Perioperative Management of Patients with Rheumatic Diseases
This patient was a 51 year-old female, a known case of long-standing RA and hypertension. She had significant small joint involvement that caused disabling deformities in both hands with ulnar deviation and swan neck deformity involving multiple fingers. Hand x-rays revealed extensive peripheral joint erosions bilaterally. At baseline, she was sedentary because her painful knees limited her level of activity. She was on MTX 7.5mg weekly, Prednisolone 5 mg daily, Infliximab 3mg/kg IV every 8 weeks, Lisinopril 10 mg. Amlodipine 5 mg and Aspirin 81 mg. She was scheduled for reconstructive hand surgery.\nThe female was screened for C1-2 subluxation. Intraoperatively, it is important to avoid musculoskeletal trauma. Therefore, padding, careful joint positioning and avoidance of sudden movements of the neck and torso are important to prevent injury, including neurovascular compromise or fracture. PFT was indicated to screen for pulmonary fibrosis, given the severity of rheumatoid arthritis. She was instructed to stop Aspirin 1 week before Anti-hypertensive medications continued with sips of water perioperatively. Methotrexate was suggested to continue, with no increased risk of infection, wound healing or flare. Infliximab, an anti-TNF blocker was with held one week before and re-started at least one week after surgery. If Infliximab was being administered every 8 weeks, it was surgery. Anti-hypertensive medications were continued with sips of water perioperatively. MTX was continued, with no increased risk of infection, wound healing or flare. Infliximab, an anti-TNF blocker was held one week before and re-started at least one week after surgery. If Infliximab was being administered every 8 weeks, it was recommended that this elective surgery be scheduled in the middle of the eight-week period. With regards to Prednisolone, as the patient had only been taking 5mg/day of Prednisolone daily, there was no need to screen for suppression of her hypothalamic-pituitary-adrenal axis, nor to administer stress doses of steroids. The current dose was continued perioperatively. Since this was a clean procedure of relatively short duration, prophylactic antibiotics were not indicated. Early ambulation was adequate for VTE prophylaxis.