Systemic Lupus Erythematosus

Question 9 from the first paper of 2005 asked the candidates to list the clinical features and manifestations of SLE. Specific focus was on the influence of these various manifestations on the course of ICU stay, and how you might go about managing them.

Manifestations of Systemic Lupus Erythematosus 
and their influences on ICU management
Topic Area Manifestations Influence on ICU management
Airway Cricoarytenoiditis
  • Need for intubation
  • Difficult intubation
  • Risk of post-extubation stridor
Respiratory Pulmonary fibrosis
  • Impaired gas exchange
  • Restrictive ventilatory defect
  • Need to test pleural fluid for ANA
Pulmonary hypertension
  • Hypoxia
  • Hypothension in response to high PEEP
  • Right heart failure
Circulatory Myocarditis
  • Need for inotropes, IABP or ECMO
  • Potential need for RV biopsy for diagnosis
Constrictive pericarditis
  • Obstructive cardiac failure
  • Danger of colchicine therapy
  • Need for cardiothoracic surgical release
Increased risk of coronary artery disease
  • MI is higher on the list of differentials for hemodynamic instability, even in young females
Neurological Cerebral vasculitis
  • A differential diagnosis of seizures and decreased level of consciousness
  • Impaired blood brain barrier
Endocrine Cushing syndrome due to chronic steroid use
  • Hyperglycaemia
  • Hyponatremia
  • Fluid overload
Renal Lupus nephritis
  • Pre-existing renail impairment
  • Susceptibility to nephrotoxins is increased
Gastrointestinal Gastrointestinal tract vasculitis
(and/or ulceration)
  • Vigilant monitoring for GI haemorrhage
  • Malabsorption of feeds may occur
Hepatic Hepatic vein thrombosis due to APLS
  • A differential for ascites and hepatic failure in SLE patients
  • Anticoagulation will be required
Haematological Anaemia of chronic disease
  • Impaired haemopoietic response to haemorrhage
  • Increased transfusion requirements
Haemolytic anaemia
  • MAHA needs to be considered in the anaemic SLE patient
  • Vasulitic and haemolytic screening needs to be performed
  Antiphospholipid syndrome
  • Risk of bleeding is increased
  • Risk of thrombosis is increased
  • Risks of anticoagulation need to be balanced with benefits
Infectious Immunossuppression, and the risk of sepsis
  • Need to consider opportunistic organisms in the selection of antibiotic cover


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