Sjogren's syndrome—implications for perioperative practice - Home Study Program

AORN Journal,  March, 2003  by Lynn M. Petruzzi,  Frederick B. Vivino

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Before surgery. The preoperative nurse may be the first to discover that a patient has SS during the preoperative visit or telephone call. The nurse should assess the patient's general status, including medication usage, and determine whether recent laboratory studies have been obtained. It is important to determine whether there is extraglandular involvement. A rheumatologist most likely is the coordinator of the patient's care and can provide information the patient cannot. The anesthesia care provider and perioperative team members should be notified of the patient's diagnoses, and the plan of care should be discussed (Table 4).

Preoperatively, the patient should be instructed to continue his or her usual eye and oral care and medication regimen. The patient also should be instructed to bring an adequate supply of his or her favorite artificial tears, saliva, and other treatments to the hospital. Patients should be asked whether they regularly use vitamin E oil. If indicated, vitamin E oil should be discontinued two weeks before surgery because it may have an anticoagulant effect. A prolonged NPO status should be avoided, and the patient should be allowed clear liquids until two hours before surgery, if possible. (40)

Day of surgery. When the patient arrives in the preoperative area, the perioperative nurse performs a full assessment of the patient's ocular and oral status, skin condition, and mobility. All information obtained about the patient's SS status should be documented. The perioperative nurse should ensure that preoperative and intraoperative medications with anticholinergic effects, such as atropine, diphenhydramine, glycopyrrolate, and promethazine, are avoided. (41) Patients taking long-term steroid medications should receive stress doses for surgery. This should include IV steroids on call to the OR followed by perioperative stress doses until the patient is clinically stable. (42) The circulating nurse turns up the temperature in the OR before the patient is brought to the room because patients with SS are susceptible to Raynaud's phenomenon.

Intraoperatively, the circulating nurse should observe several precautions. Associated arthritis or fibromyalgia can affect the movement and positioning of the patient on and off the OR bed. The circulating nurse, therefore, coordinates the care provided by the entire perioperative team during this process, or if possible, the circulating nurse should have the patient transfer and position himself or herself.

If possible, regional anesthesia is preferred because anesthetic gases are drying and cause a decrease in tear production. If general anesthesia is required, the anesthesia care provider adds a humidifier to the rebreathing system. Additionally, he or she lubricates and places the endotracheal tube or laryngeal mask airway very carefully. The anesthesia care provider may place a dental guard if the patient has multiple caries and thin oral mucosa. Intubation may be difficult if the rheumatic process involves the cervical spine or temporal mandibular joints. The anesthesia care provider should lubricate the patient's eyes every 30 minutes and gently tape the patient's eyelids, avoiding pressure.