Background/Purpose: Fiber optic intubation is the preferred method of airway management during anesthetic procedures for patients with RA. The purpose of our study was to determine the frequency of fiber optic intubation in surgical procedures of patients with RA and cancer.

Methods: All RA patients who attended a preoperative anesthesia consultation at a large cancer center from 2007 to 2014 were eligible for this study. We included adults (> 18 year of age) with diagnosis of RA made by a physician or patients with self-reported history of RA and disease modifying anti-rheumatic drugs (DMARDS) use, including prednisone (past or current). Only first procedure in this time period per patient was included. Cervical spine imaging within 1 year prior to procedure was included. All subluxation reported were reviewed by radiologist for second review and to document to appropriate distances.

Results: In relation to cancer, we found 409 patients (83.4%) had malignancies and 122/409, 29.8% had two or more cancers diagnosed since admission. A total of 81/490, 16.5% had non-malignant tumors such as thyroid or pancreatic cysts, primary hyperparathyroidism, large lipomas, or benign breast nodules. The patients were followed-up for a mean of 34.5 months (95% CI 32.2 – 36.9). A total of 99 deaths occurred during the period of observation and 3/99 (3%) deaths occurred within 30 days from the date of the procedure. None had spinal cord compression complications. Among those who died, the median age was 67 years (range 36 – 86). Patients who died within 30 days from date of surgery had a median age of 71 years (range 63 – 85) and all three had major surgical procedures: esophagectomy, cystoprostatectomy, or wide neck dissection. Age was not a factor associated with mortality when both groups were compared. Hospital mortality (deaths occurring ≤ 30 days after admission) was 0.6%. None of the patients had spinal cord compression.76% of the patients had imaging done. 12.7% had subluxations C1-C7; 5.3% had RA related C1- C2 subluxation; 8.2% had C2-C7 subluxation. We found different types of RA subluxations: anterior atlanto-axial distance (AAD) in 21 patients was abnormal  (3- 13.2 mm); posterior atlanto-axial distance (PAAD) was also abnormal (18- 26.8 mm); subaxial distance in 4 patients ranged between 5mm to 16 mm; cranial settling was observed in 3 patients. Other spine abnormalities found were erosions, osteoarthritis, spondylolisthesis, spontaneous fusions, and post-operative fusions. The most common type of intubation was endotracheal in 387 (79.1%). Only 66 out of 492 (13.6%) had fiber optic intubation. There was evidence of neurological post-operative neurological injury in one case (0.2%).

Conclusion: Although fiber optic intubation could reduce the risk of neurological complications in patients with RA and cancer undergoing surgical procedures, few received this airway management. Patients with RA and cancer could be the target of an intervention to educate providers and reduce the risk of neurological complications during surgical procedures. More research is needed to consider this to standardize the airway management in these patients.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/fiber-optic-intubation-in-patients-with-rheumatoid-arthritis-who-had-a-surgical-procedure/