Systemic Lupus Erythematosus Angelique Davis Q: Why does seal have scars on his face? A: Discoid Lupus

SLE: Introduction  An autoimmune, multisystem chronic inflammatory disease with flares and remissions  Antinuclear antibodies, targeting DNA, RNA, and cell membrane structures, are present in more than 95% of SLE patients  Occurs in about 1:1000 women and more often in young childbearing aged female patients  9:1 female to male ratio  Occurs more often in women of Asian or African descent  Symptoms vary from mild to severe

Diagnosing SLE, must have at least 4 of the below criteria:

Clinical Manifestations of SLE  Macular facial rash, only present in 1/3- 1/2 of patients  Migratory polyarthritis and dermatitis  Polyarthritis that causes out of proportional pain Unknown (2013). SLE face. Retrieved from content/uploads/2013/09/SLEFace.png

Systemic Manifestations of SLE  SLE affects  CNS  Heart  Lungs  Kidneys  Liver  Neuromuscular  skin Nursing School. (2007, ). Medical Surgical Nursing Mneumonics [Blog post]. Retrieved from mnemonics.html

SLE: CNS involvement  Occurs in 1/3-1/2 of patients  Due to vasculitis  Atypical migraines  Anxiety  Mild depression  Mild cognitive impairment  Polyneuropathy  Myelitis  Seizures  Stroke

SLE: Heart  Most common signs and symptoms are pericarditis  Causing chest pain, friction rub, ECG changes, and pericardial effusion  ECG changes include Sinus Tachycardia, Atrial Fibrillation, A-V conduction blocks, prolonged QT intervals

SLE: Lungs  Lupus pneumonia causes:  Diffuse pulmonary infiltrates  Pleural effusions  Dry cough  Dyspnea  Arterial hypoxemia  Pleuritis  Late sign “shrinking lung syndrome”  Decreases total lung capacity and volume  PFT’s show a restrictive lung disease  Decreased diffusion capacity

SLE: Kidneys  Lupus nephritis is present in 60% of patients due to the disease itself and treatment  Hallmark symptom is glomerulonephritis with proteinuria and less common hematuria  Proteinuria, hypertension and decreased creatinine clearance are usual manifestations of lupus nephritis  Anemia

SLE: Musculoskeletal  Non-erosive arthritis  Osteoporosis  Atlanoaxial subluxation  May need fiberoptic intubation  Epiglottitis  Rheumatoid type nodules on vocal cords  Cricoartenoiditis  With active SLE symptoms, one may watch for post- intubation subglottic stenosis

SLE: Liver  LFTs are abnormal in about 30% of patients  Anemia  Leukopenia  Thrombocytopenia  Antiphospholipid syndrome

SLE: Skin  Rash  Alopecia  Photosensitivity  Pathology of mucous membranes  Oral or nasopharyngeal ulcers

Anesthetic Considerations  No technical “best” way to plan an anesthetic for SLE patients.  Very much depends on current status of SLE patient and organ involvement  Medication regimen

Pharmacotherapy for SLE  Carrillo, S. T., Gantz, E., Kaye, R. J., & Kaye, A. D. (2012). Anesthetic considerations for the patient with systemic lupus erythematosus. M.E.J. Anesth, 21(4),

Anesthesia Management for SLE  Perioperative assessment  CXR, PFTs, Echo, Labs, ECG  Neck ROM, mucosal, laryngeal, and vocal cord involvement  Consultations  Intraoperative Management  Depends on findings from pre-op assessment  If patient taking cyclophosphamide  lengthens response time to SCh  Postoperative Management  If renal or liver organ involvement, drugs may accumulate, causing prolonged sedation or paralysis. This may lead to an increased recovery time  May want to consider medications that are not organ dependent on elimination, i.e. remifentanil or cisatracurium

Summary of SLE  SLE is an autoimmune multisystem disease  SLE has exacerbations and remissions  Anesthetic management will vary according to the severity of organ involvement and medication regimen of the SLE patient  SLE patients with organ involvement are at higher risk of complications.  Maintain a low threshold for ordering labs, ECGs, etc. or insertion of invasive monitoring devices

References  Barash, P. G., Cullen, B. F., Stoelting, R. K., Cahalan, M. K., Stock, M. C., & Ortega, R. (2013). Clinical anesthesia (7th ed.). Philadelphia: Lippincott Williams & Wilkins.  Ben-Menacham, E. (2010). Systemic lupus erythematosus: a review for anesthesiologists. Anesthesia & Analgesia, 111(3),  Carrillo, S. T., Gantz, E., Kaye, R. J., & Kaye, A. D. (2012). Anesthetic considerations for the patient with systemic lupus erythematosus. M.E.J. Anesth, 21(4),  Hines, R. L., & Marschall, K. E. (2012). Stoelting’s Anesthesia and Co-existing disease (6th ed.). Philadelphia, PA: Elsevier.  Hochberg, M. C. (1997). Arthritis Rheum. 40(9),  Nursing School. (2007, ). Medical Surgical Nursing Mneumonics [Blog post]. Retrieved from mnemonics.htmlhttp://studentnurses3.blogspot.com/p/medical-surgical-nursing- mnemonics.html  Unknown (2013). SLE face. Retrieved from content/uploads/2013/09/SLEFace.png