How may a history of severe rheumatoid arthritis influence the intensive care management of a 55 year-old woman with faecal peritonitis?
Rheumatoid arthritis is associated with a myriad of effects and complications. An ICU relevant list may include:
a) manifestations of the disease itself and its complications:
- bone and joint destruction ( atlantoaxial subluxation)
- vasculitis (renal impairment)
- pulmonary fibrosis
- neutropenia, anaemia, thrombocytopenia (eg Felty’s Syndrome)
b) related to treatment
Steroids- immunosuppression, skin changes, diabetes Methotrexate- immunosuppression, skin changes, diabetes NSAIDS- prone to renal failure, peptic ulcer disease etc Gold penicillamine
From this it can be seen that the ways that RA influences ICU management may be manifold. The candidate was expected to briefly explain the consequences of these factors in the management of faecal peritonitis.
The complications of rheumatoid arthritis, and the ways in which they influence critical care for these patients, is discussed in the answer to Question 30.1 from the first paper of 2008.
- Difficult intubation, as caused by the abovementioned issues:
- Poor neck extension due to C-spine arthritis
- Risk of spinal cord injury due to atltantoaxial subluxation
- Poor mouth opening due to TMJ arthritis
- Poor vocal cord opening due to laryngeal arthritis or crico-arytenitis
- Poor respiratory reserve due to pulmonary fibrosis
- Difficulty assessing all of these issues in the context of an ICU intubation - you are not seeing this person in the pre-admission clinic; likely they are trying to die in some sort of advanced life support scenario.
- Difficult mechanical ventilation:
- Oxygenation pproblems:
- Pulmonary fibrosis, diffusion defect
- Pulmonary hypertension
- Ventilation problems
- Pleural effusions
- Restrictive lung disease with poor complicance
- Weaning problems:
- Poor muscle strength due to steroid myopathy
- Delayed extubation if the intubation was difficult
- Oxygenation pproblems:
- Cardiac and vascular problems:
- Propensity to arrhythmias
- Increased risk of ischaemic heart disease
- Diastolic failure due to restrictive cardiomyopathy and pericardial disease make fluid resuscitation challenging
- Cardiac weirdopathy (eg. failure due to amyloid deposition needs to be considered in the differential diagnosis of an otherwise unexplained heart failure when the patient also has RA)
- Difficult vascular access (limb deformities)
- Poor mobility and deformity promotes the development of pressure areas
- Neuropsychiatric problems:
- Steroid-induced psychosis - extubation may be interesting
- Psychological problems of chronic disease
- Increased analgesic requirements (chronic opiate/NSAID use)
- Electrolyte and endocrine abnormalities associated less with RA than with its treatment:
- Chronic steroid use may promote hypoadrenalism
- Electrolyte derangement due to chronic steroid use
- Renal problems:
- RA-associated (eg. glomerulonephritis, amyloidosis)
- Treatment-associated (eg. NSAID-induced damage)
- Does one commit to long term dialysis in this setting?
- Gastrointestinal and nutritional problems:
- "Rheumatoid cachexia" due to cytokine-driven hypermetabolism promotes the need for more protein and calories (Roubenoff et al, 1994) - but it is unclear whether they benefit from "overfeeding", as they tend to become cachexic in spite of a theoretically adequate dietary intake.
- Gastic erosion/ulceration due to chronic steroid and NSAID use suggests that this group should get PPIs routinely
- Haematological disturbances
- Anaemia of chronic disease: will you transfuse them?
- Thrombocytopenia (Felty's) - increased risk from neuraxial procedures and vascular access
- Immune and infectious issues
- Increased risk of infection
- Increased propensity to be often seen in hospitals tends to result in increased risk of MRO colonisation
- Weird antiRA drugs may interact with antibiotics