Periop Flashcards
Periop items to review in pt w/ rheum dz
-Disease control/activity
-Med changes
-Steroid related: stress dosing, bacterial ppx
-Cervical spine dz
-CV risk
-DVT ppx
** Periop tests**
LFTs (if on NSAIDs, DMARDs)
-PT/PTT, INR (if APLA, liver dz, bleeding d/o)
-CXR (if cardioresp dz, thoracic surg, sx)
-PFT (same as CXR)
-C spine XR (flexion and extension views) - for JIA/RA/Ax Spa
Why C spine XR in RA
Atlantoaxial subluxation can compress spinal cord with extreme flexion/extension during intubation
Atlantoaxial subluxation pathogenesis
Inflamm/weakness of transverse ligament holding odontoid process of C2 against anterior arch of C1
Atlantoaxial subluxation RF in RA
-Corticosteroid use
-Seropositive RA
-Peripheral joint destruction
-Involvement of cervical nerves (paresthesias, neck pain, weakness
-Nodules (RA)
Established dz (>10yrs)
Atlantoaxial subluxation Dx
Space between odontoid process and anterior arch of atlas >3mm on lateral flexion/extension XR= instability
->7-8mm = risk of spinal cord compromise
Atlantoaxial subluxation Mx
Instability: Surgical stabilization before surgery
-Mild/asymptoamtic dz: intubate w/ fiberoptic assistance
-Soft C-spine collar throughout periop
Manifestations of cricoarytenoid (CA) dz
Tracheal pain
-Dysphonia
-Stridor
-Dyspnea
-Dysarthria
Cricoarytenoid (CA) periop management
FIberoptic laryngoscopy or intubation
-Systemic/local GC injection
-Elective tracheostomy if vocal cords chronically adducted
When to stop ASA before surgery
7-10d except if 2ndary prevention of CV events
When to stop NSAID before surgery
1 week before OR (~4 half lives)
RF for adrenal insuff
Cushing’s
-Pred >20mg daily x5, or >5mg daily x30
** How to treat stress dose**
Hydrocort 50 (mod surg)-100mg (maj surg) intraop
-Then 50-100mg IV q8h for 24h
-Then resume PO dose (mod), or decrease to 50mg (maj) IV q8h for next 24h
-Then resume PO dose
Testing for Adrenal insuff
Cosyntropin stim test (ACTH analog) → measure cortisol 30 and 60 min after
-Normal = >20ug/dL @ 30 or 60 min
Abx ppx in prosthetic joint surgery
Ancef or Vanco within 60min of incision, then for 1 day post op
Recommendation for abx ppx in pt w/ prosthetic joints before dental procedure
ONLY for invasive dental (NOT routine cleaning)
– Low risk: no evidence for abx
– High risk: amox, keflex, or azithro
-*not reqd for small joint replacements, pins, plates, screws
High risk popln w/ prosthetic joints that need abx before dental procedure
Immunocompromised: AIDS, cancer, Feb neut, RA on DMARD (EXCLUDE HCQ and MTX) or pred >10mg/d
-DM
-Prosthetic joint infxn
-Arthroplasty w/i last year
-Dental procedure manipulating gingiva or oral mucosal perf
Types of Pt w/ aPLs ABs that shld be given abx prior to dental/urologic/GI procedures
ONLY if gingival tissue, oral mucosa affected:
– Prosthetic valves
– Hx of IE
– Hx of cardiac transplant w/ valve regurg
– Unrepaired cyanotic congenital heart defects
Periop approach of pt APL+ w/o clot hx
Controversial: continue ppx LMWH or therapeutic warfarin for 1-6wks postop (including postpartum)
DVTp s/p Joint replacement: options and duration
Warfarin INR2-3 10+d pre-OR then up to 42d s/p THA, up to 10d s/p TKA
-LMWH: 10d preop up to 42d post-THA
-Heparin: 5000U SC before surgery, then q8h after
-Pneumatic compression device > compression stocking: for entire admission
-Fonda - preop and up to 10-42d postop
-ASA NOT recommended for DVT ppx
** Medications that can be continued throughout surgery as per ACR 2022 Guidelines **
MTX, SFZ, LFN, HCQ
Doxy
Apremilast
For severe SLE: AZA, MMF, CNI,
Ritux, Benlysta, Anifrolumab, Voclosporin
** Management of JAKi around surgery **
Hold 3d prior (can be 1 week if hx of infxn or PJI)
Schedule Surgery on Day 4
** What to do about biologics with elective THA/TKA, list them **
TNFi, Ritux, Toci, IL17, IL12/23, IL23
- Hold prior to surgery
- Schedule surgery after next dose is due (unless pain severe or poor dz control)
**applies to RA, AS, PsA, JIA
NOT SLE
** Dosing of DMARDs in SLE before surgery, and list them**
MMF, AZA, CNI, Ritux, Benlysta, Anifrolumab
-Not severe SLE = Hold 1 week prior to surgery
- Severe = continue throughout
-Schedule surgery for end of dosing cycle eg month 5 for Ritux
** When to restart held meds**
14d after surgery or once signs of good wound healing, no infxn, and sutures removed
** Dosing of DMARDs before elective surgery - prednisone**
Continue throughout
-NO stress dosing for knee/hip replacements
Disease spec precautions periop:
-SS
DO: give lubricating gel and tears to prevent corneal abrasion.
DONT give pilocarpine/cimeviline periop (causes bronchospasms and bradycardia)
Disease spec precautions periop:
-JIA
Micrognathia and C spine instability affects intubation
Disease spec precautions periop:
-Ank spond
Cspine immobility affects intubation
-Restrictive chest excursion increase PNA risk
-Heterotopic ossification complicates THA
Disease spec precautions periop:
-PsA
Skin flare at surgical site (Koebner phenom)
Disease spec precautions periop:
-Active vasculitis
Arterial puncture/devices increase vasospasm and vascular occlusion
Disease spec precautions periop:
-SLE
Thrombocytopenia → IVIG if emergent surgery
-Increased CV risk
Disease spec precautions periop:
-Raynad
POCT glucose check → hard to heal
-O2 monitor not accurate (use forehead/earlobe)
Disease spec precautions periop:
-SSc
Poor venous access at thickened skin
-Hard intubation if decreased oral aperture
-Cardiac: increased arrhythmia
-Pulm: pHTN → worse outcomes
-GI: Gerd → increased aspiration risk, dysmotility → postop ileus
-GU: SRC risk increased in hypovolemia
** Periop - MTX - when to schedule surgery **
Anytime
Periop - SFZ - when to schedule surgery
Anytime
Periop - LFN - when to schedule surgery
Anytime
Periop - HCQ - when to schedule surgery
Anytime
Periop - Doxy - when to schedule surgery
Anytime
Periop - Apremilast - when to schedule surgery
Anytime (continue throughout surgery)
** Periop - MMF - when to schedule surgery **
Severe SLE: Anytime
-Mild SLE: 1wk after last dose
** Periop - Aza - when to schedule surgery **
Severe SLE: Anytime
-Mild SLE: 1wk after last dose
** Periop - Cyclosporine - when to schedule surgery **
Severe SLE: Anytime
-Mild SLE: 1wk after last dose
** Periop - Tacro- when to schedule surgery **
Severe SLE: Anytime
-Mild SLE: 1wk after last dose
Periop - Ritux - when to schedule surgery
Severe SLE: Month 4-6mo
-Mild SLE: Month 7
Periop - Belimumab (weekly)- when to schedule surgery
Severe SLE: Anytime
-Mild SLE: week 2
Periop - Belimumab (q4wk) - when to schedule surgery
Severe SLE: Week 4
-Mild SLE: Week 5
Periop - Anofrulimab (q4wk)- when to schedule surgery
Week 4
Periop - Voclosporine - when to schedule surgery
Continue
Periop - Infliximab (q4,6,8wks) - when to schedule surgery
Week 5, 7, 9
Periop - Adalimumab (q2wks)- when to schedule surgery
Week 3
** Periop - Etanercept (weekly) - when to schedule surgery **
Week 2
Periop - Golimumab (q4 or 8 wks)- when to schedule surgery
Week 5 or 9
Periop - Abatacept (monthly or weekly)- when to schedule surgery
Week 5 or 2
Periop - Certoluzimab (q2 or 4 wks)- when to schedule surgery
Week 3 or 5
Periop - Toci (q1 or 4wk)- when to schedule surgery
Week 2 or 5
Periop - Anakinra (daily)- when to schedule surgery
Day 2
Periop - Secukinumab (q4wks) - when to schedule surgery
Week 5
Periop - Ustekinumab (q12wks)- when to schedule surgery
Week 13
Periop - Ixekizumab (q4wk) - when to schedule surgery
Week 5
Periop - Guselkumab (q8wks) - when to schedule surgery
Week 9
** Periop - Tofa (daily)- when to schedule surgery **
Day 4
-STOP JAKi 3d prior to surgery
** Periop - Baracitnib (daily)- when to schedule surgery **
Day 4
-STOP JAKi 3d prior to surgery
** Periop - Upacitnib (daily)- when to schedule surgery **
Day 4
-STOP JAKi 3d prior to surgery
