King Abdullah Medical City Department of Anesthesia
Jul 16, 2015
Perioperative Management of Sickle Cell Disease Patients
ByMohamed Ahmed
SayedalahlMD Anesthesia & Surgical Intensive
Care
Monday, February 23, 2015
-October 1902, Ohio state university.
-1905 North African Arab subjects.
-1910, James Herrick, detailed case report.
-1927, sickling by deoxygenation & reversed by reoxygenation.
-Clinical hypothesis:
-1955, 1st major review:
One of students noticed elliptical RBCs
Jaundice, dyspnea, LN, dark urine, leg ulcers,
epigastric pain & anemia
deoxygenation→sickling→vasoocclusion→moredeoxygenation→moresickling(vicious circle)
High incidence of perioperative serious and potentially fatal
complications
Epidemiology
- Mutant -globin gene → Hereditary hemoglobinopathy → production of variant Hb ( Hb SS) → Sickle cell anemia
- Variations in & Around sickle gene → different haplotypes ( 4 haplotypes in Africa & 1 Arabo-Indian or Asian haplotype in India & Persian gulf region)
- Heterozygous carrier state → SCT
Genotypes of Sickle cell disease
- Sickle cell anemia (Homozygous, HB SS)
Sickling occurs at PO2 ˂ 40 mmHg
- Sickle cell trait (Heterozygous, HB AS)
Sickling occurs at PO2 ˂ 20 mmHg
- Sickle-Hemoglobin C disease (HB SC)
- Sickle- β thalassemia disease (HB S β thal)
Gene penetration (heterogenicity)• Genotype differences (sickle cell anemia,
sickle cell trait, sickle cell HB C, sickle cellthalassemia)
• Haplotype differences (African, Arabo-Indian)
• HB synthesis, mutltistep, numerous genes(timing, extent and coordination)
• Extreme variability in HbF production• Polymorphism at cellular level (RBCs
membrane structure & function, hemecatabolic enzymes, nitric oxide generatingsystems & inflammatory mediators.
Molecular biology
1- Absence of the negative charge → instability of oxygenated hemoglobin → denaturation & break → RBCs hemolysis.
2- Hydrophobic amino acid → decrease in solubility of deoxygenated HB → polymerization & precipitation → sickling of RBCs.
Biochemistry
altered NO synthetase, increased leucocytic count,
activated coagulation pathway, increased circulatory cytokines
Historical hypothesis of RBCs sickling:
Role of endothelial and vascular dysfunction:- Survival of patients with SCD + cyanotic HD
- Studies:Effect of hypobaric hypoxia
Effect of inhalation of hypoxic gas mixture (FiO2 10-15%)
- Ascent to high altitudes or long aircraft flights
Clinical Picture
Progressive organ damage , intermittent periodsof severe pain & pulmonary complications
Severity and progression → markedly variable:Relatively benign course Early organ dysfunction and death
Pulmonary & Neurological complications
Chronic renal failure
Many deaths not attributed to chronic organ failure acute episode of pain, respiratory compromise, stroke
Clinical Picture…cont
Pain crises or VOC:
Most common sites: lumbar spine (49%), abdomen (32%),
femoral shaft (30%), and knee (21%)
Triggering events: without cause (˃50%), perceived skin
cooling (34%), emotional stress (10%), physical exertion (7%), and alcohol consumption (4%)
Arise from cortical infarction or from marrow infarction
Abdominal pain: bowel dysfunction, organ infarction, referred
from the ribs
Clinical Picture…cont
The acute chest syndrome (ACS):acute pneumonia like, new pulmonary infiltrate involving at leastone complete lung segment, but excluding atelectasis.
Additional diagnostic feature: chest pain, pyrexia greater than38.5°C, tachypnea, wheezing, & cough.
Precipitants: infectious pathogens, fat embolism after bone
marrow infarction, pulmonary infarction and surgical procedures.
Chronic progressive lung damage:persistent inflammatory process → lower airway obstruction &airway hyperreactivity → fibrosis and a progressive restrictivedisease → pulmonary hypertension, and right-sided cardiachypertrophy & and severe hypoxemia.
Clinical Picture…cont
-Neurological: (stroke)
Infarctive : in adolescence, intimal hyperplasia.
Hemorrhagic : third decade of life, rupture of chronically damaged arteries.
Renal: (Nephropathy)
Papillary necrosis → painful gross hematuria
Glomerular lesions → proteinuria
Hyposthenuria → specific gravity ˂1010
Chronic renal failure → third or fourth decade
Perioperative Epidemiology
Perioperative complications:
SCD-specific complications: Pain crisis and ACS
SCD-related complications:
Erythrocyte alloimmunization and transfusion reactions
Nonspecific complications:, bleeding, infection , fever, thrombosis, embolism, and death from causes other than SCD.
Preoperative Assessment
- Determine the risk of perioperative SCDcomplications
- Most frequent procedures: cholecystectomy,splenectomy, dilation and curettage, caesareansection, hysterectomy, adenotosillectomy,myringotomy and orthopedic prosthetic surgery.
- Incidence of complications: 3% for orthopedicsurgery, 8% for non-obstetrical intraabdominalsurgery, 17% for caesarean section andhysterectomy.
Perioperative Management
Erythrocyte Transfusion
Indications: prevention or treatment.
Rationale: dilution of sickle cells.
Studies:
Transfusion Vs Nontransfusion
Aggressive Vs Conservative
CPB and craniotomies
Alloimmunization: Non-ABO AB against Rh, Kell, & Lewis, 8-50% in SCD, causes.
Perioperative ManagementProphylactic erythrocyte transfusion remains a treatment with many complications.
Lack of clinical guidelines.
The National Heart, Lung, and Blood Institute (NHLBI)
SCD perioperative management Guideline.doc
Intraoperative Management
Improvement of Oxygen Delivery
Oxygen delivery impaired: obstructive or restrictive lung disease, vascular damage, abnormal rheology, peripheral A-V shunting ↑NO scavenging.
Compensatory mechanisms: ↑MV, ↑cardiac SV, ↓ PVR, ↑2,3- DG, and ↓Hct, and ↑ NO production.
Induced hypotension & autologous transfusion
Intraoperative ManagementOxygenation-Hypoxia as a precipitant of perioperative SCD-specific complications.
Prolonged O2 supplementation:-Suppression of erythrogenesis.-Withdrawal → VOC.
Little rationale:-Avoidance of preoperative anxiolytic medication.-Intraoperative hyperoxygenation.-Prolonged postoperative O2 supplementation.
Maintenance of adequate oxygenation
Intraoperative Management
Hydration
- Dehydration as a cause of perioperative complications.
- Adequate hydration.
- Modification of fluid management .
Intraoperative Management
Thermoregulation-Hypothermia as a precipitant of SCD complications
-Hyperthermia (SCT)
-Maintenance of normothermia.
Acid-base Regulation-Acidosis accelerates erythrocyte deformation.
-Alkalinization is not effective .
-Maintenance of normal acid-base balance.
Intraoperative Management
-Anesthetic technique
-GA Vs. RA
-Epidural anesthesia or Analgesia:
Pain control
VD
Oxygenation
-Avoid or minimize tourniquet
Postoperative Management- Oxygen supplementation.
- Adequate hydration.
- Aggressive pain management.
- Incentive spirometry.
- Early ambulation.
- Consider daily CBC, platelet and reticulocyte.
Postoperative ManagementPain Crisis
- Analgesia: Opioids: morphine, PCA, Fentanylpatch, Pethidine, (tolerance), NSAID, Corticosteroids,Epidural analgesia
- Incentive spirometry
- Supplemental oxygen
- Adequate hydration
- Erythrocyte & plasma transfusion.
- ACS, precipitated by pain crisis.
- psychological distress.
Postoperative Management
Acute Chest Syndrome
- 3 days after surgery and lasted 8 days
- Early incentive spirometry, bronchodilator therapy, supplemental oxygen, adequate analgesia, and broad-spectrum antibiotics.
- Blood transfusion.
- Nitric oxide and corticosteroids.
- Mechanical ventilation.