Anesthetic concerns in rheumatoid arthritis

1. 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

2. History • 400 BC ‘gout’ was used to describe all types of arthritis. • Jacob in 1800 ==== described rheumatoid arthritis (RA) as asthenic gout

3. 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

4. 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

5. MCP and PIP affected but distal IP??

6. Before that • Fever • Fatigue, • Malaise • Skeletal and muscle pain • Phase of Synovial inflammation

7. Score -- Six or more

8. Lower limbs are also affected

9. Extra articular

10. Extra articular

11. Atlantoaxialsubluxation (AAS) • Anterior • Posterior • Vertical • Lateral

12. Management of rheumatoid arthritis • Symptom relief ↖ • Para , NSAIDs, weak opioids , steroids • Regress the disease process ↙ • Disease modifying anti-rheumatic drugs (DMARDs),

13. 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

14. Anti TNF alpha • Infliximab • Adalimumab • Etanercept • Certolizumab

15. Anaesthetic challenges

16. Preoperative assessment • Surgeries Related Unrelated

17. 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

18. Instability

19. 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 to accommodate the occiput – described

20. 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

21. 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

22. Systemic illness • Cardiovascular • 50 % of mortality in RA • Pericarditis, aortic regurgitation, arrhythmias • vasculitis – coronary • ECG , ECHO

23. Cardiovascular • Myocarditis, amyloidosis, • Granulomatous disease • Endocarditis • Left ventricular failure • Evaluate even in young patients • CVS risk same as diabetes mellitus

24. 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

25. 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

26. 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 )

27. 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

28. 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 !!

29. 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

30. 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 .

31. Anaesthesia

32. 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

33. 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

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

35. 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.

36. 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 dilutionalhyponatremia and water intoxication with overt convulsive manifestations.

37. Postoperative pain • No PCA – difficult to use for patients – joints affected. • Parenteral narcotics – √ • Paracetomol -- √ • Epicath -- √ • Physiotherapy – lungs !!, spine fixed !! • renal function monitoring • Post op renal failure in otherwise healthy RA !!

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

39. Thank you all