P057: ANESTHETIC MANAGEMENT OF A PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS AND RAYNAUD'S PHENOMENON UNDERGOING EXTENSIVE SPINAL RECONSTRUCTION FOR SEVERE KYPHOSCOLIOSIS
Emily M McFarlane, BS1; Melodie Nasr2; Gisele J Wakim, MD3
1University of Miami Miller School of Medicine; 2University of Florida; 3University of Miami/Jackson Health System
Patients with systemic lupus erythematosus (SLE) and Raynaud’s phenomenon present distinctive perioperative challenges during complex spinal reconstruction due to risks of vascular compromise, exaggerated inflammatory responses, and multisystem involvement.
We report the anesthetic management of a 55-year-old woman with severe kyphoscoliosis undergoing T10–L5 posterior fusion with lateral L3–4 anterior column release, decompression, osteotomy, and interbody fusion. Her history includes SLE in remission for five years, Raynaud’s phenomenon, chronic pain syndrome, hypertension, gastroesophageal reflux disease, and multiple drug allergies. Indications included debilitating pain (9/10), inability to stand beyond 45°, and bladder incontinence. She was cleared by primary care and rheumatology. ASA physical status was IV. Airway assessment (Mallampati III) supported direct laryngoscopy with fiberoptic equipment available due to possible cervical spine involvement.
When SLE coexists with Raynaud’s phenomenon, secondary Raynaud’s should be assumed, as it involves both vasospasm and fixed vascular defects, increasing the risk of ischemia. A key intraoperative priority was mitigating Raynaud’s risk: we maintained normothermia, minimized vasoconstrictors, and performed frequent perfusion checks during prolonged positioning. Ultrasound-guided femoral arterial access was chosen over radial artery cannulation to reduce the risk of digital ischemia and upper extremity vascular compromise. Additionally, we proactively assessed for calcium channel blocker use to anticipate and manage hypotension and bradycardia.
For SLE-specific considerations, a thorough medication review was essential. Given azathioprine’s potential to attenuate neuromuscular blockade, we planned for adjusted dosing and vigilant quantitative monitoring; in this patient, standard rocuronium dosing (0.6 mg/kg) was sufficient. Immunosuppression informed enhanced infection prevention through strict temperature control and early postoperative wound surveillance. Rheumatology clearance was critical to evaluate renal, cardiac, pulmonary, and hematologic involvement. Despite baseline opioid tolerance from a preoperative fentanyl patch, fentanyl 100 mcg at induction and sufentanil 0.2 mcg/kg/hr, achieved adequate analgesia while supporting hemodynamic stability. Estimated blood loss was 500 mL, and postoperative anemia required transfusion of two units of packed red blood cells.
This case highlights the need for multidisciplinary planning in patients with SLE and Raynaud’s undergoing spinal surgery. The combined challenges of autoimmune disease, vascular compromise, and chronic immunosuppression call for a tailored approach that prioritizes hemodynamic stability, infection control, and tissue perfusion, providing a framework for anesthetic management in similarly high-risk cases.
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