THE ROLE OF AGE AND SEX IN RHUMATIC ARTHITIS , WHAT

IS BETTER TO ANAESTHETIZE THE PATIENT LOCAL OR

GENERAL ANAESTHESIA .
SUMMARY :
R.A. is a serious disease with serious
complications . It may affect the patient activity , in high humidity
areas like sirte , the percentage is high , but still the females are
more affected than males , the age can be early or late . It may
affect the choice of anaesthesia wither local or GA. , it may cause
complications intraoperative or post operative , it depends on the
severity and type of operation , it needs rapid management in
emergency cases especially when the patient is obese this will
worsen the condition .

INTRODUCTION :
Among out patients R.A. is of high incidence ,
age and sex are playing very important role , while it is uncommon
among surgical patients , but still has effect in giving G.A. or L.A.
especially in old age group in this city .

METHODS AND MATERIALS :

24 Patients were studied here , 21 as out
patients , 3 as surgical patients .
As out patients : Females = 13 Age group ( 12 – 70 ) years
.
Males = 8 Age group ( 14 – 60) years .
As surgical patients: 2 Patients for G.A.
1 Patients for L .A.
G.A. :
1- Male patient for ophthalmologic operation at age 35
years .
2- Female patient for cholycystoctomy at age of 58 years .
3- Male patient for renal stone removal at age of 65 years.

STATISTICS AND RESULTS :

As out patients :Females = 13 , Males = 8
So the percentage is : F = 61.9 % , M = 39.1 %
As surgical patients : Females = 1 , Males = 2
So the percentage is : F = 33.3 % , M = 66.6%
The age group for boyh are above 35 years .
DISCUSSION:
R.A. is non supporative , systemic inflammatory
disease of unknown cause characterized by asymmetrical
polyarthitis affecting peripheral joints and extra –articular
structure . It is autoimmuns disease ( disturbance of autoimmune
system ) . R.A. is present in most of patients serum ( 90 % ) , other
investigations had been done with the following results :
C.R.PROTIEN = 70 %
ASO TITER = +VE IN 80 %
ESR =MORE THAN 20 IN 80 %
PCV , HB LOW IN 90 %
The exact cause is unknown , but many factors are playing role :
1- Viral infection like herpis zoster , diphtheroids .
2- Genetic predisposition : RA patient relative are more prone
to be affected .
3- Initiating factors : causes joint inflammation and not cure
after acute episode .
RA is generalized disorder of connective tissue affecting articular
and extra articular structures . Articular could be represented by
deformity , swelling and pain in affected joints . While in non-
articular causes systemic effects like fatigue , weight loss malaise
, sometimes low grade pyrexia , skin is thin and papery , nodules ,
vasculitis , cardiac involvement ( pericarditis ) . Respiratory
features , pleurisy , pleural effusion and pulmonary fibrosis ,
sjogrners syndrome ( dry eyes and mouth ) ,scleritis , conjectivitis
.Felty ‘s syndrome (Spolenomegaly & WBC ) , neurogical features ,
neuropathies , cervical melopathy. Chief complain of all patients
who are studied here are : pain and swelling the hands and feet ,
with redress , small subcutenousnodules at small joints especially
surgical patients in whom endotracheal intubation is very difficult
and causes major problems in anaesthesia , therefore in cold
cases the pre-operative examination is very important to decide
the type of anaesthesia which will be given because this disease
has another effect on spinal anaesthesia because of difficulty to
insert the spinal needle into the spinal space and then failure of
spinal anaesthesia in addition to the patient might have cardiac or
respiratory problem so the condition will be worst in both general
and spinal ( anaesthesia ) . So pre-operative all investigations
must be done , but in emergency conditions this will cause major
problem and rapid management as the following :
All measures for difficult intubation e.g. :
a- Pre oxygenation with 100 % for 3 min .
b- Suxamethonium 2 mg / Kg / I.V. to have full relaxation .
c- Pillow under patient’s head .
d- Style and N.G. tube must be inserted pre-intubation .
 e- Fibro-optic laryngoscope .
f- In absence of Fibro-optic laryngoscope , criciod
pressure must be applied and then by machintosh
laryngoscope endotracheal intubation will be done . If
in spite of all these measures , still difficult intubation
no need for more trials , otherwise it will hurt the
patient because his neck is stiff . LMA can be applied in
this case .

In spinal anaesthesia: introduction of spinal needles is ver

difficult , bending of patient’s back also difficult , so we have to
use a very fine needle size ( 25 or 26 guage ) , choose the exact
position which can be easy to insert the needle , otherwise we can
change to general anaesthesia . Complication of spinal
anaesthesiapost operatively like Back Ache is of great value
because RH> patient having already back ache , so the condition
will be worst , neurological complication can occure while the
RH.patient may coplain already of some neurological damage . In
case of renal stone removal , the choice was spinal , but because
of difficulty of introducing the needle into subarcniod space , it
changed to general anaesthesia , but since he was an old man ,
anemic , there was risk of hypotension , when changed to G.A. , all
measures to correct hypotension were done like :
1- I.V. infusion ringer lactate 500 ml.
2- Avoidance of Halothane .
3- Sleeping dose , thiopental 5 mg / Kg / I.V.
4- Pancuronium 4 mg I.V as muscle relaxant .
In G.A. the complications may worsen the condition of RH.patients
especially if respiratory damage may occure post operatively or
the Rh.patient is already complain of respiratory damage . The
side effects of anaesthesia drugs also may worsen the patient ‘s
condition for example Pyrexia of Rh.patient may be increased by
drugs like Halothane oe Ketamine which may produce malignant
hyperpyrexia .

Complications :
1- Septic arthritis .
2- Amyliodosis .
3- Osteo porosis .
4- Atlanto – occipital Sublaxation .
Diagnosis :
1- History .
2- Clinical examination according to USA Rh.Association .
3- Investigations :
a- Classical ( 7 criteria ) .
 b- Definite ( 5 criteria ) .
c- Probable ( 3 criteria ) .
Prognosis is poor if Rh.factor is high , erosions of the joint surface
appear early , nodules , systemic manifestation ant tissue type is
DR 3 / DR 4 .
Management :
1- Treatment by drugs .
2- Physiotherapy .
3- Rest .
4- Surgery .
5- Correction of deformity and artificial ( prosthetic joints
may be required ) .

Drugs which are used in treatment of R.A . :

1- Auranofin .
2- Celecoxib . ( Cox ¯² inhibitor ) .
3- Chloroquine : Adult = 150 mg / day for 3 – 6 m .
Children = 3 mg / Kg for 3 – 6 m .
4- D – Penicillamine : 125 – 250 mg / day / before meal for
one month .
5- Diclofenac .
6- Flurbi profen ( NSAID ) : 150 – 200 mg ( by 3 – 4 divided
doses ) up to 300 mg / day .
7- Glocusamine .
8- Cartigen ointment ( Glucosamine Sulphate ) .
5% w/w + Boswellia serrata .
10% w/w + Methyl Salicylate .
15% w/w + Capsicum olearein .
0.2% w/w + Menthol .
4% w/w + Cinnamon oil 2% w/w .
9- Ibuprofen .
10-Indomethacin .
11-Ketaprofen : dose = 50 mg , 2 – 3 times / day up to 300
mg / day .
12-Leflunomide L dose = 100 mg / day for 3 days up to 20
mg / day ( maintainance ) .
13-Mefanamic acid .
14-Meloxicam in dose of 7.5 – 15 mg .
15-Namumetone ( NSAID) : The dose = 1 – 2 mg / at bed
time .
Then 500 mg in next
morning .
16-Naproxen .
17-Oxyfentutazone : Pyrasolone ( NSAID ) .
 18-Piroxicam ( NSAID ) .
19-Rofecoxib .
20-Serratiopeptidase ( anti – inflammatory enzyme ) .
21-Tenoxicam ( oxicam NSAID ) : the dose = 20 mg / day .
22-Trypsin / chymotrypsin : 100 1000 u / S.L tab .
Conclusions :
R.Arthritis can affect males and females but still females are
affected more as out patient , but totally are equal , the onset of
age could be at early age or late age group , family history ,
hereditary factors , and environmental factors play role in this
disease , since these patients are living in high humidity area , the
choice between general & spinal anaesthesia depends on patients
conditions , severity of signs ans symptoms , difficulty in doing
endotracheal intubation in general anaesthesia or difficulty of
introducing the spinal needle into the subarcniod space . Also
depends on whether the operation is emergency or cold case .

References :
1- Basic Pharmacology – R. W. Foster . P : 329 .
2- CIMS 77 , April 2002 – Update Prescribe ‘s Handbook . P :
204 – 224 .
3- A practice of anaesthesia – Wylie & Chuchill – Davidson ‘
s – fifth edition . P : 868 , 888 .
4- Tidy’s physiotherapy : P : 133 , 134 , 136 , 137 .