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
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
- 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
- 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