Rheumatoid Arthritis

Question 1

What is the underlying pathology in the joints of

patients with rheumatoid arthritis?

Answer 1

Cellular hyperplasia occurs in the synovium with progressive infiltration by lymphocytes, plasma cells, and fibroblasts. The articular cartilage is eventually completely destroyed.

Question 2

What symptoms characterize rheumatoid arthritis?

Answer 2

Rheumatoid arthritis is characterized by symmetric
polyarthropathy that affects weight-bearing joints and proximal interphalangeal and metacarpophalangeal joints. It is typically
worse in the morning. In the most severe forms, every joint can be affected except for the lumbar and thoracic spine.

Question 3

What are the treatment options for rheumatoid

arthritis?

Answer 3

Medical therapy is directed toward palliative treatment. Corticosteroids suppress many of the inflammatory symptoms of RA. Anticytokine agents such as etanercept, adlimumab,
and infliximab interfere with the cytokine known as tumor necrosis factor and help slow the progression of the disease. Methotrexate is effective in reducing symptoms, as are immunosuppressive drugs such as cyclophosphamide and cyclosporine.

Question 4

What are the major anesthetic considerations for the patient with rheumatoid arthritis?

Answer 4

Because of the arthritic changes involving the laryngeal, temporomandibular, and cervical joints, a careful airway evaluation is crucial. The chronic use of NSAIDs may inhibit platelet function and lead to liver and/or kidney dysfunction which may alter the pharmacologic plan. The use of
cyclophosphamide can inhibit plasma cholinesterase and prolong the duration of action of succinylcholine. The use of long-term corticosteroid therapy will warrant extra steroid
coverage.

Question 5

What is the most common hematologic abnormality accompanying rheumatoid arthritis?

Answer 5

Anemia

Question 6

What is the most common pulmonary complication of rheumatoid arthritis?

Answer 6

Pleural effusion

Question 7

What cardiac complications may be present in the

patient with rheumatoid arthritis?

Answer 7

Approximately 1/3 of patients with rheumatoid arthritis exhibit pericardial thickening with effusion. Pericarditis, myocarditis, and coronary artery arteritis may be present. Aortitis may produce dilation of the aortic root and subsequent aortic
regurgitation. The cardiac conduction system can be disrupted by the presence of rheumatoid nodules.

Question 8

What are the airway management concerns in the

patient with rheumatoid arthritis?

Answer 8

The disease often affects the temporomandibular joint and restricts mouth opening. It can also affect the joints of the larynx and cause generalized edema and laryngeal swelling. Cervical spine instability may be present and atlantoaxial
subluxation can push the odontoid process into the foramen magnum during laryngoscopy.