10. RHEUMATOLOGIC CONCERNS
SPECIFIC CONCERNS IN RA PATIENTS:
1) Cervical spine disease-particularly C1-C2 subluxation, which is a major concern for endotracheal anesthesia. Cervical spine instability may be asymptomatic but usually occurs in patients with longstanding, deforming disease. If not done previously, C-spine flexion/ extension films are recommended on patients with signs or symptoms referable to the cervical spine and on patients with erosive disease and joint deformities. Anesthesia must be made aware of any cervical spine involvement.
2) Cricoarytenoid arthritis-another major concern for endotracheal anesthesia. Cricoarytenoid joint involvement may cause difficulty with intubation and, because of trauma related to the ET tube, may also lead to stridor and airway obstruction after extubation. If the patient has any history or symptoms of laryngeal involvement, anesthesia must be made aware. ENT consultation may also be appropriate. Flexible bronchoscope should always be available in the OR when intubating RA patients in case of underlying cricoarytenoid disease.
3) TMJ arthritis-easy to detect on exam; decreases the oral aperture for intubation.
4) Pulmonary disease-common in RA patients. Pleural effusions and pulmonary nodules due to RA are typically not of significance for surgery; however, pulmonary fibrosis is more of a concern, particularly if hypoxia and/or dyspnea is present. Preoperative CXR is warranted if not done previously.
5) Cardiac disease-cardiac manifestations of RA are not common and include pericardial effusion, conduction disturbances, AV blocks, regurgitant valve lesions, and cardiomyopathy.
6) Infection-overall risk is increased in RA patients, even those who are not receiving steroids or immuno-suppressant agents.
7) Stress dose steroids-recommended for patients on steroid therapy within the past one year.
8) Immunosuppressant agents-should be held during the postoperative recovery period.
9) TNF inhibitors (such as Enbrel or Remicade)-may significantly increase infection risk and should be held during the postoperative recovery period. A heightened awareness for perioperative infection is also warranted in patients taking these medications.
SYSTEMIC LUPUS ERYTHEMATOSUS
*SLE is a multisystem disorder, and surgical risk associated with the disease is related to specific organ involvement, the severity of the involvement, and the activity of the disease. There is also a belief that the stress of surgery may trigger a lupus flare (although this has not been formally studied).
SPECIFIC CONCERNS IN LUPUS PATIENTS:
1) Renal disease-varies in degree from asymptomatic to complete renal failure and associated hypertension and edema.
2) Cardiopulmonary involvement-pericarditis, pleuritis, pneumonitis are possible manifestations.
3) Infection-overall risk is increased in lupus patients, even those who are not receiving steroids or immunosuppressant agents.
4) Hematologic abnormalities-leukopenia, anemia, thrombocytopenia can be chronic findings but may worsen with active disease or acute illness.
5) Lupus anticoagulant-associated with thrombosis (not bleeding) and a prolonged PTT. This does not interfere with surgery itself, but postoperatively leads to a higher risk of venous or arterial thrombosis.
6) Abdominal pain-may be related to peritonitis, pancreatitis, or mesenteric ischemia due to lupus.
7) Neurologic manifestations-psychiatric disturbances are the most common; strokes and seizures are also possible but much less common.
8) Stress dose steroids-recommended for patients on steroid therapy within the past one year.
9) Immunosuppressant agents-should be held during the postoperative recovery period.
10) Disease activity - clinically active disease is managed acutely with high dose steroids.