Systemic Lupus Erythematosus

Question 1

Definition and incidence

Answer 1

this is a chronic multisystem disease, commonest in young ♀, especially in pregnancy.

It is characterized by the presence of numerous antibodies, including antinuclear antibody, and immune-mediated tissue damage. Although joints may be affected, there is no deformity or bony erosion and no specific airway implications. the main anaesthetic implications are CVS disease, renal disease, coagulation status, and increased risk of infection

Question 2

Preoperative assessment

Answer 2

• Skin and joint involvement is common, as are oral and pharyngeal ulcerations.
• CVS:pericarditis in 15% of cases. Myocarditis and endocarditis are less common. Raynaud’s phenomenon 30%. CAd from atherosclerosis and other mechanisms common.
• Respiratory system:infections and pes common. pleuritis and pleural effusion. pulmonary fibrosis less common.
• Neurological:cranial and peripheral nerve lesions may occur, 2° to arteritis and ischaemia. transverse myelitis, leading to weakness or paraplegia, occurs rarely. depression, psychosis, andfits.
• Renal:glomerulonephritis is a serious complication and may lead to nephrotic syndrome and renal failure.
• haematological:clotting disorders or hypercoagulable states can occur. Check FBC and clotting status. Immune thrombocytopenia or circulating anticoagulants (e.g. antibodies to factor VIII) may be present. Up to a third of patients with SLe may demonstrate features of antiphospholipid syndrome (see E p. 226). this is a hypercoagulable state which paradoxically may be associated with the presence of lupus anticoagulant and a prolonged Aptt. Since a prolonged Aptt may indicate either a clotting disorder or a hypercoagulable s

tate, further haematological advice should be sought. • higher risk of stroke with antiphospholipid antibodies.

• Steroids and other immunosuppressant drugs areused.

Question 3

Anaesthesia

Answer 3

• there may be absolute or relative contraindications to neuraxial blocks in patients taking anticoagulants or in patients with coagulopathy (see E p. 1141). the presence of a peripheral nerve lesion may be a relative contraindication to neuraxial/regional nerve blockade.
• Maintenance of normothermia may reduce the risk of infection, as well as lessening the impact of Raynaud’s phenomenon, if present.
• Laryngeal erythema and oedema are common—try to minimize trauma to the airway.
• Consider hourly urine output and invasive monitoring.
• Steroid supplementation (see E p. 165).
• Strict asepsis with invasive procedures, as increased risk of infection.