How is the rheumatoid arthritis patient evaluated for anesthesia?

How is the rheumatoid arthritis patient evaluated for anesthesia?

A thorough history and physical examination should be conducted with particular attention to the above systems. These patients commonly have concomitant illnesses such as hypertension, coronary artery disease, and chronic obstructive pulmonary disease.

A thorough airway examination is necessary in the RA patient, including evaluation of Mallampati classification, thyromental distance, mouth opening, and neck move-ment. Since these patients may be limited in activity a focused cardiac examination may reveal limited informa-tion, but should be done nonetheless. Auscultation of the chest should be performed to assess for murmurs, rubs, or gallops. An electrocardiogram should be done to assess any conduction delays. A history of shortness of breath may warrant an echocardiogram and/or stress test and possibly a complete cardiology evaluation. Chest pain may be related to coronary artery disease or pleuritis.

Auscultation of the lungs should be performed looking for any areas of decreased breath sounds. A chest radiograph will show the presence of pulmonary fibrosis or emphy-sema. Pulmonary function tests, while an excellent indica-tor of the progression of rheumatoid obstructive and restrictive pulmonary disease, are useful preoperatively only in the severely affected patient.

Hematocrit should be performed to assess the degree of anemia. Basic electrolytes including sodium, potassium, BUN, and creatinine will reveal the extent of renal dysfunc-tion. A history of medication use is of course necessary. Many drugs used to treat RA have side-effects that need to be con-sidered; for example, DMARDs cause myelosuppression. The patient taking steroids may need perioperative stress doses.

Though commonly neglected by the anesthesiologist, it is necessary to ask the patient how comfortable he or she will be in the lateral decubitus position, which is used for total hip arthroplasty. The RA patient may suffer from stiffness not allowing maximum flexibility as required by the surgeon. One must ask the patient whether the upper and lower extremities and back need to be padded to provide for comfort. During a regional anesthetic, the awake patient can help in the positioning. However, during a general anesthetic the anesthesiologist will need to ensure that the patient is appropriately positioned.