Download Rheumatoid Arthritis

Rheumatoid Arthritis
19/12/10
FANZCA Part II Notes
OHOA page186-188
SP Notes
Data Interpretation - Venkatesh
- multisystem disease which can range from mild -> severe
- autoimmune disorder characterised by a bilateral, peripheral symmetrical inflammatory
arthritis with a number of other systemic associations.
CLINICAL FEATURES
- AIRWAY: decreased TMJ mobility -> poor mouth opening, limited head and neck extension,
potential atlanto-axial subluxation (anterior, posterior, lateral and vertical), cricoi-aretynoid
arthritis (neck pain, head feels like it is falling forward on flexion, arm symptoms, posterior
fossa or brainstem symptoms, limb symptoms)
- RESPIRATORY: restrictive lung disease, kyphoscoliosis, pulmonary fibrosis, pneumonitis,
pleural effusions, bronchiolitis obliterans
- CARDIOVASCULAR: amyloid infiltration of myocardium, restrictive pericarditis, conduction
abnormalities, valve pathology, IHD
- MUSCULOSKELETAL: joint changes and decreased ROM and pain, manual dexterity, worse
on morning but improves with motion, ulnar deviation, dorsal wrist subluxation, Boutionniere,
Swan-neck deformity, z-deformity of thumb
- ANALGESIA: chronic pain management (adjuncts like ketamine and gabapentin may be
required)
- HAEMATOLOGICAL: anaemia may be multi-factorial (chronic disease, NSAID induced GI
blood loss, drug induced marrow suppression)
Medications
- immunosuppressants and steroids -> increased risk of infection and potential for adrenal
suppression.
- should be off monoclonal antibodies for 2/52.
Co-morbid conditions
-
IHD
PMR
obstructive lung disease
smoking
systemic vasculitis
INVESTIGATIONS
-
routine bloods: organ dysfunction, drug levels
rheumatoid factor +ve (70%)
anti-CCP (highly specific)
anaemia of chronic disease
Jeremy Fernando (2010)
- thrombocythaemia
- elevated inflammatory markers
- c-spine xrays: (major destruction, duration > 5yrs, symptoms or signs)
1. atlanto-axial subluxation -> posterior C1 transverse ligament destruction -> cord
compression (normal <3mm)
2. atlantoaxial impaction -> superior migration of odontoid and cranial settling ->
cephalad movement of dens into foramen magnum -> compression of brainstem
3. subaxial subluxation -> C2-C7 step ladder deformity
- AADI = anterior atlanto-dens interval (<3mm)
- PADI = posterior atlanto-dens interval (<14mm) -> more predictive
- CXR: restrictive changes, effusions, nodules
- spirometry: restrictive pattern, decreased volumes
- flow-volume loops
- CT or MRI
- ECHO: rule out structural heart disease (restrictive pericarditis\cardiomyopathy), PHT ->
RVF
MANAGEMENT
DMARDS
-
steroids: acute flares
methotrexate: pneumonitis, oral ulcers, hepatotoxic
hydroxychloroquine: retinopathy
gold
sulfasalazine: rash, decreased sperm count, oral ulcers
TNF alpha inhibitors (etanercept, leflunomide): reactivation of Tb, heart failure
Symptomatic Control
-
paracetamol
NSAIDS
intra-articular injections
opioids
-
rheumatologist referral
orthopaedic spinal/neurosurgical referral (C1-C2 fusion)
cervical collars
physio
discussion about RA vs GA
spinal precautions
Intraoperative Management
- GA (may require AFOI)
- RA (may be difficult and could fail)
Jeremy Fernando (2010)
-
careful positioning and pressure area care
steroid supplementation
good analgesia
IVF fluid
temperature cares
aseptic techniques for invasive procedures (IVC insertion)
ICU Management
- limited respiratory reserve with restrictive lung disease (decreased compliance)
- caution with vasoconstrictors c/o Raynauds
- many have labile haemodynamics
- immunosuppressed
- GORD cares
- PCA for pain relief (may need to be nurse controlled c/o of difficulty using)
- regular paracetamol
- NSAIDS if not contraindicated
- physio (incentive spirometry and percussion therapy)
- monitoring
- DVT prophylaxis
- difficult access
- re-institute DMARD ASAP (gold, pencillamine, methotrexate, azathioprin) -> doesn’t seem to
change rates of post-operative wound infection
- caution with TNF-alpha blockers -> severe infections reported
- look for complications of medications and disease: restrictive lung disease, anaemia
Jeremy Fernando (2010)