Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 9  |  Issue : 1  |  Page : 89-91  

Anesthesia management in a patient with systemic lupus erythematosus and left ventricular thrombus


Department of Anaesthesia, MS Ramaiah Medical College, Bengaluru, Karnataka, India

Date of Web Publication22-Dec-2015

Correspondence Address:
Leena Harshad Parate
Department of Anaesthesia, MS Ramaiah Medical College, MSRIT Post, Bengaluru - 560 054, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.167959

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  Abstract 

Systemic lupus erythematosus (SLE) is a complex autoimmune disorder with heterogeneous presentation. We discuss the perioperative management of a female having SLE with left ventricular thrombus who was scheduled for bilateral femoral head core decompression. Warfarin was stopped preoperatively in order to bring down international normalized ratio <1.5 and restarted postoperatively on next day.

Keywords: Anesthesia, left ventricular thrombus, systemic lupus erythematosus


How to cite this article:
Parate LH, Shenoy B, Vig S, Dinesh CN. Anesthesia management in a patient with systemic lupus erythematosus and left ventricular thrombus . Med J DY Patil Univ 2016;9:89-91

How to cite this URL:
Parate LH, Shenoy B, Vig S, Dinesh CN. Anesthesia management in a patient with systemic lupus erythematosus and left ventricular thrombus . Med J DY Patil Univ [serial online] 2016 [cited 2020 Aug 8];9:89-91. Available from: http://www.mjdrdypu.org/text.asp?2016/9/1/89/167959


  Introduction Top


Systemic lupus erythematosus (SLE) is an inflammatory autoimmune disorder characterized by multiple organ dysfunctions due to autoantibodies and immune complex-mediated tissue destruction. It's estimated prevalence is 1 per 1000 population with male to female ratio of 1:10 and primarily affects women of childbearing age. [1] Here we report a case of SLE with left ventricular (LV) thrombus who was scheduled for bilateral femoral head core decompression.


  Case Report Top


A 15-year-old female admitted with complain of pain in both hip joints. She was evaluated and diagnosed as bilateral femoral head necrosis and posted for core decompression. She was a known case of SLE since past 3 years and was on oral prednisolone 10 mg. She had a history of acute anterior wall myocardial infarction (AWMI) 2 years back. Coronary angiogram revealed single vessel disease of left anterior descending artery. It was managed conservatively. Since then she has been started on metoprolol 25 mg OD and aspirin 75 mg. After 1-year, she developed one episode of generalized tonic-clonic convulsions. MRI scans showed features of vasculitis. She was started on levetiracetam and her seizures subsided.

She was diagnosed with hypertension 4 months back and has been taking losartan 2.5 mg BD, carvedilol 3.125 mg BD and torsemide 10 mg BD daily. Urine investigations revealed significant proteinuria. Renal biopsy confirmed diagnosis of lupus nephritis class IV. She received monthly cyclophosphamide injection for 4 months. After 2 months, she had bronchopneumonia and myocarditis with LV thrombus and was managed conservatively with intravenous (IV) antibiotics, IV steroids and heparin IV infusion. Since then she has been started on warfarin 2 mg OD.

Preanesthesia examination revealed pallor, cushingoid features with "moon facies" and multiple striae. Sinus tachycardia (110/min) and hypertension (150/90) was noted. Airway assessment showed Mallampati IV view and normal neck movements. Investigations showed Hb: 9.31 g%, platelet count: 3.1 lakhs, prothrombin time: 35.3, international normalized ratio (INR): 3.86, activated partial thromboplastin time (APTT): 53.5, APTT ratio: 1.98, serum creatinine: 1.4 mg%. Electrocardiogram (ECG) was suggestive of old AWMI. Two-dimensional echo revealed ejection fraction 40% with septal wall akinesia and LV thrombus measuring 22 mm × 16 mm. Chest X-ray was normal. Warfarin was stopped, and it was decided to take her for surgery once INR falls below 1.5. Patient was put on subcutaneous injection enoxaparin 40 mg BD. Six days after discontinuation of warfarin, her INR came down to 1.2, and she was posted for surgery.

She was kept nil by mouth for 6 h. Her routine antihypertensive, antiepileptic and steroid medications were continued till the day of surgery. 18 G IV cannula was secured with difficulty. Standard monitoring (ECG, noninvasive blood pressure, pulse oximetry) were applied. General anesthesia was induced with midazolam 1 mg, fentanyl 2 mcg/kg and propofol 1 mg/kg. After checking adequacy of mask ventilation atracurium, 0.5 mg/kg was given. Airway was secured with Proseal LMA 3 (The Laryngeal Mask Company Limited, Seychelles) and anesthesia was maintained on isoflurane (0.4-1.2%) in oxygen and air with atracurium 0.1 mg/kg IV boluses. Normothermia was maintained with hot air blanket. Procedure lasted for 2 h. Intraoperative course was uneventful with minimal blood loss and was replaced with crystalloids. IV paracetamol 1 g was given for analgesia. After the reversal with neostigmine 50 mcg/kg and glycopyrrolate 10 mcg/kg, she was extubated and shifted to the postanesthesia care unit and thence to ward on next day. Postoperatively her Hb dropped to 7.2 g% and was transfused 1 unit of packed red cells. Warfarin was restarted on next day. She was discharged 5 days later with advice to follow-up.


  Discussion Top


Anesthesia management of SLE patient should focus on multiple organ involvement, deranged coagulation system and airway involvement. Avascular necrosis of femur commonly affects 10% of SLE patients and is associated with high-dose steroid therapy. [2] Our case represents a classical case of SLE with disease affecting almost every organ. Young females with SLE are more prone for coronary artery disease even in the absence of any risk factors. Cardiac involvement can result in myocarditis, pericarditis while valvular lesion characteristically known as Libman-Sacks endocarditis. Coronary vasculitis and accelerated atherosclerosis lead to the high prevalence of ischemic heart disease in these patients. Patients are predisposed to fatal intraoperative events like myocardial infarction. [3] Rhythm and conduction abnormalities are common in these patient. Hence 5 lead ECG and invasive blood pressure monitoring becomes crucial in these patients coming for major surgeries.

Special care is to be taken while manipulating airway in these patients. Cricoarytenoid arthritis, laryngeal edema, vocal cord palsy and atlanto occipital joint subluxation can result in unanticipated difficult airway. These patient are more prone for subglottic stenosis even after a short duration of intubation and in extreme cases may require tracheostomy. [4] Avoiding intubation using supraglottic airway devices or use of fiberoptic intubation technique are safer approaches in these patients.

Anemia and thrombocytopenia are commonly seen in SLE patients. The presence of lupus anticoagulant is associated with prolonged partial thromboplastin time but the risk of bleeding is rare, and thus regional anesthesia can be practiced safely. [2] The presence of antiphospholipid antibodies increases the risk of venous and arterial thrombosis for which indefinite anticoagulation with warfarin is required to keep INR in between 2 and 4. American college of chest physicians recommends interruption of warfarin 5 days before surgery. Bridging therapy is indicated in patients who are high risk for developing thromboembolism. [5] In patients receiving anticoagulants, performing regional anesthesia should consider benefit and risk as postoperative reintroduction of anticoagulants is necessary. Neurological involvement in SLE is termed as neuropsychiatric SLE. The manifestation may vary from headache, seizures, stroke to even demyelinating disease. Pulmonary involvement includes acute lupus pneumonitis, diffuse alveolar hemorrhage and interstitial lung disease. Renal involvement is manifested by hypertension, proteinuria and renal insufficiency. General principle for renal protection should be followed even in the presence of normal serum creatinine and urine analysis. [6]

Majority of these patients are on prolonged steroid therapy, and it can result in hypothalamic pituitary axis suppression. Patient with cushingoid features on chronic high-dose steroid therapy are more prone for adrenal suppression. Since our patient was on low dose steroid, additional steroid was not required. [7] Antibiotic prophylaxis should be given as steroids, and immunosuppressant therapy lowers the immunity. Patients receiving immunosuppressant could response differently to anesthetic drugs. Cyclophosphamide induced plasma cholinesterase inhibition can prolong the action of succinylcholine. [8] Drugs excreting by the renal route should be used judiciously. Normothermia should be maintained as these patients are more prone for Raynaud's phenomenon.

We conclude anesthesia management of these patients is based on a careful assessment of multiorgan involvement, hypercoagulable state and perioperative medications.

 
  References Top

1.
Carrillo ST, Gantz E, Baluch AR, Kaye RJ, Kaye AD. Anesthetic considerations for the patient with systemic lupus erythematosus. Middle East J Anaesthesiol 2012;21:483-92.  Back to cited text no. 1
    
2.
Davies SR. Systemic lupus erythematosus and the obstetrical patient - implications for the anaesthetist. Can J Anaesth 1991;38:790-5.  Back to cited text no. 2
    
3.
Ozaki M, Minami K, Shigematsu A. Myocardial ischemia during emergency anesthesia in a patient with systemic lupus erythematosus resulting from undiagnosed antiphospholipid syndrome. Anesth Analg 2002;95:255.  Back to cited text no. 3
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4.
Raj R, Murin S, Matthay RA, Wiedemann HP. Systemic lupus erythematosus in the intensive care unit. Crit Care Clin 2002;18:781-803.  Back to cited text no. 4
    
5.
Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9 th ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141 2 Suppl:e326S-50.  Back to cited text no. 5
    
6.
Ben-Menachem E. Review article: Systemic lupus erythematosus: A review for anesthesiologists. Anesth Analg 2010;111:665-76.  Back to cited text no. 6
    
7.
Axelrod L. Perioperative management of patients treated with glucocorticoids. Endocrinol Metab Clin North Am 2003;32:367-83.  Back to cited text no. 7
    
8.
Norris JC. Prolonged succinylcholine apnoea resulting from acquired deficiency of plasma cholinesterase. Anaesthesia 2003;58:1137.  Back to cited text no. 8
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