- Airway Management: Patients with rheumatoid arthritis may have cervical spine instability (e.g., atlantoaxial subluxation), temporomandibular joint involvement limiting mouth opening, and cricoarytenoid arthritis causing laryngeal obstruction. Preoperative airway evaluation is crucial, potentially requiring advanced techniques like fiberoptic intubation if deep sedation leads to airway compromise; prefer regional or minimal sedation when possible to avoid intubation risks.
- Perioperative Medication Management: Continue hydroxychloroquine (Plaquenil) and methotrexate through the procedure to prevent disease flare, as guidelines recommend for elective surgeries including dental; however, withhold if there’s a history of severe infections. Monitor for potential need for glucocorticoid stress dosing if the patient is on steroids (though not specified here).
- Infection Risk: Immunosuppression from rheumatoid arthritis and medications like methotrexate increases postoperative infection risk. Implement strict aseptic techniques, consider perioperative antibiotic prophylaxis, and ensure wound monitoring, especially for an extensive procedure like multiple extractions and implants.
- Drug Interactions and Anesthetic Agents: Avoid nitrous oxide in sedation regimens due to interaction with methotrexate causing folate depletion. Carefully titrate IV sedatives (e.g., midazolam, propofol) considering potential altered pharmacokinetics from RA medications; also, be cautious with local anesthetics containing vasoconstrictors if cardiovascular involvement is present.
- Systemic Organ Assessment: Rheumatoid arthritis can affect cardiovascular (increased risk of disease), pulmonary (e.g., interstitial lung disease from methotrexate), and hematologic systems (e.g., anemia, thrombocytopenia). Conduct preoperative evaluation including blood tests, ECG, and pulmonary function if indicated, with close intraoperative monitoring under sedation to manage reduced physiologic reserve.
Top 5 Anesthetic Considerations for a Patient with Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease increases anesthetic risk during dental procedures due to limited respiratory reserve and sensitivity to sedatives. This article outlines five key considerations to support safe sedation, oxygen management, and respiratory monitoring.
