Rheumatoid arthritis
Anesthetic relevance C spine instability Adrenal suppression
Anesthetic management Airway manipulation: consider awake fiberoptic if severe Regional anesthesia preferred if able
Specialty Anesthesia
Signs and symptoms {{{signs_symptoms}}}
Diagnosis
Treatment


Rheumatoid arthritis is a common chronic inflammatory arthritis affecting 1% of adults and is characterized by symmetrical polyarthropathy and significant systemic involvement.

Anesthetic implications

Preoperative optimization

Careful systemic examination to identify systemic manifestations of the disease

Airway:

  • Atlanto-axial instability is present in about 25% of RA patients. It is critical to assess neck range of motion with associated symptoms, including upper extremity weakness/numbness -> if present warrant further imaging. Starting with flexion/extension c -spine x ray and may require CT/MRI
  • Jaw range of motion/TMJ
  • Consider regional with natural airway vs awake fiberoptic vs extremely careful DL/VL depending on preop findings

Neuro:

  • Identify peripheral neuropathies for proper position intraop

Cardiac:

  • Often limited functional ability -> assess further cardiac workup with RCRI, activity, and surgical risk per AHA preop cardiac guidelines
  • CAD risk
  • Murmur identification and symptomology ->may require echo or other cardiac workup

Pulmonary:

  • Consider CXR if suspicious physical exam findings concerning for effusions
  • Possible restrictive lung defects

GI:

  • Stop NSAIDs preop
  • CMP for LFTs

Renal:

  • Stop NSAIDs preop
  • CBC for Creatinine and BUN
  • If on chronic steroids, consider continuing chronic dose and watch for symptoms of adrenal suppression. >20mg prednisone per day for >3 weeks is associated with higher risk of adrenal suppression and may require stress dose steroids.

Intraoperative management

Anesthesia plan

  • GA
    • LMA possibly difficult to insert due to abnormalities. Consider aspiration risk factors
    • ETT must be placed with with potentially unstable cervical spine in mind. Based on preop ROM, radiology, consider video placement with minimal movement vs awake fiberoptic. Classical sniffing position increases risk of anterior atlanto-axial subluxation
  • Regional
    • Regional/local blockade preferred to avoid airway instrumentation and its associated risks in RA
    • Regional blocks or even epidural anesthesia are safe in RA patients assuming there are no other contraindications.

Positioning

  • Meticulous positioning in patients preoperative position of comfort
  • Consider eye drops given patients increased risk of corneal ulcerations

Sterile technique

  • Full aseptic technique is especially important given likely immunosuppression

Hypotension

  • Consider adrenal suppression and stress dose steroids

Postoperative management

Infections

  • Post operative infection risk is higher given the degree of immunosuppression

Signs and symptoms

Neurological: Peripheral neuropathy, autonomic dysfunction

Cardiovascular: Pericardial effusions, amyloidosis, CAD, aortic regurgitation, peripheral vasculitis, difficult vascular access

Pulmonary: Restrictive defects, rheumatoid nodules, pleural effusions, DMARD pulmonary toxicity

Gastrointestinal: Often on chronic NSAIDs with increased ulcer/bleeding risk

Hepatic: Decreased serum albumin, hepatomegaly, drug toxicity

Renal: Chronic renal insufficiently from medications, adrenal suppression

Hematological: Chronic anemia, bone marrow suppression from drug therapy

Infectious: Increased risk infections from immunosuppressants

Diagnosis

Symmetrical erosive polyarthripathy most often affecting joints of the hand (often PIP and MCP_ and feet associated with morning stiffness. Joint stiffness is classically worse in the morning and after periods of prolonged inactivity. Diagnosis is clinical and can be confirmed with laboratory markers including Anti-CCP and elevated inflammatory markers

Treatment

Medication

Symptom relief

  • NSAIDs: side effects of bleeding, nephrotoxicity
  • Corticosteroids
  • Opioids

Disease modification

  • Methotrexate is generally first line agent
    • Anti-metabolite, inhibiting the dihydrofolate reductase enzyme required to produce purine.
    • Immunosuppressive, hepatotoxic, risk of pulmonary fibrosis
  • Azathioprine
    • Side effects of cholestatic hepatitis, bone marrow suppression
  • Etanercept
    • Binds TNF and can cause flu like symptoms and demyelinating disorders
  • Infliximab
    • Anti-TNF antibody and is associated with extrapulmonary TB

Surgery

Frequently require multiple orthopedic interventions given degree of joint destruction

References