Collagen Vascular Diseases

(Table 23-16: Types of Collagen Vascular Diseases)

Rheumatoid arthritis is a chronic inflammatory disease characterized by symmetric and significant polyarthropathy (hands and wrists first, cervical spine as reflected by MRI) and systemic involvement (Table 23-17: Extra-Articular Manifestations of Rheumatoid Arthritis).
1. The goals of therapy are induction of a remission, improved function, and maintenance of a remission. Drugs used for treatment include nonsteroidal anti-inflammatory drugs, corticosteroids, and disease-modifying antirheumatic drugs. (Methotrexate may the first-line treatment for patients with early rheumatoid arthritis.)
2. Management of Anesthesia
  1. The joint effects of rheumatoid arthritis (temporomandibular joints, cervical spine, cricoarytenoid joints) can render direct laryngoscopy and tracheal intubation difficult.
  2. Atlantoaxial instability is relatively common, and flexion of the neck may compress the spinal cord.
  3. The need for postoperative ventilatory support should be anticipated if severe restrictive pulmonary disease is present.
  4. Restriction of joint mobility necessitates careful positioning to minimize the risk of neurovascular compression.
Systemic lupus erythematosus (SLE) is an autoimmune disease with diverse clinical (polyarthritis, dermatitis, renal failure, pericarditis, pulmonary hypertension) and immunologic manifestations.
1. Drug-induced SLE (phenytoin, hydralazine, isoniazid) is usually mild and resolves within 4 weeks of discontinuation of the drug.
2. Management of anesthesia is influenced by disease-induced organ dysfunction and drugs used in treatment.
  1. Renal dysfunction is common and necessitates preoperative evaluation.
  2. Laryngeal involvement may manifest postoperatively as laryngeal edema or stridor.
  3. Supplemental steroids may be necessary in patients being treated with corticosteroids.
Systemic sclerosis (scleroderma) is an autoimmune collagen vascular disease that affects the skin (thickened and swollen), joints, and visceral organs (pulmonary interstitial fibrosis and impaired diffusing capacity, pericardial effusion, renal dysfunction, decreased gastrointestinal motility).
1. Raynaud's phenomenon is present in 85% of patients, and the lungs are involved in more than 80%.
2. Management of anesthesia is influenced by the degree of organ dysfunction.
  1. The risk for aspiration pneumonitis during induction of anesthesia may be increased because of the high incidence of gastroesophageal reflux.
  2. Tracheal intubation may be difficult because fibrotic and taut skin can hinder active and passive opening of the mouth and severely restrict mobility of the temporomandibular joint.
  3. Chronic arterial hypoxemia may reflect restrictive lung disease and impaired oxygen diffusion.
  4. Venous access may be difficult.
  5. Skeletal muscle involvement may increase the sensitivity to muscle relaxants.
Inflammatory myopathies (dermatomyositis/polymyositis) are characterized by severe muscle weakness and noninfectious inflammation. Patients with dermatomyositis manifest a characteristic erythematous rash over the face, neck, and upper chest.
1. Pulmonary diseases (interstitial pneumonitis, alveolitis, bronchopneumonia) are often present.
2. Aspiration pneumonitis (dysphagia and gastroesophageal reflux) is a common complication.
3. The most effective treatment is with corticosteroids.
4. Management of Anesthesia
  1. Tracheal intubation may be difficult in patients with restricted joint mobility.
  2. Despite the theoretical potential for SCh to produce hyperkalemia in these patients, there is no evidence that this occurs.
  3. It should be anticipated that considerable individual variation will occur in response to nondepolarizing muscle relaxants.

section name header

Information ⬇

Outline ⬆