What are the anesthetic considerations for the rheumatoid arthritis patient?

What are the anesthetic considerations for the rheumatoid arthritis patient?

Airway

The RA patient may have atlantoaxial instability of the cervical spine. Excessive manipulation of the neck during endotracheal intubation or while positioning the patient can result in devastating consequences such as atlantoaxial subluxation. Cricoarytenoid arthritis presents with hoarse-ness, pain on swallowing, dyspnea, stridor, and tenderness over the larynx. Erythema and edema of the vocal cords may result in a narrowed glottic opening. Temporomandibular joint arthritis may limit mouth opening.

Cardiac

Though common, cardiac complications rarely necessi-tate intervention prior to the induction of anesthesia.

Many patients develop pericarditis and/or pericardial effu-sion, which may progress to cardiac tamponade. Valvular abnormalities develop secondary to rheumatoid nodules. Rheumatoid nodules may be present in the conduction system of the heart resulting in dysrhythmias and various degrees of conduction blockade.

Pulmonary

The most common pulmonary symptom is pleuritis or pleural effusion. Rheumatoid nodules can be seen on pleu-ral biopsy. Interstitial pneumonitis can be present and can ultimately progress to pulmonary fibrosis. Small airway disease and emphysema can also occur in the rheumatoid patient. Many DMARDs, including methotrexate, gold, and cyclophosphamide, can cause interstitial lung disease.

Renal

Renal problems are rare in RA patients and are usually related to treatment with NSAIDs or DMARDs. Amyloidosis may occur secondary to long-standing inflammation.

Hematologic

Normochromic, normocytic anemia of chronic disease is usually present. Patients may also have B₁₂ and folic acid deficiency.

Other systems

Vasculitis and cutaneous and ocular manifestations may also be present. Peripheral neuropathy may be significant due to local compression from synovial inflammation.