What is the best pre and post-operative management for a patient with a history of smoking and possible psoriatic arthritis who is scheduled for amputation?

Perioperative Management for Amputation in a Patient with Smoking History and Possible Psoriatic Arthritis

This patient must stop smoking immediately and ideally delay surgery for 4-8 weeks if the amputation is not urgent, as smoking increases infection and reamputation risk by 2.5-fold in amputation patients. 1, 2, 3

Preoperative Optimization

Smoking Cessation (Critical Priority)

Smoking cessation is the single most important modifiable risk factor for this patient. The evidence is particularly compelling for amputation surgery:

• Cigarette smokers have 2.5 times higher risk of infection and reamputation compared to non-smokers after lower extremity amputation 3
• Minimum 4 weeks of preoperative abstinence is required to reduce respiratory and wound-healing complications 1, 2, 4
• Optimal timing is 6-8 weeks for maximal cardiopulmonary benefit and wound healing 4
• Smoking during the healing phase compromises cutaneous blood flow and increases microthrombosis risk 3

Cessation intervention protocol:

• Initiate intensive counseling (face-to-face or telephone) with written materials 2, 4
• Add nicotine replacement therapy or varenicline as pharmacologic adjuncts 4
• Begin weekly counseling sessions 4-8 weeks preoperatively if surgery can be delayed 4
• Patient must abstain from cigarettes at minimum one week before surgery to normalize coagulation, fibrinogen levels, and eliminate free radicals 3

Critical caveat: If this is an urgent amputation (e.g., for acute limb-threatening ischemia or infection), do not delay surgery for smoking cessation—the risk of disease progression outweighs cessation benefits 2, 4. However, encourage immediate cessation and provide support throughout the perioperative period 2.

Psoriatic Arthritis Management

If the patient is on immunosuppressive therapy for psoriatic arthritis, medication timing must be carefully coordinated:

• Withhold biologic DMARDs before surgery, scheduling the procedure at the time of the next missed dose (e.g., adalimumab given every 2 weeks: schedule surgery in week 3) 1
• Withhold tofacitinib for at least 7 days prior to surgery 1
• Continue current daily glucocorticoid dose if patient is on steroids—do NOT use stress-dose steroids 1
• **Optimize glucocorticoid dose to <20 mg/day prednisone equivalent** before surgery when possible, as doses >15 mg/day increase infection risk 1

Preoperative Counseling and Education

The patient must receive dedicated preoperative counseling from a multidisciplinary team (surgeon, anesthesiologist, nurse) covering 1:

• Surgical procedure details and expected recovery timeline
• Smoking's specific impact on amputation healing and reamputation risk
• Pain management strategies
• Early mobilization expectations
• Respiratory physiotherapy requirements 1

Perioperative Antibiotic Prophylaxis

Administer cefazolin 1 gram IV 30-60 minutes before surgical incision 5

Intraoperative redosing:

• For procedures >2 hours: give cefazolin 500 mg-1 gram during surgery 5
• Continue every 6-8 hours for 24 hours postoperatively 5

Extended prophylaxis consideration:

• In amputation where infection would be devastating, prophylaxis may continue for 3-5 days post-surgery 5

Postoperative Management

Medication Resumption (for Psoriatic Arthritis)

Restart biologic therapy once the wound shows evidence of healing (typically ~14 days), when 1:

• All sutures/staples are removed
• No significant swelling, erythema, or drainage present
• No clinical evidence of surgical or non-surgical site infections

Smoking Cessation Continuation

Provide cessation support throughout the entire perioperative period 2

• The patient must continue abstinence during the healing phase to prevent wound complications 3
• Cigarette smoking during healing dramatically increases infection and reamputation risk 3

Critical Pitfalls to Avoid

1. Do not allow short-term smoking cessation (<4 weeks) if surgery is elective—benefits are unclear for respiratory complications and inadequate for wound healing 1
2. Do not use stress-dose glucocorticoids in patients on chronic steroids for psoriatic arthritis—continue their usual daily dose 1
3. Do not restart biologic DMARDs early—wait for clear wound healing evidence (~14 days) to minimize infection risk 1
4. Do not delay urgent amputation for smoking cessation—disease progression risk outweighs cessation benefits in emergent situations 2, 4
5. Do not underestimate the specific amputation risk—cigarette smokers have 2.5-fold higher reamputation rates 3