Rheumatoid Arthritis 

 

 

Considerations 

 

  • Potential for difficult airway & unstable c-spine:

    • TMJ involvement, atlanto-axial instability (AAI)*, cricoarytenoid arthritis  

  • Multisystem disease:

    • Respiratory: interstitial fibrosis, pulmonary hypertension, pleural effusions

    • Cardiovascular: pericarditis, AI, pericardial effusions, conduction system defects, LV dysfunction, accelerated CAD 

    • CNS: peripheral neuropathy resulting from nerve compression, carpal tunnel syndrome, & tarsal tunnel syndrome are common, chronic pain

    • Renal: chronic renal failure possible (drugs, amyloidosis, vasculitis)

    • Heme: chronic anemia, thrombocytopenia, neutropenia (Felty’s syndrome)

  • Medication side effects: corticosteroids, NSAIDs, immunosuppressives (cyclosporine, cyclophosphamide, methotrexate), stress dose steroids if needed 

  • Technical difficulties with lines & patient positioning, fragile skin

 

 

Goals 

 

  • Safe establishment of airway & preservation of c-spine integrity

  • Careful positioning & documentation of pre-existing neurologic symptoms

  • Rule out systemic disease & manage any existing abnormalities, especially cardiopulmonary 

 

 

Pregnancy Considerations

 

  • Obstetric management: vaginal delivery is preferred, cesarean section is reserved for obstetrical indications 

  • Anesthesia: 

    • Regional definitely ok if platelets within normal limits 

    • Document pre-existing injuries 

    • If GA: very cautious airway management!!

 

 

*Approach to AAI 

 

  • Indications for X-ray are controversial 

  • Indications suggested in literature: 

    • Severe disease requiring steroids, methotrexate, & immunosuppressants 

    • Obvious symptoms 

    • Disease >10 years 

  • On X-ray distance from the anterior arch of the atlas to the odontoid process > 3 mm confirms the presence of atlantoaxial subluxation

  • This abnormality is important, because the displaced odontoid process can compress the cervical spinal cord or medulla or occlude the vertebral arteries. When atlantoaxial subluxation is present, care must be taken to minimize movement of the head & neck during direct laryngoscopy to avoid further displacement of the odontoid process & damage to the spinal cord. It is helpful to evaluate preoperatively whether there is interference with vertebral artery blood flow during flexion, extension, or rotation of the head & cervical spine. This can be accomplished by having the awake patient demonstrate head movement or positioning that can be tolerated without discomfort or other symptoms.