A 55-year-old female is admitted to your ICU with severe respiratory failure caused by a community acquired pneumonia. She has a history of rheumatoid arthritis.
What factors related to her rheumatoid arthritis require consideration during her care in the ICU?
The relevant factors include those related to the RA disease process itself- musculoskeletal and systemic (extra-articular), and those related to the therapies for RA.
Using a system-wise approach the following areas require assessment and consideration-
Airway- The patient is likely to required invasive mechanical ventilation and intubation needs to be planned. Assessment should be performed considering
Ventilation- Potential underlying
Generally, there was a good discussion about airway involvement and respiratory issues. Most candidates discussed effects of immunosuppression on organisms and risk of nosocomial infections.
Most considered need to supplement steroid use. Many candidates were unclear about the details of associated cardiac disease. Not many discussed the likelihood of chronic pain, including opioid use and its implications.
The following overlong word spill is cut-and-pasted from other stereotyped questions about how rheumatoid arthritis affects management. As this time the examiners have produced an excellent model answer, one can only rearrange the information, and there is little to be added.
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.