The Role Of Age

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 Males = 8

As surgical patients:

Age group ( 12 – 70 ) years Age group ( 14 – 60) years .

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 nonarticular 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 : 1234-

Septic arthritis . Amyliodosis . Osteo porosis . 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 .