dr. s. parthasarathy md., da., dnb, md (acu), dip. diab.dca, dip. software statistics phd (physio)...
TRANSCRIPT
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SICKLE CELL DISEASE AND ANAESTHESIA
Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu), Dip. Diab.DCA, Dip. Software statisticsPhD (physio)Mahatma Gandhi medical college and research institute , puducherry – India
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What is this?
Edward Irons in Noel - 1904
Normally Hb consists of alpha and beta chains
Normal is Hb A Foetal is Hb F
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What is it?
Sickle cell disease is a genetically
inherited abnormality of
haemoglobin in which valine replaces
glutamine at the sixth position on the
beta chains of the haemoglobin
molecule. This haemoglobin is
termed Haemoglobin S (usually
written HbS).
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Hb AA - normal Hb AS – sickle cell trait 20-40% HbSS – sickle cell disease 85 – 90%
when HbS becomes deoxygenated it comes out of solution forming long crystals called "tactoids" which distort the red cell.
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Sickling
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Microscopy
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Shape abnormal – ok ??
Deoxygenated HbS is 50 times less soluble in blood than deoxygenated HbA.
it comes out of solution forming long crystals called "tactoids" which distort the red cell and cause it to become crescent shaped.
Initially this is reversible with oxygenation but repeated sickling in the low oxygen tension of the microcirculation causes membrane damage. The cell wall becomes brittle and permanently deformed or "sickled
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Major problems
Life span 10 – 20 days instead of ______
chronic haemolytic anaemia with a haemoglobin of around 5-8g/dl.
The structural change and associated increase in blood viscosity promotes venous stasis
Blood flow compromise and tissue infarction
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Precipitators
HbF Acidosis Hypoxemia Venous stasis Dehydration Infections
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Clinical scenario
Patients with sickle trait are usually fit and healthy
Sickle cell disease Hb F normally is 1 % - protects Childhood onset to go on till
40-50 years
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Presentation
Pain crises or VOC Thigh Lumbar Knees
Later on splenic infarct, renal failure but death due to ACS and stroke
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Respiratory - the "acute chest syndrome".
Dyspnoea, cough , haemoptysis and pleuritic chest pain
Repeated episodes can lead to compromised lung function, pulmonary hypertension and respiratory failure.
Airway hyper reactivity !!
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Genito urinary
sickling in the vasa recta. Loops of henle damage Priapism
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Hepatic
Jaundice Gall stones Liver cell failure due to multiple
infarcts
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More common
Skeletal. Sickling and microvascular occlusion within bones and epiphyseal plates often leads to shortening of the limbs and gross deformity of joints. Osteomyelitis may occur.
Skin. Leg ulcers following skin infarcts are common - complicated by trauma and poor hygiene.
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Neurological.
"Acute brain syndrome" is rare but serious. It is characterised by confusion with variable neurological defects.
Whilst most resolve spontaneously permanent damage can occur.
There is an increased incidence of subarachnoid haemorrhage, blindness and deafness, neuropathy
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Diagnosis
hemoglobin (Hb) electrophoresis will confirm the diagnosis and provide the percentage of abnormal HbS.
prevalence of HbSS is 1:625 (0.2%)
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Anaesthetic considerations cholecystectomy, splenectomy, dilation and
curettage, caesarean section, hysterectomy, tonsillectomy and
adenoidectomy, myringotomy, and orthopedic prosthetic surgery
were the most frequently performed
procedures 18 and 16.5 % events
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No urgency for the knife
Sometimes a crisis may mimic acute abdomen
Have they taken h influenza and pneumovac
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Investigations
Chest radiograph, hemoglobin oxygen
saturation, and lung function tests may delineate the degree of pulmonary pathology
Bad xray – bad post op course
Blood grouping and transfusion history
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Examine kidney and brain
assessment of renal pathology SSD – low BP But if we have high BP look for renal
parameters Psychiatric problems, seizures, poor
school performance, developmental retardation may be markers of insidious neurologic vascular damage and cerebral infarction
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Investigations
Hb, blood microscopy to check for sickle cells, Howell Jolly bodies and sideroblasts, all features of the disease. TC DC
ECG Rt dominance Urine for occult infections LFT – unconjugated bilirubin due to
hemolytic anemia Cholestasis evidence
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Preop
correct infections Correct dehydration Anemia Preop HbA should be more than 40 % Earlier they said it was 70 % Preoperative physiotherapy and
breathing exercises
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Specific procedures
Chole OBG Ortho Neuro CPB
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Aims
perioperatively. avoid hypoxia, acidosis, hypotension, dehydration and hypothermia
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Principles GA Good intravenous access for maintenance of
intravascular volume Adequate oxygenation Endotracheal intubation for general
anesthesia to ensure a controlled airway and adequate ventilation
Maintenance of adequate oxygen-carrying capacity through judicious use of red cell transfusions
Maintenance of normothermia Opioids for analgesia carefully titrated for
perioperative and postoperative analgesia Avoidance of tourniquet use ??
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Monitoring
Pulse oximetry NIBP, temperature Blood loss CVP Urine output ECG Position of the patient
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Co morbid conditions
Lungs CVS Renal Hepatic
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Regional anaesthesia Drugs – less No problem about lungs liver etc. Vasodilation and less vaso occlusive
crisis Early post op analgesia But No adrenaline Regional blocks may cause
hypotension and hypoperfusion Skeletal abnormalities may confound
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Post op
The postoperative complications most likely to occur in the sickle cell disease (SCD)
patient include vaso-occlusive crisis (VOC), pulmonary infarction, acute chest syndrome
(ACS), and infection.
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Sickle cell crisis- types acute clinical picture generally caused by
sickling of red blood cells in the microcirculation.
Vascular occlusion crises with organ infarction , pain
Hemolytic crises with hematologic features of sudden hemolysis ( associated with G6PD disease)
Sequestration syndrome with sequestration of red blood cells in the liver and spleen causing their massive, sudden enlargement, and an acute fall in peripheral hematocrit.
Aplastic crises with bone marrow suppression
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obstruct capillaries and restrict blood flow to an organ, resulting in ischaemia, pain, necrosis and often organ damage
common in patients with co-existent G6PD deficiency
This autosplenectomy increases the risk of infection from encapsulated organisms
triggered by parvovirus B19, which directly affects erythropoiesis
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Sickle cell crisis
Bed rest Hydration Oxygen therapy Treatment of infection Analgesics (consider patient-controlled
analgesia) Consider regional analgesia Transfusion to reduce the HbS concentration Incentive spirometry Maintenance of normothermia
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Newer modalities
Exchange transfusion Hydroxy urea – stimulates Hb
F production Inhaled nitric oxide
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Of no benefit ??
Alkalization using magnesium glutamate or sodium bicarbonate in an attempt to increase oxygen affinity to haemoglobin in the red blood cell.
Antiplatelet and anticoagulants to reduce infarction.
Hyperbaric oxygen, high concentration oxygen therapy.
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The basis of sickle cell
the fundamental of management remains meticulous observation and vigilance of the basic principles of safe anesthesia
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Summary
HbSS Preop – hydration, O2 and end
organs Intra op – hydration, temp, O2, CO2 ,
assess end organs Post op pain relief Previously it was sickling alone Now it is sticking also
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Thank you all