Preparing for surgery
Most of us will be faced with the need for surgery at some point in our lives. Surgery may present some particular challenges in people who have lupus, so proper preparation is important. Although we may not be able to adequately prepare for emergency surgeries, there are many things that can be done for elective surgeries, to increase the possibility of a safe outcome.
Call and see your rheumatologist ASAP when you know that a surgery is needed
If the surgery can be delayed (this is often called elective surgery), it is best to plan well ahead of time. Surgery may induce a lupus flare or may cause complications if surgery is performed while having a flare, so it's important to know the status of your lupus before having a procedure. Additionally, some people with lupus may have problems with wound healing, especially if they have vasculitis (inflammation of the blood vessels) that affects the skin, or if they are at an increased risk of developing infections because of lupus. Platelet counts, the use of other immune suppressant medicines, active infection and blood clotting problems should be discussed thoroughly with the healthcare provider treating your lupus as well as your surgeon before undergoing surgery.
Keep all your doctors in the loop
It is very important that the surgeon and the rheumatologist communicate with each other. In a perfect world, the surgeon would contact the rheumatologist to request recommendations on your health and medications, and the rheumatologist would respond to those recommendations. Unfortunately, this does not happen nearly as often as it should. I recommend that patients initiate this communication themselves, by asking the surgeon to contact the rheumatologist, and vice versa.
If you have significant organ involvement or any organ damage (from lupus or other conditions), it is also important to get the input of any additional specialists who take care of you. Your primary care doctor should also be involved with surgical preparation recommendations. Making appointments with your primary care doctor, rheumatologist and other specialists is one of the best ways to ensure that you get thorough evaluations and recommendations for surgery.
Know which medications to stop, and whether dosages need to be increased or decreased
Some medications need to be stopped prior to surgery and restarted later on. Some examples include blood thinners and medications that suppress the immune system. Your rheumatologist and other doctors can supply specific recommendations.
Steroids: Steroids, such as prednisone and methylprednisolone, require special attention. Many surgeons request that steroids be stopped in order to prevent any problems with healing after surgery. However, many people who have lupus should actually have their steroid doses increased around the time of surgery. This is because, if someone has been on steroids for a significant length of time, they may have a condition called adrenal insufficiency. Adrenal insufficiency happens when the adrenal glands do not produce enough of certain hormones. Our bodies actually need the adrenal glands to provide higher doses of natural steroids during the stress of surgery. However, for the person who has adrenal insufficiency due to long term steroid use, the adrenal glands are unable to meet this need, and this can be dangerous. It is important that the rheumatologist communicate with the surgeon and anesthesiologist about the need for increased steroids at the time of surgery, if the possibility of adrenal insufficiency exists.
Over the counter medications and supplements: It is also important that you report all over the counter medications and any herbal supplements that you take, because some of them can interfere with surgery by causing increased bleeding. Other supplements (for example, kava, valerian and St. John’s wort) can have dangerous interactions with medications used for anesthesia. If you are on a lot of medications, it may be difficult to remember all the different times that you should stop and start your medicines. It is a good idea to write down and track all directions on a chart or calendar.
Tell your surgeon if you have Sjogren’s, Raynaud’s or any other additional health conditions
Thirty to fifty percent of people who have lupus also have dryness problems due to a condition called Sjogren’s (pronounced SHOW’ grenz) syndrome in which the immune system attacks the body’s moisture producing glands. Sjogren’s syndrome can present problems during and after surgery, due to the dry conditions usually found in the operating room and the hospital. If you have Sjogren’s syndrome, notify your surgeon, anesthesiologist, and recovery room nurses of your condition and request that special attention be provided, in order to ensure adequate lubrication and moisturization. If you take either Evoxac (cevimeline) or Salagen (pilocarpine) for Sjogren’s syndrome, these may need to be stopped a day before surgery in order to prevent any breathing problems at the time of surgery.
Many people who have lupus suffer from Raynaud’s, where the arteries of the fingers and toes have tighter passages than normal. When these arteries constrict due to colder temperatures or stress, the fingers and toes can become uncomfortably cold, turning blue and/or pale in color. Since operating rooms are typically kept much cooler than normal, it is important to ask the anesthesiologist if it is possible to increase the operating room temperature slightly. You should also ask for additional blankets, socks, a hat, and covers for the hands and feet, in order to decrease the potential for a Raynaud’s flare before, during and after surgery.
Though preparation for surgery may be more time consuming for someone with lupus, you won’t regret the extra safety measures you are taking. By taking proactive steps to prepare for surgery, you will increase the likelihood of a safe outcome, a result that is always worthwhile in the end.
is author of the forthcoming book, “The Lupus Encyclopedia”, and a practicing rheumatologist in Greenbelt, Maryland. He is currently Chair of the Medical Scientific and Advisory Committee of the Lupus Foundation of America DC/MD/VA chapter