|LETTER TO THE EDITOR
|Year : 2022 | Volume
| Issue : 4 | Page : 601-602
Anesthetic management of a 42-year-old woman with a known case of sickle cell anemia posted for open cholecystectomy
Aparna Bagle, Chandrakala
Department of Anaesthesiology, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||02-Aug-2022|
|Date of Acceptance||31-Oct-2022|
|Date of Web Publication||29-Dec-2022|
Department of Anaesthesiology, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth. Pune 411018, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bagle A, Chandrakala. Anesthetic management of a 42-year-old woman with a known case of sickle cell anemia posted for open cholecystectomy. MGM J Med Sci 2022;9:601-2
|How to cite this URL:|
Bagle A, Chandrakala. Anesthetic management of a 42-year-old woman with a known case of sickle cell anemia posted for open cholecystectomy. MGM J Med Sci [serial online] 2022 [cited 2023 Feb 7];9:601-2. Available from: http://www.mgmjms.com/text.asp?2022/9/4/601/365968
| Introduction|| |
Sickle cell anemia is hereditary hemolytic anemia resulting from the formation of abnormal hemoglobin (HbS). Functionally, sickle hemoglobin has less affinity for oxygen as well as less solubility. It is an inherited chronic hemolytic anemia associated with a variable number of acute painful vaso occlusive episodes. The continuous destruction of irreversibly sickled cells leads to anemia and hematocrit is typically 18% to 30% due to extravascular hemolysis. RBC survival is reduced to 10–15 days, compared with up to 120 days in normal individuals. Cholelithiasis is a well-recognized complication of chronic hemolysis. Increased perioperative complications may result from vaso occlusion after transient hypoxia, hypothermia, dehydration, or acidosis. Inadequate post-operative pain control may reduce respiratory effort, leading to poor pulmonary toilet and relative hypoxia.
| Case report|| |
A 42years old female patient weight 55kg came to our hospital with chief complaints of pain abdomen radiating to the arm and back. The patient is a known case of sickle cell anaemia for 10 years. She had dyspnea on exertion and bilateral (b/l) knee joint pain. She had a history of inability to walk for 2years. As she had avascular necrosis of the hip. The patient underwent ERCP+CBD stenting four times in the past 5 years. MRI pelvis and both hips suggestive of B/L hip avascular necrosis with multiple bony infarcts with bone marrow reconversion in the pubic bone. USG abdomen and pelvis showed hepatomegaly, cholelithiasis with cholecystitis, and CBD stent in situ. 0n general examination pulse rate of 86/min and blood pressure of 120/70mmhg. Hb was 8.9, and one unit of PCV transfusion and incentive spirometry started preoperatively. She was kept fasting for midnight and was started on ringer lactate 80ml/hr to avoid dehydration. After a thorough pre-anesthetic evaluation with informed consent, the patient was taken up for surgery under ASA3. All monitors were attached. as the coagulation profile of the patient was normal, planned for epidural and general anesthesia. In a sitting position under all aseptic precautions, 18G Touhy’s epidural needle was inserted at the L1-L2 intervertebral space. Epidural space was achieved at 4 cm and the catheter was fixed at 11 cm. then the patient was made to sleep in the supine position. Pre-medication glycopyrrolate 0.2 mg and midazolam 1 mg iv were given. Induction was done with propofol and atracurium 25 mg. The patient was intubated with a 7.5-cuffed ET tube. The patient was maintained on O2+air+isoflurane on controlled ventilation. Utmost care was taken during induction to avoid hypotension and hypoxia.  A nasopharyngeal temperature probe was passed for temperature monitoring. Regular ABG analysis was done to rule out hypoxia and acidosis. For analgesia epidural top-up with 6ml 0.25% bupivacaine +3 mg morphine was given. In the end, the patient was reversed with neostigmine and glycopyrrolate extubated well, and shifted to the critical care unit for observation. Postoperative analgesia with epidural top given with 0.125% bupivacaine+50 mg tramadol 8cc with morning and evening for two days.
| Discussion|| |
The case shows the importance of preoperative assessment and planning before surgery for adequate analgesia to prevent mishaps in the perioperative period. . The epidural analgesia may cause hypotension and hypoperfusion which was prevented with pre-loading of IV fluid. The patient maintained volume control throughout the procedure to achieve good oxygenation and normocarbia. Regular epidural top-up has been given to prevent Vaso occlusive crisis. Vaso occlusion results in recurrent painful episodes and a variety of serious organ system complications that can lead to disabilities and early death. The patient should be normothermic during perioperative and hypothermia must be avoided as this will lead to shivering and peripheral stasis which leads to hypoxia and increased sickling. Acute chest syndrome is one of the most serious complications but its pathogenesis is not known. It is difficult to differentiate respiratory distress due to bacterial infection from acute chest syndrome. So, it is advised to start the patient on broad-spectrum antibiotics in the perioperative period. Incentive spirometry should be started perioperatively to prevent pulmonary complications. Meticulous anesthetic management in the form of avoiding acidosis, hypoxia, hypothermia, hypovolemia, maintaining normocarbia, good intraoperative and postoperative pain relief with epidural infusion, post-operative thromboprophylaxis, postoperative oxygen therapy, chest physiotherapy, nebulization, incentive spirometry with early mobilization and regular ABG monitoring played an important role in improving the patient outcome.
| Conclusion|| |
To conclude proper planning and optimal perioperative preparation are key to the successful management of sickle cell disease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ingle SS, Ubale P Anesthetic management of a patient with sickle cell disease for common bile duct exploration. J Anaesth Clin Pharmacol 2011;27:547-9.
Akrimi S, Simiyu V Anaesthetic management of children with sickle cell disease. BJA Educ 2018;18:331-6.
Singh Y, Chabra A, Venkateswaran V, Trikha A Sickle cell disease in pregnancy and anaesthetic implications: A narrative review. J Obstet Anaesth Crit Care 2021;11:70-80.
Walker I, Trompeter S, Howard J, Williams A, Bell R, Bingham R, et al
. Guideline on the peri-operative management of patients with sickle cell disease: Guideline from the association of anaesthetists. Anaesthesia 2021;76:805-17.