Ankylosing Spondylitis
Considerations
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Potential difficult airway
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Risk of ↓ c-spine mobility/fusion/instability
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Atlanto-axial subluxation possible
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Multisystem disease with extra-articular features:
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Cardiac: aortic insufficiency, myocarditis, conduction defects, cardiomegaly, cardiomyopathy, pericardial effusion
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Respiratory: restrictive lung disease from parenchymal fibrosis & chest wall musculoskeletal disease
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Neuro: spondylolisthesis (cord compression), uveitis
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Heme: anemia of chronic disease
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Difficult/impossible regional & neuraxial anesthesia due to poor positioning, axial spine fusion, epidural space obliteration, & underlying radiculopathies/neuropathic pain
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Higher risk epidural hematoma (ASRA)
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Paramedian might be a better approach
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Medications: NSAIDS, steroids, immunomodulators: marrow suppression, platelet dysfunction, renal impairment, need for steroid coverage, ↑ infection risk
Goals
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Minimize c-spine manipulation with airway management, consider AFOI, videolaryngoscopy, lighted stylet
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Management of multisystem disease features, especially cardiopulmonary
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Patient positioning
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Recognition of difficult neuraxial & unpredictable response to neuraxial local anesthetics
Pregnancy Considerations
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Complicated due to difficult airway & difficult neuraxial technique, have multiple plans in place
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For neuraxial: consider paramedian approach & ultrasound guidance