Case 2--1996. Anesthetic management of a patient with hemoglobin SS disease and mitral insufficiency for mitral valve repair

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.

Perioperative Management of Sickle Cell Disease in Paediatric Cardiac Surgery

In sickle cell disease, cardiopulmonary bypass may induce red cell sickling. Partial exchange transfusion reduces the circulating haemoglobin S level. We report the management of a child with sickle cell disease who required surgical closure of a ventricular septal defect. Preoperative exchange transfusion of 50% of the total blood volume was performed with fresh packed red cells over three days. Further exchange transfusion was performed as cardiopulmonary bypass commenced. The haemoglobin S level was reduced from 76% to 37%. The blood removed from the patient during the exchanges was processed allowing storage and re-infusion of the patient's plasma and platelets. Combined preoperative and intraoperative exchange transfusions, instead of a single stage 50% volume exchange, was effective and potentially avoids larger haemodynamic effects. Cardiopulmonary bypass was conducted at normothermia and cold cardioplegia was avoided (fibrillatory arrest was used during the surgical repair).

Cardiopulmonary Bypass without Preoperative Exchange Transfusion in Sicklers

The effect of hypothermic cardiopulmonary bypass techniques on the sickling process was evaluated in patients with sickle cell hemoglobin. It was presumed that intraoperative hemolysis, as identified by hemoglobinuria, reflected increased sickling. Data of 43 patients with sickle cell traits and 2 with sickle cell disease, who were operated on under cardiopulmonary bypass and cold cardioplegic arrest in a tertiary center from the beginning of 1995 to the end of 2004, were retrospectively analyzed. A mean nasal temperature of 30.8°C ± 2.1°C was achieved. Three patients with sickle cell trait developed intraoperative hemoglobinuria, albeit with normal surrogate values for hemolysis. However, they had significantly lower mean hemoglobin levels during cardiopulmonary bypass compared to those sickle cell patients who did not exhibit hemoglobinuria (hemoglobin, 6.0 ± 0.2 vs. 7.4 ± 0.9 g·dL−1, p < 0.01). Total drainage and blood transfusion requirements in patients with normal and sickle cell hemoglobin were similar. It was concluded that hypothermic cardiopulmonary bypass with cold cardioplegia is safe in sickle cell patients. Maintenance of adequate hemoglobin levels during cardiopulmonary bypass may be important to avoid triggering a sickling process.

Mitral valve replacement in sickle cell disease

Cardiac dysfunction, including mitral valve regurgitation and congestive heart failure, can occur in patients with sickle cell disease. However, major surgery poses a greater risk in this population. This paper reports on the management of a patient with sickle cell disease who underwent successful replacement of the mitral valve.

Fast-track cardiac anesthesia in patients with sickle cell abnormalities

We conducted a retrospective review of 10 patients with sickle cell trait (SCT) and 30 patients (cohort control) without SCT undergoing first-time coronary artery bypass graft surgery with cardiopulmonary bypass. Demographic, perioperative management, and outcome data were collected. Both groups were matched according to age, weight, duration of surgery, and preoperative hemoglobin (Hb) concentration. Distribution of gender, medical conditions, pharmacological treatment, and preoperative left ventricular function were similar between the groups. The comparisons were analyzed in respect to postoperative blood loss and transfusion rates, as well as duration of intubation, intensive care unit, and hospital length of stay (LOS). All patients underwent fast-track cardiac anesthesia. A combination of cold crystalloid and blood cardioplegia was used. The lowest nasopharyngeal temperature was 33 degrees C. There were no episodes of significant hypoxemia, hypercarbia, or acidosis. None of the patients had sickling crisis during the perioperative period. The postoperative blood loss was 687 +/- 135 vs 585 +/-220 mL in the SCT and control groups, respectively. The trigger for blood transfusion during cardiopulmonary bypass was hematocrit <20% and Hb <75 g/L postoperatively. Three SCT patients (30%) and 10 control patients (33%) received a blood transfusion. Median extubation time was 4.0 vs 3.9 h; intensive care unit LOS was 27 vs 28 h; and hospital LOS was 6.0 vs 5.5 days in the SCT and control groups, respectively. There were no intraoperative deaths. One patient in the SCT group died from multiorgan failure 2 mo after surgery.

IMPLICATIONS

Fast-track cardiac anesthesia can be used safely in patients with sickle cell trait undergoing first-time coronary artery bypass graft surgery. Extubation time and intensive care unit and hospital length of stay are comparable to those of matched controls, and blood loss and transfusion requirements are not increased. A hematocrit of 20% seems to be a safe transfusion trigger during cardiopulmonary bypass in these patients.