11.5 Rheumatoid Arthritis

Question 1

A 72-year-old patient with longstanding severe rheumatoid arthritis (RhA) presents for total knee
replacement.

a) Which joints may be affected in RhA and indicate why this involvement is of relevance to anaesthesia.
(4 marks)

Answer 1

> > RhA is characterised by a
chronic symmetrical polyarthritis of (mainly)
peripheral joints, especially the fingers,
elbows, ankles, but also more
proximal joints, shoulders,
neck, knees, hips.

Any of these may be relevant to anaesthesia as they may be the focus of an operation and so dictate the choices of anaesthetic technique.

Also, the involvement of any joint may
make positioning for regional anaesthesia problematic.

> > Temporomandibular joint:
may impact on mouth opening and, hence,
ease of intubation.
May necessitate fibreoptic intubation.

> > Cricoarytenoid joint fixation: **
may cause preoperative hoarseness.
Minimal oedema may therefore
cause airway obstruction postoperatively.

> > Atlantoaxial subluxation:
assess range of movement and symptoms
whilst the patient is awake.

Excessive movement (such as with airway
management) can cause cord compression. 
May necessitate fibreoptic intubation.

> > Cervical ankylosis: **
causing limited neck extension, difficult airway.

> > Costovertebral and costotransverse joints: **
restrictive lung defect.

> > Small joints of hand:**
limited ability to manage PCA.

Question 2

b) Which systemic features of RhA may be elicited during preoperative assessment? (10 marks)

Answer 2

Airway:
» Difficult airway for reasons detailed in part (a).

Respiratory:
» Fibrosing alveolitis causing restrictive defect.
» Pleurisy with effusion.
» Nodules.
» Costochondral disease causing reduced chest wall compliance.

Cardiovascular:
>> Pericarditis and pericardial effusions, 
rarely leading to tamponade, usually
gradually restrictive
 and requiring pericardectomy.

>> Rheumatoid nodules in 
any layer of the heart, 
damaging valve function,
causing conduction defects, 
rarely congestive cardiac failure.

> > Increased atherosclerosis
and coronary artery disease.

Neurological:
» Peripheral neuropathy due to:
• Peripheral nerve entrapment (carpal tunnel, ulnar, lateral popliteal).
• Mononeuritis multiplex due to vasculitis.
• Drug treatment.
» Autonomic dysfunction: blood pressure and heart rate lability, gastric
paresis.
» Compression of nerve roots due to spinal involvement (especially cervical
spine).

Endocrine:
» Chronic steroid use:
compromises glucose tolerance, may ultimately
result in diabetes.
Consider the need for perioperative replacement,
effect on immune function, skin fragility.

Haematology:
» Normochromic, normocytic anaemia
of chronic disease.

> > Iron deficiency anaemia
due to chronic gastrointestinal losses
with NSAID treatment.

> > Thrombocytosis due to inflammation.

> > Bone marrow depression due to
disease-modifying anti-rheumatic drugs
(DMARDs).

Immune, infection:
» Increased susceptibility to infection
due to DMARDs or TNF inhibitors.

Cutaneoumusculoskeletal:
» Friable skin (due to chronic steroid loss),
risk of damage with dressings
for cannulae, handling.

> > Fixed joint deformities –
care with positioning.

Renal:
>> Chronic inflammation may cause amyloidosis.
>> Drug treatments may cause CKD.
>> CKD affects metabolism of drugs
used perioperatively.

Hepatic:

> > Methotrexate may cause liver cirrhosis, which will impact on drug
metabolism.

Question 3

c) Outline the preoperative investigations that are specifically indicated in this patient and the
derangements that each may show. (6 marks)

Answer 3

FBC
>> Neutropaenia: 
should not continue with elective surgery
 if the patient is
currently neutropaenic.

>> Anaemia: 
further investigations may be 
indicated to determine the
underlying cause.
 Efforts should be made to 
correct anaemia before
major surgery.

> > Platelet level: impacts on
feasibility of neuraxial technique.

Renal function:
>> Elevated urea, creatinine, 
reduced glomerular filtration rate – 
chronic kidney disease may 
occur due to drugs or the disease itself.

Liver function tests:
» Transaminases and alkaline phosphatase
may rise in active disease.

> > Derangements in all liver
function tests may occur
due to liver cirrhosis
caused by methotrexate.

ECG:
» Conduction disorders.
» Left ventricular hypertrophy.

Chest x-ray:
» Indicated if there are respiratory symptoms.
May reveal pleural effusions,
infection, fibrotic lung disease, nodulosis.

Lung function tests:
» If respiratory symptoms.
Usually reveals a restrictive pattern.

Echocardiogram:
>> If a murmur is noted or there 
are symptoms or signs to suggest poor
cardiac function. 
Regurgitant valves may be due to nodulosis or
pericardial fibrosis.

24-hour ECG tape:
» If the patient has palpitations
that cannot be diagnosed on resting ECG
alone. Arrhythmias may be due to nodulosis of the conduction pathways.

Nasendoscopy and ENT assessment:
» If there is preoperative hoarseness of the voice or other indicator of airway limitation.

Flexion/extension x-rays or MRI of the cervical spine:
» If the patient has pain or neurological symptoms on neck extension or flexion.