Perioperative Medical Care of Rheumatic Disease Patients Having Orthopaedic Surgery

In-Depth Topic Review


C. Ronald MacKenzie, MD

Attending Physician, Hospital for Special Surgery
Professor of Clinical Medicine, Weill Cornell Medical College
Professor of Clinical Public Health, Weill Cornell Medical College
Co-Medical Director, Center for Brachial Plexus and Traumatic Nerve Injury
Non-Operative Director, Spine Care Institute

  1. Definition
  2. Components of a Preoperative Medical Evaluation
  3. Assessment of Operative Risk
  4. Perioperative Management of Co-Morbidities
  5. Management of Specific Clinical Problems
  6. Outcomes
  7. Annotated Bibliography

I. Definition

Surgical correction for disorders or injury to the musculoskeletal system is common clinical situation among individuals who suffer from chronic rheumatologic disease. Rheumatologists, internists, and primary care physicians are often asked to provide a preoperative medical evaluation and participate in post-operative care of such patients. Understanding the concerns of the orthopaedic surgeon with regard to such patients can assist in the collaboration. The purpose of the preoperative medical evaluation and subsequent perioperative management is:

  • identification of co-morbid conditions that may affect perioperative clinical decision-making;
  • assessment of risk (both in magnitude and type) and;
  • identification and management of potential post-operative complications, the risk of which might be reduced if considered preoperatively.

II. Components of a Preoperative Medical Evaluation

A. Timing

The preoperative evaluation should take place, whenever possible, in the office setting several weeks before surgery. While not always possible, for instance in the setting of acute injury requiring surgical correction (i.e. fracture), such anticipatory evaluation allows for sufficient time for discourse with other physicians' involved in the patient's care, for additional consultation and further investigation and, if necessary, for the institution of therapy directed at optimizing the patient's medical status prior to the contemplated surgery. The evaluation's findings should serve as a focal point of communication between all those involved in the patient's care.

B. Guidelines

No consensus exists regarding what constitutes the optimal preoperative medical evaluation. A given patient's needs depend on such factors as: age, functional capacity, existing co-morbidity, and the type of anesthesia and surgery to be performed. However, general guidelines can provide a useful framework for such evaluations.

Except in young patients and those having minor surgical procedures, most patients should undergo a complete medical history and physical examination prior to the surgical procedure. Among the few studies that have been reported, several have failed to demonstrate the value of routine preoperative testing. Nonetheless a number of investigations may be considered appropriate and are commonly performed on patients prior to major orthopaedic surgery. Depending on the nature of the orthopaedic problem and the magnitude of surgery required to correct it, as well as the nature and severity of co-existing diseases, such testing might include a complete blood count, urinalysis and urine culture (for those patients undergoing total joint arthroplasty), and complete blood chemistries. Routine measurement of the prothrombin (INR) and partial thromboplastin times have not been demonstrated to be of value as preoperative investigations. However, in patients requiring anticoagulants after surgery (i.e. those having total joint arthroplasty), a specific exception would seem justifiable. A 12-lead electrocardiogram and chest radiograph are also indicated particularly in the elderly and those undergoing major joint or spine surgery.

III. Assessment of Operative Risk

One of the primary purposes of the preoperative medical evaluation is the identification of patients at higher risk for post-operative complications. The standard clinical examination is the principle screening method for the detection of conditions likely to affect surgical outcome. However, two rating systems are useful in identifying patients who are most likely to develop postoperative complications.

The best known and most widely used is the American Society of Anesthesiologist (ASA) Physical Status Scale, which has been in use for more than 30 years and which has a high correlation with the patient's post-operative course. The ASA 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 sub-designation E, denotes emergency surgery.

A second system, less commonly used, focuses only on the risk of cardiac complications. The salient features of this rating system, the Goldman Cardiac Risk Index, along with other more recent observations are discussed in greater detail below.

IV. Perioperative Management of Co-Morbidities

The following discussion addresses co-morbidities roughly in order of their frequency in the surgical population. Table 1, below, is a useful chart that summarizes medication concerns and reminders related to co-morbid conditions.

Table 1: Perioperative Evaluation and Care*

Category

Medications

Reminders

Cardiac

Continue medications through surgery

  • May have to change to transdermal, IV, or sublinguinal equivalents
  • Avoid abrupt withdrawal
  • Avoid rapid diuresis before surgery

Bacteremic surgery may seed endocardium

Hypertension

Continue most medications through surgery, using non-oral forms if necessary

  • Change ganglionic blockers and MAO inhibitors to other agents

Only severe (diastolic over 110) or malignant hypertension needs control pre-operatively in most cases

Endocrine

Diabetes:

  • Stop oral hypoglycemics 1 day surgery; discontinue chlorpropamide and glyburide 3 days before surgery
  • For insulin users, ½ usual insulin dose before surgery with dextrose and water and sliding scale insulin; for prolonged NPO or brittle diabetes, insulin drip.

Thyroid Disease:

  • Continue thyroid supplements through surgery
  • Reduce L-thyroxine dose by 20% for long-term parenteral use

Corticosteroids:

  • Stress doses if used regularly within a year of surgery, tapering over 3-4 days to maintenance after surgery.

 

Even young diabetic patients have autonomic insufficiency.

 

 

 

 

 

 

Prolonged anesthetic effect after surgery may suggest hypothyroidism

Gastro-intestinal and Hepatic

  • Cimetidine may precipitate confusion, delirium in the elderly
  • Malabsorption, dysmotility of bowel, hepatic dysfunction may significantly alter pharmacodynamics of perioperative medications, including anesthetic
  • Nutritional assessment, vitamins
  • History of risk factors for hepatitis B or C
  • History of alcohol use

Renal

Caution with nephrotoxins, including acetaminophen.

  • Watch for bleeding disthesis
  • Theophylline clearance may be decreased by cimetidine, erythromycin, ciprofloxacin

Rheumatologic

NSAIDs: stop 5 – 7 days before surgery (reversible platelet function)

  • Cervical spine disease may compromise safe intubation
  • Treat asymptomatic bacteruria in patients undergoing total joint arthroplasty
  • Patients with severe SICCA syndrome require lubricant eye drops.

Hematology

Hold cytotoxic or immunosuppressive drugs before surgery

Consider autologous blood transfusion requirements well in advance of surgery

Neurology

Continue Anti-convulsant therapy

  • Phenothia-zines may lower seizure threshold
  • Atropine may precipitate delerium in Parkenson’s disease

Geriatrics

Polypharmacy common in the elderly; continue medications only if indicated

  • Nutritional assessment
  • Delerium may be caused by sundowning, infection, ischemia, drug effect (sedatives especially), alcohol withdrawal, electrolyte imbalance, hypoxia
  • Discharge planning essential pre-operatively
  • Advance directives should be discussed well before surgery

Miscellaneous

  • Ask about non-prescription drugs and supplements
  • Alcohol and illicit drug use should be considered possible
  • HIV risk factors
  • Patient many be unaware of pregnancy
  • Patient fears and expectations
  • Vaccination status

*MacKenzie, CR, Sharrock, NE. Perioperative Medical Considerations with Rheumatoid Arthritis. Perioperative medical considerations in patients with rheumatoid arthritis. Rhem Dis Clin North Am. 1998 Feb; 24(1):1-17. Reprinted with permission.

A. Coronary Artery Disease

The contribution of cardiovascular disease to the risk of noncardiac surgery cannot be overstated and is, fortunately, the most investigated and well documented arena of perioperative medicine. The literature pertaining to this subject has been extensively reviewed elsewhere and practical guidelines intended to guide physicians involved in the assessment and care of patients in the perioperative have been published.

The predictive value of the routine clinical assessment, including the medical history, physical examination, electrocardiogram and chest X-ray is well established, at least with respect to the identification of the presence of pre-existing cardiac disease. However it is also important to define disease severity, stability and prior treatment as these factors, working in concert with other clinical characteristics such as age, functional capacity (as determined by simple activity questionnaires), co-morbidity (particularly diabetes mellitus, peripheral vascular disease, chronic pulmonary disease) and type of surgery to be performed (major orthopaedic procedures tend to be of intermediate risk) ultimately define post-operative risk.

A series of factors may predict postoperative myocardial infarction, congestive heart failure, and death after orthopaedic surgery.

The major predictors of increased perioperative cardiac risk include:

  • recent myocardial infarction (<30 days);
  • unstable or severe angina;
  • poorly compensated congestive heart failure;
  • significant arrhythmias;
  • severe valvular disease.

Intermediate predictors of increased perioperative cardiac risk include:

  • mild angina;
  • prior myocardial infarction by history or pathological Q waves;
  • compensated or prior congestive heart failure;
  • diabetes.

Minor predictors of increased perioperative risk include:

  • advanced age;
  • abnormal ECG;
  • rhythm other than sinus;
  • low functional capacity;
  • prior stroke;
  • poorly controlled hypertension;
  • prior cardiac revascularization, currently asymptomatic.

The indications for preoperative exercise stress testing with or without nuclear scanning or ambulatory electrocardiography (Holter monitoring) are not clear. Ultimately, the decision will depend on the physician's estimates of the effectiveness, risk, and costs of such evaluations. Feasibility also may come into play given the functional compromise of the orthopaedic patient and the frequent need to perform surgery relatively urgently.

Nonetheless, guidelines have emerged from a large body of clinical data.

  • Patients who have no clinical markers of risk, as well as those who have had coronary revascularization within the prior five years and remain asymptomatic, are at such low risk for postoperative cardiac complications that further screening appears unjustified.
  • In the remaining patients, mainly those with some risk factors for coronary artery disease, the issue of screening is particularly relevant. Exercise stress testing may be indicated and ultimately helpful in selected patients. Such decisions can be reached in conjunction with cardiology consultation. The decision to further evaluate cardiac risk depends on the nature of surgery, but is seldom necessary before minor surgical procedures.

The relevant therapeutic considerations mainly relate to medication management. Recognition of the protective role of beta-blockade in the perioperative setting is perhaps the most significant advance in perioperative medical care. Based on several definitive studies and general concensus, B-blockade in patients undergoing major noncardiac surgery has been shown to reduce the risk for postoperative cardiac complications (myocardial ischemia and infarction) and mortality.

Questions relevant to this issue are:

(1)  Which patients should receive B-blockers perioperatively?
Criteria for deciding which patients should be treated with B-blockers are summarized in Table 2:

Table 2:  Recommendations for the Use of Peri-Operative Beta Blockers*

1. Peri-operative beta-blockage should be used in patients with any of these criteria:

  • Ischemic heart disease, defined as:
    --History of myocardial infarction or Q-waves on EKG
    --History of angina pectoris
    --Positive stress test
    --History of angioplasty or coronary artery bypass graft
  • Cerebrovascular disease, defined as: History of transient ischemic attack or cerebrovascular accident
  • Diabetes mellitus requiring insulin therapy
  • Chronic renal insufficiency, defined as baseline creatinine ³ 2.0.

2. Use beta-blockade in patients meeting any 2 of the following criteria:

  • Age 65 or older
  • History of hypertension (treated or untreated)
  • Current smoker
  • History of hypercholesterolemia (treated or untreated)
  • Diabetes mellitus not requiring insulin therapy

3. Possible contra-indications for beta blockers (often such patients may still cautiously receive beta blockers on a case-by-case basis):

  • Bradycardia – heart rate < 60
  • Congestive heart failure if uncontrolled
  • Asthma/COPD history, especially if severe and/or uncontrolled
  • History of intolerance of beta blockers

4. Timing and choice of peri-operative beta-blockers

  • These agents may be started a week or more prior to surgery, on the morning of surgery, in the holding area or intra-operatively. If the patient has been started on oral b -blockers prior to admission, they should take their oral dose on the morning of surgery. In patients receiving hypotensive epidural anesthesia, the anesthesiologist may prefer starting b -blocker in the PACU rather than the O.R.
  • Atenolol and metoprolol are the recommended oral agents. In elderly patients, give lower dose, e.g. Lopressor 12.5mg bid. In younger patient, could start with Toprol XL 50mg qd.
  • The duration of beta blockade post-operatively is not definitive in the literature. A minimum of one week is suggested, and most patients should be treated for a month, or until follow up by their internist or cardiologist. The beta blocker should be appropriately tapered when discontinuing.

*Auerbach AD, Goldman L: Beta Blockers and Reduction of Cardiac Events in Noncardiac Surgery: Scientific Review, JAMA, 287:11, 1435-1444, 2002.

(2)  Which B-blocking agent should be used?
Studies demonstrating benefit of B-blockade have used B1-selective agents and within that group of medications, no advantage of any specific agents has been shown. Atenolol 50 mg daily or Lopressor 25 mg bid would appear to be suitable choices.

(3) When should B-blocker use be started preoperatively? Physicians should attempt to begin therapy early enough in order to achieve a degree of B-blockade which would generally require several days. Nonetheless if it is not possible to initiate treatment in this timeframe, the medication can be given intravenously by the anesthesiologist at the initiation of anesthesia. Patients already taking beta-blockers prior to surgery should be advised to continue the medication up to and including the morning of surgery.

Patients taking long-acting nitrates should be given the drug on the morning of surgery as well; cutaneous nitrates can be continued post-operatively until the patient resumes oral intake.

Patients taking ACE inhibitors are at increased risk of circulatory instability, especially if the medication is taken immediately prior to surgery. Thus, the administration of preoperative cardiac medication should be discussed and coordinated with the anesthesiologist prior to surgery.

As with risk assessment, the optimal surveillance strategy for detecting post-operative myocardial infarction has not been well-studied. In patients with no preoperative evidence of coronary disease, detection strategies can be restricted only to those patients who develop signs or symptoms of cardiac dysfunction or ischemia. In those at greater risk for postoperative cardiac complications, surveillance for ischemic events should begin with an EKG immediately after surgery, with additional daily testing on each of the first two post-operative days. While CPK levels are usually elevated due to the muscle trauma associated with surgery, cardiac isoenzymes and, more recently, serial serum troponins are useful in the detection of myocardial infarction, particularly in those patients whose surveillance EKG's reveal changes suggestive of ischemia.

B. Other Cardiovascular Diseases

1. Hypertension
Blood pressure measurements should be taken in the lying and sitting position to determine the maximal orthostatic fall in blood pressure as well as the degree of blood pressure control. Patients are then classified as untreated, hypertensive controlled on medication, or hypertensive despite therapy. As the perioperative morbidity associated with chronic hypertension is largely a function of the presence of the major end organ (cardiac, neurologic, renal) complications, the preoperative examination should focus on assessment of these classic complications of poorly controlled hypertension. Such determinations are relatively easily made from the common preoperative laboratory studies and EKG.

Although controversy exists about whether mild to moderate hypertension (diastolic = 110 mg Hg) increases the risk of surgery, patients whose blood pressure is above this range likely are at greater risk and should be stabilized with anti-hypertensive therapy prior to surgery. Patients who are in satisfactory control preoperatively should continue their medication, taking it on the morning of surgery and subsequently throughout the post-operative period, if their blood pressure allows. However, due to bed rest, fluid losses, and the hypotensive influences of various medications employed in the postoperative setting, some patients may temporarily require less (or no) anti-hypertensive medication.

2. Valvular Heart Disease
Surgical risks in patients with valvular heart disease depend on the valve affected as well as the nature and severity of the valvular lesion. The lesion conferring the highest perioperative risk is hemodynamically significant aortic stenosis. Mitral valve disease and aortic insufficiency, if not severe, are usually well tolerated, although any valvular disease associated with significant left ventricular dysfunction (NYH Class 3 or 4) increases the risk of surgery. Therefore, patients with a significant cardiac murmur, accompanied by signs or symptoms of left ventricular dysfunction, should undergo an echocardiographic assessment preoperatively, particularly if a major orthopaedic procedure is planned. Invasive hemodynamic monitoring perioperatively may be indicated in patients at higher risk.

3. Cardiomyopathies
The chronic cardiomyopathies, whether or the dilated or hypertrophic type, are associated with an increased incidence of post-operative congestive heart failure. Indeed the hypertrophic cardiomyopathies generally are considered a relative contraindication to epidural or spinal anesthesia.

4. Arrhythmias and Conduction Abnormalities
Arrhythmias and conduction diseases may be a marker for underlying pulmonary disease, metabolic abnormalities, or drug toxicity. Therefore, the clinician should search for such conditions preoperatively and institute corrective action, if possible, before surgery.

A problem that arises with some frequency is the patient with chronic atrial fibrillation on long-term anticoagulation. As the risk of embolic stroke in such patients who are not anti-coagulated is low, it is safe to temporarily discontinue warfarin (Coumadin) for a sufficient period of time preoperatively to allow for normalization of the prothrombin time and INR. Five days is generally sufficient.

C. Pulmonary Disease

Chronic obstructive lung disease (chronic bronchitis, emphysema) and asthma are the two most prevalent forms of chronic pulmonary disease and, as such, are the pulmonary problems seen most frequently in the preoperative setting. They are also demonstrated major predictors of post-operative pulmonary complications, which may be pulmonary or non-pulmonary.

Minor pulmonary complications (atelectasis, bronchitis) are increased in patients who smoke (See PDF on "Managing Smoking Cessation for Healing"), who have a chronic cough or have abnormal spirometry. The risk of severe post-operative pulmonary complications (pneumonia, respiratory failure) is increased mainly in those patients with marked impairment in lung function (FEV1<1.5 liters). Among the non-pulmonary factors which contribute to the risk of post-operative complications are age, obesity, longer duration of anesthesia, over-sedation, and poor patient effort.

The risk of perioperative lung dysfunction depends, in large part, upon the type of surgery performed. Patients with severe lung impairment can tolerate minor procedures, even under general anesthesia. The risk of pneumonia following major peripheral surgery (such as hip or knee surgery) is low, even in the patients with chronic lung disease. (This is in marked contrast to intra-abdominal or intrathoracic surgery, which is associated with a high risk of atelectasis or pneumonia in patients, particularly in patients with severe COPD.)

Regional anesthesia for surgery on the extremities circumvents many of these problems. However, interscalene block may transiently paralyze the ipsilateral diaphragm and reduce the FVC by 30-40%.14 Therefore patients with COPD undergoing shoulder surgery, in which interscalene block is frequently employed, should have pulmonary function studies performed preoperatively. In patients with severely impaired pulmonary function (FEV1 < 1 leter), interscalene block should be avoided altogether. Otherwise, patients with COPD fare well with this anesthesia, especially in the sitting position.

Patients who have been using bronchodilators on a chronic basis before surgery should be given their standard dosage the night before surgery; bronchodilator therapy should be administered post-operatively either systemically or by nebulizer. Incentive spirometry and early mobilization are helpful in the prevention of post-operative atelectasis.

D. Endocrine Problems

1. Diabetes Mellitus
Diabetes is the most important endocrine disorder encountered in surgical patients. Diabetics are at slightly greater risk of postoperative death, a consequence of their greater prevalence of ischemic heart disease. Further, diabetics with autonomic insufficiency (manifested by postural hypotension, impotence, nocturnal diarrhea) may be at risk for sudden cardio-pulmonary arrest postoperatively.

The control of the serum glucose tends to be the focus of medical management postoperatively, and numerous approaches to diabetic therapy have been reported. A common approach for insulin users is the so-called "sliding scale" regimen; one-half to two-thirds of the patient's usual morning long-acting insulin dose is given on the morning of surgery together with 5% dextrose. Supplemental short-acting insulin is then given as dictated by finger stick blood sugars four times a day. This regimen is continued until the patient resumes oral intake. A different regimen is indicated for patients taking oral hypoglycemic agents: these medications can be taken the day before surgery and resumed when the patient is eating, except for chlorpropamide (Diabinese), which should be discontinued several days before surgery because of its long half-life.

2. Chronic Corticosteroid Therapy
Since many rheumatic disease patients take corticosteroids, prophylaxis against adrenal insufficiency and management of the patient's corticosteroid therapy in the perioperative setting are critically important. Patients believed to be at increased risk for adrenal insufficiency include: those currently taking > 20 mg hydrocortisone daily, those who have taken such doses for > two weeks in the preceding year, and those who are receiving replacement corticosteroid therapy for known adrenal insufficiency.

Traditionally, such patients have been given a so-called "stress-dose" therapy when undergoing major surgical procedures:

  • 100 mg of hydrocortisone prior to surgery;
  • a second 100 mg administered intra-operatively;
  • 100 mg IV q8h for 24 hours after surgery;
  • 50 mg IV q8h the next day;
  • a single IV dose of 100 mg on the third postoperative day;
  • return to the patient's usual oral dose of corticosteroid on the fourth postoperative day.

This approach has been called into question recently however by a report concerning patients undergoing orthopaedic procedures. In this small, non-randomized study, patients given only their baseline doses of glucocorticoid demonstrated no clinical or laboratory evidence of adrenocortical insufficiency postoperatively, suggesting that the commonly employed "stress doses" of corticosteroid may be unnecessary, at least in patients undergoing orthopaedic surgery. In patients undergoing minor procedures (i.e. surgery on the distal extremities) or those requiring regional or local anesthesia, a single preoperative dose of 100 mg can be considered sufficient coverage because the normal metabolic response (i.e. additional adrenocorticoid secretion) to minor surgery is minimal.

E. Gastrointestinal Disease

Gastrointestinal problems, both exacerbations of chronic conditions or problems arising de novo, may complicate the post-operative period and produce significant morbidity. Peptic ulcer disease, a reasonably common problem in the orthopaedic/rheumatic disease population due to the high usage of non-steroidal anti-inflammatory agents, may become active after surgery; it is particularly problematic in patients who require anticoagulation prophylaxis, such as those who have undergone arthroplasty.

Therefore, patients with a history of peptic ulcer disease, GI bleeding or active symptoms of dyspepsia should receive prophylactic H2-blocker therapy throughout the post-operative period. In the presence of a strong clinical suspicion that an active peptic process is ongoing, the surgery should be canceled, a work-up performed, and treatment instituted before proceeding. In patients at risk for the development of GI bleeding after surgery, serial stool guaiacs are a good surveillance approach.

Development of an abdominal ileus is a relatively common postoperative complication, albeit not one restricted to patients with chronic gastroenterological problems. An important predisposing factor is the postoperative use of aggressive narcotic-based analgesics, coupled with an over zealous reintroduction of oral intake in the early phase of recovery. Careful consideration should be given as to the optimal timing of the resumption of oral intake of both liquids and solids, and potent narcotic therapy should be weaned down as quickly as possible, particularly in patients with chronic gastrointestinal complaints and conditions

F. Genitourinary Conditions

As a consequence of bed rest, the use of narcotics and epidural anesthesia, and the presence of prostatic disease, urinary catheters are frequently placed in patients after major orthopaedic surgery. In general, such 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. If urinary catheters are removed within 48 hours of surgery and urinary retention is avoided, the risk of urinary tract infection is small.

Prostatic disease leading to urinary outflow obstruction is a common problem in men after orthopaedic surgery. In patients with significant chronic symptomology, urologic consultation should be obtained prior to surgery and therapy (including TUR) performed, if deemed necessary. In patients with a propensity to urinary retention and thoses with enlarged prostate glands who report obstructive symptomology, therapy with agents such as terazosin (Hytrin) and tamsulosin (Flomax) could be instituted before or at the time of surgery.

In patients with a history of nephrolithiasis, dehydration should be rigorously avoided so to help prevent development of acute renal colic.

G. Infectious Complications

The risk of infection in a prosthetic joint is of great concern in patients undergoing total joint arthroplasty. Efforts to prevent and detect any infectious process is of utmost importance. 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, formal dental consultation may be appropriate in patients with poor oral hygiene and dentition.

Prophylactic antibiotic therapy for total joint arthroplasty patients should begin< 2 hours before surgery and continue for 24 hours. The recommended protocol at Hospital for Special Surgery involves cefazolin 1 gram q8h (total of three doses) or, in penicillin allergic patients, vancomycin 1 gram q12h (total of two doses).

H. Neurologic Problems

1. Confusional States
Elderly patients are at significant risk for the development of confusional states after surgery due to a confluence of factors arising in the perioperative setting, including sedatives, analgesics, anesthesia, fever, metabolic derangements, and the disorienting effects of an unfamiliar environment. For example, in patients undergoing emergent surgical repair of a fractured hip, 30- 50% have been reported to develop significant changes in cognitive functioning. Although such changes are usually a transient phenomenon, clinicians should focus on the detection and treatment of correctable causes thatmay present in this unusual fashion, particularly in the geriatric patient population. Such causes include: metabolic disturbances (hyponatremia, hypoxemia); offending medications (which might well be discontinued); infection; and acute conditions (respiratory failure, myocardial infarction, cardiac arrythmias, congestive heart failure, pulmonary and fat embolism syndrome, etc.)

Likewise, elderly patients and patients with underlying neurological dysfunction (e.g. alcoholism, Parkinsonism) are at increased risk for postoperative delirium. Formal neurologic consultation and work-up is occasionally necessary though generally unrevealing.

2. Neuropraxias
The neuropraxias arise more often after upper and lower extremity surgery as they are generally a compression phenomenon resulting from prolonged positioning of the extremity during surgery or casting. Early detection and intervention is critical to the ultimate outcome in these circumstances. Theefore, all those involved in postoperative care must keep this problem in mind. Patients with antecedent neurological disease are at increased risk of neuropraxia.

I. Emotional/Psychiatric Problems

Patients who live with the consequences of chronic rheumatic diseases or orthopaedic problems may suffer emotional difficulties due to chronic pain, disability, and limitations in career opportunities, social interactions, and personal relationships. Because surgery is a significant life stress, such individuals may require additional emotional support perioperatively. Further, some patients may be taking or require anti-depressant or anti-anxiolytic medication. In the relatively rare patient who is being treated with monoamine oxidase inhibitors, it is recommended that the medication be discontinued preoperatively and the anesthesiologist alerted to the situation. Patients on these agents are at risk of marked circulatory instability with general anesthesia and certain narcotics, especially meperidine.

V. Management of Specific Clinical Problems

Specific clinical problems that may be encountered and benefit by perioperative management are discussed here roughly in order of how often they are encountered.

A. Thrombo-embolic Disease

Prevention of thromboembolic phenomenon after orthopaedic surgery is the most thoroughly studied of potential postoperative complications. Pulmonary embolism, perhaps the most dreaded complication of orthopaedic surgery, remains an important cause of postoperative mortality. Numerous protocols have documented efficiency in minimizing this risk.

Prevention begins at the time of the procedure. Expeditious surgery reduces the risk of deep venous thrombosis following operations such as total hip replacement. The type of anesthesia employed is also important; epidural anesthesia reduces the risk of proximal deep venous thrombosis following total hip replacement by two- to threefold and also reduces the overall risk of deep venous thrombosis by at least 20%. Other intraoperative interventions, such as hypotensive anesthesia and intraoperative heparin administration, further reduce thrombogenesis.

Mechanical means of reducing risk of thromboembolism also have proven efficacy and include pneumatic compression boots, foot pumps, compression stockings, foot flexion/extension exercises, and early ambulation. These maneuvers are safe, effective and do not increase the risk of bleeding.

The mainstay of treatment is anticoagulation, although its benefit is becoming more controversial. Prophylactic anticoagulation is begun immediately following surgery. Regimes include warfarin (Coumadin) with a target INR in 2.0 to2.5 range, formerly subcutaneous heparin 5000 units BID-TID, and more recently low molecular weight heparin. A new low molecular weight heparin, fondaparinux (Xantidar), has been reported to be even more effective in the prevention of venous thrombosis than enoxaparin (Lovenox) in patients undergoing total joint arthroplasty and after hip fracture repair. Aspirin is also effective when combined with other modalities and continues to have its proponents.

A multimodal approach, relying on a combination of intraoperative modalities, postoperative mechanical devices, early ambulation, and low intensity postoperative anticoagulation, is preferred for the majority of patients by most experts and clinicians.

B. Hip Fracture

Hundreds of thousands of patients are admitted to hospital in the United States annually for treatment of a fractured hip, resulting in major costs to society, to patients, and to their families. Within the first year of fracture, 20% of elderly hip fracture patients die, compared to 9% of age-matched, non-fracture patients. Further, one-sixth of patients who survive one year after fracture are confined to long-term care facilities, while another one-third continue to require assistive devices or the help of others to manage their daily activities. Therefore, after a fracture of the hip, most patients experience permanent impairment in functional capacity and the rates of permanent institutionalization are high. Risk factors thought to increase the need for nursing home placement include living alone prior to the fracture, having no children, and female gender.

The majority of hip fractures occur in frail, elderly women with osteoporosis who have sustained a fall. Indeed, falls are the most common antecedent event in these circumstances, and fractures are the most common serious fall-related injury. Risk factors for hip fracture include: increasing age, poor general health, maternal history of hip fracture, a history of hyperthyroidism, poor depth perception, use of psychoactive medication; sedentary lifestyle, low bone mineral density and, of course, osteoporosis.

Hip fractures can be divided into two major categories: intracapsular fractures of the femoral head and extracapsular fractures (intertrochanteric or subtrochanteric). The current approach to treatment is surgical, utilizing either internal fixation (pinning) or prosthetic joint replacement. Although a matter of ongoing debate, more severe (i.e. displaced) intracapsular fractures of the femoral head are often treated with prosthetic joint replacement because they may result in a serious compromise to the blood supply of the femoral head leading to osteonecrosis, collapse of the femoral head, and secondary osteoarthritis. Internal fixation is the usual surgical approach to displaced femoral neck fractures. However, in the frail, elderly patient with lower anticipated functional requirements and life-expectancy, such fractures may treated with total joint arthroplasty as well.

C. Fat Embolism Syndrome

Fat embolism syndrome is not uncommon after total joint arthroplasty, particularly in patients undergoing simultaneous bilateral procedures. Time of onset is variable; hemodynamic instability may develop almost immediately (presaged by a rise in pulmonary artery pressure when the prosthesis is cemented) or more insidiously over the first two to three postoperative days. In the latter group, it is often very unclear what is happening early on because patients gradually become moderately to severely hypoxemic after surgery, 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, require aggressive supportive measures (i.e. intubation), and become life-threatening.

Treatment is supportive and includes the administration of increased concentrations of inspired oxygen (possibly via ventilator), the prevention of pulmonary hypertension by fluid restriction and the use of diuretics and venodilators, and the prevention of pain. Corticosteroid therapy has not been demonstrated to be of benefit and is not recommended.

Pulmonary artery catheterization may be helpful to guide therapy; if the pulmonary artery diastolic pressure is maintained at <20 mm Hg, respiratory insufficiency is usually prevented. In severe cases, systemic manifestations of fat embolization may occur and become associated with myocardial infarction or severe brain injury. Whether this represents transpulmonary transfer or passage of fat through a patent foreman ovale is unknown.

D. The Difficult Neck

Some patients with rheumatoid arthritis, generally those with advanced and aggressive disease, may manifest significant cervical spine involvement with instability arising from atlantoaxial or subaxial subluxation. This complication presents both important risks to the patient undergoing surgeryand significant challenges for the anesthesiologist, particularly if endotracheal intubation is required. These patients have an increased risk for cord compression during intubation or from uncontrolled neck movement during positioning for surgery.

Cervical spine instability should be ruled out prior to surgery with flexion/extension films in those patients with neck pain or crepitus on range of motion testing, radicular symptoms, or arm and/or leg weakness. Affected patients should wear a soft cervical collar to the operating room, both for neck immobilization and as a warning to all involved not to over-manipulate the neck. When possible, epidural or spinal anesthesia should be employed.

Additional problems arising from the rheumatoid disease process include involvement of the temporomandibular joint, which may limit jaw opening, and arthritis of the cricoarytenoid joints. Because these problems also may influence the choice of airway management, the anesthesiologist should be informed preoperatively about these manifestations of the disease process as well.

The rigid cervical spine of the patient with ankylosing spondylitis may also present technical challenges for the anesthesiologist during intubation. A fiberoptic method is often employed in this clinical context.

E. Immunosuppressive/Anti-Inflammatory Therapy

In rheumatic disease patients, the question often arises as to what, if anything, should be done about their regimens of methotrexate and other immunosuppressive agents. Little data exists to guide recommendations for immunosuppressive therapy in the perioperative setting. Whether or not such agents increase the potential for infection or delay wound healing is uncertain, but it has become common practice and seems prudent to discontinue such therapy one to two weeks prior to surgery and then restart it approximately one to two weeks post-operatively. Acute disease flares resulting from the abrupt discontinuation of immunosuppressive therapy for such brief periods are unusual and can usually be managed with corticosteroids.

Anti-inflammatory therapy, particularly aspirin, should be discontinued five days before the surgical procedure because their anti-platelet effects may increase the risk of bleeding. This does not appear to be necessary with the new COX-II inhibitors, such as celecoxib (Celebrex) and rofecoxib (Vioxx), as they do not interfere with platelet function.

F. The Integument

As a result of chronic therapy (i.e. corticosteroids, immunosuppressive agents) or as a manifestation (i.e. decubitus ulceration) of the debilitating consequences of underlying rheumatic disease or orthopaedic condition, skin integrity may be compromised before and after procedures in patients undergoing orthopaedic surgery. In addition, delayed wound healing and a propensity to infection may result from these influences. The early institution of preventive measures to combat the development of decubitus ulcers (particularly of the heels and buttock region) is vital to an uncomplicated post-operative course.

G. The Eye

Patients taking chronic optic medication should have their eye drops instilled prior to surgery, especially if a prolonged procedure 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 Sjogren's syndrome who require artificial tears to prevent perioperative conjunctival injury.

Patients in the prone position are at risk for ocular injury secondary to external pressure. Patients with underlying vasculitis of the optic vessels are at particular risk of ischemic injury to the eye. Thus the anesthesiologist must take particular care to position the patient carefully avoiding excessive pressure on the eye and provide appropriate eye protection.

VI. Outcomes

The ultimate purpose of the preoperative medical evaluation and perioperative care in general is to improve patient outcome. Through the preoperative identification of comorbidities and other relevant problems, treatments that improve the patient's capacity to withstand the rigors of surgery and its aftermath can be implemented early, often before the surgery takes place. As perioperative medicine has become a field of inquiry in its own right, the clinical characteristics that predict those patients at risk have become increasingly more defined. Indeed, intervention trials directed at reducing post-operative complications are more frequently being conducted, leading to significant reductions in postoperative morbidity and mortality. Perhaps no group of patients has benefited more from these advances than the often frail, elderly, and functionally compromised patient suffering from one of the rheumatic diseases.

VII. Annotated Bibliography

  1. Vandam, LD, Desai,Sukumar PD. Evaluation of the Patient and Preoperative Preparation. In. Clinical Anesthesia, Ed. Barash PG, Cullen BF, Stoelting RK. Philadelphia: J.B. Lippincott Co., 1989. Chapter 15, pg. 407-438. This contains the American Society of Anesthesiologist (ASA) Physical Status Scale for preoperative risk evaluation.
  2. Goldman K, Caldera DL, Nussbaum Sr, et al. Multifactorial index of cardiac risk in non-cardiac procedures. N Eng J Med 1977 Oct 20; 297(16): 845-850. Classic article describing the cardiac risk factors for patients undergoing non-cardiac surgery. The general observations have held up well over time.
  3. Eagle K. ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery. Circ 93: 1280-1317, 1996. An exhaustive reference article detailing virtually every aspect of the clinical problem of cardiac risk assessment in patients undergoing non-cardiac surgery.
  4. Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med. 1996 Dec 5;335(23):1713-20. The first study to demonstrate the cardio-protective effects of beta-blockers in the non-cardiac surgical setting. Largely a result of this study, the use of beta-blockers in such circumstances has become standard medical practice.
  5. Sharrock NE, Salvati EA. Hypotensive epidural anesthesia for total hip arthroplasty: a review. Acta Orthop Scand 1996 Feb;67(1):91-107. Review. Describes the use of epidural anesthesia in hip replacement though observations pertain to all lower extremity joint replacement surgery.
  6. Fleisher LA, Eagle KA: Clinical practice. Lowering cardiac risk in noncardiac surgery. N Engl J Med. 2001 Dec 6; 345(23):1677-82. Review. Succinct review of current strategies for reducing the risk of cardiac complications in patients undergoing non-cardiac surgery. Covers the identification of patients at risk, prophylactic interventions, the role of monitoring, and potential therapies. The paper concludes with a review of current guidelines and recommendations.
  7. Poldermans D, Boersma E, Bax JJ, Thomson IR, van de Ven LL, et al.: The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med. 1999 Dec 9;341(24):1789-94.
  8. Geerts WH, Heit JA, Clagett GP, Pineo GF, Colwell CW, et al. Prevention of venous thromboembolism. Chest. 2001 Jan;119(1 Suppl):132S-175S. Review. An exhaustive review of the clinical problem of venous thromboembolism and its prevention.
  9. Auerbach AD, Goldman L: Beta Blockers and Reduction of Cardiac Events in Non-cardiac Surgery: Scientific Review, JAMA, 287:11, 1435-1444, 2002.

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