Safe surgery in sickle cell disease

Perioperative care of children with sickle cell disease: A systematic review and clinical recommendations

Children with sickle cell disease (SCD) require specific perioperative care, and clinical practice in this area remains poorly defined. We aimed to conduct a systematic, PRISMA-based review of the literature, available clinical guidelines and practice recommendations. We also aimed to extract any valuable information for the "best of available-evidence"-based prevention of perioperative adverse events in children with SCD, and highlight the most urgent priorities in clinical research. As data sources, US National Library of Medicine, Medline, National Guideline Clearinghouse, International Guideline Network, TRIP databases were searched for any content until January 2019. We also included institutional, consortia and expert group guidelines. Included were reports/guidelines in English, French, German, and Italian. Excluded were reports on obstetrical and fetal management. We identified 202 reports/guidelines fulfilling the criteria outlined above. A majority focused on visceral, cardiovascular and orthopedic surgery procedures, and only five were multicenter randomized controlled trials and two prospective randomized studies. After grading of the quality of the evidence, the extracted data was summarized into clinical recommendations for daily practice. Additionally, we designed a risk-grading algorithm to identify contexts likely to be associated with adverse outcomes. In conclusion, we provide a systematic PRISMA-based review of the existing literature and ancillary practice and delineate a set of clinical recommendations and priorities for research.

Analysis of oral health conditions and risk factors for dental caries in patients with sickle cell disease

ABSTRACT Objective: To analyze the oral health conditions and risk factors for caries in patients with sickle cell disease. Methods: An observational, cross-sectional study was conducted in the clinic of the Association of Persons with Hemoglobinopathies of Alagoas, in the city of Maceió-AL, Brazil. The sample composed of 43 patients were included by census sampling. The ICDAS/DMFT/dmf-t caries indices were used, and simplified oral hygiene, salivary flow and buffer capacity tests were performed. Patients were interviewed to check their level of knowledge about oral hygiene and diet. Spearman correlation and ANOVA statistical tests were applied (p<0.05). Results: The mean DMFT was 15.49±4.43; oral hygiene regular (IHOS=2.22±0.18); mean salivary flow 0.92±0.26, and mean buffer capacity 4.60±0.32. Correlation was found between salivary flow and buffer capacity (p = 0.009). Patients with the highest caries prevalence, in the age-ranges 6 to 12, and 20 to 26 years, had the lowest buffer capacity values (p = 0.04). Interviews showed that 58% did not use dental floss, 88% consumed cariogenic snacks, 100% reported never having received guidance from dentists about the cariogenic potential of foods and 60% reported the use of anticholinergic medications to reduce drooling (Tramal® and morphine) during pain crises. Conclusion: These patients presented extremely high caries prevalence, with predominance of carious teeth. The salivary parameters analyzed and level of knowledge about oral hygiene and cariogenic diet presented, showed that patients with sickle cell disease belonged to a group with risk for development of dental caries.

Sickle cell disease, dentistry and conscious sedation

The features of sickle cell disease (SCD) are described. Two case reports of patients treated in a Dental Institute are presented and the dental management of patients with SCD discussed. Since infection is one of the major risk factors for sickle cell crisis, the prevention of oral disease and infection is vital for this group of patients and there is no contra-indication to the delivery of dental treatment under local anaesthetic with inhalational sedation if required in the primary care setting. Since patients with sickle cell disease are particularly vulnerable to the effects of periods of hypoxia, which may produce significant morbidity, and because of the additional practical challenges in sedating this group of patients, intravenous sedation should be undertaken in a specialist unit.

CLINICAL RELEVANCE

The increasing prevalence of sickle cell disease highlights the importance of dentists practising in multi-cultural communities having an understanding of this condition and its implications on their clinical practice. This will facilitate the safe management of patients with sickle cell disease.

Preoperative screening for sickle cell disease in children: clinical implications

PURPOSE

Preoperative screening of at-risk patients for sickle cell disease (SCD) is recommended as a method to decrease perioperative morbidity. However, the effectiveness of pre-operative screening in accomplishing this goal has never been demonstrated. We undertook a retrospective study to determine the prevalence of positive test results among those screened preoperatively at our institution and to determine whether amendments to present screening guidelines can be recommended.

METHODS

The hematology laboratory database of a university teaching hospital was searched to identify all patients who underwent preoperative screening for SCD from October 1999 to October 2003. The medical records of those patients testing positive were reviewed.

RESULTS

Of 1,906 children screened preoperatively, 79 (4.1%) were diagnosed as having sickle cell trait and three (0.16%) as having some form of SCD: one had homozygous hemoglobin S and two had sickle-hemoglobin C disease. Two of the three had a family history for SCD and none had a preoperative hemoglobin concentration < 10 g.dL(-1). No patient developed perioperative sickle-related complications.

CONCLUSION

Preoperative screening of 1,906 children identified only one asymptomatic child with undiagnosed SCD and a negative family history, suggesting that routine preoperative screening for SCD is rarely of significant clinical value in our population. Had preoperative screening not been performed, no child requiring preoperative transfusion would have been missed, representing a long-run probability of at least 99.84% that no at-risk child would require transfusion. We recommend that preoperative screening for SCD be undertaken selectively, giving consideration to the risks and benefits of screening to the individual patient.

Minor elective surgical procedures using general anesthesia in children with sickle cell anemia without pre-operative blood transfusion

BACKGROUND

Pre-operative red blood cell (RBC) transfusions are often recommended for patients with sickle cell disease (SCD) who require elective surgery under general anesthesia. However, definitive randomized studies demonstrating the benefit of transfusions in this setting have not been conducted. In particular, the merits of transfusion prior to minor or low-risk surgical procedures in children with SCD have not been demonstrated.

PROCEDURE

We hypothesized that children with sickle cell anemia (Hb SS) who have minor elective surgical procedures develop few complications even without pre-operative transfusion. We accessed our Comprehensive Sickle Cell Program's Database to identify all such procedures performed during a 13-year period. Medical records were reviewed to characterize the surgical procedure, the use of transfusions, and perioperative complications.

RESULTS

Twenty-eight children with Hb SS had a total of 38 minor surgical procedures. No perioperative transfusions were given in 34 of the cases (85%). Five of these 34 surgeries (15%) were associated with minor post-operative complications (fever or transient pain). No post-operative acute chest syndrome was encountered.

CONCLUSIONS

Minor or low-risk elective surgical procedures in children with Hb SS may not routinely require pre-operative transfusion. A randomized clinical trial to compare transfusion with no transfusion for minor surgical procedures is needed.

Should cholecystectomy be performed concomitantly with splenectomy in children with sickle-cell disease?

Splenectomy and cholecystectomy are among the common surgical procedures required to treat complications of sickle-cell disease (SCD), and when performed separately have been shown to be safe and effective. To determine whether cholecystectomy be performed concomitantly with splenectomy (CSC) in these children, we studied a total of 130 children who underwent splenectomy for various hematologic diseases at our hospital. The most common indication was SCD. Ninety-nine patients (86 SCD and 13 sickle-B-thalassemia) underwent splenectomy and 19 (19.2%) (12 males and 7 females, mean age 13.4 years [7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18]) underwent CSC due to concomitant gallstones, which were asymptomatic in 13 cases. Those with an admission hemoglobin (Hb) of less than 10 g/dl were transfused with packed erythrocytes to increase their Hb to 10-12 g/dl and their hematocrit to 30%-40%. All patients received intravenous hydration the night before surgery at a rate of 1(1/2) times their maintenance rate, which was continued postoperatively until they were able to tolerate adequate oral fluid intake. The indications for splenectomy in those who had CSC were: acute splenic sequestration crisis in 12, splenic abscess in 3, hypersplenism in 2, and massive splenic infarction in 2. Eight patients had massive splenomegaly (spleen weight >1 kg). In 7 cases CSC was done through a left-upper-quadrant (LUQ) transverse incision, in the remaining 12 through an upper midline incision. There was no mortality and only 2 patients developed postoperative complications; a wound infection in 1 and a hematoma in the splenic bed in another. With good perioperative management, CSC is both safe and effective for children with SCD. Both procedures can be performed safely through an upper midline or a LUQ transverse incision, even in the presence of massive splenomegaly.

The role of red blood cell exchange transfusion in the treatment and prevention of complications of sickle cell disease

Patients with sickle cell disease have abnormal red blood cells (RBCs). This can cause chronic hemolytic anemia and vaso-occlusion leading to tissue hypoxemia and organ dysfunction. RBC exchange transfusion can, without increasing the whole-blood viscosity, quickly replace abnormal erythrocytes with normal and raise the hematocrit resulting in improved delivery of oxygen to hypoxic tissues. Unfortunately, transfusion can also be associated with complications. This paper reviews the role of transfusion, both simple and exchange, in the treatment and prevention of sickle-related complications. The benefits of exchange versus simple transfusion and transfusion versus alternative therapies are discussed.

Laparoscopic cholecystectomy in adults with sickle cell disease

BACKGROUND

Chronic hemolysis predisposes adults with sickle cell disease (SCD) to the formation of bilirubinate cholelithiasis.

METHODS

To study the impact of laparoscopic cholecystectomy (LC) on this groups, we reviewed our records of all patients with SCD and cholelithiasis treated electively from 1991 to 1999. During that period, 13 consecutive patients with SCD underwent elective LC for symptomatic cholelithiasis. Nine patients (69.2%) were managed with a preoperative transfusion regimen to achieve a hemoglobin value of >/=10 g/dl, independent of hemoglobin S percentage. Five patients who presented with jaundice were referred for preoperative endoscopic retrograde cholangiopancreatography (ERCP), which identified choledocholithiasis in two of them. Three other patients underwent intraoperative cholangiography, which revealed common bile duct stones in one patient.

RESULTS

One patient developed pyrexia for 2 days. There were no vaso-occlusive crises or deaths. The mean hospital stay was 3.3 days.

CONCLUSIONS

LC has proven to be a safe and efficacious method for the treatment of symptomatic cholelithiasis in this high-risk population. Hematologists are now more willing to refer early, well-prepared patients with SCD and uncomplicated gallbladder disease for elective LC.

Cholecystectomy in Jamaican children with homozygous sickle-cell disease

Twenty-seven children aged 18 years and under with homozygous sickle-cell disease had open cholecystectomy for symptomatic gallstones over the 12-year period 1985-1997. Emergency procedures (done during period of acute exacerbation of symptoms) were performed on 16 patients. Four with haemoglobin levels greater than 1 g/dl below their steady state received a simple blood transfusion preoperatively designed to raise haemoglobin levels to 10 g/dl. All had acute or acute on chronic cholecystitis based on histological examination of gallbladder specimens. Twelve had common bile duct stones. In two patients calculi were missed intraoperatively but these subsequently passed into the duodenum after a period saline irrigation via an in-situ t-tube. Six developed the acute chest syndrome (aetiology not determined) and this progressed to multi system failure and death in one. This high level of postoperative mobility and mortality may in part be due to the high proportion of emergency procedures.

Sickle cell disease: implications for perioperative care

Sickle cell disease is an inherited hemoglobinopathy that develops from a genetic mutation and the production of a dysfunctional variant of hemoglobin. A number of physiological disturbances encountered during the perioperative period (blood loss, hypotension, acidosis, and hypoxia) may induce "sickling" of the biochemically altered hemoglobin, producing painful microvascular occlusion, hemolytic anemia, and impaired oxygen delivery. The only available curative therapy requires bone marrow transplantation. The purpose of this article is to review the pathophysiology of sickle cell disease and the pertinent preoperative, intraoperative, and postoperative care of patients with the disease.

Tonsillectomy, adenoidectomy, and myringotomy in sickle cell disease: perioperative morbidity. Preoperative Transfusion in Sickle Cell Disease Study Group

PURPOSE

To compare the rates of perioperative morbidity of patients with sickle cell anemia who were randomly assigned to 2 preoperative transfusion regimens and to identify predisposing factors for perioperative complications.

PATIENTS AND METHODS

Investigators at 36 centers enrolled 118 patients who were scheduled to have elective surgery and agreed to randomization between 2 preoperative transfusion regimens. Forty-seven subjects were enrolled but not randomized, including 20 who were not transfused before surgery. Perioperative management was based on a prescribed care plan.

RESULTS

Tonsillectomy and/or adenoidectomy (TA) were performed on 136 persons, and 29 had myringotomy as their primary procedure. There were no differences in the frequency of complications between the randomized groups. The serious, non-transfusion complication rates for randomized patients were 32% (34 of 107) for TA and 36% (4 of 11) for myringotomy. A history of pulmonary disease was a predictor of postoperative sickle cell-related events for patients undergoing TA surgery.

CONCLUSIONS

The more intensive transfusion regimen did not result in fewer perioperative complications. The high frequency of complications emphasizes the need for anticipatory management of persons undergoing TA. A history of pulmonary disease identifies patients at increased risk for sickle cell-related events after TA surgery. Patients undergoing myringotomy have a low frequency of sickle cell-related events but a significant frequency of other serious perioperative complications.

Successful surgical outcome in children with sickle hemoglobinopathies: the Duke University experience

BACKGROUND/PURPOSE

Surgery in patients with sickle hemoglobinopathies can be problematic because of the potential for sickling events in the perioperative and postoperative period. The authors and others have previously reported successful surgical outcomes using an aggressive erythrocyte transfusion regimen, designed to alleviate anemia and to reduce the percentage of sickle hemoglobin to below 30%. Recently, a randomized trial compared this aggressive regimen with a more conservative transfusion regimen and found no differences in perioperative complications. The incidence of complications, however, was very high in each group (31% to 35%).

METHODS

The authors therefore analyzed retrospectively their surgical experience in children with sickle hemoglobinopathies over the past 10 years to determine the efficacy of an aggressive transfusion regimen and skilled perioperative care in their patient population.

RESULTS

A total of 130 surgical procedures were performed on 92 children including 54 cholecystectomies (42%), 23 splenectomies (18%), 12 ENT procedures (9%), 11 central line placements and removals (8%), 7 herniorrhaphies (5%), 7 appendectomies (5%), and 16 miscellaneous operations (13%). The mean age of the children was 10 years (range, 1 to 22 years), and the mean weight was 32.1 kg (range, 9.9 to 76.8 kg). The average hemoglobin (mean +/- 1 SD) at the time of surgery was 11.2+/-1.3 g/dL, and the average percent hemoglobin S was 21+/-11%.

CONCLUSIONS

Relatively few transfusions were required to achieve these endpoints, and the complications resulting from transfusions were minimal. Similarly, the number of perioperative and postoperative events was very low.

The pathophysiology of the sickle hemoglobinopathies and implications for perioperative management

Patients with sickle hemoglobinopathies are at risk for unique postoperative complications and increased mortality. Understanding the pathophysiology of these disorders is important for safe perioperative management. Because there is no animal model for sickle cell disease, understanding has progressed through in vitro studies and clinical observations. This review describes the clinical manifestations of the sickle hemoglobinopathies with special emphasis on current knowledge of pathophysiology. It also discusses issues of preoperative screening, transfusion, and postoperative care.

Preanesthesia transfusion and sickle cell anemia patients: case report and controversies

Preoperative transfusion of sickle cell anemia (SCA) patients prior to general anesthesia is considered a routine procedure to ensure adequate levels of normal adult hemoglobin A to prevent a sickle cell crisis. Blood transfusion risks have led some clinicians to question this procedure. A case report is presented in which a SCA patient developed a delayed hemolytic reaction from a transfusion given prior to dental treatment under general anesthesia. The controversy of transfusion in this patient group is presented.

Management of the oral and maxillofacial surgery patient with sickle cell disease and related hemoglobinopathies

The oral and maxillofacial surgery patient with a sickle cell hemoglobinopathy presents a complex and challenging clinical management problem. The potential for significant morbidity and mortality among these patients is great. Thus the surgeon must adhere to sound principles of medical and surgical practice to avoid major difficulties. This article describes the complex pathophysiology, clinical course, and management principles of the oral and maxillofacial surgery patient with sickle cell disease.

Surgical management of children with hemoglobinopathies

Sickle hemoglobinopathies include sickle cell disease, sickle-C disease, and sickle-beta thalassemia. Patients with these disorders commonly suffer a multitude of destructive events to vital organs, especially to the central nervous system, the spleen, the kidney, the lung, and the heart as a result of microvascular plugging by the sickled erythrocytes. Thoughtful preparation for anesthesia and operation, especially when directed by experienced individuals, can greatly reduce the hazard of inducing the sickle crises that formerly plagued individuals with sickle hemoglobinopathies who faced major operations under general anesthesia. The patient must be free of any acute illness, especially one involving the respiratory system. Adequate hydration preoperatively combined with avoiding perioperative hypoxia, hypothermia, and acidosis, the triggers for sickling, will go far toward avoiding sickle-induced complications. Modern transfusion therapy, consisting of multiple small transfusions of Hb A erythrocytes administered over several weeks prior to the operation, not only corrects the chronic anemia but suppresses erythropoiesis of cells containing Hb S in the patient's bone marrow and leaves him or her with a majority of cells containing Hb A. This provides a safety net in case a sickle-inducing insult occurs despite the best efforts to avoid one. Individuals with sickle hemoglobinopathies may require any of the operations common to all children, for example, herniorrhaphy, appendectomy, tonsillectomy, and circumcision, but a significant number will develop calcium bilirubinate cholelithiasis and possibly cholecystitis as a result of the continual increased load of bile salts resulting from the shortened lifespan of the cells containing Hb S. Also, although most individuals with Hb S will gradually suffer splenic infarction by late childhood, a significant number of infants will experience acute splenic sequestration crisis, a life-threatening entity, the recurrence of which is prevented by splenectomy. Several publications have demonstrated that such surgical procedures can be performed in large numbers of patients with sickle hemoglobinopathies without deaths and with minimal morbidity.