Preoperative preparation, intraoperative care, and postoperative management of patients with sickle cell disease (SCD) remain a challenge for anaesthetists, as published in Anaesthesia and Intensive Care Medicine. This topic was discussed by Eilidh Waddell and Kailash Bhatia.

Patients with SCD are at increased risk of surgery complications, including pain episodes, acute chest syndrome, stroke, renal failure, infections, and venous thromboembolism. Therefore, Waddell and Bhatia believe the preoperative preparation of patients with SCD should consider the following:

  • Multidisciplinary team, constituted by an anesthetist, an hematologist, and a surgeon
  • Availability of exchange transfusion
  • Detailed preoperative assessment by a senior member of the anesthetic team to assess disease severity
  • Additional investigations depending on the type of surgery and end organ damage (eg, full blood count, renal function tests, baseline oxygen saturations, overnight sleep study, echocardiogram, transcranial Doppler, etc)
  • A group and screen for antibody and a cross match
  • The need for preoperative transfusion
  • Pain management plans
  • The need for central line in case of difficulty in venous access
  • Minimization of starvation time and encouragement of hydration
  • Priority of these patients on the operating list, if possible, and avoidance of cancellations due to administrative reasons, particularly in patients who received a transfusion beforehand
  • A documented care plan written by the multidisciplinary team, especially in cases of high-risk surgery

Regarding intraoperative care, Waddell and Bhatia recommended:

  • Avoidance of triggers that may lead to crisis, with special care to maintain good hydration, avoid hypoxia and hypothermia, replace blood loss, and prevent acidosis
  • Careful patient positioning
  • Avoidance of the use of arterial tourniquets. When needed, the limb should be previously exsanguinated and patient’s oxygen levels and acid-base balance should be kept as normal as possible
  • The use of antibiotics for surgical prophylaxis and adoption of aseptic techniques during invasive procedures
  • The titration of anesthetic agents, sedatives, analgesics, and neuromuscular blockade along with antiemetics according to patient’s renal fucntion
  • Pondering the choice of regional versus general anaesthetic considering patient’s age and preference, as well as type of surgery
  • Avoidance of hypotension and hypoperfusion during an anesthetic procedure

Their recommendations for the postoperative period included:

  • A low threshold for admission to a critical care unit if necessary
  • Maintenance of oxygen saturation at levels greater than 95%
  • Effective pain relief, early mobilization, hydration, and thromboprophylaxis
  • Special attention to patients with increased risk factors (eg, prolonged immobility or previous venous thromboembolism
  • Incentive spirometry and physiotherapy if needed
  • Regular inspection of indwelling venous cannulas for signs of thrombophlebitis
  • Close communication between all clinical team members throughout the all perioperative period

Additionally, special considerations should be taken into account in cases of acute pain, acute chest syndrome, blood transfusion, and hyperhemolysis, as well as if patients are children, pregnant women, or individuals with COVID-19.

Reference

Waddell E, Bhatia K. Anaesthesia for patients with sickle cell and other haemoglobinopathies. Anaesth Intensive Care Med. Published online January 25, 2022. doi:10.1016/j.mpaic.2021.10.020