Perioperative Management of Patients with Rheumatic Diseases
This patient is a 55 year-old female, known case of lupus nephritis on Mycophenolate 2g daily, Hydroxychloroquine 300 mg daily and Prednisolone 10mg daily. She was admitted to the orthopedic service for a right total hip replacement due to avascular necrosis of the right hip.\nThe patient was on Prednisolone more than 5mg/d chronically and was scheduled to undergo a moderate stress procedure, thus stress dose steroids in the form of Hydrocortisone 50 mg IV, then postoperatively 20mg IV every 8 hours for 3 doses, then pre-operative dose was resumed on post-operative day 2.\nFurthermore, THR is a major surgery, thus the patient required a chest x-ray, ECG and persantine thallium for pulmonary and cardiac screening. Hydroxychloroquine and mycophenolate were continued to the morning of surgery, and resumed with oral intake and because SLE patients who have renal involvement and are on steroids are considered to be at higher risk for developing perioperative complications. Screening laboratory investigations should include CBC, renal profile and urinalysis. If the patient is found to be anemic, preparations for autologous blood donation including iron and erythropoietin may be appropriate, as substantial blood loss often occurs perioperatively. Even an asymptomatic urinary tract infection should be treated before proceeding with THR.\nDual VTE prophylaxis was recommended to be initiated, preferably with LMWH at least 12 hours before surgery and extended to 35 days after; intermittent pneumatic compression device was recommended to be used during the hospital stay along with perioperative antibiotics, such as IV Cefazolin.