Sickle cell anemia coming for LSCS
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vibha naik
Mar 9, 2010, 3:51:08 AM3/9/10
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Hi,
Today I did a patient with sickle cell anemia - homozygous trait for LSCS.
23 year old female - primi with breech, full term for elective LSCS.
ANC period showed low Hb repeatedly and was investigated - diagnosed by Hb electrophoresis - almost 50% HbS and 50% HbA
Currently Hb - 10.4gm% (build up on iron supplements in the last couple of weeks)
Other invsg like blood counts, platelets, RBS, creat - WNL
short lady with petechial rashes over some parts of body, swollen and slightly deformed small joints.
I read up some literature -
Some would recommend GA for elective LSCS - Sickle india forum gives guidelines for management of such patients including pregnancy. It recommends GA for LSCS - though has not given its advantage over Spinal.
(http://www.sickleindia.com/doctor_zone.php )
Update in anesthesia has a very good article on Sickle cell disease and anesthesia which gives most of the stuff we need to know.
http://www.nda.ox.ac.uk/wfsa/html/u04/u04_008.htm
I found an article published in CJA 2008 which suggests that GA and high leucocyte count could be responsible for postnatal sickling.
http://www.ncbi.nlm.nih.gov/pubmed/18451115?log$=activity
I planned to give Spinal over GA as it has less chances of hypoxia and improvement in peripheral circulation due to regional is advantageous.
Though there are some limitations of spinal - technical difficulty due to affection of spine, hypotension associated can slow the circulation increasing the chances of sickling.
Management -
Starting an iv line requires tourniquet application over the hand and it can stimulate sickling. And since iv line cannot be secured without obstructing venous return, I started the patient on O2, and used intermittent compression rather than the standard tourniquet to secure iv line. Preloading to maintain good hydration is very essential for these patients.
Spinal procedure was not difficult after proper positioning. Lateral - L3-4 space - 25g - 2ml 0.5% Bupivacaine - level T6. Oxygen supplementation all through out. Vasopressors ready to avoid hypotension. We switched off AC (it was terribly stuffy) to avoid vasoconstriction due to cold in the upper limbs. And extra pint of fluid, adding only pitocin (avoid methergin as far as possible as it induces vasoconstriction), avoiding hypotension was all that we did. Intraop was uneventful.
Postop patient shifted to high dependency area and O2 continued for 3-4 hours. Important to monitor urine output. For postop analgesia, opioids can be used as long as they do not cause respiratory depression. NSAIDs can also be used as long as kidneys are well flushed. We used a combination - low dose opioids + Diclofenac.
Hoping that all the ground work I did for this case would be helpful for me as well as others later in time. :)
Dr Vibhavari Naik, MD
Consultant Anesthesiologist,
Smile Train Project,
Nizams Institute of Medical Sciences,
Hyderabad, India.
E-mail: vib...@yahoo.co.in
Mobile: +91 9959189958
Today I did a patient with sickle cell anemia - homozygous trait for LSCS.
23 year old female - primi with breech, full term for elective LSCS.
ANC period showed low Hb repeatedly and was investigated - diagnosed by Hb electrophoresis - almost 50% HbS and 50% HbA
Currently Hb - 10.4gm% (build up on iron supplements in the last couple of weeks)
Other invsg like blood counts, platelets, RBS, creat - WNL
short lady with petechial rashes over some parts of body, swollen and slightly deformed small joints.
I read up some literature -
Some would recommend GA for elective LSCS - Sickle india forum gives guidelines for management of such patients including pregnancy. It recommends GA for LSCS - though has not given its advantage over Spinal.
(http://www.sickleindia.com/doctor_zone.php )
Update in anesthesia has a very good article on Sickle cell disease and anesthesia which gives most of the stuff we need to know.
http://www.nda.ox.ac.uk/wfsa/html/u04/u04_008.htm
I found an article published in CJA 2008 which suggests that GA and high leucocyte count could be responsible for postnatal sickling.
http://www.ncbi.nlm.nih.gov/pubmed/18451115?log$=activity
I planned to give Spinal over GA as it has less chances of hypoxia and improvement in peripheral circulation due to regional is advantageous.
Though there are some limitations of spinal - technical difficulty due to affection of spine, hypotension associated can slow the circulation increasing the chances of sickling.
Management -
Starting an iv line requires tourniquet application over the hand and it can stimulate sickling. And since iv line cannot be secured without obstructing venous return, I started the patient on O2, and used intermittent compression rather than the standard tourniquet to secure iv line. Preloading to maintain good hydration is very essential for these patients.
Spinal procedure was not difficult after proper positioning. Lateral - L3-4 space - 25g - 2ml 0.5% Bupivacaine - level T6. Oxygen supplementation all through out. Vasopressors ready to avoid hypotension. We switched off AC (it was terribly stuffy) to avoid vasoconstriction due to cold in the upper limbs. And extra pint of fluid, adding only pitocin (avoid methergin as far as possible as it induces vasoconstriction), avoiding hypotension was all that we did. Intraop was uneventful.
Postop patient shifted to high dependency area and O2 continued for 3-4 hours. Important to monitor urine output. For postop analgesia, opioids can be used as long as they do not cause respiratory depression. NSAIDs can also be used as long as kidneys are well flushed. We used a combination - low dose opioids + Diclofenac.
Hoping that all the ground work I did for this case would be helpful for me as well as others later in time. :)
Consultant Anesthesiologist,
Smile Train Project,
Nizams Institute of Medical Sciences,
Hyderabad, India.
E-mail: vib...@yahoo.co.in
Mobile: +91 9959189958
The INTERNET now has a personality. YOURS! See your Yahoo! Homepage.
HITENDRA MAHAJAN
Mar 9, 2010, 11:48:34 AM3/9/10
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Congrats! Keep it up.
Date: Tue, 9 Mar 2010 14:21:08 +0530
From: vib...@yahoo.co.in
Subject: Sickle cell anemia coming for LSCS
To: isan...@googlegroups.com
Sena, Shah Rukh and the fight over Mumbai Sign up now.
NILESH TATAR
Mar 9, 2010, 2:33:02 PM3/9/10
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Congratulations. Really unique case done with good preparation.
I truely agree with the decision to give regional anesthesia.
Dr.Nilesh Tatar
From: vibha naik <vib...@yahoo.co.in>
Sent: 09 March 2010 02:21 PM
To: isan...@googlegroups.com
I truely agree with the decision to give regional anesthesia.
Dr.Nilesh Tatar
From: vibha naik <vib...@yahoo.co.in>
Sent: 09 March 2010 02:21 PM
To: isan...@googlegroups.com
Subject: Sickle cell anemia coming for LSCS
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