Anesthetic concerns in rheumatoid arthritis Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip....

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