Sjogren's Syndrome and General Anesthesia
Sjogren’s syndrome presents unique considerations and implications for surgery and general anesthesia. As with other disorders, the risks of anesthesia with Sjogren’s syndrome, also called ‘sicca syndrome,’ increase with more severe disease.
If you have mild Sjogren’s (pronounced show-grins), you will likely not have more risk of serious adverse events than average. With severe or long-standing disease involving more body systems, the risk will increase.
Discussing your concerns and issues with the anesthesiologist can help to minimize these risks. While the anesthesia provider may be familiar with Sjogren's syndrome, he or she may not realize that the disease can be systemic or know the extent of disease in your case.
What is Sjogren's Syndrome?
Like other autoimmune disorders, the symptoms of Sjogren’s result from an attack by the body’s own immune system. The white blood cells that normally fight off infection, mistake part of your body for something that doesn’t belong there.
In Sjogren’s syndrome, the main targets of these rogue cells are the moisture-producing glands throughout the body. Dry, irritated eyes and mouth are the most recognized symptoms of the disorder. What is less well known is that this is really a systemic disease affecting the whole body.
The antibodies that cause the problems circulate throughout the body leading to a chronic inflammatory state. This causes generalized symptoms such as fatigue, low-grade fever and joint aches as well as various effects on vital organ systems.
Introduction to Sjogren's Syndrome
General Anesthesia and Sjogren's Syndrome
With this background, it becomes easier to understand why there are special considerations for Sjogren's syndrome and general anesthesia. As with other systemic, autoimmune disorders, Sjogren's causes disturbances throughout the body. Let's examine a few of the main issues from head to toe.
Central Nervous System: A great many Sjogren's patients complain of 'brain fog' with their disorder. This may get worse temporarily after anesthesia. Have a responsible caretaker stay with you for the first few days after surgery. It is unknown whether or not people with Sjogren's are more prone to post-operative cognitive dysfunction.
Eyes: Dry eyes are more prone to corneal abrasions. When you are asleep under anesthesia, the eyes are usually protected with ointment, tape or both. You can ask your anesthesiologist to apply lubricating ointment to the eye about every half-hour while you are asleep.
Mouth and Nose: During anesthesia, the nose and mouth will become more dry. It may be advisable to apply lubricating ointment to the nose prior to 'going under.' You will not be able to drink for several hours before surgery, but ask if you can rinse your mouth (without swallowing) if it gets excessively dry. A mouth without normal saliva production also is more apt to develop problems with the teeth. There is a risk of a tooth being dislodged or loosened when the breathing tube is placed, so do alert the anesthesia provider if you have loose, broken, false or decaying teeth.
Throat: A breathing tube between the vocal cords or breathing mask in the back of the throat will be used during general anesthesia in most cases. The lining of the throat is exceedingly sensitive and having a dry throat will make the usual sore throat after anesthesia even worse. In addition, the throat can swell a bit if it is very irritated which makes it harder to breathe after the tube is removed. You can ask the anesthesiologist to make sure the tube or mask is very well lubricated. Having the oxygen humidified in the recovery room will also help, so you may want to arrange for that ahead of time, as well.
Lungs: If you suffer from recurrent bronchitis or pneumonia, make sure you work with your rheumatologist or primary medical doctor to make sure you are as healthy as possible before your surgery. If you are sick with a lower respiratory illness when you show up for your procedure, it will likely be canceled.
Stomach and Digestion: Heartburn and acid reflux occur frequently with Sjogren's syndrome and can predispose to complications after anesthesia. As you lose consciousness and as you are waking from anesthesia, your protective airway reflexes do not function properly. These reflexes normally prevent the stomach contents from entering the lungs. If you have excess acid or the symptoms of GERD, you may be at more risk for pneumonia from aspiration of stomach contents into the lungs. If you take acid-suppressing medication, it will likely be recommended that you take that the morning of surgery. Or, you can be given a dose in your IV before going to sleep.
Muscles and Joints: Aches and pains throughout the body can get worse temporarily after anesthesia. When you are unconscious under anesthesia, you don't move at all- not even the little movements that your body makes during nighttime sleep. When you wake from anesthesia, you may have more stiffness for a couple days. Heating pads and pain medications will help.
Skin: Because of the dryness of the skin, you may be more prone to abrasions and pressure ulcers. The operating room staff pads your joints and any pressure points that contact the operating bed. If you know your skin is very fragile, it might be worth mentioning this again on the morning of surgery so that extra padding can be used if necessary.
Sjogren's Medications and Anesthesia
It will be very important to bring a current list of medications to your prep appointment and on the day of surgery. Some medications have implications for anesthesia.
In particular, let the doctors and nurses know if you take any pills to increase secretions. Medications like pilocarpine and cevimeline help with saliva production, but affect the nervous system in other ways, too. These effects can be easily managed during anesthesia as long as the anesthesiologist knows that they are caused by a medication. Also, it is important that they know if you take immunosuppressants or herbal supplements.
HOW TO PREPARE FOR GENERAL ANESTHESIA IF YOU HAVE SJOGREN'S SYNDROME
The best preparation will involve a collaboration between your surgeon, the anesthesia department, your rheumatologist and you.
- Make sure the doctor treating your Sjogren's knows you have surgery planned. Decide which medications can be continued and which should be stopped prior to surgery.
Discuss these medicines with your surgeon. If you are taking medicines to suppress the immune system, for example, you may need to time your last dose carefully to avoid having excessive risk of infection after surgery.
Make your preop appointment with the anesthesia department well in advance of your surgery. This allows the anesthesia doctor to contact you, your surgeon and your rheumatologist if necessary, to discuss and plan for any issues.
Usually all that is necessary is making the anesthesiologist aware of your Sjogren's, the medications you take and any special issues you may have. Being educated and passing your experience on to the providers will ensure that you have a safe and smooth anesthetic.