a) List the reasons why an underlying diagnosis of rheumatoid arthritis may make intubation difficult in a critically ill patient.
b) Briefly outline how rheumatoid arthritis may influence intensive care management of the patient following intubation.
Limited neck mobility
Cervical spine instability
Limited mouth opening (TMJ)
Underlying lung disease – e.g. ILD – further reducing her respiratory reserve
Underlying cardiac disease – cardiac failure, IHD, valvular disease.
May influence choice of induction agent(s).
Impaired renal, hepatic function – more likely from medications for RA.
May influence choice of induction/paralysing agents.
Related to the RA itself
RA can be a multisystem disease.
Respiratory – pulmonary fibrosis, pleural effusion, reduced chest wall compliance.
Cardiac – increased risk of IHD, pericardial disease, valvular insufficiency, cardiac failure.
Renal – insufficiency directly related to the RA is rare, although does occur (GN, IN, amyloid).
Haematological – e.g. anaemia (chronic disease), thrombocytopenia (Felty’s).
Amyloidosis – cardiac, renal, hepatic.
Skin / pressure sores.
Difficult venous / arterial access – limb deformity.
Secondary amyloidosis affecting liver spleen and kidneys.
Decisions re-extubation if difficult intubation.
Post-extubation – difficulties with chest physiotherapy, mobilisation.
Psychosocial aspects of patient with chronic illness.
Related to the treatment for RA
Immunosuppression – infectious complications.
Other cytopaenias – anaemia, thrombocytopenia.
Need for adequate steroid replacement if long-term use.
Pulmonary – e.g. ILD from MTX, gold.
Renal – more likely related to medications that RA itself – e.g. NSAIDS, cyclosporine, penicillamine, gold.
Hepatic – e.g. MTX, Azathioprine.
Upper GI bleeding – NSAID, SSZ use.
Myopathy, skin breakdown, hyperglycaemia – steroids.
Examiners' comments: Candidates did not think broadly enough, e.g. in part (a) confined their answer to issues relating to C-spine disease.
Talley and O'Connor is a good source for the clinical features of RA.
Arnett, Frank C., et al. "The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis." Arthritis & Rheumatism31.3 (1988): 315-324.
Chanin, Katia, et al. "Pulmonary manifestations of rheumatoid arthritis." Hospital Physician 37.7 (2001): 2328.
Grassi, Walter, et al. "The clinical features of rheumatoid arthritis." European Journal of Radiology 27 (1998): S18-S24.
Krane, S. M., and L. S. Simon. "Rheumatoid arthritis: clinical features and pathogenetic mechanisms." The Medical clinics of North America 70.2 (1986): 263-284.
Canelli, Robert, John P. Weaver, and Elifce Cosar. "Anesthetic Considerations for Cervical Fusion Surgery in Advanced Rheumatoid Arthritis and Severe Pulmonary Hypertension." (2012).
Roubenoff, Ronenn, et al. "Rheumatoid cachexia: cytokine-driven hypermetabolism accompanying reduced body cell mass in chronic inflammation." Journal of Clinical Investigation 93.6 (1994): 2379.
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.