Preoperative Evaluation of Discoid Lupus Erythematosus for Anesthesia
For patients with discoid lupus erythematosus (DLE) undergoing surgery, the preoperative evaluation should focus on medication management, assessment of disease activity, and identification of organ involvement to minimize perioperative complications.
Disease Assessment
- Determine if the patient has isolated DLE or if there are signs of systemic lupus erythematosus (SLE)
- Assess current disease activity and stability
- Document extent and location of skin lesions, particularly on the face and neck which may impact airway management
- Evaluate for scarring that could affect intubation or positioning
Medication Management
Topical Treatments
- Continue topical treatments for DLE (steroids, calcineurin inhibitors) through the perioperative period
- For patients using high-potency topical steroids like fluocinonide 0.05%, these can be continued as they don't significantly impact surgical outcomes 1
Systemic Medications
If the patient has only DLE without systemic involvement:
- Hydroxychloroquine: Can be continued through surgery as it has minimal impact on perioperative infection risk 2
- Acitretin: Consider withholding for 1 week before surgery due to potential for increased bleeding risk 1
If the patient has features of systemic lupus:
- For non-severe SLE: Withhold mycophenolate mofetil, azathioprine, cyclosporine, or tacrolimus 1 week prior to surgery 3
- For severe SLE: Continue immunosuppressive medications through surgery to prevent disease flares that could increase morbidity and mortality 3
- For biologics (belimumab, rituximab): Plan surgery at the end of the dosing cycle 3
Perioperative Risk Assessment
Cardiovascular Evaluation
- Assess for pericarditis, valvular disease, or pulmonary hypertension if there are systemic features
- ECG to evaluate for conduction abnormalities
Pulmonary Evaluation
- Evaluate for interstitial lung disease or pleuritis if systemic features are present
- Consider pulmonary function tests if there is respiratory involvement
Renal Function
- Check creatinine, BUN, and urinalysis to assess for lupus nephritis
- Recent studies show increased risk of postoperative acute renal failure (OR=7.23) in patients with recent SLE-related hospitalization 4
Hematologic Assessment
- Complete blood count to evaluate for cytopenias
- Coagulation studies (PT, PTT) to assess for antiphospholipid antibodies
Anesthesia Considerations
Airway Management
- Document facial scarring or lesions that may impact mask ventilation or intubation
- Consider video laryngoscopy for patients with significant facial/neck involvement
- Plan for potential difficult airway if there is significant scarring
Positioning
- Document areas of active lesions to avoid pressure on these sites during positioning
- Consider padding for areas with active inflammation or scarring
Medication Selection
- Avoid medications that may exacerbate photosensitivity if possible
- Consider stress-dose steroids if the patient has been on long-term steroid therapy
Postoperative Monitoring
- Monitor for disease flares, which may be triggered by surgical stress
- Resume medications according to wound healing status
- For patients on biologics or immunosuppressants that were withheld, restart once the wound shows evidence of healing (typically ~14 days) 3
- Monitor for infections, as patients with lupus have higher risk of postoperative infections 4
Special Considerations
- Patients with recent SLE-related hospitalizations (within 6 months) have significantly higher risks of postoperative complications and mortality (OR=2.39) 4
- The risk of surgical complications is higher in emergency surgeries compared to elective procedures in lupus patients 5
- Higher preoperative steroid doses correlate with increased postoperative complications 5
By following this structured approach to preoperative evaluation of DLE patients, anesthesiologists can minimize perioperative risks and optimize outcomes for these patients undergoing surgery.