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1. Rheum RC > Periop > Flashcards

Periop Flashcards

1
Q

Periop items to review in pt w/ rheum dz

A

-Disease control/activity
-Med changes
-Steroid related: stress dosing, bacterial ppx
-Cervical spine dz
-CV risk
-DVT ppx

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2
Q

** Periop tests**

A

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

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3
Q

Why C spine XR in RA

A

Atlantoaxial subluxation can compress spinal cord with extreme flexion/extension during intubation

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4
Q

Atlantoaxial subluxation pathogenesis

A

Inflamm/weakness of transverse ligament holding odontoid process of C2 against anterior arch of C1

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5
Q

Atlantoaxial subluxation RF in RA

A

-Corticosteroid use
-Seropositive RA
-Peripheral joint destruction
-Involvement of cervical nerves (paresthesias, neck pain, weakness
-Nodules (RA)
Established dz (>10yrs)

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6
Q

Atlantoaxial subluxation Dx

A

Space between odontoid process and anterior arch of atlas >3mm on lateral flexion/extension XR= instability
->7-8mm = risk of spinal cord compromise

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7
Q

Atlantoaxial subluxation Mx

A

Instability: Surgical stabilization before surgery
-Mild/asymptoamtic dz: intubate w/ fiberoptic assistance
-Soft C-spine collar throughout periop

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8
Q

Manifestations of cricoarytenoid (CA) dz

A

Tracheal pain
-Dysphonia
-Stridor
-Dyspnea
-Dysarthria

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9
Q

Cricoarytenoid (CA) periop management

A

FIberoptic laryngoscopy or intubation

-Systemic/local GC injection

-Elective tracheostomy if vocal cords chronically adducted

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10
Q

When to stop ASA before surgery

A

7-10d except if 2ndary prevention of CV events

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11
Q

When to stop NSAID before surgery

A

1 week before OR (~4 half lives)

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12
Q

RF for adrenal insuff

A

Cushing’s
-Pred >20mg daily x5, or >5mg daily x30

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13
Q

** How to treat stress dose**

A

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

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14
Q

Testing for Adrenal insuff

A

Cosyntropin stim test (ACTH analog) → measure cortisol 30 and 60 min after

-Normal = >20ug/dL @ 30 or 60 min

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15
Q

Abx ppx in prosthetic joint surgery

A

Ancef or Vanco within 60min of incision, then for 1 day post op

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16
Q

Recommendation for abx ppx in pt w/ prosthetic joints before dental procedure

A

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

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17
Q

High risk popln w/ prosthetic joints that need abx before dental procedure

A

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

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18
Q

Types of Pt w/ aPLs ABs that shld be given abx prior to dental/urologic/GI procedures

A

ONLY if gingival tissue, oral mucosa affected:
– Prosthetic valves
– Hx of IE
– Hx of cardiac transplant w/ valve regurg
– Unrepaired cyanotic congenital heart defects

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19
Q

Periop approach of pt APL+ w/o clot hx

A

Controversial: continue ppx LMWH or therapeutic warfarin for 1-6wks postop (including postpartum)

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20
Q

DVTp s/p Joint replacement: options and duration

A

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

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21
Q

** Medications that can be continued throughout surgery as per ACR 2022 Guidelines **

A

MTX, SFZ, LFN, HCQ
Doxy
Apremilast

For severe SLE: AZA, MMF, CNI,
Ritux, Benlysta, Anifrolumab, Voclosporin

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22
Q

** Management of JAKi around surgery **

A

Hold 3d prior (can be 1 week if hx of infxn or PJI)
Schedule Surgery on Day 4

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23
Q

** What to do about biologics with elective THA/TKA, list them **

A

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

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24
Q

** Dosing of DMARDs in SLE before surgery, and list them**

A

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

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25
Q

** When to restart held meds**

A

14d after surgery or once signs of good wound healing, no infxn, and sutures removed

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26
Q

** Dosing of DMARDs before elective surgery - prednisone**

A

Continue throughout
-NO stress dosing for knee/hip replacements

27
Q

Disease spec precautions periop:
-SS

A

DO: give lubricating gel and tears to prevent corneal abrasion.

DONT give pilocarpine/cimeviline periop (causes bronchospasms and bradycardia)

28
Q

Disease spec precautions periop:
-JIA

A

Micrognathia and C spine instability affects intubation

29
Q

Disease spec precautions periop:
-Ank spond

A

Cspine immobility affects intubation
-Restrictive chest excursion increase PNA risk
-Heterotopic ossification complicates THA

30
Q

Disease spec precautions periop:
-PsA

A

Skin flare at surgical site (Koebner phenom)

31
Q

Disease spec precautions periop:
-Active vasculitis

A

Arterial puncture/devices increase vasospasm and vascular occlusion

32
Q

Disease spec precautions periop:
-SLE

A

Thrombocytopenia → IVIG if emergent surgery
-Increased CV risk

33
Q

Disease spec precautions periop:
-Raynad

A

POCT glucose check → hard to heal
-O2 monitor not accurate (use forehead/earlobe)

34
Q

Disease spec precautions periop:
-SSc

A

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

35
Q

** Periop - MTX - when to schedule surgery **

A

Anytime

36
Q

Periop - SFZ - when to schedule surgery

A

Anytime

37
Q

Periop - LFN - when to schedule surgery

A

Anytime

38
Q

Periop - HCQ - when to schedule surgery

A

Anytime

39
Q

Periop - Doxy - when to schedule surgery

A

Anytime

40
Q

Periop - Apremilast - when to schedule surgery

A

Anytime (continue throughout surgery)

41
Q

** Periop - MMF - when to schedule surgery **

A

Severe SLE: Anytime

-Mild SLE: 1wk after last dose

42
Q

** Periop - Aza - when to schedule surgery **

A

Severe SLE: Anytime
-Mild SLE: 1wk after last dose

43
Q

** Periop - Cyclosporine - when to schedule surgery **

A

Severe SLE: Anytime
-Mild SLE: 1wk after last dose

44
Q

** Periop - Tacro- when to schedule surgery **

A

Severe SLE: Anytime
-Mild SLE: 1wk after last dose

45
Q

Periop - Ritux - when to schedule surgery

A

Severe SLE: Month 4-6mo
-Mild SLE: Month 7

46
Q

Periop - Belimumab (weekly)- when to schedule surgery

A

Severe SLE: Anytime
-Mild SLE: week 2

47
Q

Periop - Belimumab (q4wk) - when to schedule surgery

A

Severe SLE: Week 4
-Mild SLE: Week 5

48
Q

Periop - Anofrulimab (q4wk)- when to schedule surgery

A

Week 4

49
Q

Periop - Voclosporine - when to schedule surgery

A

Continue

50
Q

Periop - Infliximab (q4,6,8wks) - when to schedule surgery

A

Week 5, 7, 9

51
Q

Periop - Adalimumab (q2wks)- when to schedule surgery

A

Week 3

52
Q

** Periop - Etanercept (weekly) - when to schedule surgery **

A

Week 2

53
Q

Periop - Golimumab (q4 or 8 wks)- when to schedule surgery

A

Week 5 or 9

54
Q

Periop - Abatacept (monthly or weekly)- when to schedule surgery

A

Week 5 or 2

55
Q

Periop - Certoluzimab (q2 or 4 wks)- when to schedule surgery

A

Week 3 or 5

56
Q

Periop - Toci (q1 or 4wk)- when to schedule surgery

A

Week 2 or 5

57
Q

Periop - Anakinra (daily)- when to schedule surgery

A

Day 2

58
Q

Periop - Secukinumab (q4wks) - when to schedule surgery

A

Week 5

59
Q

Periop - Ustekinumab (q12wks)- when to schedule surgery

A

Week 13

60
Q

Periop - Ixekizumab (q4wk) - when to schedule surgery

A

Week 5

61
Q

Periop - Guselkumab (q8wks) - when to schedule surgery

A

Week 9

62
Q

** Periop - Tofa (daily)- when to schedule surgery **

A

Day 4
-STOP JAKi 3d prior to surgery

63
Q

** Periop - Baracitnib (daily)- when to schedule surgery **

A

Day 4
-STOP JAKi 3d prior to surgery

64
Q

** Periop - Upacitnib (daily)- when to schedule surgery **

A

Day 4
-STOP JAKi 3d prior to surgery

1. Rheum RC (23 decks)

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