AZA, CsA or TAC
  • Severe SLE - severe organ manifestations : nephritis, CNS lupus, hemolytic anemia (Hb s 9.9), Pit 5 50k, vasculitis including pulmonary hemorrhage, myocarditis, pneumonitis, myoenteritis, hepatitis, severe keratitis/uveitis/scleritis, optic neuritis : SLEDAI를 활용한다.
  • Not severe SLE : Withhold the current dose of MTX, MMF, AZA, CsA or TAC 1 week prior

3. Disease-specific Issue

1. Sjogren syndrome

  • Pilocarpine : hold d/t muscarinic effect
  • bronchospasm, bradycardia, involuntary urination, vomiting, hypotension, tremor
  • Lubricating gel & artificial tears
  • The use of anticholinergic medications should be minimized

2. Ankylosing spondylitis

  • Regional anesthesia : ligament calcification & ossification

3. Antiphospholipid antibody syndrome

  • Aspirin (1 week), NOAC (약제에 따라)

4. Cardiac risk assessment

  • Coronary disease
  • Pulmonary artery hypertension

** Emergency가 아니라면 CV risk를 꼭 check한다.

Last update: January 4, 2022
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