Question 30.1

College Answer

a)  Describe four (4) abnormalities visible in this patient’s hand.
•    Ulnar deviation
• Wasting of dorsal interosseous muscles
• Boutoniere deformity of index and middle finger
•    Subluxation at metacarpal-phalangeal joints
• Z-deformity of thumb

b)  What is the most likely diagnosis?
• Rheumatoid arthritis

c)  List three (3) associated abnormalities that may complicate intubation in patient’s with this condition?
• Arthritis of tempero-mandibular joint -> limited mouth opening
• Atlanto-axial subluxation -> spinal cord injury possible
• Degenerative arthritis in C-spine -> difficult visualisation of larynx
• Laryngeal arthritis -> poor vocal cord opening
• Pulmonary fibrosis -> poor respiratory reserve

Discussion

Rheumatoid hands make an appearance in Question 10.3 from the second paper of 2013.

In general, the clinical features of rheumatoid arthritis include the following:

• Symmetric joint swelling, MCP > DIP
• Morning stiffness  lasting at least 1 h before maximal improvement 
• Extra-articular synovitis (tenosynovitis, bursitis)
• General symptoms (malaise, fatigue, weight loss, fever)
• Hand signs as mentioned above:
  • Ulnar deviation
  • Z deformity of the thumb
  • Swan neck deformities
  • Swelling of metacarpo-phalangeal joints
  • Wasting of small muscles of the hand
  • Boutonnieres deformity

The site clinicalexam.com has an excellent entry on RA, with extensive lists of signs and examination techniques.

The rest of this question would benefit from a structured answer.

An article on anaesthetic considerations in RA has a niic etable (Table 2) of extra-articular manifestations of rheumatoid arthritis.

The following features of RA act as influences in the critical care of these patients

1. Difficult intubation, as caused by the abovementioned issues:
   1. Poor neck extension due to C-spine arthritis
   2. Risk of spinal cord injury due to atltantoaxial subluxation
   3. Poor mouth opening due to TMJ arthritis
   4. Poor vocal cord opening due to laryngeal arthritis or crico-arytenitis
   5. Poor respiratory reserve due to pulmonary fibrosis
   6. 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.
2. Difficult mechanical ventilation:
   1. Oxygenation pproblems:
      1. Pulmonary fibrosis, diffusion defect
      2. Pulmonary hypertension
   2. Ventilation problems
      1. Pleural effusions
      2. Restrictive lung disease with poor complicance
   3. Weaning problems:
      1. Poor muscle strength due to steroid myopathy
      2. Delayed extubation if the intubation was difficult
3. Cardiac and vascular problems:
   1. Propensity to arrhythmias
   2. Increased risk of ischaemic heart disease
   3. Diastolic failure due to restrictive cardiomyopathy and pericardial disease make fluid resuscitation challenging
   4. 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)
   5. Difficult vascular access (limb deformities)
   6. Poor mobility and deformity promotes the development of pressure areas
4. Neuropsychiatric problems:
   1. Steroid-induced psychosis - extubation may be interesting
   2. Psychological problems of chronic disease
   3. Increased analgesic requirements (chronic opiate/NSAID use)
5. Electrolyte and endocrine abnormalities associated less with RA than with its treatment:
   1. Chronic steroid use may promote hypoadrenalism
   2. Electrolyte derangement due to chronic steroid use
6. Renal problems:
   1. RA-associated (eg. glomerulonephritis, amyloidosis)
   2. Treatment-associated (eg. NSAID-induced damage)
   3. Does one commit to long term dialysis in this setting?
7. Gastrointestinal and nutritional problems:
   1. "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.
   2. Gastic erosion/ulceration due to chronic steroid and NSAID use suggests that this group should get PPIs routinely
8. Haematological disturbances
   1. Anaemia of chronic disease: will you transfuse them?
   2. Thrombocytopenia (Felty's) - increased risk from neuraxial procedures and vascular access
9. Immune and infectious issues
   1. Increased risk of infection
   2. Increased propensity to be often seen in hospitals tends to result in increased risk of MRO colonisation
   3. Weird antiRA drugs may interact with antibiotics

Canelli, Robert, John P. Weaver, and Elifce Cosar. "Anesthetic Considerations for Cervical Fusion Surgery in Advanced Rheumatoid Arthritis and Severe Pulmonary Hypertension." (2012).

McInnes, Iain B., and Georg Schett. "The pathogenesis of rheumatoid arthritis." New England Journal of Medicine 365.23 (2011): 2205-2219.

Samanta, R., K. Shoukrey, and R. Griffiths. "Rheumatoid arthritis and anaesthesia."Anaesthesia 66.12 (2011): 1146-1159.