Anesthetic challenges in a case of Rheumatoid Arthritis (RA): A case report

Objectives: Rheumatoid arthritis (RA) is a chronic systemic inflammatory disorder primarily affecting joints but also involving extra-articular systems such as the cardiovascular, respiratory, and hematological systems. This case report aims to highlight the challenges in anesthetic management of RA patients with interstitial lung disease (ILD) undergoing orthopaedic surgery. Materials and Methods: A 72-year-old female with RA, ILD (methotrexate-induced), and severe comorbidities, including bi-ventricular failure, pulmonary hypertension, and atlanto-axial subluxation, presented for right hip arthroplasty. Due to multiple joint deformities and systemic complications, a comprehensive preoperative assessment was conducted. Spinal anesthesia was chosen using hyperbaric bupivacaine with buprenorphine, and invasive arterial and central venous lines were placed with difficulty due to limited neck mobility and wrist flexion deformities. Hemodynamic stability was maintained with blood replacement and norepinephrine infusion, and tranexamic acid was administered to minimize blood loss. Results: The patient tolerated spinal anesthesia well, with stable intraoperative hemodynamics. Challenges included limited mobility, difficult vascular access, and the need for careful airway management due to cervical spine instability. Postoperative care was tailored to minimize RA progression and manage systemic complications. Conclusions: RA patients undergoing surgery require thorough preoperative assessment, considering systemic involvement and medication effects. Spinal anesthesia is a preferable approach to avoid airway complications associated with atlanto-axial subluxation. Proper positioning, pressure point protection, and aseptic techniques are crucial due to joint deformities and immunosuppression. ILD must be carefully monitored, and individualized anesthetic strategies should be employed to enhance patient safety and surgical outcomes.