Important issues to address in the preoperative history and physical examination of patients with rheumatic diseases
Medication management: patients with inflammatory rheumatic diseases may be on medications that increase their chance of developing perioperative complications such as infections or poor wound healing. A guideline published by the American College of Rheumatology and the American Association of Hip and Knee Surgeons (ACR/AAHKS) in 2017 helps with the management of these medications (see Questions 22 and 23).
CV risk: patients with inflammatory rheumatic disease have an increased risk of CV events. Many are elderly and/or physically impaired; therefore, determining CV risk may be more difficult because of physical inactivity. In the absence of specific recommendations for patients with rheumatic disease, it is prudent to at minimum follow guidelines for the general population set forth by the American Heart Association/American College of Cardiology. These guidelines do not recommend advanced cardiac evaluation (such as a pharmacologic stress test) in patients requiring emergency surgery; in elective surgeries, the risk of the surgery and patient-specific risk categories are taken into account to determine whether additional cardiac testing is necessary.
• Patients with active cardiac disease (unstable coronary artery disease, decompensated heart failure, hemodynamically significant valvular disease, high-grade arrhythmias) typically require pharmacologic stress testing regardless of the risk of surgery.
• Low-risk surgical procedures (dental surgery, ocular surgery, inguinal repair) do not typically warrant additional evaluation regardless of patient-specific risk factors.
• Moderate-risk surgical procedures (total knee arthroscopy, total hip arthroscopy, arthrodesis) do not typically warrant additional evaluation for low-risk patients (patients with no more than one of the following: history of ischemic heart disease, history of heart failure, history of cerebrovascular disease, current diabetes requiring insulin treatment, serum creatinine >2.0 mg/dL).
• Moderate-risk surgical procedures in higher-risk patients, especially those with a low functional status, may require pharmacologic stress testing and referral to a cardiologist is indicated. Low functional status in this setting is commonly defined as an inability to complete four metabolic equivalents (METs) or the equivalent of climbing one set of stairs.
• High-risk surgical procedures (vascular surgery, intrathoracic, or intraabdominal surgery), especially in patients with a low functional status, may require pharmacologic stress testing and referral to a cardiologist is indicated.
Cervical spine disease: a good rule of thumb is to obtain cervical spine radiographs that include dynamic imaging in flexion and extension in any rheumatoid arthritis (RA) patient with longstanding disease (>10 years) and/or hand deformities, even if they do not have neck symptoms. In addition, patients with axial spondyloarthritis and juvenile idiopathic arthritis may also be at risk for instability of the cervical spine, and preoperative radiographs in these patients should be considered as well.
Occult infections: patients should be examined for cavities and/or signs of dental abscess, pharyngitis, and skin infection (look at the feet); testing should be performed for cystitis in symptomatic patients as well, as all may serve as sources of infection for total joint arthroplasties. Patients with an enlarged prostate are at increased risk of catheter-induced postoperative urinary tract infections.
