Systemic Lupus Erythematosus (SLE)

 

 

Considerations 

 

  • Potential difficult airway but usually NOT an issue:

    • C-spine arthritis

    • Cricoarytenoid arthritis

    • Recurrent laryngeal nerve palsy

  • Multisystem complications of SLE:

    • CNS: central & peripheral sensorimotor & autonomic neuropathies, seizure, stroke, mood, confusion, organic disease, transverse myelitis

    • Cardiovascular: pancarditis with myocarditis (conduction disease, CHF), pericarditis (effusions/tamponade), non-infectious endocarditis (aortic & mitral regurgitations), accelerated coronary disease, hypertension, pulmonary hypertension 

    • Pulmonary: restrictive lung disease (ILD, pleuritis, effusions), pulmonary hypertension/RV failure, infection, pulmonary hemorrhage.

    • Renal: lupus nephritis, CRF

    • Hematology: antiphospholipid-Ab syndrome common, risk of thromboembolism, anemia, thrombocytopenia, leukopenia factor deficiency (VIII, IX, XII) with implications for regional anesthesia 

    • Liver dysfunction can occur 

    • MSK: vasculitis, arthritis, joint immobility, migratory polyarthritis

  • Medications:

    • Steroids (Cushings/hyperglycemia/adrenal suppression/need for stress dose)

    • Immunosuppresants/antimalarials

    • NSAIDs

    • Anticoagulants/ASA

  • Potential for acute exacerbation with surgery, stress, infection & pregnancy

  • Obstetric & cardiac anesthesia, especially in those with aPL antibodies or APS, requires multidisciplinary management at a specialist center

 

 

Pregnancy Considerations 

 

  • ↑ risk of preterm labour & intrauterine fetal death

  • Multidisciplinary management: rheumatology, obstetrics, anesthesia 

  • Potential coagulopathy may contraindicate use of neuraxial → ensure early hematology consult 

    • ↑ PTT can have 2 causes: 

      • Presence of lupus anticoagulant: just a lab abN so clinically ok for neuraxial, these patients can actually be hyper-coagulable 

      • Autoantibodies against specific coagulation factors (e.g., VIII, IX, XII): risk of true coagulopathy → neuraxial contraindicated  

  • Document any pre-existing central or peripheral sensorimotor & autonomic neuropathies prior to regional technniques

  • Potential for neonatal lupus & congenital heart block

 

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