Perioperatives Management bei Patienten mit rheumatoider Arthritis

Zusammenfassung

Die operative Versorgung von Patienten mit rheumatoider Arthritis setzt große Erfahrung voraus, daher sollte die Indikation zur Operation interdisziplinär von einem Rheumaorthopäden in Zusammenarbeit mit seinem internistischen Kollegen getroffen werden. Im Rahmen der Operation müssen bestimmte Strategien verfolgt werden, da die Erkrankung aufgrund ihres systemischen Charakters das perioperative Management durch zahlreichen Komorbiditäten, aber auch durch nötige medikamentöse Therapien und gleichzeitig bestehenden Defektsituationen an mehreren Gelenken, deutlich erschwert. Für die Durchführung der Operation ist daher eine enge Zusammenarbeit zwischen Anästhesie und Chirurgie unerlässlich. Auch die postoperative Nachbehandlung gestaltet sich durch bestehende Defektsituationen an anderen, nicht frisch operierten Gelenken mit ihrer oft stark reduzierten Belastbarkeit schwierig. Zusätzlich können die Erkrankung selbst und ihre medikamentöse Therapie zu Immundepressionen mit schweren Komplikationen führen.

Abstract

The surgical treatment of patients with rheumatoid arthritis requires a great deal of experience. Therefore, the indication for surgery should be based on interdisciplinary collaboration between a surgeon specialised in rheumatic orthopaedic surgery and an internal medicine specialist. When operating on these patients, specific strategies need to be pursued as the disease significantly complicates the perioperative management due to its systemic nature and numerous comorbidities as well as through drug-related complications and simultaneous defect situations in several joints. Consequently, close collaboration between anaesthesiology and surgery is necessary for the surgical procedure to be carried out successfully. Also the postoperative treatment is complicated by existing defect situations in other joints, often with greatly reduced load bearing capacity. Furthermore, the disease itself and its drug treatment may lead to immunodepression with severe complications.

Schlüsselwörter

Rheumatoide Arthritis - perioperativ - Rheumaorthopädie

Key words

rheumatoid arthritis - perioperative - rheumasurgery

• Literatur

• 1 Rehart S, Henniger M. Rolle des Orthopäden bei der Therapie rheumatischer Erkrankungen mit Biologika. Der Orthopäde 2014; 43: 585 -595
• 2 Grennan DM, Gray J, Loudon J et al. Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery. Ann Rheum Dis 2001; 60: 214-217
• 3 Sany J, Anaya JM, Canovas F et al. Influence of methotrexate on the frequency of postoperative infectious complications in patients with rheumatoid arthritis. J Rheumatol 1993; 20: 1129-1132
• 4 Krüger K, Albrecht K, Rehart S et al. Empfehlungen der Deutschen Gesellschaft für Rheumatologie zur perioperativen Vorgehensweise unter Therapie mit DMARDs und Biologika bei entzündlich-rheumatischen Erkrankungen. http://dgrh.de/fileadmin/media/Praxis___Klinik/Therapie-Empfehlungen/perioperativ/periop_final230813_ueberarbeitung_kk.pdf
• 5 Visser K, Katchamart W, Loza E et al. Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with a focus on rheumatoid arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative. Ann Rheum Dis 2009; 68: 1086-1093
• 6 Tanaka N, Sakahashi H, Sato E et al. Examination of the risk of continuous leflunomide treatment on the incidence of infectious complications after joint arthroplasty in patients with rheumatoid arthritis. J Clin Rheumatol 2003; 9: 115-118
• 7 Fuerst M, Mohl H, Baumgartel K et al. Leflunomide increases the risk of early healing complications in patients with rheumatoid arthritis undergoing elective orthopedic surgery. Rheumatol Int 2006; 26: 1138-1142
• 8 Barnard AR, Regan M, Burke FD et al. Wound healing with medications for rheumatoid arthritis in hand surgery. ISRN Rheumatol 2012; 2012: 251962
• 9 Escalante A, Beardmore TD. Risk factors for early wound complications after orthopedic surgery for rheumatoid arthritis. J Rheumatol 1995; 22: 1844-1851
• 10 Den Broeder AA, Creemers MC, Fransen J et al. Risk factors for surgical site infections and other complications in elective surgery in patients with rheumatoid arthritis with special attention for anti-tumor necrosis factor: a large retrospective study. J Rheumatol 2007; 34: 689-695
• 11 Bongartz T, Halligan CS, Osmon DR et al. Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis. Arthritis Rheum 2008; 59: 1713-1720
• 12 Kawakami K, Ikari K, Kawamura K et al. Complications and features after joint surgery in rheumatoid arthritis patients treated with tumour necrosis factor-alpha blockers: perioperative interruption of tumour necrosis factor-alpha blockers decreases complications?. Rheumatology (Oxford) 2010; 49: 341-347
• 13 Gilson M, Gossec L, Mariette X et al. Risk factors for total joint arthroplasty infection in patients receiving tumor necrosis factor α-blockers: a case-control study. Arthritis Res Ther 2010; 12: R145
• 14 Hirao M, Hashimoto J, Tsuboi H et al. Laboratory and febrile features after joint surgery in patients with rheumatoid arthritis treated with tocilizumab. Ann Rheum Dis 2009; 68: 654-657
• 15 Toussirot E, Pertuiset E, Sordet C et al. Safety of rituximab in rheumatoid arthritis patients with a history of severe or recurrent bacterial infection: observational study of 30 cases in everyday practice. Joint Bone Spine 2010; 77: 142-145
• 16 Nishida K, Nasu Y, Hashizume K et al. Abataceptmanagement during the perioperative period in patients with rheumatoid arthritis: report on eight orthopedic procedures. Mod Rheumatol 2014; 24: 544 -545
• 17 Winking M. Die rheumatische Wirbelsäule; Journal für die Neurologie. Neurochirurgie und Psychiatrie 2014; 15: 82-88
• 18 S3 Leitlinie Vermeidung von perioperativer Hypothermie 2014 Version 8 vom 30.04.2014, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, Deutsche Gesellschaft für Chirurgie, Österreichische Gesellschaft für Anästhesie, Reanimation und Intesnivmedizion et al. http://www.awmf.org/uploads/tx_szleitlinien/001-018l_S3_Vermeidung_perioperativer_Hypothermie_2014-05.pdf
• 19 Romlin B, Petruson K, Nilsson K. Moderate superficial hypothermia prolongs bleeding time in humans. Acta Anaesthesiol Scand 2007; 51: 198-201
• 20 Rajagopalan S, Mascha E, Na J et al. The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology 2008; 108: 71-77
• 21 Frank SM, Fleisher LA, Breslow AB et al. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events: A randomized clinical trial. JAMA 1997; 277: 1127-1134
• 22 Forbes SS, Eskicioglu C, Nathens AB et al. Evidence-based guidelines for prevention of perioperative hypothermia. J Am Coll Surg 2009; 209: 492-503
• 23 Wolfe F, Caplan L, Michaud K. Treatment for rheumatoid arthritis and the risk of hospitalization for pneumonia: associations with prednisone, disease-modifying antirheumatic drugs, and anti-tumor necrosis factor therapy. Arthritis Rheum 2006; 54: 628-634
• 24 Jain A, Witbreuk M, Ball C et al. Influence of steroids and methotrexate on wound complications after elective rheumatoid hand and wrist surgery. J Hand Surg Am 2002; 27: 449-455
• 25 Dixon WG, Kezouh A, Bernatsky S et al. The influence of systemic glucocorticoid therapy upon the risk of non-serious infection in older patients with rheumatoid arthritis: a nested case-control study. Ann Rheum Dis 2011; 70: 956-960