Rheumatoid arthritis

OVERVIEW

  • Rheumatoid Arthritis = autoimmune disorder characterised by a bilateral, peripheral symmetrical inflammatory arthritis with a number of other systemic associations.
  • multisystem disease which can range from mild -> severe

CLINICAL FEATURES

  • AIRWAY:
    decreased TMJ mobility -> poor mouth opening, limited head and neck extension, potential atlanto-axial subluxation (anterior, posterior, lateral and vertical), cricoi-aretynoid arthritis (neck pain, head feels like it is falling forward on flexion, arm symptoms, posterior fossa or brainstem symptoms, limb symptoms)
  • RESPIRATORY:
    restrictive lung disease, kyphoscoliosis, pulmonary fibrosis, pneumonitis, pleural effusions, bronchiolitis obliterans
  • CARDIOVASCULAR:
    amyloid infiltration of myocardium, restrictive pericarditis, conduction abnormalities, valve pathology, IHD
  • MUSCULOSKELETAL:
    joint changes and decreased ROM and pain, manual dexterity, worse on morning but improves with motion, ulnar deviation, dorsal wrist subluxation, Boutionniere, Swan-neck deformity, z-deformity of thumb
  • ANALGESIA:
    chronic pain management (adjuncts like ketamine and gabapentin may be required)
  • HAEMATOLOGICAL:
    anaemia may be multi-factorial (chronic disease, NSAID induced GI blood loss, drug induced marrow suppression)

Medications

  • immunosuppressants and steroids -> increased risk of infection and potential for adrenal suppression.
  • should be off monoclonal antibodies for 2/52.

Co-morbid conditions

  • IHD
  • PMR
  • obstructive lung disease
  • smoking
  • systemic vasculitis

INVESTIGATIONS

  • routine bloods: organ dysfunction, drug levels
  • rheumatoid factor +ve (70%)
  • anti-CCP (highly specific)
  • anaemia of chronic disease
  • thrombocythaemia
  • elevated inflammatory markers
  • c-spine xrays: (major destruction, duration > 5yrs, symptoms or signs)

1. atlanto-axial subluxation -> posterior C1 transverse ligament destruction -> cord compression (normal <3mm)
2. atlantoaxial impaction -> superior migration of odontoid and cranial settling -> cephalad movement of dens into foramen magnum -> compression of brainstem
3. subaxial subluxation -> C2-C7 step ladder deformity

  • AADI = anterior atlanto-dens interval (<3mm)
  • PADI = posterior atlanto-dens interval (<14mm) -> more predictive
  • CXR: restrictive changes, effusions, nodules
  • spirometry: restrictive pattern, decreased volumes
  • flow-volume loops
  • CT or MRI
  • ECHO: rule out structural heart disease (restrictive pericarditis\cardiomyopathy), PHT -> RVF

MANAGEMENT

DMARDS

  • steroids: acute flares
  • methotrexate: pneumonitis, oral ulcers, hepatotoxic
  • hydroxychloroquine: retinopathy
  • gold
  • sulfasalazine: rash, decreased sperm count, oral ulcers
  • TNF alpha inhibitors (etanercept, leflunomide): reactivation of Tb, heart failure

Symptomatic Control

  • paracetamol
  • NSAIDS
  • intra-articular injections
  • opioids
  • rheumatologist referral
  • orthopedic spinal/neurosurgical referral (C1-C2 fusion)
  • cervical collars
  • physio
  • discussion about RA vs GA
  • spinal precautions

Intraoperative Management

  • GA (may require AFOI)
  • RA (may be difficult and could fail)
  • careful positioning and pressure area care
  • steroid supplementation
  • good analgesia
  • IVF fluid
  • temperature cares
  • aseptic techniques for invasive procedures (IVC insertion)

ICU Management

  • limited respiratory reserve with restrictive lung disease (decreased compliance)
  • caution with vasoconstrictors c/o Raynauds
  • many have labile haemodynamics
  • immunosuppressed
  • GORD cares
  • PCA for pain relief (may need to be nurse controlled c/o of difficulty using)
  • regular paracetamol
  • NSAIDS if not contraindicated
  • physio (incentive spirometry and percussion therapy)
  • monitoring
  • DVT prophylaxis
  • difficult access
  • re-institute DMARD ASAP (gold, pencillamine, methotrexate, azathioprin) -> doesn’t seem to change rates of post-operative wound infection
  • caution with TNF-alpha blockers -> severe infections reported
  • look for complications of medications and disease: restrictive lung disease, anaemia

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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