What factors must be addressed preoperatively in patients with rheumatoid arthritis

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What factors must be addressed preoperatively in patients with rheumatoid arthritis

Cervical spine— an unstable cervical spine attributable to arthritic involvement places a patient at risk for catastrophic neurologic loss when the neck is manipulated during intubation. Preoperative lateral flexion and extension radiographs of the cervical spine are mandatory in patients with RA, especially if they have neck symptoms or long-standing disease with peripheral joint deformities. An increased anterior atlantodens interval >3 mm indicates disruption of the transverse ligament. An anterior atlantodens interval >7 mm or posterior atlantodens interval of ≤14 mm suggests cervical spine instability.

Autologous blood transfusion— preoperative autologous blood donation should be discussed.

Temporomandibular arthritis (especially patients with juvenile idiopathic arthritis [JIA]) and cricoarytenoid arthritis —may make intubations more difficult.

Immune status— infection rates are significantly higher in patients with RA, partly because of the disease process and partly because of the immunosuppressive drugs used to control it. Patients should be on the lowest corticosteroid dosage possible. It is recommended that methotrexate be withheld for the week of surgery and the week after surgery (controversial) . At least one dose of a biologic should be held before surgery. Glucocorticoids even at low doses increase the risk for postoperative infections.

Nutritional status— patients with RA may be relatively malnourished, which predisposes them to infection. Patients with a total lymphocyte count >1500/mm 3 and albumin level >3.5 g/dL are less prone to infections.

Hypothalamic–pituitary–adrenal axis— patients on chronic corticosteroid therapy are unable to respond normally to surgical stress. They must receive increased corticosteroids (stress dose) immediately preoperatively, intraoperatively, and postoperatively.

Cardiovascular status— patients with RA are at risk for premature atherosclerosis (relative risk 1.5×). Attention should be given to anginal chest pain and bruits.

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