Anesthetic concerns in rheumatoid arthritis

Dr. S. Parthasarathy MD., DA., DNB, MD (Acu),

Dip. Diab.DCA, Dip. Software statistics PhD (physio)

Mahatma gandhi medical college and research institute, puducherry, India

History

• 400 BC ‘gout’ was used to describe all types of arthritis.

• Jacob in 1800 ==== described rheumatoid arthritis (RA) as asthenic gout

Introduction

• Symmetrical polyarthropathy and significant systemic involvement

• 1 % incidence • Females preponderance • 30 – 55 years • HLA DR 4 association in 70% • RA seropositive in 80 % cases• Viral, bacterial, environmental factors, smoking

Clinical features

• Rheumatoid arthritis is a heterogeneous inflammatory arthritis.

• Typical presentation is with persistent, painful joint swelling with morning stiffness• MCP and proximal Interphaleangeal joints

affected. ( DIP spared )• The course of the disease is characterized by

exacerbations and remissions

MCP and PIP affected but distal IP??

Before that

• Fever • Fatigue,• Malaise • Skeletal and muscle pain

• Phase of Synovial inflammation

Score -- Six or more

Lower limbs are also affected

Extra articular

Extra articular

Atlantoaxial subluxation (AAS)

• Anterior • Posterior • Vertical • Lateral

Management of rheumatoid arthritis

• Symptom relief ↖

• Para , NSAIDs, weak opioids , steroids • Regress the disease process ↙• Disease modifying anti-rheumatic drugs

(DMARDs),

DMARDs

• Methotrexate– antimetabolite • 5 or 10 mg once a week

• GI toxicity, liver , myelosuppression can occur

• Leflunamide, hydroxychloroquine, sulfasalazine, azathioprine

• Liver, kidney, ILD, hypertension, pneumonia

Anti TNF alpha

• Infliximab• Adalimumab• Etanercept • Certolizumab

Anaesthetic challenges

Preoperative assessment

• Surgeries

Related

Unrelated

Airway assessment

• assess the range of neck flexion and extension• TMJ mobility and mouth opening• Preoperative cervical spine – ?? No guidelines • Cervical Spine Radiographs in Patients With

Rheumatoid Arthritis Undergoing Anesthesia• JCR: Journal of Clinical Rheumatology &

Volume 18, Number 2, March 2012

Instability

Airway • Cricoarytenoid arthritis – hoarseness , voice

changes, stridor, URTI • Laryngeal amyloidosis and rheumatoid nodules

may also cause obstruction• Preoperative nasendoscopy

Anaesthesiologist decides

doughnut head ring with a large enough hole toaccommodate the occiput – described

Consider during anaesthesia- airway

• 1 Using a facemask or supraglottic airway device. (Intubating LMA)

• 2 Using the smallest internal diameter tracheal tube possible.

• 3 Avoiding trauma at intubation

• MRI c spine • In emergency – consider as unstable

Airway

• The Bellhouse technique (angle from the neutral

head position to extreme extension, without moving

the neck) of assessing the occipito-atlanto-axial

(OAA) extension capacity may be unreliable due to

compensatory subaxial extension

Systemic illness

• Cardiovascular

• 50 % of mortality in RA

• Pericarditis, aortic regurgitation, arrhythmias • vasculitis – coronary • ECG , ECHO

Cardiovascular

• Myocarditis, amyloidosis, • Granulomatous disease• Endocarditis • Left ventricular failure

• Evaluate even in young patients• CVS risk same as diabetes mellitus

Respiratory system • respiratory investigations (chest radiographs, arterial

blood gases and lung function tests) due to the possibility

of pulmonary involvement (fibrosis, nodules, effusions)

Respiratory myopathy.• Restrictive defect , • Reduced chest wall compliance (costochondral disease)

• Reduction in gas exchange and exercise-induced

hypoxemia

Renal system

• Subclinical renal dysfunction is commonly seen in rheumatoid arthritis patients.

• One study • 11% had proteinuria, 10% had deficient

urinary concentration, and 8% had reduced glomerular filtration.

• Routine renal function tests to be done

Neurological and ocular

• Peripheral neuropathy• Autonomic dysfunction• Kerato-conjunctivitis• Apply Methylcellulose eye – • 15% of patients with RA • Peripheral vasculitis and Raynaud’s

phenomenon• ( temperature monitoring )

Clotting • hypercoaguable state

• due to

• 1. Increased plasma levels of fibrinogen, von

Willebrand factor, plasminogen activator inhibitor,

and other acute phase reactants,

• 2. direct vascular injury due to dyslipidemia

associated with glucocorticoid therapy or rheumatoid

vasculitis

HB and blood grouping

• Anaemia is common anaemia of chronic disease (normocytic, normochromic)

• Drugs ?? • gastrointestinal haemorrhage,• myelosuppression. • Parenteral iron ?? • The preoperative haemoglobin should be

brought to at least 10.0 gm for elective surgery = blood answer !!

Steroids

• Patients taking more than 10 mg prednisolone per

day should be given appropriate perioperative

steroid cover.

• Fragile veins makes peripheral venous access

unreliable and central venous access is often difficult

due to neck deformity

Drugs • Corticosteroids cause insulin resistance, hypertension,

hypercholesterolaemia and hypertriglyceridaemia

• NSAIDs- bleeding??

• Methotrexate – myelosupression, liver toxicity

• All drugs to continue ?? Even TNF alpha antagonists ??

• Infection – but recent studies okays continuing

• Metoclopramide – careful dosage .

Anaesthesia

Regional anaesthesia – consider • It avoids airway manipulation,

• good postoperative pain relief, reduces polypharmacy.

• Catheter techniques may be used for effective

postoperative analgesia

• Technically difficult due to spinal arthritis and loss of

anatomical landmarks from contractures or deformities.

• direct invasion of nerve by rheumatoid nodules

• A higher than normal level in spinal

General anaesthesia- airway

• USE LMA if possible

• FOL or video laryngoscopes ready

• A surgical tracheostomy under local anaesthesia may

be indicated in emergency situations and in patients

who have symptoms of upper airway obstruction

General anaesthesia

• Nitrous oxide and methotrexate ?? – • air -O2 – agent• Positioning in fragile patients• Opioids – ok • Blood glucose and antibiotics , asepsis • Tourniquets even three – used

Airway in extubation

• Considering the use of an airway exchange catheter at extubation.

• Extubating in a suitable environment and at the appropriate time (obstruction often develops some time after extubation).

• In severe cases, a pre-operative tracheostomy may be required.

Beware of IV FLUIDS

• Rheumatoid patients are often slight of build, and

frequently adults may weigh only 35 kg or less.

Routine adult fluid balance orders may precipitate a

dilutional hyponatremia and water intoxication with

overt convulsive manifestations.

Postoperative pain

• No PCA – difficult to use for patients – joints affected.

• Parenteral narcotics – √• Paracetomol -- √• Epi cath -- √

• Physiotherapy – lungs !!, spine fixed !!• renal function monitoring • Post op renal failure in otherwise healthy RA !!

Summary

• What is it ?? Incidence ?? • Drugs • Preoperative concerns ( airway and systems) • Intra operative concerns • Post op pain control • Post op physiotherapy and renal monitoring

Thank you all