Surgery and Pred?

[Miserere]

I am due to have a knee replacement fairly soon - I met someone else with PMR yesterday and she asked me whether I intended to increase my dose of Pred prior to surgery. I'd not thought about this and I hope it's not necessary. Can anyone advise? Thank you.

[DorsetLady PMRGCAuk volunteer]

Shouldn’t be necessary…. If you discuss with with your surgeon and anaesthetist before operation you should be given an infusion of hydrocortisone during the procedure… and monitored afterwards.

But certainly don’t be in too much of a hurry to taper your Pred after the operation - wait until you have recovered.

Previous post on same subject - healthunlocked.com/pmrgcauk...

[Miserere in reply to DorsetLady]

Thank you, DorsetLady

[PMRpro Ambassador]

Not off your own bat, no. Make sure the anaesthetist knows you are a long term corticosteroid patient, they will provide intra-operative cover in the drip you will have. Then watch out for potential flare symptoms, It is often handy to get your rheumatologist onside pre-op so there is no argument with ward staff if you do need a bit more pred for a flare.

[Miserere in reply to PMRpro]

The surgeon knows I am on 6.5mg and the pre-assessment nurse - she ensured that the surgeon knew as she thought I might need to be on a lower dose before surgery. I don't have a rheumatologist so will take my own pred in and take what I seem to need. Thank you.

[PMRpro Ambassador in reply to Miserere]

That isn't the point - you will need intra-operative steroid to avoid a potential adrenal crisis, and that is the responsibility of the anaesthetist, not the surgeon and certainly not the assessment nurse who was actually increasing that risk with the idea you should reduce the dose further. Anaesthetists know the problems, surgeons often don't. Some hospitals will not allow patients to take their own medications - so it is better to clarify that in advance,

[Miserere in reply to PMRpro]

I will contact the assessment nurse again as I have one or two other questions as well and she is the only contact I have. I don't think that I will see the anaesthetist until the day of the operation - I shall ask about that as well.

[cranberryt in reply to Miserere]

Correct. You will see them the day of and tell them then. They will know what to do. Last surgery I had, they told me not to take my meds that morning and they put extra in my IV. If you will be in the hospital several days, they should provide your prednisone for you but you might want to bring your meds with you just in case.

[Miserere in reply to cranberryt]

Thank you, cranberryt - this sounds reasonable but will check with nurse as well.

[piglette]

A lot of orthopaedic surgeons seem to be paranoid about steroids, mine was, and want you at as low a dose as possible. I think they are afraid of infection. Don’t ask us, ask your surgeon and anaesthetist!!!

[PMRpro Ambassador in reply to piglette]

The next email to the notification of your post was a medical article about infections in knee replacements ...

[piglette in reply to PMRpro]

Scary! I can manipulate email receipts!

[Miserere in reply to piglette]

The surgeon does not seem at all bothered. More concerned about pain killers as I don't take ibuprofen because of pred and I had an allergic reaction to paracetamol a few years ago. I use Flexiseq and occasionally Voltarol. The pre-assessment nurse (anaesthetics) showed a bit more concern.

[piglette in reply to Miserere]

Are you talking about painkillers after the op or during the op? I would have thought they will use opiods during the op.

[Miserere in reply to piglette]

Painkillers afer the op. The surgeon said he would need to address this so no idea what with. Am hoping I don't need them for too long.

[piglette in reply to Miserere]

For my hip I was offered Gabapentin and paracetamol. I refused the Gabapentin although they were not too happy.

[Miserere in reply to piglette]

Will look up Gabapentin - doubt I can take paracetamol.

[cranberryt in reply to Miserere]

my mother is allergic to most pain killers. She had a very difficult time with pain after her knee surgery. She kept in touch with the surgeon after and they tried several things before finding something that worked. For her it was fentanyl patches and CBD roller. (we are in the US). It was a real struggle for her until they found the right balance. She actually had the second knee done yesterday. You will need to advocate for yourself both at the hospital and after and tell them very clearly if anything isn’t working and be persistent until you get relief!

[Miserere in reply to cranberryt]

Thanks for the advice - I will bear that in mind! Hope your mother's second op goes well, cranberryt.

[piglette in reply to cranberryt]

I had fentanyl during the op, but opiods make me sick, not to mention constipated. It was quite interesting trying to throw up during a hip op.

[Miserere in reply to piglette]

Oh, wow!

[piglette in reply to Miserere]

The anaesthetist held my head!!

[cranberryt in reply to piglette]

I had the same issue during my c-section! I think the patch worked better at home for her because it didn’t make her nauseous.

[piglette in reply to cranberryt]

I think my body was designed to react to all medicines and vaccines and to fight like mad if anyone tried to take anything out of it such as blood!

[Bella59]

I have had two hip replacements in the last two years.My first one i had to reduce to zero.Second op was six months later and i was allowed to stay on five mgs Pred.Every surgeon has there preferred procedures.I made sure the anaesthetist knew what dose i was taking.After op i upped the Pred.Good luck with your op and make sure you do the exercises.

[Miserere in reply to Bella59]

Thank you, Bella59 - people I have met who have had it done have also stressed the post-op exercises and I shall make sure I do whatever I can. I can't wait to be mobile again.

[S4ndy]

It's the Anesthetist you need to discuss all this with. I am on 5mg a day of pred and recently underwent back surgery. The Anesthetist saw me before my op and told me he would be giving ne extra steroid during the op and not to worry. I did not flare after the surgery. I did have a problem getting my drugs off the staff at the right time though. They managed to lock them away and then couldn't get the locked box open! Took several members of staff to release my drugs! Hope your surgery goes well.

[Miserere in reply to S4ndy]

Thank you!

I don't think that I am due to meet the anaesthetist prior to the op but I will check. I assume he/she will have been given all the information they need.

[S4ndy in reply to Miserere]

I thought that was standard seeing the Anesthetist on the day of your surgery. I always have but that may be because I was in a private hospital. I seem to recall seeing one on my one foray into the NHS again on the day of surgery. Anyway, just mention it when they wheel you down into the Anesthetic room as the Anesthetist should be there. Good luck, knee surgery is my next op. Seeing a surgeon next month.

[DorsetLady PMRGCAuk volunteer in reply to S4ndy]

I always have …

[Miserere in reply to DorsetLady]

Will let you all know but I doubt I shall see anyone prior to the op as no-one has mentioned it.

[piglette in reply to Miserere]

I saw mine at the pre op although in the end she was not the anaesthetist I had! I saw the actual one just before the op and he did the spinal. We talked about holidays!!

[DorsetLady PMRGCAuk volunteer in reply to Miserere]

On the day of the surgery it’s usual for both the surgeon and the anaesthetist come to the admissions ward to talk to you before they go down to the theatre… I would be most surprised if they didn’t.

[Miserere in reply to DorsetLady]

Thanks - I will just check but I'm sure that's what will happen.

[PMRpro Ambassador in reply to Miserere]

The anaesthetists usually appear at some point the evening before or outside the induction room - not necessarily the one who is in theatre but it is more often than not.

[Spudleyboy]

The only thing I can say is that had a hernia operation two weeks before my diagnosis for PMR the Rheumatologist would not start me on pred for six weeks as the steroids lower your emune system and the body takes longer to heal

[PMRpro Ambassador in reply to Spudleyboy]

That's fine if you are in a position to delay the pred - but if you are already a long term pred patient they can't do that.

[Myfoe]

I recently had back surgery I was advised to continue my meds 8mg prednisone but to stop methotrexate I did meet the anesthesiologist the morning of surgery he was up to speed on my medications and added some prednisone in the IV in reflection I wonder if the IV prednisone wasn’t more readily available to my body since the week after surgery was almost PMR pain free… I was given oral pain meds but only needed it for a couple days BUT I foolishly reduced my prednisone 1/2mg the week after surgery BIG mistake I woke to a major flare that has been plaguing me for weeks.. best of luck for a speedy recovery

[Miserere in reply to Myfoe]

That sounds very encouraging, Myfoe - thank you - and I shall be sure not to reduce too quickly after surgery.

[piglette in reply to Miserere]

I increased after my op recommended by my surgeon. My inflammation markers shot up as well.

[confused2]

I have had two knee replacements and didn't adjust my prednisone. The first one I was still on prednisone and the second one I had just been off prednisone for 2 months. No problem.

[Miserere in reply to confused2]

That's brilliant news, confused2! I will keep my fingers crossed.

[Darkchocolate1]

Had a total hip replacement surgery 3 weeks ago while on 11 mg of prednisone. The endocrinologist (I am in the US) wrote instructions on steroid dosing during and after my surgery. The anesthesiologist agree with her plan. I did not reduce my daily 11 mg before surgery and received IV steroids during surgery and for several days after surgery. I had no PMR pain during the ten days I was in the hospital. My endocrinologist told me to go to 10 mg prednisone per day when I finished the IV prednisone which I did. Now at 3 weeks post surgery I am having adrenal insufficiency symptoms and am miserable as a result. I am contracting my endo to see if I can increase prednisone dose for a while and how much. My rehab is going well and I seem to be progressing as most patients do. You likely won’t have access to your own meds while in the hospital. Mine were locked up and I had an alarm on my bed and chair if I got up without an aide with me.

I am sure everyone is different but have no fear they are prepared to get you through your post op period. Best wishes on your surgery. I am glad I had the surgery my pain is so much less already.

[Miserere in reply to Darkchocolate1]

Thank you Darkchocolate1. I'm sorry to hear you are having symptoms of adrenal insufficiency and I hope you are able to overcome that. One through surgery I will stay at the same level of Pred for a month or two until I feel more comfortable. I expect to be in hospital for no more than two days and maybe less. Although I've gone through all the prep work, i.e. pre-assessment and review and sign off with the surgeon, I still don't have an actual date. The surgeon said he would find out and let me know so I am waiting still. Of course, the industrial action that we have going on over here may delay things.

[Miserere]

Spoken to the pre-assessment nurse - she said that if the surgeon is happy with the Pred dose then that will be fine - I shall also, hopefully, be able to talk to the anaesthetist on the day. I certainly won't reduce my Pred too quickly afterwards and I will hope not to have to increase either. I admit to a certain amount of trepidation but then I am sure that is the case pre most surgery for most people. I am due to start reducing the dose again in another week as I seem OK now at 6.5mg - it could be another six weeks before surgery - will see how things go.

Apparently I will also need to take my own medication in, i.e. Prednisolone, and take the dose as normal - it must be in it's original packaging with my name on it - so at least that is clear. I'm not sure about supplements as I normally take an Omega 3, Vit C and CoQ10 but hopefully I shall only be in for a short time.

Onward and upward!!🙂

[PMRpro Ambassador in reply to Miserere]

I wouldn't bother with the supplements - it just confuses them!!!