A 46-year-old ASA III man is scheduled to have a total knee replacement. His past medical history is remarkable for severe rheumatoid arthritis (RA) with cervical spine involvement. He was recently diagnosed with atlanto-axial subluxation (AAS), but he has no neurological symptoms and signs. He has a history of gastroesophageal reflux disease (GERD), but it is well controlled with proton pump inhibitors. His other medications are a nonsteroidal anti-inflammatory drugs (NSAIDs) and low-dose glucocorticosteroid therapy.
On physical examination, he weighs 67 kg (148 lb) and is 167 cm (5 ft 6 in) tall (BMI of 23.9 kg·m−2). Examination of his airway reveals that he has a full beard, small chin, no teeth, 3.0 cm of mouth opening, and that his neck is fixed in moderate flexion. This same surgery was previously canceled, as the patient refused to complete an awake intubation using a flexible bronchoscope (FB). The patient emphatically refuses to consent to an awake intubation.
PREOPERATIVE ANESTHETIC ASSESSMENT
What Is Rheumatoid Arthritis? What Are the Anesthetic Implications of This Illness?
Rheumatoid arthritis (RA) is a chronic multisystem illness. It is the most common form of chronic inflammatory arthritis and affects approximately 1% of adults (range 0.3%–2.1%) in the United States and Europe. Women are typically affected two to three times more often than men and the prevalence increases with age. The etiology of RA remains unknown, but it is evident that complex interaction between environmental factors (including infectious agents) and the immune system in genetically susceptible individuals plays an essential role.1 The class II major histocompatibility complex allele HLA-DR4 has been found to be a major genetic risk factor. The onset of RA is typically gradual between the age of 35 and 50, and may be of a nonspecific nature.2,3 Synovial inflammation, cartilage damage, and bone erosion with subsequent destruction of joint integrity are the hallmarks of this illness. The course is characterized by symmetrical polyarthropathy and variably, considerable systemic involvement. As the disease progresses, cervical spine involvement becomes common, second only to involvement of the metatarsophalangeal joint.1
Extraarticular manifestations of RA are widespread and can affect as many as 40% of patients, 15% of whom appear to be severely affected.1,2 Many of these manifestations have a serious impact on anesthesia care. Cardiac manifestations most commonly present as pericarditis with effusion (in one-half of patients), but may also include cardiac conduction abnormality, granulomatous myocarditis, and valvular pathology. Rheumatoid vasculitis can affect almost any organ system and may produce coronary arteritis contributing to a coronary syndrome. Pleuropulmonary pathology, which occurs more commonly in men, includes pleural disease, effusion, pleuropulmonary nodules, interstitial fibrosis, obliterative bronchiolitis, and pneumonitis. The prevalence of airflow obstruction in rheumatoid patients is remarkably high, suggesting it might be the most common form of pulmonary involvement.4 Rheumatoid nodules ...