What the Anesthesiologist Should Know before the Operative Procedure?
Surgical stabilization of the wrist can involve arthrodesis (fixation, using screws, plates, or bone grafts) or arthroplasty (total joint replacement with artificial hardware). While traumatic injury is the most common cause for these procedures in younger patients, joint involvement by rheumatoid arthritis (RA) is the more common reason in the older patient. In RA, arthrodesis is often the first step to restore stability and function, usually with good partial success. When both hands are involved (the common scenario), arthroplasty may be considered for one or both hands in order to provide better function. Anesthetic considerations are generally similar for both procedures, and particular issues involve the choice of primary anesthetic (general versus regional), use of a pneumatic tourniquet, and site of donor bone graft if one is to be harvested.
1. What is the urgency of the surgery? What is the risk of delay in order to obtain additional preoperative information?
These procedures are generally elective.
Emergent: If emergent surgery is required due to trauma, surgery should be delayed only for critical evaluations or interventions due to the risks of infection and blood loss.
Urgent: These are rarely urgent surgeries.
Elective: A thorough preoperative evaluation with all necessary optimization is warranted.
2. Preoperative evaluation
A standard preanesthetic assessment should be performed with special attention paid to comorbid conditions. In this patient population the most common considerations involve the multiorgan and systemic effects of RA.
Medically unstable conditions related to RA that warrant further evaluation include cervical spine instability, myocardial ischemia, and pulmonary dysfunction (see below). Delaying surgery may be indicated if: cervical neurologic dysfunction suggests potential instability of atlanto-occipital joint with risk of subluxation during intubation.
3. What are the implications of co-existing disease on perioperative care?
Careful airway examination is appropriate because of frequent temporomandibular joint involvement with RA, as well as potential vocal cord immobilization due to cricoarytenoid joint arthritis. A smaller endotracheal tube may be needed if intubation is required. Erosion of cervical vertebrae may create an unstable C-spine, which necessitates careful manipulation of the head/neck. A difficult airway may require an awake fiberoptic intubation.
b. Cardiovascular system
Standard evaluation consistent with current AHA/ACC guidelines should be performed. Patients with RA may have coronary arteritis, predisposing them to cardiac ischemia. They may also have myocarditis, pericarditis, valvular pathology (commonly aortic insufficiency), or conduction defects.
A careful history is necessary for RA patients because joint involvement frequently limits activity, making exercise tolerance difficult to assess. ECG, echocardiography, stress testing, and cardiac consultation should be considered.
Obstructive and reactive airway diseases should be optimized.
Obstructive sleep apnea places patients at an increased risk of respiratory depression when opioids are used for postoperative analgesia. The severity of disease must be assessed (apnea-hypopnea index from sleep study) and a plan for postoperative continuous positive airway pressure (CPAP) therapy should be included if appropriate.
In the RA patient population, pleural effusions, interstitial fibrosis, pneumonitis, and pulmonary arteritis are more common. If symptoms are present, chest radiography and arterial blood gases may be indicated.
Renal dysfunction secondary to arteritis is common, and renal function should be assessed in patients with advanced RA.
Rheumatoid patients may have radiculopathies if there is spinal involvement. Any peripheral neuropathy should be evaluated preoperatively and documented.
Adrenal suppression can be associated with the chronic steroid therapy in RA. Though wrist surgery poses only a mild stress, stress dose steroids may be necessary perioperatively (see dosing below).
Rheumatoid patients may be anemic from chronic disease or their anti-inflammatory medications. Though blood loss is usually minimal, checking a preoperative Hg/Hct is warranted.
h. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan:
Pre-existing musculoskeletal deformities may require special attention to patient positioning.
Vasculitis and chronic steroid use can render veins fragile, making vascular access difficult.
4. What are the patient’s medications and how should they be managed in the perioperative period?
Patients with RA are frequently on aspirin or nonsteroidal anti-inflammatory (NSAID) medications which may interfere with platelet function. These are traditionally discontinued a week before surgery. Other herbal and OTC medications (i.e., Vitamin E, garlic, ginseng) that interfere with coagulation should also be discontinued.
a. Are there medications commonly seen in patients undergoing this procedure that may require special concern?
Medications specific to RA include steroids, methotrexate, and other disease-modifying antirheumatic drugs (DMARDs). Steroids should be continued and additional coverage provided during the perioperative period to compensate for adrenal suppression (i.e., hydrocortisone 100 mg IV q8hours x3 started on day of surgery).
Methotrexate may produce pulmonary changes/toxicity. However, this is a low risk and continuation of the drug may help reduce postoperative flares of the primary disease.
Other DMARDs have immunosuppressive properties and may affect the risk of infection. Consultation with a rheumatologist and the surgical team is warranted to weigh the risk of surgical site infection with that of RA flares.
b. What should be recommended with regard to continuation of medications taken chronically?
Cardiac: Anti-anginal drugs should be continued in the perioperative period. For hypertension, beta-blockers and calcium-channel blockers should be continued, but ACE-inhibitors/ARBs and diuretics should be held the day of surgery.
Pulmonary: If reactive airway disease is present, bronchodilators should be continued.
Antiplatelet drugs should be discontinued, as mentioned. If therapy is being employed because of a coronary stent, abrupt discontinuation presents significant risks, and consultation with a cardiologist about perioperative management is indicated.
Psychiatric drugs, HIV antiretrovirals, and medications for Parkinson’s disease should be continued.
c. How to modify care for patients with known allergies?
Avoid known allergens. If sulfa allergy is present, use of celecoxib is contraindicated.
Latex allergy- If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
Ensure that all operating room staff is aware of any sensitivity, and all latex-containing items are removed.
d. Does the patient have any antibiotic allergies? (common antibiotic allergies and alternative antibiotics)
Cephalosporins are indicated for prophylactic administration. If a severe allergy to penicillin exists, vancomycim or clindamycin are suitable alternatives.
e. Does the patient have a history of “allergy” to anesthesia?
Malignant hyperthermia (MH)
Documented: Avoid all triggering agents such as succinylcholine and volatile anesthetics. Follow a proposed general anesthetic plan: total intravenous anesthesia with propofol ± opioid infusion ± nitrous oxide. Closely monitor end-tidal CO2 and temperature. Ensure an MH cart is available and relevant staff are trained on management procedures. [MH protocol and hotline].
Local anesthetics/muscle relaxants: True allergies are rare. There is no cross-reactivity between amino-ester and amino-amide local anesthetics, so alternatives are available.
5. What laboratory tests should be obtained?
Hemoglobin levels: indicated in RA patients because of frequent anemia.
Electrolytes: not indicated unless there is a history of renal disease or diuretic use.
Coagulation panel: indicated in chronically anticoagulated patients whose anticoagulant is being held for surgery.
Platelet dysfunction may be present with drug therapy, but there is no reliable test.
Imaging: As mentioned, cardiac stress test if history suggests significant cardiac or coronary disease (in absence of exercise history). Cervical spine films appropriate if neck instability or neurologic symptoms.
Chest radiography and pulmonary function tests if indicated by history.
6. Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
Regional anesthesia, general anesthesia, or a combination of the two are the anesthetic options. Regional anesthesia via a brachial plexus block is preferred as it increases patient satisfaction, speeds PACU discharge times, and spares manipulating the fragile c-spine and often challenging airway of the rheumatoid patient.
a. Regional anesthesia
The ideal choices here would be the infraclavicular or supraclavicular nerve blocks because of the great reliability of providing anesthesia to all branches of the brachial plexus below the shoulder and the ease of inserting a continuous catheter. The infraclavicular approach is deeper and single injection may be more challenging, but it does offer a stable skin surface for catheter fixation. When compared to a supraclavicular block, the infraclavicular block produces significantly less phrenic nerve block due to its more distal location along the brachial plexus. An axillary block could be used but may be less effective in preventing tourniquet discomfort of proximal arm. An interscalene block would likely be inadequate for this procedure.
Benefits: Substantial postoperative analgesia; 12 to 18 hours can be achieved with a single injection of 0.5% bupivacaine or ropivacaine, but a continuous infusion catheter can provide 72 to 96 hours of relief, and can allow earlier discharge home. In the RA patient, regional techniques can avoid the necessity of airway manipulation.
Drawbacks: The discomfort of lying in one position for the extended surgery may require intraoperative sedation. Loss of motor function with a prolonged block may impair mobility in the severely arthritic patient postoperatively. There is a small risk of pneumothorax with both supraclavicular and infraclavicular blocks that does not exist with axillary blocks. If a bone graft is taken from an area not covered by the brachial plexus block, supplemental anesthesia may be required.
b. General anesthesia
Benefits: General anesthesia may offer better control of ventilation if pulmonary dysfunction is present, and may provide greater comfort for the patient for other nonsurgical areas (back, other arthritic limbs).
Drawbacks: In the absence of regional anesthesia, patients may experience significant postoperative pain requiring opioid use. Also, the risk of developing persistent post surgical pain (PPSP) maybe increased. Pre-exisiting chronic pain syndromes may make postoperative pain management more challenging in this patient population and may also make them more likely to develop PPSP. Postoperative nausea and vomiting are significant issues, especially if opioids are used for analgesia.
Airwayconcerns: In the RA patient, significant issues with the airway and neck movement may make intubation challenging. The use of an LMA may be an acceptable alternative to avoid extensive neck manipulation (and associated risk of neurological injury).
c. Monitored anesthesia care
Monitored care with local anesthetic injection by the surgeon would not provide adequate anesthesia for this procedure.
7. What is the author’s preferred method of anesthesia technique and why?
Regional anesthesia is our preferred method for several reasons. Peripheral blockade avoids the need for airway manipulation, with its inherent risks in this population. The potential for prolonged postoperative analgesia with a continuous technique is another advantage. With dense analgesia present at the end of the procedure, PACU issues are minimal.
Of the regional techniques available, continuous infraclavicular blockade with ultrasound guidance is preferred because it minimizes tourniquet discomfort and the deep-set catheter dislodges less readily than from the supraclavicular approach. It also avoids the high incidence of hemidiaphragmatic paralysis that occurs with supraclavicular injections, which could be a significant problem in patients with pre-existing pulmonary disease. The deeper location of the perivascular injection with this technique, however, makes vessel compression impossible in the event of inadvertent vascular puncture in an anticoagulated patient.
Continuous supraclavicular blockade has been shown to be equally effective and shares the advantage of minimizing tourniquet discomfort. The superficial location of the nerves and clearer ultrasound images at this depth make vascular injury less likely. Either approach is suitable for the procedure itself if a long-acting drug such as bupivacaine or ropivacaine is used, and the transition to a continuous infusion postoperatively is easily achieved. Adequate time is needed (20 to 30 minutes) to allow surgical anesthesia to be completely achieved.
If a bone graft is planned (usually with an iliac crest donor site), general anesthesia may be required for part of the procedure. Airway maintenance with an LMA should be considered to avoid extensive manipulation of the cervical spine.
8. What prophylactic antibiotics should be administered?
Prophylactic antibiotics are important in this procedure, especially if hardware is to be inserted. Current surgical care improvement project (SCIP) recommendations are for intravenous 1-2 grams of cefazolin, with clindamycin 600-900 mg or vancomycin 1 gm as alternatives in the presence of penicillin allergy. Vancomycin is preferred if Methicillin Resistent Staph Aureus (MRSA) is a concern. All antibiotic administration should be completed before the tourniquet is inflated and within one hour prior to incision.
9. What do I need to know about the surgical technique to optimize my anesthetic care?
The use of a tourniquet will affect decisions about regional block (must include upper arm, and may require sedation and analgesia if procedure is prolonged and ischemic pain ensues).
Patient comfort is the most frequent problem because of other joint involvement and chronic pain. Comfortable positioning before incision and sedation intraoperatively may be useful.
10. What are the most common intraoperative complications and how can they be avoided/treated?
Patient comfort in a long procedure (especially if a regional block is used) may pose a challenge, especially with pre-existing musculoskeletal pain. Blood loss is usually not an issue if a tourniquet is employed.
Cardiac complications: If good analgesia is present, cardiac stress is minimized. If CHF was present preoperatively, fluid administration should be limited and cardiac status monitored closely.
Pulmonary complications: Probability of pulmonary issues will be more closely associated with preexisting disease.
Neurologic complications: Neurological injury from nerve blocks is rare, but possible. Compression or ischemic injury from prolonged tourniquet time is a concern. There may also be distal nerve injury related to the procedure. If general anesthesia with an endotracheal tube is necessary, the same care with neck manipulation should be exerted on extubation as was appropriate for intubation in the presence of cervical instability.
11. What analgesic modalities can I implement for postoperative pain?
A multimodal analgesic approach can reduce the opioid requirement (and thus minimize opioid-related adverse effects), while effectively controlling postoperative pain.
Preoperative: Acetaminophen 1000 mg on the day of surgery and the use of an adjuvant such as gabapentin (300 mg) or pregabalin (150 mg, or 75 mg if age > 70 or presence of kidney disease) would be beneficial. If acceptable to the surgeon, NSAIDs on the morning of surgery (celecoxib 200 mg) may be considered as well.
Intraoperative: Continuous peripheral nerve blockade with an infusion of local anesthetic such as ropivacaine 0.2% or bupivacaine 0.1% would be ideal. A ketamine bolus of 0.25 mg/kg on induction could be beneficial. If opioids are used, they should be titrated to the effect of good analgesia without side effects such as nausea and vomiting. An intraarticular injection of steroid and/or local anesthetic may also be beneficial.
Postoperative: Continuation of the peripheral nerve blockade would be most beneficial. Acetaminophen could be dosed every 6 hours for up to 4 grams daily. If acceptable to the surgeon in terms of risk of bleeding, initiation/resumption of NSAIDs would be beneficial as well. If opioids are required, a patient-controlled infusion may be satisfactory.
12. What level of bed acuity is appropriate?
These patients do not usually require intensive observation but may be kept in the hospital overnight for pain therapy, postoperative antibiotics, and to assess for potential aggravation of rheumatoid symptoms.
13. What are common postoperative complications, and ways to prevent and treat them?
Postoperative pain control and flare of rheumatoid arthritis are the most common complications, as discussed above. Postoperative bleeding, infection, and deep venous thrombosis are less frequent issues.
14. What’s the Evidence?
Saleh, KJ. “Perioperative Treatment of Patients with Rheumatoid Arthritis”. J Am Acad Orthop Surg. vol. 23. 2015 Sep. pp. e38-48.
Goodman, SM. “Rheumatoid arthritis: Perioperative management of biologics and DMARDs”. Semin Arthritis Rheum. vol. 44. 2015 Jun. pp. 627-32.
Jaffe, RA, Schmiesing, CA, Golianu, B. “Anesthesiologist’s Manual of Surgical Procedures”.
Garson, L. “Implementation of a Total Joint Replacement Focused Perioperative Surgical Home: A Management Case Report”. Anesth Analg. vol. 118. 2014. pp. 1081-9.
Parvizi, J, Bloomfield, MR. “Multimodal pain management in orthopedics: implications for joint arthroplasty surgery”. Orthopedics. vol. 36. 2013 Feb. pp. 7-14.
Halawi, MJ, Grant, SA, Bolognesi, MP. “Multimodal Analgesia for Total Joint Arthroplasty”. Orthopedics. vol. 38. 2015 Jul 1. pp. e616-25.
Chin, KJ, Singh, M, Velayutham, V, Chee, V. “Infraclavicular brachial plexus block for regional anaesthesia of the lower arm”. Cochrane Database Syst Rev. vol. 17. 2010. pp. CD005487
Perlas, A, Lobo, G, Lo, N, Brull, R, Chan, VW, Karkhanis, R. “Ultrasound-guided supraclavicular block: outcome of 510 consecutive cases”. Reg Anesth Pain Med.. vol. 34. 2009. pp. 171-6.
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- What the Anesthesiologist Should Know before the Operative Procedure?
- 1. What is the urgency of the surgery? What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- 4. What are the patient’s medications and how should they be managed in the perioperative period?
- a. Are there medications commonly seen in patients undergoing this procedure that may require special concern?
- b. What should be recommended with regard to continuation of medications taken chronically?
- c. How to modify care for patients with known allergies?
- d. Does the patient have any antibiotic allergies? (common antibiotic allergies and alternative antibiotics)
- e. Does the patient have a history of “allergy” to anesthesia?
- 5. What laboratory tests should be obtained?
- 6. Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
- 7. What is the author’s preferred method of anesthesia technique and why?
- 8. What prophylactic antibiotics should be administered?
- 9. What do I need to know about the surgical technique to optimize my anesthetic care?
- 10. What are the most common intraoperative complications and how can they be avoided/treated?
- 11. What analgesic modalities can I implement for postoperative pain?
- 12. What level of bed acuity is appropriate?
- 13. What are common postoperative complications, and ways to prevent and treat them?