Sickle cell pain crises - dr braslavskaya

Sickle cell pain crises - dr braslavskaya

Transcript

1. Pain Crisis in Sickle Cell Disease and Anesthetic Considerations Supreet Grewal, MD Karina Braslavskaya, MD (CA-1) 04/28/20
2. Introduction Affects 70,000 – 80,000 Americans; occurs in 1 in 500 African Americans and 1 in 1000- 1400 Hispanic Americans Sick cell gene evolved in sub-Saharan Africa, the Arabian Peninsula and Central India References available upon request
3. References available upon request Inheritance • Autosomal Recessive • 4 different genotypes exist • Hb SS is the homozygous mutation with the most severe manifestation
4. Molecular Basis of Sickle Cell Anemia • 4 different genotypes exist • Hb SS is the homozygous mutation with the most severe manifestation References available upon request
5. Pathophysiology Polymerizations of Hb SS following a trigger RBC Clumping leads to endothelial damage Inflammatory mediators and adhesion molecules are released References available upon request
6. Common Surgical Procedures in Sickle Cell disease References available upon request
7. Anesthetic Concerns • Increased risk of perioperative morbidity and vaso-occlusive crisis What would you like in the pre-op evaluation?
8. Pre-op Considerations and Optimization What kind of anesthetic techniques would you consider using? When would you consider a blood transfusion? References available upon request
9. Avoid Triggers References available upon request Avoid prolonged fasting Consider IV hydration Routine use of supplemental O2 – NOT RECOMMENDED Incentive spirometry before and after cases Routine transfusion is controversial Avoid Acidosis, Hypotension and Hypoxia
10. Intra-op • Closely monitor administration of respiratory depressants to prevent hypoventilation leading to respiratory acidosis • Intubation after paralysis with a short-acting agent • Maintain saturation >92% and OR temperature no less than 24C • There are no absolute contraindications to sedation in patients with SCD; • General Anesthesia can be safely administered with volatile or intravenous agents References available upon request
11. Complications References available upon request •Acute Chest Syndrome •Acute Pain crisis •Post-op infection •Renal Failure •Pulmonary HTN •Aplastic crisis •Neurologic deficits
12. Post-op Care References available upon request Surgical pain, hypoventilation, and a high incidence of pulmonary infarction predisposes to formation of sickling cells Pain Control Incentive Spirometry Hydration DVT Prophylaxis
13. References available upon request Acute Painful Episode New onset pain that lasts at least 4 hours for which there is no explanation other than vaso-occlusion that requires therapy with parenteral opioids or ketorolac in medical facility
14. References available upon request Management of Sickle Cell Pain • Non-pharmacologic • Heat/cold packs, distraction, relaxation, massage, music, acupuncture • Pharmacologic • Nonopioids (Acetaminophen, NSAIDS, topical agents and corticosteroids) • Opioids (mu-agonists, mixed agonists/antagonist buprenorphine and partial agonist pentazocine) • Adjuvants (Antihistamines, benzodiazepines, antidepressants, anticonvulsants) • Regional Techniques • Local anesthetics via neuraxial blocks or peripheral nerve blocks can be used but patients should be monitored closely as there have been case reports of sickle cell crises induced peripheral neuropathy after neuraxial blocks • Transfusion • No data that supports routine transfusion; does not shorten the duration of a pain crisis
15. References available upon request Management of Sickle Cell Pain in the Hospital 1. Multidimensional assessment for a choice of Analgesics 2. Determine the route – Fixed schedule vs PCA pump 3. Titrate Doses until maintenance dose is reached 4. Treat breakthrough pain 5. Treat neuropathic pain and side effects of the analgesics 7. Begin to switch to oral analgesics 8. Prevent withdrawal with clonidine patch or methadone
16. References available upon request Conclusion Management requires careful preparation and close attention to factors that can precipitate sickle cell crisis
17. References • Available upon request