LUPUS AND ANESTHESIA
Sherry Ikalowych, CRNA, MS
Terry Lahita, CRNA
A selection from the Lupus Foundation of America Newletter Article Library
Approximately 16,000 people develop Systemic Lupus Erythematosus (SLE) in the United States each year. Lupus, or SLE, is a chronic, noninfectious, inflammatory disease that affects about 10-15 times as many women as men. The disease is characterized by exacerbations and remissions and the onset of the disease can be slow or sudden. The extent and severity of the symptoms can vary from person to person.
If you are a person with SLE and need to have surgery and anesthesia, either for a
condition related to your disease or for an unrelated problem, there are certain things you should know. If you are well informed and know what to expect, the experience can be much safer and less stressful.
Because of your special needs, the team of medical professionals caring for you will thoroughly interview you about your medical condition. When someone from the anesthesia team sees you they will have many questions that are important to your care during surgery.
It may help if you see your lupus doctor before surgery to get a “medical clearance”. This clearance is a summary of your medical history, including recent lab tests, x-rays and electrocardiogram. Sometimes these tests have to be repeated before surgery.
Special additional tests may also be requested in order to evaluate the current condition of your organ systems, nervous system and blood. When a medical clearance is not obtained prior to admission, the anesthetist may request that it be done while you are in the hospital.
In general, anything you think is important for the anesthetist to know is important. There are, however, a few things that you should be sure to mention:
It is essential that you give the anesthetist a list of all medications you are currently taking. This will help your anesthesia team decide what type of anesthetic will be best for you and will guide your medical management both before, during and after surgery. Of particular significance is your steroid dose, which may have to be increased for “stress coverage”.
If you have joint involvement that will limit the movement of your neck, jaw, back or limbs, be sure to tell the anesthetist. This information is important in the evaluation of your airway and will help the operating room nurses to properly position you on the operating table.
Certain antiseptic cleaners or tape can be irritating to the skin of people that are particularly sensitive. If your lupus symptoms include skin rash or sensitivity, special anti-allergy materials can be used to minimize reactions. These things can be noted on your chart when you mention them to the anesthetist.
If you, or a member of your family, have had a problem with anesthesia in the past the anesthetist will want to know this. If the anesthetic was administered in the hospital where you are having your current surgery, your previous anesthesia record can be checked to help determine the best plan.
Respiratory problems, whether related to your lupus or not, should be reported to the anesthetist. A history of smoking, asthma, bronchitis, pneumonitis, collapsed lung, etc., is very important information.
If a doctor has told you in the past that you have a “heart murmur”, a very fast or slow heart rate, skipped beats, high blood pressure, etc., the anesthetist should know about it even if you are not under treatment for it.
Don’t forget to tell the anesthetist about all allergies to drugs, food (especially shellfish which would preclude the use of certain surgical cleansing scrubs), latex (which would preclude the use of certain gloves and tubing), and environmental factors.
Since SLE patients usually have low hematocrit levels, it is a good idea to talk to your surgeon about the possibility of a blood transfusion. If a transfusion may be necessary, you may be able to donate a unit of your own blood a week or two before your operation just in case it is needed. If this is not possible, you should understand the risks and benefits of bank blood if a transfusion is absolutely necessary for you.
If you know that you have antiphospholipid antibodies be sure to inform your surgeon and anesthesia team. The presence of this antibody can cause either too much bleeding or too much clotting and tests must be done to determine which one.
Once all the necessary information has been collected, the anesthetist will discuss anesthetic options with you. One option may be general anesthesia where you will be maintained unconscious and pain-free through the use of intravenous medications and anesthetic gases. Sometimes when you are asleep a tube may be placed in your windpipe. In some instances this tube may remain in place after surgery until you are fully awake and breathing normally.
Another anesthetic plan may be regional technique (spinal or epidural). This involves the placement of an anesthetic solution through a needle or catheter into your back. Sometimes, in longer procedures, the catheter may remain in place so that additional medication can be injected as needed during and/or after surgery. An epidural catheter can also be inserted prior to a general anesthetic for post operative pain relief.
Local anesthesia may be preferable for some procedures. In this technique the surgeon or the anesthetist can inject the operative area with anesthetic that will numb only the area the surgeon is working on. During the injection of the local anesthetic you will be given intravenous medications that will make you drowsy but not completely asleep. An anesthetist will remain with you during your operation to make sure you are as comfortable as possible.
Regardless of the type of anesthetic that you receive, safety is the primary concern of the anesthetist. While you are undergoing your operation and anesthetic: your breathing, heart and blood pressure, as well as several other parameters will be carefully monitored by the anesthetist.
When surgery is finished, you will be taken to a post anesthesia care unit (PACU), or recovery room. Here the nurses will monitor you while you fully recover from your anesthetic. If you had regional anesthesia, this means having sensation and movement return to the area of the body that has been anesthetized. When your surgeon, the anesthetist and the recovery room nurses decide you are ready, you will be discharged either to your home (if you were admitted for “same day surgery”) or to your regular hospital room.
Pain medication will be available to you during your recovery period. This can be provided in several ways. The most common way is on a demand basis where you will ask the nurse for medication and she/he will provide you with the medication that your doctor has ordered for you. The second is by patient controlled analgesia, or PCA. This is a pump attached to your intravenous line that will allow you to give yourself a pre-set dose of pain medication, as you need it. And thirdly, you may have an epidural catheter in place through which your pain medication can be delivered.
Occasionally, after a stressful event such as surgery, your lupus symptoms may temporarily get worse. It may be necessary to adjust you medications, especially your steroids. Your lupus doctor will care for you during this period in order to minimize and hopefully avoid any worsening of your symptoms. It will be important for you to report to your doctor any new symptoms or worsening of your usual symptoms at this time.
Your anesthesia care team is always available to answer any questions you might have—please feel free to call them whether before or after your surgery so they can answer your questions and help you through your surgical experience with the least stress possible.