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