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?
 

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College answer

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

  • Decreased TM joint mobility and consequently poor mouth opening.
  • Cervical spine involvement – limited head and neck extension, potential atlanto-axial dislocation.
  • Cricoaretynoid arthritis

Ventilation- Potential underlying

  • Pulmonary fibrosis -decreased lung compliance complicating ventilation for CAP, decreased reserve
  • Kyphoscoliosis
  • Presence of pleural effusions/pleuritis

Cardiovascular- consider

  • Presence of pericarditis/myocarditis
  • Amyloid infiltration of myocardium- restrictive cardiomyopathy
  • Increased risk of coronary disease.
  • Associated    Raynaud’s    phenomenon/vasculitis    and exaggerated  response      to vasoconstrictors.

Haematological-

  • Likely to have anaemia of chronic inflammation-
  • May    be    neutropenic    (associated    with    Felty’s syndrome)   and                consequently immunosuppressed

Musculoskeletal/Integument-

  • Joint changes and decreased range of movements/stiffness- risk of early contractures
  • Increased risk of pressure areas
  • Muscle atrophy/myositis/Steroid induced myopathy- early development of critical illness weakness.
  • Osteopenia- risk of bone loss, fractures.

Immunological-

  • Immune suppression from treatments- steroids, monoclonal antibodies. Susceptible to opportunistic infections- might influence antimicrobial choice.

Endocrine-

  • Stress dose steroids if on chronic steroid therapy

Pain management-

  • Likely opiate tolerance

Eye care-

  • Dry eyes/scleritis/episcleritis-risk of corneal ulceration, infections.

Rheumatological-

  • specialist input and advice re: ongoing management of RA especially if active disease.
  • Consideration of withholding disease modifying agents

Examiner’s Comments:

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.

Discussion

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.

  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 problems:
      1. Pulmonary fibrosis, diffusion defect
      2. Pulmonary hypertension
    2. Ventilation problems
      1. Pleural effusions
      2. Restrictive lung disease with poor compliance (kyphosis)
    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. Increased risk of microvascular dysfunction with vasopressor use (Raynauds, etc)
    4. Diastolic failure due to restrictive cardiomyopathy and pericardial disease make fluid resuscitation challenging
    5. 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)
    6. Difficult vascular access (limb deformities)
    7. 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: need to supplement steroids in critical illness
    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 due to immunesuppression
    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
    4. Risk of eye infections with chronically dry eyes, scleritis and episcleritis

References

References

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.