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Q: Why does seal have scars on his face? A: Discoid Lupus Systemic Lupus Erythematosus Angelique Davis SLE: Introduction An autoimmune, Occurs in about 1:1000 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 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 1/31/2 of patients Migratory polyarthritis and dermatitis Polyarthritis that causes out of proportional pain Unknown (2013). SLE face. Retrieved from http://drcamisasblog.com/wpcontent/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 http://studentnurses3.blogspot.com/p/medical-surgical-nursingmnemonics.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 postintubation 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), 483-492. 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), 665-676. 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), 483-492. 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), 1725. Nursing School. (2007, ). Medical Surgical Nursing Mneumonics [Blog post]. Retrieved from http://studentnurses3.blogspot.com/p/medical-surgical-nursingmnemonics.html Unknown (2013). SLE face. Retrieved from http://drcamisasblog.com/wpcontent/uploads/2013/09/SLEFace.png