[Anesthesiological considerations in rheumatic diseases]

Anaesthesia in patients with rheumatic diseases is a special challenge because chronical inflammatory activity leads to multiple pathological alterations. Airway management is of special importance in the perioperative period. If regional anaesthesia techniques are not practicable, intubation of the trachea by direct laryngoscopy may be found difficult or impossible. Possible reasons are the decreased range of motion of the cervical spine and the mandibular joint leading to a reduced opening of the mouth and reduced dorsal extension of the cervical spine. Furthermore, there is the problem of compression of the myelon in patients with subaxial instability of the cervical spine during laryngoscopy. To avoid these complications, fibre-optic intubation should be performed. Visceral manifestations of the underlying disease need particular attention, especially when related to the cardiac (diseases of the endo-, myo- or pericard), the pulmonary (pleural effusion, fibrosis, restriction) or the haematological (anaemia, chronic infection, thrombocytosis) system. Side-effects of medical treatment include adrenal insufficiency because of long-term corticosteroid therapy, coagulation disorders, gastric ulcer or impaired liver or kidney function following non-steroidal antiinflammatoric drugs (NSAID) or methotrexate therapy. Elective major surgery requires a concept for optimal gaining and using of autologous blood resources (preoperative blood donation, blood salvage) to avoid homologous blood transfusion. Even patients with chronic anaemia should not be excluded from preoperative blood donation because they are adapted to low haemoglobin levels. In pain therapy, besides NSAID, corticosteroids, immunosuppressive drugs and disease modifying antirheumatic drugs (DMARD) can be combined with non-opioid or opioid analgetics. Moderate additional opioid therapy can be remarkably successful.