Systemic Lupus Erythematosus (SLE)
With the incidence of systemic lupus erythematosus (SLE) increasing, anesthesiologists are more likely to be exposed to patients with the disease. Next weeks we'll be discussing various aspects of SLE, and this week, we'll be discussing the anesthetic implications of SLE.
1. What are the cardiopulmonary implications of SLE on anesthesia?
2. Is there a role for nitric oxide in patients with SLE?
3. What causes of SLE morbidity and mortality are important to the anesthesiologist?
本周讨论SLE的麻醉：
1、SLE麻醉相关的心肺问题？
2、笑气能否用于SLE患者？
3、导致SLE发病和死亡的原因中，麻醉医生关心哪些内容？
参考答案：
1、SLE麻醉相关的心肺问题？
限制性疾病肺动脉高压（PH）和广泛间质水肿时SLE终末期肺脏的典型表现，因此，应通过各种措施使肺血流达到最佳程度，如避免肺血管阻力增加、肺水肿形成，减少回心血量等。从麻醉管理的角度，这意味着可避免出现低氧、高碳酸血症、内源性儿茶酚胺释放或出现瓦尔萨尔瓦动作[1]。因此，很多研究者认为应尽可能的使用局部麻醉，然而，有报道认为，在没有麻醉的情况下，全身使用抗凝剂可产生自发性椎管内血肿，这已成为一不争的事实[2]。
需要使用全麻时，应采用类似于心脏麻醉的诱导和维持方法[1]。麻醉诱导和维持采用依托咪酯，以降低喉镜插管时的反应，术中加强监测，通过血管活性药控制肺循环和体循环压力。
2、笑气能否用于SLE患者？
虽然已经有大量关于笑气（即使长时间使用）作为肺动脉扩张剂用于严重PH患者的报道[3]，但尚没有关于其用于继发于SLE导致的肺部疾病患者。似乎可通过逻辑推理得出，终末期PH使用笑气有益处。有趣的是，有严重SLE的患者全身和脑脊液中的笑气浓度增高，而脑脊液中的笑气浓度与疾病的严重程度密切相关[4]。虽然笑气能否用于SLE患者尚不清楚，但有一些研究人员推测认为，笑气至少可能作为SLE疾病严重程度的判断指标之一[5]。
3、导致SLE发病和死亡的原因中，麻醉医生关心哪些内容？
如上所述，包括冠心病在内的心肺疾患是SLE患者死亡的最主要原因。此外，急性血管事件如血栓、中风、肾功能衰竭也是围术期死亡的原因之一。全身血流动力学和血液流变学与SLE死亡病的显著关系使之成为麻醉医生关注的重点内容。
常有可能被忽视的是，感染也是威胁SLE患者生命的重要原因之一。由于激素和免疫抑制药的全身使用，可发生多种细菌、病毒和条件致病菌感染发生[6]，因此，在SLE患者治疗过程中，应注意严格的无菌操作。
What are the cardiopulmonary implications of SLE on anesthesia?
Pulmonary hypertension and diffuse interstitial edema with restrictive disease represent the end-stages of SLE on the lung. As such, pulmonary blood flow must be optimized by avoiding increases in pulmonary vascular resistance, formation of pulmonary edema, and decreases in systemic venous return to the right atrium. In terms of anesthetic management, this means the avoidance of hypoxia, hypercapnia, endogenous catecholamine release, or Valsalva maneuvers (1). The controlled administration of regional anesthesia has been advocated by many investigators when applicable, however, systemic anticoagulation must be acknowledged as spontaneous spinal hematomas, without anesthetic intervention, have been reported (2).
Should general anesthesia be necessary, a controlled, cardiac anesthesia-like induction and maintenance has been suggested (1). Included in this management are the use of an etomidate or narcotic induction and maintenance, with the blunting of responses to laryngoscopy and strict monitoring and control of pulmonary and systemic pressures with inotropic and vasodilatory agents.
Is there a role for nitric oxide in patients with SLE?
Although there have been a number of reports citing the benefits of even long term use of nitric oxide as a pulmonary arterial dilator in patients with severe pulmonary hypertension (3), its use has not been described in patients with pulmonary disease secondary to SLE. It seems logical to conclude that in end stage pulmonary hypertensive disease, the use of nitric oxide may confer some benefit. Of interest, patients with significant SLE have been noted to have elevated levels of nitric oxide both systemically and in the cerebral spinal fluid which strongly correlate to the severity of the disease process (4). While the role of this nitric oxide remains unknown, some investigators have speculated that it can at least be used as a marker of SLE severity (5).
What causes of SLE morbidity and mortality are important to the anesthesiologist?
As mentioned above, the cardiopulmonary issues including coronary arterial disease, are the most important causes of death in patients with SLE. In addition, acute vascular events, such as thrombosis and stroke, and renal failure represent leading causes of morbidity, and may manifest in the perioperative period. The strong association of SLE mortality to systemic hemodynamics and blood rheology make these issues of pressing concern to anesthesiologists.
In addition, and frequently overlooked, infections represent a significant threat to patients with SLE. Due to the multisystem nature of the disease as well as the steroid and immunosuppressive drugs utilized, various bacterial, viral and opportunistic infections have been noted to occur (6). Strict aseptic technique should be utilized with all procedures performed in these patients.
References:
1. Cuenco J, Tzeng G, Wittels B. Anesthetic management of the parturient with systemic lupus erythematosus, pulmonary hypertension, and pulmonary edema. Anesthesiology. 1999;91(2):568-70.
2. Goker B, Block JA. Spinal epidural hematoma complicating active systemic lupus erythematosus. Arthritis Rheum. 1999;42(3):577-8.
3. Perez-Penate G, Julia-Serda G, Pulido-Duque JM, Gorriz-Gomez E, Cabrera-Navarro P. One-year continuous inhaled nitric oxide for primary pulmonary hypertension. Chest. 2001;119(3):970-3.
4. Svenungsson E, Andersson M, Brundin L, et al. Increased levels of proinflammatory cytokines and nitric oxide metabolites in neuropsychiatric lupus erythematosus. Ann Rheum Dis. 2001;60(4):372-9.
5. Gilkeson G, Cannon C, Oates J, Reilly C, et al. Correlation of serum measures of nitric oxide production with lupus disease activity. J Rheumatol. 1999;26(2):318-24.
6. Huang JW, Hung KY, Yen CJ, Wu KD, Tsai TJ. Systemic lupus erythematosus and peritoneal dialysis: outcomes and infectious complications. Perit Dial Int. 2001;21(2):143-7.
编辑：ache
