2007-07-04 00:00 来源:丁香园 作者:西门吹血
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  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?












  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.


  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