anesthetic concerns in rheumatoid arthritis dr. s. parthasarathy md., da., dnb, md (acu), dip....
TRANSCRIPT
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