Anesthesia management of a patient with Lupus really depends on how severe the condition is and the magnitude of organ dysfunction. An individualized approach is especially important and should be based on the degree of the involvement of the various systems, current medications the patient is taking, and on laboratory investigations.

Difficult Airway Risk – Prepare for difficult intubation and use smaller-sized tubes where possible. Laryngeal mucosal ulceration/edema, subglottic stenosis, cricoarytenoid arthritis, and recurrent laryngeal nerve palsy is present in up to a third of patients with Lupus. Symptoms range from mild to acute airway obstruction and vocal cord paralysis.

Essential Labs – CMP, CBC with coagulation profile, platelet count should be no older than 30 days, EKG if cardiac problems are suspected, chest X-ray (if pleural effusion or interstitial pneumonitis is seen clinically). If the patient is affected renally, a creatinine clearance (no older than 30 days) and 24 h urine protein should be checked.

Essential monitors – Standard monitors, A-line (if the patient is demonstrating lupus-associated cardiac problems)

Drugs to Avoid – Avoid the use of hydralazine and procainamides – both of these drugs have been known to cause drug-induced SLE. Isoniazid, D-penicillamine, and a-methyldopa are also culprits to drug-induced SLE. Avoid anything nephrotoxic.

Drug selection – Where possible, use drugs that do not heavily rely on renal clearance (eg. cisatracurium).

Control Stress – Use anxiolytics and other CNS depressants to keep the stress response to a minimum at the critical junctions of anesthesia – lupus is exacerbated by stress.

This condition is an inflammatory disease which affects multiple systems. It is characterized by antinuclear antibody production. Stress exacerbates the condition and may be seen in higher incidence among surgical patients, parturients, and infection.

This is a very common problem, affecting 1 in 1000 people overall. Incidence is higher in women than men (10:1). Peak incidence occurs between 15-40 years of age.

Diagnosis – antinuclear antibody screening test is very sensitive. 95% of SLE patients have these antibodies. Furthermore, the diagnosis is highly likely if the patient has 3 of 5 of the following: antinuclear antibodies, iconic butterfly-shaped mylar rash, thrombocytopenia, serositis, and nephritis.

Symptomology by system:

Cutaneous/skin – Mylar butterfly-shaped rash on the face. This is in approximately half of the patients with lupus and is worsened with exposure to sunlight. Alopecia is a common finding. Discoid lesions may appear on the scalp, face, and upper trunk in approximately 25% of patients.

Joints – Bilateral/symmetrical transient arthritis in the hands, wrists, elbows, knees, and ankles is common in 90% of patients. Lupus does not appear to cause arthritis in the spine.

CNS – Neurologic problems can span anywhere in the CNS. Seizures, CNS demyelination, psychosis, and acute confusional states may be present. Cognitive problems are observed in as high as 1/3 of these patients.

Cardiac – Pericarditis is the most common cardiac manifestation. CHF may develop in extreme cases. Aortic and mitral valve abnormalities may also occur and are identified by echocardiography. Myocarditis, arthrosclerosis, and myocardial ischemia are also manifest in some cases.

Pulmonary – Lupus pneumonia is a common pulmonary problem. Restrictive lung disease is a typical finding when pulmonary function tests are employed. Pulmonary hypertension is seen in some.

Renal – The most common renal problem is glomerulonephritis with proteinuria. When GFR is severely impacted/reduced, oliguric renal failure may result. Hematuria may also be present. Risks of renal hypertension are heightened when the patient is taking more than 30 mg of prednisolone daily.

Hepatic – 30% of these patients will show abnormal liver function tests.

Neuromuscular – Myopathy with proximal skeletal weakness and elevated serum creatinine kinase is a common neuromuscular manifestation of lupus. Tendinitis is also very common and may result in tendon rupture.

Blood – Antiphospholipid antibodies can cause thromboembolism. Reduced white blood cells, granulocyte abnormalities, and decreased levels of complement (C3/C4) are all components of a higher risk of infection. Thrombocytopenia and higher levels of circulating anticoagulants will cause a prolonged aPTT and heighten the risk of intraoperative bleeding. Anemia is found in about half of SLE patients.