Rheum Flashcards
(31 cards)
What is rheumatoid arthritis?
common chronic inflammatory arthritis
autoimmune
What are the major clinical features of rheumatoid arthritis?
MSK - articular stiffness and swelling including C-spine instability
Lungs – dyspnoea – diffuse interstitial fibrosis or effusion
Heart – chest pain from pericarditis
What are the clinical features on exam of rheumatoid arthritis?
o Hands – symmetrical small joint synovitis
o Neck – cervical spine tenderness/↓rotational movement (atlanto-axial instability affects 25%)
o Lung – effusion, fibrosis, infection, nodules
o Heart – pericardial rub (pericarditis), diastolic murmur (AR)
What Ix are useful in rheumatoid arthritis?
o Cervical spine x-rays - Distance between posterior aspect of C1 arch & anterior aspect of odontoid peg should be no more
than 3mm in adults
o Bloods – Hb, platelets
o CXR
o ECG
o Echocardiogram – pericardial effusion, AR
What are the anaesthetic issues in rheumatoid arthritis?
- Resp disease - restrictive lung disease
- Cardiac disease incl pulm HTN secondary to pulmonary fibrosis
- Atlanto-axial instability
- Steroid dependence and need for supplementation
What is Ankylosing Spondylitis?
autoimmune non-rheumatic arthropathy
Characterised by:
o Involvement of spine, especially sacroiliac joints
o Asymmetrical peripheral arthritis & synovitis
o Absence of rheumatoid nodules or detectable circulating rheumatoid factor
What are clinical features on history of Ankylosing Spondylitis?
o Persistent pain & morning stiffness (worse at rest but improves with
exercise) in lower spine + sacroiliac joints
o Visual impairment, photophobia, eye pain
o Fatigue, weight loss, low-grade fever
What are clinical features on exam of Ankylosing Spondylitis?
o Back + sacroiliac joints:
- Loss of lumbar lordosis + thoracic kyphosis
- Severe flexion deformity of lumbar spine
o Lungs: decreased chest expansion (<5cm), upper lobe fibrosis
o Heart: signs of aortic regurgitation (1%)
What are Ix for Ankylosing Spondylitis?
o FBC – mild normochromic anaemia
o Spine x-ray – bamboo spine, erosion of sacroiliac joints
o ECG – conduction defects
o Echocardiography – aortic regurgitation
o RFTs – restrictive defect
What are the anaesthetic issues with Ankylosing Spondylitis?
- Potentially difficult airway
o Limited mouth opening with temporomandibular joint involvement → difficult laryngoscopy & LMA insertion
o Stiff & deformed spinal column prevents appropriate cervical spine motion for intubation → need fiberoptic or video laryngoscope assistance
o Excessive neck extension in patients with chronic cervical kyphosis can cause vertebrobasilar insufficiency & neurological injury
o AFOI – safest option - Restrictive lung disease from costochondral rigidity & fixed flexion deformity of thoracic spine
- Technically difficult neuraxial blockade – use paramedian approach
- Aortic regurgitation – avoid sudden increases in SVR
What is scleroderma?
connective tissue disease associated with excess production & deposition of collagen, glycosaminoglycans + fibronectins within connective tissues
What are some of the clinical features of scleroderma?
o Oesophageal hypomotility
o Prominent skin sclerosis - limited mouth opening and neck movement
o Pulm Fibrosis
o Pulm HTN (if severe)
o Renal impairment
o Pericarditis
o Dilated cardiomyopathy
What are some features on exam of scleroderma?
o General appearance – ‘bird-like’ facies, weight loss
o Hands - Calcinosis, atrophy distal tissue pulp (Raynaud’s), sclerodactyly,
telangiectasia
o Head - Alopecia, reduced opening mouth
o Heart – pulmonary hypertension, pericarditis, heart failure
o Lungs – fibrosis
What are some Ix for scleroderma?
o Blood – ANA positive (40%)
o ECG – look for signs of pericarditis, arrhythmias or conduction disturbances
o CT chest – pulmonary fibrosis
o Echocardiogram – pericardial effusion indicated by presence of echolucent area
adjacent to cardiac structures, abnormal right heart chamber size + motion
indicates pulmonary hypertension, note RVSP
o RFTs – isolated low DLCO + reduced lung volume are common early, abnormal results likely due to
interstitial fibrosis or pulmonary hypertension due to vasculopathy
What are some anaesthetic issues with scleroderma?
o Difficult peripheral IV access
o Difficult airway management
o Aspiration risk due to oesophageal dysmotility
o Restrictive lung disease
o Myocardial fibrosis - risk of cardiac failure, conduction defects
o Renal impairment
o Raynaud’s - avoid vasoconstrictors and if severe avoid radial artery for art line
Whats SLE?
Chronic multisystem inflammatory disease characterised by autoantibody production
What are some clinical features of SLE?
o Cardiovascular – conduction abnormalities, non-infective endocarditis, accelerated
atherosclerosis + CAD, myocarditis, pericarditis, heart failure
o Respiratory – pleuritis, pleural effusions, pneumonitis, restrictive lung disease, pulmonary hypertension
o Renal – nephritis, oedema, dialysis
o CNS – psychosis, seizures, peripheral neuropathy
o Hematological – anaemia, leucopenia, thrombocytopenia, thrombosis
What are some clinical features on exam of SLE?
o General inspection – Cushingoid appearance, weight, mental state
o Chest – pericarditis, pleural effusion, pleurisy, pulmonary fibrosis, collapse or infection
What Ix for SLE?
o Bloods – electrolytes, urea, Cr, Hb, WCC, platelets, APTT
o Antibodies - Anti-double-stranded DNA (anti-dsDNA) is highly specific (70% positive), Anti-nuclear antibody (ANA)
o ECG – silent ischaemia, conduction abnormalities
o Echocardiography – valvular dysfunction, Libman-Sacks endocarditis
o CXR – pleural effusion, pneumonitis, subglottic stenosis
o RFTs
What are some anaesthetic issues for SLE?
- Cardiac, resp or renal impairment
- Haematologic – severe thrombocytopenia
- Need for steroid replacement
- Risk of atlanto-axial instability
- Careful positioning
What is Marfan’s syndrome?
Autosomal dominant, multisystem connective tissue disease
What are some clinical features of marfan’s syndrome?
Cardiac - dilated aorta, valvular heart disease (MR from MVP, AR)
Resp - pneumothorax, Restrictive defect due to pectus excavatum/kyphoscoliosis, Emphysema, bronchogenic cysts & honeycomb lung lead to pneumothorax
Skeletal – high arched palate
What are some clinical features on exam of marfan’s syndrome?
o Cardiovascular - Aortic dilation, dissection or rupture with associated AR
- Valve dysfunction/prolapse – MR resulting from MVP is common, look for AR
- Heart failure, pulmonary hypertension
- Conduction abnormalities
o Respiratory
- Restrictive defect due to pectus excavatum/kyphoscoliosis
- Emphysema, bronchogenic cysts & honeycomb lung lead to pneumothorax
o Skeletal – high arched palate, long tubular bones → tall stature, pectus excavatum, kyphoscoliosis, joint hyperextensibility
What are some Ix of marfan’s syndrome?
o ECG – bundle branch block
o Echocardiography – MVP, MR, tricuspid valve prolapse, AR, dilatation of aortic root
o CXR – apical bullae, pneumothorax, cardiomegaly, pulmonary oedema
o TOE, chest CT/MRI or aortography for suspected dissection
