FRCA Notes

Rheumatoid Arthritis

The curriculum asks us to describe 'the perioperative implications of rheumatological disease, including but not limited to rheumatoid arthritis'.

Resources

  • RA is a multi-system, autoimmune disease
  • It typically causes a symmetrical inflammatory polyarthropathy affecting the:
    • Neck (atlanto-axial joint)
    • Upper limb: Wrists/Shoulders/Elbows
    • MCPJ and PIPJ (relative sparing of the DIPJ) of the hands
    • Lower limbs: ankles
  • It has a number of extra-articular features that occur in >50% of patients and may be of particular anaesthetic relevance
  • Incidence 1.5 - 3.6/100,000/yr
  • More common in women (3x)
  • Peak onset 30 - 55yrs
  • Affects 2% of the UK population

  • Auto-immune disease of uncertain aetiology
  • 70% of cases are associated with the HLA-DR4 subtype
  • 80% of cases are sero-positive for rheumatoid factor

  • Risk factors:
    • Female gender
    • Family history of RA
    • Altered gut flora
    • Food allergies/intolerances
    • Psychological distress
    • Cigarette smoking
    • Heavy metal exposure

Airway and C-spine

  • TMJ dysfunction may limit mouth opening
  • Atlanto-axial subluxation, most commonly anteriorly, in up to 25%
    • May be asymptomatic
    • Pain radiating to the occiput is the earliest and most common symptom
    • Upper limb paraesthesia or painless sensory loss can occur
    • May require pre-operative X-rays of the cervical spine (AP, lateral flexion/extension and peg views), esp. if symptoms are present
    • Defined as >4mm between odontoid peg and atlas if >44yrs (or >3mm if younger)
  • Cervical spine ankylosis
  • Crico-arytenoid involvement can cause hoarse voice and even stridor
  • Rheumatoid nodules and amyloidosis can cause narrowed glottis

Respiratory

Extra-articular feature Consequence
Pleural effusions (most common) Reduced lung volumes & compliance
Costochondral disease Reduced chest wall compliance
Rheumatoid nodules (up to 3cm) May be mistaken for neoplastic lesions of the lung
Fibrosing alveolitis (rare) Restrictive lung defect

Cardiovascular

Extra-articular feature Consequence
Pericardial effusions Reduced CO ± risk of tamponade
Granulomatous disease Conduction defects
Myocarditis LV failure, ↓ CO
Peripheral vasculitis/Raynaud's Difficulty detecting peripheral SpO2
Valvular disease
↑ rate of atherosclerotic heart disease

Neurological

Extra-articular feature Consequence
Peripheral neuropathy Meticulous care with positioning
↑ risk of perioperative nerve injury
Autonomic neuropathy Impaired reflex responses to intra-operative hypotension
Keratoconjunctivitis sicca (15%) Higher risk of corneal abrasions and dry eyes
Frailty
Carpal tunnel syndrome
Nerve root or cord compression

Renal

  • Amyloidosis and renal failure may be a sequela of RA
  • NSAID-induced nephropathy

Haematological

  • Anaemia of chronic disease (normocytic, normochromic)
  • Iron deficiency anaemia secondary to occult GI bleeding from NSAID use
  • Prothrombotic state

Medication-related

  • Side-effects from steroids including glycaemic control issues, thin skin and easy bruising
  • Immunosuppression due to the effect of drugs such as steroids, methotrexate, sulfasalazine, penicillamine and gold
  • Deranged LFTs

Symptom relief

  • Non-pharmacological methods e.g. physiotherapy, occupational therapy
  • NSAIDs (non-selective or COX-2-selective)
  • Corticosteroids for acute flares
  • Long-acting opioids for chronic pain relating to joint destruction

Disease-modifying anti-rheumatic drugs (DMARDs)

Drug Mechanism Side-effects
Methotrexate Anti-metabolite GI & hepatic toxicity
Pulmonary toxicity (2-7%)
Immunosuppression
Drug interactions
Ciclosporin Calcineurin inhibitor Hypertension
Nephrotoxicity
Sulfasalazine Immunomodulator Stevens-Johnson syndrome
Azathioprine Purine antagonist Slow acetylation ↑ risk of toxicity
Pancreatitis
Gold salts Unknown Glomerulonephritis
Hydroxychloroquine Blocks toll-like receptors Ocular toxicity
Leflunomide Pyrimidine antagonist Hepatic toxicity
Anakinra IL-1 receptor antagonist Pulmonary toxicity
Biologics (1st line)
Etanercept, infliximab, adalimumab		 Anti-TNFɑ agents Reactivation latent infection
Heart failure
↑ lymphoma
Biologics (2nd line)
Tocilizumab, rituximab, abatecept		 Various As with 1st line agents


Perioperative management of the patient with rheumatoid arthritis


History and examination

  • Full history to elicit control of disease, extra-articular features, drug history and presence of symptoms inc. neuropathy
  • Examination to exclude cardiorespiratory disease and atlanto-axial subluxation
  • Detailed airway assessment

Investigations

  • Bloods: FBC, U&E, LFT
  • X-rays of the cervical spine
  • FNE by ENT colleagues to check for crico-arytenoid dysfunction
  • Consider CXR if concern over pulmonary involvement or drug-induced pulmonary toxicity
  • Lung function testing to look for restrictive lung defect
  • 12-lead ECG looking for LV strain, conduction deficits
  • ± TTE if suspicion of cardiac involvement

Optimisation

  • Optimisation of anaemia if present
  • Liaison with Rheumatology re: continuing/stopping drugs in the perioperative period
  • MDT input for frailty
  • May need dietician referral for cachexia

Monitoring and access

  • AAGBI
  • May have fragile veins making venous access more difficult
  • Consider A-line if cardiorespiratory features
  • If CVC required IJV site potentially difficult due to restricted head/neck movement

Anaesthetic technique

  • Consider using regional or neuraxial anaesthesia where possible to limit airway/C-spine manipulation
  • This may however itself be challenging due to articular involvement and difficulty positioning

Airway management

  • Anticipate a difficult airway
  • If intubation is not required, consider an LMA as requires less manipulation to insert and leads to less post-operative laryngeal oedema

  • If intubation is required:
    • Consider need for awake tracheal intubation
    • No evidence that any one laryngoscopic technique is superior
    • Use MILS to ensure C-spine immobile during asleep intubation

Care bundle

  • Strict asepsis for procedures due to immunosuppression
  • Routine perioperative antibiotic prophylaxis where indicated
  • VTE prophylaxis
  • Apply methylcellulose eye drops as 15% of patients suffer dry eyes from keratoconjunctivitis sicca and are at increased risk of corneal ulceration
  • Meticulous positioning due to articular disease, existing neuropathy, high risk of further neuropathy, frailty and thin skin from steroid treatment
    • Ideally get patient to position themselves on the operating table to reduce discomfort and risk of pressure injury
  • Perioperative steroid management if on long-term glucocorticoids

  • Multi-modal approach to anti-emesis to reduce dehydration/starvation and enable resumption of RA medications
  • Multi-modal analgesic approach to ensure return to baseline mobility (be mindful may not be able to use PCA if bilateral hand disease)
  • Regular physiotherapy
  • Appropriate VTE prophylaxis