Since patients with rheumatic disease often require surgery, rheumatologists may be required to evaluate and care for patients in the perioperative setting. The goals of the preoperative medical consultation and perioperative management include the following: (1) identifying the nature, severity, and stability of all comorbid conditions affecting perioperative clinical decision-making; (2) optimizing treatment of all active medical problems; (3) assessing the risks associated with anesthesia and surgery; (4) anticipating, identifying, and managing postoperative complications; (5) educating patients and families about the perioperative experience; (6) motivating patients to adopt preoperative preventive practices (ie, smoking cessation, weight loss, medication compliance, and adherence to care plans preoperatively and postoperatively).
History & Physical Examination
The needs of the patient in the perioperative setting depends on a number of considerations, notably age, functional capacity, comorbidity, the type of anesthesia to be used, and the surgery to be performed. A complete history and physical examination remains the bedrock of the evaluation because it provides the clinical context upon which informed management decisions can be made. Patients should be asked about their prior experience with surgery and anesthesia, and the presence, severity, and stability of all comorbid conditions should be established. All medications (including over-the-counter preparations, herbs, and supplements) as well as the use of tobacco, alcohol, and other drugs should be documented.
The preoperative examination should be thorough yet focused on patient characteristics that might adversely impact the patient’s postoperative course. In addition to the vital signs, body mass index should be calculated because obesity is not only associated with various chronic diseases, it is a risk factor for surgery. Careful auscultation of the heart is important to rule out the presence of third and fourth heart sounds, which may indicate congestive heart failure. Further cardiac murmurs denote the presence of valvular heart disease, problems that may compromise cardiac function at times of physiologic stress (such as surgery). Obesity, large neck circumference, and hypertension predict obstructive sleep apnea, an important but underappreciated problem in the postoperative setting.
The benefit of preoperative laboratory testing has been examined in many studies and its benefit (or lack thereof) continues to be debated. When there are no clinical indications, laboratory studies rarely provide useful information. Thus, routine preoperative laboratory testing appears unnecessary for healthy patients undergoing minor procedures. Table 62–1 lists laboratory tests that may be considered for patients undergoing major surgical procedures.
Table 62–1. Recommendations for Laboratory Testing before Elective Surgery. |Favorite Table|Download (.pdf)
Table 62–1. Recommendations for Laboratory Testing before Elective Surgery.
|Test||Incidence of Abnormalities that Influence Management||Positive Likelihood Ratio||Negative Likelihood Ratio||Indications|
|Hemoglobin||0.1%||3.3||0.90||Anticipated major blood loss or symptoms of anemia|
|White blood cell count||0.0%||0.0||1.00||Symptoms suggest infection, myeloproliferative disorder, or myelotoxic medications|
|Platelet count||0.0%||0.0||1.00||History of bleeding diathesis, myeloproliferative disorder, or ...|
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