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Patients with rheumatic diseases often have multiple comorbidities that can affect surgical outcome. In addition, these patients are often on medications that can cause immunosuppression and increase the risk of infection. It is critical that these patients be evaluated preoperatively so that the patient’s health can be maximized and a plan with medicine, anesthesia, and surgery be coordinated preoperatively.


Preoperative Evaluation and Specific Concerns

RA is a systemic inflammatory disorder that can result in joint deformity but also affect other organ systems (Table 28-1). Patients can develop pulmonary disease including interstitial lung disease and pulmonary hypertension. Cardiac disease can include pericardial effusion and conduction disease due to rheumatoid nodules. Cricoarytenoid involvement can present with hoarseness and be problematic for anesthesia. Cervical spine instability can result in cervical spine compromise if not recognized during intubation.

TABLE 28-1Perioperative Considerations for Rheumatic Diseases

Although fewer RA patients seem to require orthopedic surgery due to better treatment, studies suggest up to 50% of RA patients will have an orthopedic procedure of any type over the course of their illness.1 RA patients are at higher risk of total hip arthroplasty (THA) and total knee arthroplasty (TKA) infection compared to OA patients (4.2% vs. 1.4%) over a 5-year period.2

There is an increased risk of cardiovascular disease in inflammatory disorders, which has been best studied in RA and systemic lupus erythematous (SLE). The risk is greater in poorly controlled disease and probably comparable to patients with diabetes.

The use of biologic therapy and biologic therapy combined with DMARD therapy has greatly increased since the late 1980s. These medications are associated with immunosuppression and a greater risk of infection perioperatively. Patients on glucocorticoids may have the highest risk of infection. One study demonstrated the RA patients on anti-TNF therapy were statistically more likely to be colonized with MSSA and MRSA than OA patients and RA patients on DMARD therapy.3

One study that examined 68,348 patients undergoing THA compared patients with OA to those with inflammatory arthritis. Those with inflammatory arthritis had a greater risk of transfusion, mechanical complications, infection, and readmission following THA.4 Many patients with inflammatory arthritis have anemia of chronic disease, and this may account for the greater need for transfusion.

Perioperative Management/Risk Reduction Strategies

Due to the increased risk of interstitial lung disease and pulmonary hypertension, the patient should have ...

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