O Doente Reumatológico Proposto para Cirurgia: Manuseamento dos Agentes Antirreumáticos no Perioperatório

  • Ana Carolina dos Santos Silva Rocha 1 Assistente Hospitalar de Anestesiologia, Serviço de Anestesiologia, Unidade Local de Saúde de Castelo Branco-EPE, Castelo Branco, Portugal.
  • Pedro Abreu Assistente Hospitalar Graduado de Reumatologia, Serviço de Reumatologia, Unidade Local de Saúde de Castelo Branco-EPE, Castelo Branco, Portugal.
Palavras-chave: Antirreumáticos; Cuidados Perioperatórios; Período Perioperatório

Resumo

As doenças reumáticas inflamatórias são distúrbios funcionais do sistema músculo-esquelético cujos sinais e sintomas são de natureza inflamatória. As situações progressivas e crónicas que necessitam de cirurgia, nomeadamente do foro ortopédico, artroplastia total da anca e/ou do joelho, estão expostas a um risco elevado de infeção da ferida cirúrgica, agravado pelo tratamento imunossupressor com agentes antirreumáticos a que estes doentes são submetidos. O objetivo deste artigo é sumariar a evidência mais recente e disponível sobre o manuseio perioperatório destes fármacos nos doentes propostos para cirurgia, a sua manutenção versus suspensão no período préoperatório e o seu reinício no pós-operatório.
Uma revisão narrativa da literatura foi conduzida com os descritores “agentes antirreumáticos/manuseamento perioperatório”, “doença reumática inflamatória/complicações pós-operatórias” e “fármacos antirreumáticos modificadores da doença” em diferentes bases de dados eletrónicas, tais como: MEDLINE, EMBASE, Cochrane Library e SciELo. Foram incluídos artigos em português e inglês publicados segundo critérios de seleção previamente definidos.
Manter o metotrexato, leflunomida, sulfassalazina e hidroxicloroquina nos doentes com doenças reumáticas inflamatórias parece ser seguro no pré-operatório.
No lúpus eritematoso sistémico grave a azatioprina, ciclosporina A, tacrolimus e micofenolato de mofetil devem ser mantidos e a sua suspensão uma semana antes da cirurgia só deve ser feita nas situações de lúpus eritematoso sistémico não grave. O tofacitinib deve ser suspenso uma semana antes do procedimento cirúrgico e reiniciado 3 a 5 dias do pós-operatório, na ausência de complicações da ferida cirúrgica.
Para os agentes biológicos, o tempo de suspensão no pré-operatório depende do ciclo de dosagem do fármaco, pelo que a cirurgia deve ser planeada para o fim de cada ciclo terapêutico. A reintrodução
deve ser feita ao 14º dia do pós-operatório, quando a ferida cirúrgica mostra sinais de cicatrização e não há evidência de infeção.
A literatura sobre o manuseamento dos fármacos antirreumáticos no perioperatório é escassa. A manutenção da terapêutica pode dificultar a cicatrização de ferida cirúrgica e predispor a infeções. A sua suspensão está associada a agudizações da doença, o que pode aumentar a necessidade de corticosteroides para o seu controlo e limitar a mobilização e a reabilitação após a cirurgia.
Pelos riscos associados e para a melhoria de todo o cuidado ao doente no perioperatório, são indispensáveis uma comunicação eficaz entre o anestesiologista e o reumatologista e mais evidência científica sobre
o tema.

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Biografia do Autor

Ana Carolina dos Santos Silva Rocha, 1 Assistente Hospitalar de Anestesiologia, Serviço de Anestesiologia, Unidade Local de Saúde de Castelo Branco-EPE, Castelo Branco, Portugal.

Mestre em Medicina pela Universidade de Coimbra

Assistente Hospitalar de Anestesiologia na ULS de Castelo Branco, EPE

Responsável da consulta externa de Anestesiologia da ULS

Assistente convidada da UBI

Membro dos Corpos Sociais da SPA

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Publicado
2019-12-28
Como Citar
Rocha, A. C. dos S. S., & Abreu, P. (2019). O Doente Reumatológico Proposto para Cirurgia: Manuseamento dos Agentes Antirreumáticos no Perioperatório. Revista Da Sociedade Portuguesa De Anestesiologia, 28(4), 223 - 231. https://doi.org/10.25751/rspa.17927