Rheumatoid arthritis

 

Issues:

 

*Extra-articular disease present in 50%*

Airway

Atlanto-axial disease:

·         Dens to anterior arch: separation >3mm, subluxation >8mm

·         Present in 30%

·         Unstable in 10%

·         Symptomatic in 3%

·         Risk spinal cord damage -> quadriplegia

·         Risk vertebral artery damage -> stroke

·         Risk difficult intubation

 

-> Pre-op C-spine imaging if at risk peri-op (e.g. airway, positioning)

-> Video laryngoscope + hyperangulated blade + minimal manipulation

-> Care with positioning for surgery

Breathing

·         Restrictive lung disease

·         Pleural effusion

Circulation

·         Accelerated CAD

·         Pericardial disease

·         Valve regurgitation

·         Cardiomyopathy

 

-> Pre-op ECG ±TTE ± stress test

-> Intra-op 5 lead ECG ± A-line + vasopressor infusion

Disability (neuro)

·         Chronic pain / opioid use

·         Depression

·         Compressive peripheral neuropathy

Kidney

·         Drug-induced CKD in 25%

Liver

·         Hepatomegaly

·         Abnormal serum proteins

Haem

·         Normocytic anaemia

·         Drug-induced marrow depression

·         Drug-induced immunosuppression

-> Pre-op plt + coag if neuraxial

Immune

·         Sjogren’s syndrome

·         Felty’s syndrome

-> Consider pausing immunosuppressants if high risk

Drugs

·         Glucocorticoids

o    Insufficiency

o    Side effects

·         Immunosuppressants

·         DMARDS

·         NSAIDs

·         Opioids

 

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