Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1450_Библиотеки_им_академика_М_И_Перельмана
.pdf
378 O. C. Nin et al.
Postoperative Care
In the postanesthesia care unit (PACU), the patient should be evaluated for anxiety and
pain. If an epidural was placed and the effect of the spinal anesthetic has dissipated
adequately, a test dose with epinephrine containing local anesthetic can be performed
in order to rule out intrathecal and intravascular location of the epidural catheter prior
to initiating the infusion. Further pain management actions can proceed as noted in
previous sections.
Continuation of the patient’s home medication regimen should proceed as toler-
ated and allowable. Psychiatric medication can be very important in the process of
recovery from surgery and should not be taken lightly. Mental health support, phys-
ical therapy,and a positive environment provided by staff are all integral to an optimal
outcome. Also, a private hospital bed is ideal for patient privacy and comfort.
A very important take-home message regarding SRS is that these gender-affirming
surgeries should be considered to be medically-necessary surgeries that can provide
potentially life-saving mental health benefits for our transgender patients [17].
References
1. Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health
Issues and Research Gaps and Opportunities. Introduction. In: The health of lesbian, gay,
bisexual, and transgender people: building a foundation for better understanding. Washington,
DC: The National Academies Press; 2011. p. 11–24. https://doi.org/10.17226/13128
2. Institute W. LGBT proportion of population: United States. 2021.
3. Newport F. In U.S., estimate of LGBT population rises to 4.5% [Internet]. Gallup. 2018 May
2022 [cited 2023 Apr 24]. Available from: https://news.gallup.com/poll/234863/estimate-lgbt-
population-rises.aspx
4. National Academies of Sciences, Engineering, and Medicine. Understanding the well-being
of LGBTQI+ populations. Washington, DC: The National Academies Press; 2020. https://doi.
org/10.17226/25877
5. Sutter M, Perrin PB. Discrimination, mental health, and suicidal ideation among LGBTQ
people of color. J Couns Psychol. 2016;63(1):98–105. https://doi.org/10.1037/cou0000126.
6. Taylor NM, King CK. Sexual health and the LGBTQ+ community. Prim Care. 2021;48(2):271–
82. https://doi.org/10.1016/j.pop.2021.02.009.
7. Afonso AM, Cadwell JB, Staffa SJ, Zurakowski D, Vinson AE. Burnout rate and risk factors
among anesthesiologists in the United States. Anesthesiology. 2021;134(5):683–96. https://
doi.org/10.1097/ALN.0000000000003722.
8. Han S, Shanafelt TD, Sinsky CA, Awad KM, Dyrbye LN, Fiscus LC, et al. Estimating the
attributable cost of physician burnout in the United States. Ann Intern Med. 2019;170(11):784–
90. https://doi.org/10.7326/M18-1422.
9. National plan for health workforce well being. National Academy of Medicine. 2022 [cited
2023 Apr 24]. Available from: https://nam.edu/initiatives/clinician-resilience-and-well-being/
national-plan-for-health-workforce-well-being/
10. Committee on Standards and Practice Parameters; Apfelbaum JL, Connis RT, Nickinovich DG;
American Society of Anesthesiologists Task Force on Preanesthesia Evaluation; Pasternak
LR, et al. Practice advisory for preanesthesia evaluation: an updated report by the Amer-
ican Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology.
2012;116(3):522–38. doi.org/https://doi.org/10.1097/ALN.0b013e31823c1067
https://t.me/med1917
Perioperative Care of the LGBQTA+ Community 379
11. Manley S, de Kelaita G, Joseph NJ, Salem MR, Heyman HJ. Preoperative pregnancy testing in
ambulatory surgery: incidence and impact of positive results. Anesthesiology. 1995;83(4):690–
3. https://doi.org/10.1097/00000542-199510000-00007.
12. Pierre N, Moy LK, Redd S, Emans SJ, Laufer MR. Evaluation of a pregnancy-testing protocol
in adolescents undergoing surgery. J Pediatr Adolesc Gynecol. 1998;11(3):139–41. https://doi.
org/10.1016/s1083-3188(98)70133-0.
13. Evron S, Glezerman M, Harow E, Sadan O, Ezri T. Human immunodeficiency virus: anesthetic
and obstetric considerations. Anesth Analg. 2004;98(2):503–11. https://doi.org/10.1213/01.
ANE.0000097193.91244.50
14. Bajwa SJS, Kulshrestha A. The potential anesthetic threats, challenges and intensive care
considerations in patients with HIV infection. J Pharm Bioallied Sci. 2013;5(1):10–6. https://
doi.org/10.4103/0975-7406.106554.
15. Evron S, Glezerman M, Harow E, Sadan O, Ezri T. Human immunodeficiency virus: anesthetic
and obstetric considerations. Anesth Analg. 2004;98(2):503–11. https://doi.org/10.1213/01.
ANE.0000097193.91244.50. PMID: 14742395.
16. New York State Department of Health AIDS Institute Clinical Guidelines Program. Viro-
logic and immunologic monitoring in HIV care [Internet]. 2022 June 16 [cited 2023 Apr 24].
Available from: https://www.hivguidelines.org/antiretroviral-therapy/cd4-and-viral-load-mon
itoring/
17. Horberg MA, Hurley LB, Klein DB, Follansbee SE, Quesenberry C, Flamm JA, et al. Surgical
outcomes in human immunodeficiency virus-infected patients in the era of highly active
antiretroviral therapy. Arch Surg. 2006;141(12):1238–45. https://doi.org/10.1001/archsurg.
141.12.1238.
18. King JT Jr, Perkal MF, Rosenthal RA, Gordon AJ, Crystal S, Rodriguez-Barradas MC, et al.
Thirty-day postoperative mortality among individuals with HIV infection receiving antiretro-
viral therapy and procedure-matched, uninfected comparators. JAMA Surg. 2015;150(4):343–
51. https://doi.org/10.1001/jamasurg.2014.2257.
19. Naziri Q, Boylan MR, Issa K, Jones LC, Khanuja HS, Mont MA. Does HIV infection increase
the risk of perioperative complications after THA? a nationwide database study. Clin Orthop
Relat Res. 2015;473(2):581–6. https://doi.org/10.1007/s11999-014-3855-8.
20. Sandler BJ, Davis KA, Schuster KM. Symptomatic human immunodeficiency virus–infected
patients have poorer outcomes following emergency general surgery: a study of the nationwide
inpatient sample. J Trauma Acute Care Surg. 2019;86(3):479–88. https://doi.org/10.1097/TA.
0000000000002161.
21. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N,
et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med.
2011;365(6):493–505. https://doi.org/10.1056/NEJMoa1105243.
22. Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, van Lunzen J, et al. Sexual activity
without condoms and risk of HIV t ransmission in serodifferent couples when the HIV-positive
partner is using suppressive antiretroviral therapy.JAMA. 2016;316(2):171–81. https://doi.org/
10.1001/jama.2016.5148.
23. New York State Department of Health AIDS Institute Clinical Guidelines Program. Periop-
erative care in adults with HIV [Internet]. 2021 Nov 16 [cited 2023 Apr 24]. Available from:
https://www.hivguidelines.org/hiv-care/perioperative-management/
24. Holkmann Olsen C, Mocroft A, Kirk O, Vella S, Blaxhult A, Clumeck N, et al. Interruption of
combination antiretroviral therapy and risk of clinical disease progression to AIDS or death.
HIV Med. 2007;8(2):96–104. https://doi.org/10.1111/j.1468-1293.2007.00436.x.
25. Li JZ, Etemad B, Ahmed H, Aga E, Bosch RJ, Mellors JW, et al. The size of the expressed HIV
reservoir predicts timing of viral rebound after treatment interruption. AIDS. 2016;30(3):343–
53. https://doi.org/10.1097/QAD.0000000000000953.
26. Skiest DJ, Su Z, Havlir DV, Robertson KR, Coombs RW, Cain P, et al. Interruption of antiretro-
viral treatment in HIV-infected patients with preserved immune function is associated with a
low rate of clinical progression: a prospective study by AIDS Clinical Trials Group 5170. J
Infect Dis. 2007;195(10):1426–36. https://doi.org/10.1086/512681.
https://t.me/med1917
380 O. C. Nin et al.
27. Russell LA, Craig C, Flores EK, Wainaina JN, Keshock M, Kasten MJ, et al. Preoperative
management of medications for rheumatologic and HIV diseases: Society for Periopera-
tive Assessment and Quality Improvement (SPAQI) consensus statement. Mayo Clin Proc.
2022;97(8):1551–71. https://doi.org/10.1016/j.mayocp.2022.05.002.
28. Coleman E, Bockting W,Botzer M, Cohen-Kettenis P,DeCuypere G, Feldman J, et al. Standards
of care for the health of transsexual, transgender, and gender-nonconforming people, version
7. Int J Transgend. 2012;13(4):165–232. https://doi.org/10.1080/15532739.2011.700873.
29. Tollinche LE, Rosa WE, van Rooyen CD. Perioperative considerations for person-centered
gender-affirming surgery. Adv Anesth. 2021;39:77–96. https://doi.org/10.1016/j.aan.2021.
07.005.
30. Tollinche LE, Walters CB, Radix A, Long M, Galante L, Goldstein ZG, et al. The perioperative
care of the transgender patient. Anesth Analg. 2018;127(2):359–66. https://doi.org/10.1213/
ANE.0000000000003371.
31. Middeldorp S, Meijers JC, van den Ende AE, van Enk A, Bouma BN, Tans G, et al. Effects
on coagulation of levonorgestrel- and desogestrel-containing low dose oral contraceptives: a
cross-over study. Thromb Haemost. 2000;84(1):4–8.
32. Gomes MPV, Deitcher SR. Risk of venous thromboembolic disease associated with hormonal
contraceptives and hormone replacement therapy: a clinical review. Arch Intern Med.
2004;164(18):1965–76. https://doi.org/10.1001/archinte.164.18.1965.
33. Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk
of venous thromboembolism: nested case-control studies using the QResearch and CPRD
databases. BMJ. 2019;364:k4810. https://doi.org/10.1136/bmj.k4810.
34. Argalious MY, Steib J, Daskalakis N, Mao G, Li M, Armanyous S, et al. Association
of testosterone replacement therapy and the incidence of a composite of postoperative in-
hospital mortality and cardiovascular events in men undergoing cardiac surgery. Anesth Analg.
2020;130(4):890–8. https://doi.org/10.1213/ANE.0000000000004115.
35. Boskey ER, Taghinia AH, Ganor O. Association of surgical risk with exogenous hormone use
in transgender patients: a systematic review. JAMA Surg. 2019;154(2):159–69. https://doi.org/
10.1001/jamasurg.2018.4598.
36. Goldstein Z, Corneil TA, Greene DN. When gender identity doesn’t equal sex recorded at birth:
the role of the laboratory in providing effective healthcare to the transgender community. Clin
Chem. 2017;63(8):1342–52. doi.org:https://doi.org/10.1373/clinchem.2016.258780
37. UCSF Gender Affirming Health Program, Department of Family and Community Medicine,
University of California San Francisco. Guidelines for the primary and gender-affirming care
of transgender and gender nonbinary people. 2nd edition [Internet]. Deutsch MB, editor. 2016
June [cited 2023 Apr 24]. Available from: https://transcare.ucsf.edu/guidelines.
38. Peitzmeier S, Gardner I, Weinand J, Corbet A, Acevedo K. Health impact of chest binding
among transgender adults: a community-engaged, cross-sectional study. Cult Health Sex.
2017;19(1):64–75. https://doi.org/10.1080/13691058.2016.1191675.
39. Morrison SD, Vyas KS, Motakef S, Gast KM, Chung MT, Rashidi V, et al. Facial feminization:
systematic review of the literature. Plast Reconstr Surg. 2016;137(6):1759–70. https://doi.org/
10.1097/PRS.0000000000002171.
40. Sayegh F, Ludwig DC, Ascha M, Vyas K, Shakir A, Kwong JW, et al. Facial masculinization
surgery and its role in the treatment of gender dysphoria. J Craniofac Surg. 2019;30(5):1339–46.
https://doi.org/10.1097/SCS.0000000000005101.
41. Kanagalingam J, Georgalas C, Wood GR, Ahluwalia S, Sandhu G, Cheesman AD. Cricothy-
roid approximation and subluxation in 21 male-to-female transsexuals. Laryngoscope.
2005;115(4):611–8. https://doi.org/10.1097/01.mlg.0000161357.12826.33.
42. Mastronikolis NS, Remacle M, Biagini M, Kiagiadaki D, Lawson G. Wendler glottoplasty:
an effective pitch raising surgery in male-to-female transsexuals. J Voice. 2013;27(4):516–22.
https://doi.org/10.1016/j.jvoice.2013.04.004.
43. Thomas JP, Macmillan C. Feminization laryngoplasty: assessment of surgical pitch eleva-
tion. Eur Arch Otorhinolaryngol. 2013;270(10):2695–2700. doi.org:https://doi.org/10.1007/
s00405-013-2511-3
https://t.me/med1917
Perioperative Care of the LGBQTA+ Community 381
44. Vowles BJ, Ahmad I, Christodoulides G. Unexpected difficult airway management in a
transgender female patient. Anaesth Rep. 2020;8(1):36–9. https://doi.org/10.1002/anr3.12042.
45. McNeill EJM. Management of the transgender voice. J Laryngol Otol. 2006;120(7):521–3.
https://doi.org/10.1017/S0022215106001174.
46. Saito Y, Nakamura K, Itani S, Tsukahara K. Type 3 thyroplasty for a patient with female-to-
male gender identity disorder. Case Rep Otolaryngol. 2018;2018:4280381. https://doi.org/10.
1155/2018/4280381.
47. Lao WP, Crawley BK. Airway considerations in transgender patients: complicated intuba-
tion. Ear Nose Throat J. 2021;100(5_suppl):755S–756S. https://doi.org/10.1177/014556132
0910680
48. Ahmad S, Leinung M. The response of the menstrual cycle to initiation of hormonal therapy in
transgender men. Transgend Health. 2017;2(1):176–9. https://doi.org/10.1089/trgh.2017.0023.
49. Frey JD, Poudrier G, Thomson JE, Hazen A. A historical review of gender-affirming medicine:
focus on genital reconstruction surgery. J Sex Med. 2017;14(8):991–1002. https://doi.org/10.
1016/j.jsxm.2017.06.007.
50. Weissler JM, Chang BL, Carney MJ, Rengifo D, Messa CA IV, Sarwer DB, et al. Gender-
affirming surgery in persons with gender dysphoria. Plast Reconstr Surg. 2018;141(3):388e–
96e. https://doi.org/10.1097/PRS.0000000000004123.
51. Tucker RP, Testa RJ, Simpson TL, Shipherd JC, Blosnich JR, Lehavot K. Hormone therapy,
gender affirmation surgery, and their association with recent suicidal ideation and depression
symptoms in transgender veterans. Psychol Med. 2018;48(14):2329–36. https://doi.org/10.
1017/S0033291717003853.
52. Tordoff DM, Wanta JW, Collin A, Stepney C, Inwards-Breland DJ, Ahrens K. Mental health
outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA Netw
Open. 2022;5(2):e220978. https://doi.org/10.1001/jamanetworkopen.2022.0978.
53. Cuccolo NG, Kang CO, Boskey ER, Ibrahim AMS, Blankensteijn LL, Taghinia A, et al.
Mastectomy in transgender and cisgender patients: a comparative analysis of epidemiology
and postoperative outcomes. Plast Reconstr Surg Glob Open. 2019;7(6):e2316. https://doi.org/
10.1097/GOX.0000000000002316.
54. Coleman E, Radix A, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, et al. Standards of
care for the health of transgender and gender diverse people, version 8. Int J Transgend Health.
2022;23(suppl 1):S1–259. https://doi.org/10.1080/26895269.2022.2100644.
55. Erickson-Schroth L, editor. Trans bodies, trans selves: a resource for the transgender
community. New York: Oxford University Press; 2014.
56. Bretschneider CE, Sheyn D, Pollard R, Ferrando CA. Complication rates and outcomes after
hysterectomy in transgender men. Obstet Gynecol. 2018;132(5):1265–73. https://doi.org/10.
1097/AOG.0000000000002936.
57. Rachlin K, Hansbury G, Pardo ST. Hysterectomy and oophorectomy experiences of female-
to-male transgender individuals. Int J Transgend. 2010;12(3):155–66. https://doi.org/10.1080/
15532739.2010.514220.
58. Bekeny JC, Zolper EG, Fan KL, Del Corral G. Breast augmentation for transfeminine patients:
methods, complications, and outcomes. Gland Surg. 2020;9(3):788–96. https://doi.org/10.
21037/gs.2020.03.18.
59. Therattil PJ, Hazim NY, Cohen WA, Keith JD. Esthetic reduction of the thyroid cartilage: a
systematic review of chondrolaryngoplasty. JPRAS Open. 2019;22:27–32. https://doi.org/10.
1016/j.jpra.2019.07.002.
60. Cho MJ, Carboy JA, Rohrich RJ. Complications in brow lifts: a systemic review of surgical and
nonsurgical brow rejuvenations. Plast Reconstr Surg Glob Open. 2018;6(10):e1943. https://doi.
org/10.1097/GOX.0000000000001943.
61. Tirrell AR, Abu El Hawa AA, Bekeny JC, Chang BL, Del Corral G. Facial feminization surgery:
a systematic review of perioperative surgical planning and outcomes. Plast Reconstr Surg Glob
Open. 2022;10(3):e4210. https://doi.org/10.1097/GOX.0000000000004210
62. Namin A, Shokri T, Vincent A, Saman M, Ducic Y. Complications in facial esthetic surgery.
Semin Plast Surg. 2020;34(4):272–6. https://doi.org/10.1055/s-0040-1721764.
https://t.me/med1917
382 O. C. Nin et al.
63. Chang J, Yung K. Gender affirming voice care: a literature review. Int J Head Neck Surg.
2021;12(3):93–7. https://doi.org/10.5005/jp-journals-10001-1448.
64. Russell CB, Hong CX, Fairchild P, Bretschneider CE. Complications after orchiectomy and
vaginoplasty for gender affirmation: an analysis of concurrent versus separate procedures using
a national database. Urogynecology (Phila). 2023;29(2):202–8. https://doi.org/10.1097/SPV.
0000000000001312.
65. Mishra K, Ferrando CA. Postoperative adverse events following gender-affirming vaginoplasty:
an American College of Surgeons National Surgical Quality Improvement Program study. Am
J Obstet Gynecol. Published online 18 Jan 2023. https://doi.org/10.1016/j.ajog.2023.01.011
66. Melancon DM, Walton AB, Mundinger G, Benson C. Surgical outcomes and complications of
genital gender affirmation surgery. Curr Sex Health Rep. 2021;13(4):107–16. https://doi.org/
10.1007/s11930-021-00318-3.
67. Salesky M, Zebolsky AL, Benjamin T, Wulu JA, Park A, Knott PD, et al. Gender-affirming
facial surgery: experiences and outcomes at an academic center. Facial Plast Surg Aesthet Med.
2022;24(1):54–9. https://doi.org/10.1089/fpsam.2021.0060.
68. Robinson IS, Blasdel G, Cohen O, Zhao LC, Bluebond-Langner R. Surgical outcomes following
gender affirming penile reconstruction: patient-reported outcomes from a multi-center, inter-
national survey of 129 transmasculine patients. J Sex Med. 2021;18(4):800–11. https://doi.org/
10.1016/j.jsxm.2021.01.183.
69. Reece-Nguyen TL, Tollinche L, Van Rooyen C, Roque RA. Current challenges faced by
transgender and gender-diverse patients and providers in anesthesiology. Int Anesthesiol Clin.
2023;61(1):26–33. https://doi.org/10.1097/aia.0000000000000384.
70. Kozato A, Fox GWC, Yong PC, Shin SJ, Avanessian BK, Ting J, et al. No venous thromboem-
bolism increase among transgender female patients remaining on estrogen for gender-affirming
surgery. J Clin Endocrinol Metab. 2021;106(4):e1586–90. https://doi.org/10.1210/clinem/dga
a966.
71. Barba-Navarro R, Tapia-Silva M, Garza-Garcia C, López-Giacoman S, Melgoza-Toral I,
Vázquez-Rangel A, et al. The effect of spironolactone on acute kidney injury after cardiac
surgery: a randomized, placebo-controlled trial. Am J Kidney Dis. 2017;69:192–9. https://doi.
org/10.1053/j.ajkd.2016.06.013.
72. Kim HT. Vocal feminization for transgender women: current strategies and patient perspectives.
Int J Gen Med. 2020;13:43–52. https://doi.org/10.2147/IJGM.S205102.
73. Goldstein Z, Corneil TA, Greene DN. When gender identity doesn’t equal sex recorded at birth:
the role of the laboratory in providing effective healthcare to the transgender community. Clin
Chem. 2017;63(8):1342–52. https://doi.org/10.1373/clinchem.2016.258780.
74. Rosendale N, Goldman S, Ortiz GM, Haber LA. Acute clinical care for transgender
patients. JAMA Intern Med. 2018;178(11):1535–43. https://doi.org/10.1001/jamainternmed.
2018.4179.
75. Peitzmeier S, Gardner I, Weinand J, Corbet A, Acevedo K. Health impact of chest binding
among transgender adults: community-engaged, cross-sectional study. Cult Health Sex.
2017;19(1):64–75. https://doi.org/10.1080/13691058.2016.1191675.
76. Cumming RJM, Sylvester K, Fuld J. P257 Understanding the effects on lung function of chest
binder use in the transgender population. Thorax. 2016;71(suppl 3):A227. https://doi.org/10.
1136/thoraxjnl-2016-209333.400.
77. Kim E, Mukerji S, Debryn D, Price R, Streed C Jr, Nozari A. Oxygen desaturation in a trans-
gender man: initial concerns and recommendations regarding the practice of chest binding: a
case report. J Med Case Rep. 2022;16(1):333. https://doi.org/10.1186/s13256-022-03527-z.
78. Kumar AH, Habib AS. The role of gabapentinoids in acute and chronic pain after surgery. Curr
Opin Anaesthesiol. 2019;32(5):629–34. https://doi.org/10.1097/ACO.0000000000000767.
79. Almazan AN, Keuroghlian AS. Association between gender-affirming surgeries and mental
health outcomes. JAMA Surg. 2021;156(7):611–8. https://doi.org/10.1001/jamasurg.2021.
0952.
80. Aquino NJ, Boskey ER, Staffa SJ, Ganor O, Crest AW, Gemmill KV, et al. A single center case
series of gender-affirming surgeries and the evolution of a specialty anesthesia team. J Clin
Med. 2022;11(7):1943. https://doi.org/10.3390/jcm11071943.
https://t.me/med1917
Perioperative Care of the LGBQTA+ Community 383
81. Aquino NJ, Ganor O, Chrisos HA, Oles N, Boskey ER. Perioperative issues with gender-
diverse youth. J Pediatr Surg Nurs. 2021;10(1):23–31. https://doi.org/10.1097/jps.000000000
0000282.
82. Oles N, Ganor O, Aquino NJ, Boskey ER. Surgical affirmation for gender-diverse youth. J
Pediatr Surg Nurs. 2021;10(1):32–9. https://doi.org/10.1097/jps.0000000000000279.
83. Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al.
Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society
clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869–903. https://doi.org/
10.1210/jc.2017-01658.
https://t.me/med1917
Sickle Cell Disease (SCD)
and Perioperative Pain Management
Cynthia Iradukunda
Abstract Sickle cell disease is an autosomal recessive disorder that involves the
inheritance of a mutant Beta globin gene. The Beta globin gene is encoded at chro-
mosome 11. The defective hemoglobin S (HbS) results from a substitution mutation
that occurs at the sixth amino acid where Glutamine is substituted for Valine on
chromosome 11 (Kumar et al, Robbins basic pathology, Elsevier, Saint Louis, pp
411–3, 2012 [1]; Lanzkron, Sickle cell anemia straight to the point of care [Internet],
2023 [2]). At least one HbS allele must be present to develop sickle cell disease. In
cases where only one HbS allele exists, co-inheritance of defective Beta hemoglobin
such as occurs in the setting of Beta thalassemia or Hemoglobin C disease may
result in clinical manifestations of sickle cell disease. Inheritance of a hemoglobin
S allele from both parents results in the most severe form of sickle cell disease
also known as sickle cell anemia (Lanzkron, Sickle cell anemia straight to the point
of care [Internet] 2023, [2]). Patients with sickle cell trait have one normal gene
(HbA) and another sickle gene and are commonly asymptomatic or have symptoms
of diminished magnitude.
Keywords Sickle cell disease (SCD)
· Postoperative surgical pain · Acute painful
crisis
· Chronic pain · And chronic opioid therapy
1 Epidemiology
The Global Prevalence of SCD increased by 41.4%. from 5.46 million people in 2000
to 7.74 million in 2021 [3]. The ancestry of patients with sickle cell disease can be
traced back to sub-Saharan Africa, the Caribbean, India, Saudi Arabia, and Mediter-
ranean countries [3, 4]. In the United States of America, approximately 100,000
people suffer from sickle cell disease, and the condition is most prevalent among
African Americans. The incidence of sickle cell disease is 1 for every 365 live births
C. Iradukunda (
B
)
Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin,
Madison, USA
e-mail: ciradukunda@uwhealth.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,
https://doi.org/10.1007/978-3-031-67648-2_24
385
https://t.me/med1917
386 C. Iradukunda
in the African-American population and 1 in every 16,300 Hispanic-American births
[5]. Recent advances in medical therapy have made it possible for patients with sickle
cell disease to survive into adulthood [5–7]. However, given the pathogenesis of sickle
cell disease, there is an increased incidence of surgery in this population compared
to the general population [1, 8, 9]. In an earlier cooperative study of surgery and
sickle cell disease, 69% of sickle cell patients underwent a single procedure, 21%
underwent two procedures and 11% had more than 2 procedures over a10 year study
period [9]. Additionally, patients with SCD who underwent surgery were reported to
have more complications, increased pain scores, and increased opioid requirements
[10–12].
2 Pathogenesis of Sickle Cell Disease
Understanding the pathogenesis of sickle cell disease and sickle cell anemia plays
a critical role in optimizing the surgical care of patients with SCD. Normal adult
hemoglobin (HbA) is a tetramer with 2 alpha and 2 beta chains encoded at chromo-
some 16 and chromosome 11 respectively [1]. A substitution mutation of glutamine
for valine at chromosome 11 results in a mutated beta Hemoglobin S (HbS). Sickle
cell disease follows an inheritance of at least one abnormal beta hemoglobin chain
(HbS) from one parent, with varying degrees of severity as dictated by the patient’s
genotype. With hemoglobin electrophoresis, the most severe forms of sickle cell
disease that is HbSS and HbSbeta
0
are found to have more than 80% of the Beta
hemoglobin mutant. [13]. Patients with sickle cell anemia (HbSS) can present with
severe features as early as 6 months and are bound to endure multiple hospital
admissions and blood transfusions [2].
Underlying the unique clinical presentations of sickle cell disease is the process of
polymerization of HbS within the red cells in the presence of hypoxia which results
in morphological changes of the red blood cell from a normal discoid to a sickle
or crescent shape. The rate of HbS polymerization is directly proportional to its
concentration within the cell. Once the cells are sickled, they increasingly adhere to
endothelium promoting thrombosis, decreased blood flow and a shortened life span
of 20 days versus 120 days of life for the normal red cell [1] When sickling occurs in
the microvasculature, partial or complete obstruction of blood flow occurs inducing
an acute or subacute vaso-occlusive painful crisis, in the affected organs. In organs
with increased transit time such as the spleen and bone marrow, the sickled cells
are subjected to increased hemolysis resulting in anemia [1, 14]. Tissue and organ
infarction usually results from multiple vaso-occlusive episodes following different
triggers. Reversing hypoxemia with improved oxygenation has been shown to atten-
uate further sickling and occasionally reverse sickling. In addition to hypoxemia,
dehydration, acidosis, cold temperatures, extreme exertion, inflammation, stress, and
infection are the other commonly identified triggers of red blood cell sickling [2].
The two major outcomes of sickled red blood cells are [1]:
https://t.me/med1917
Sickle Cell Disease (SCD) and Perioperative Pain Management 387
1. Recurrent hemolysis resulting in chronic hemolytic anemia.
2. Microvascular obstructions result in thrombosis, vascular congestion, and infarc-
tion of multiple organs resulting in sudden vaso-occlusive pain crises including
acute chest syndrome, a life-threatening complication.
3 Sickle Cell Disease and Surgery
Beginning in the preoperative period, an Anesthesia professional should work closely
with a multidisciplinary team including the patient’s primary care physician, Hema-
tologist, and the acute pain service [15–17]. Patients with SCD may require surgical
interventions to provide symptomatic relief or to definitively treat the sequalae of
infarction. Surgical encounters in SCD start early on in childhood and are generally
associated with longer hospital stays secondary to poorly controlled postoperative
pain among other factors [8, 18, 19]. Cholecystectomy, splenectomy, and adenoton-
sillectomy are reported as the most common procedures, however, other procedures
may include hip surgery for avascular necrosis of femur, incision and drainage for
abscess, surgery for priapism, cardiac surgery, neurosurgery for stroke, arteriovenous
malformations, and MoyaMoya disease [9, 20–23].
4 Perioperative Pain Management in Patients with Sickle
Cell Disease
Patients with sickle cell disease are most vulnerable in the perioperative period due
to the accentuation of multiple triggers for sickling including dehydration, stress,
surgery, hypoxia, and increased inflammation following surgical manipulation [16].
Prolonged hours of fasting predispose patients to dehydration, which in turn increases
anxiety and stress resulting in a vicious cycle of multiple triggers for polymer-
ization of the defective haemoglobin (HbS) and red cell sickling. Consequentially,
vaso-occlusive acute painful crises often occur perioperatively and complicate the
management of postoperative surgical pain.
Postoperative pain in patients with SCD remains complex and systematic
approaches to analgesia should incorporate the patient and a diverse group of medical
professionals.
5 Hematology Consult
Once the patient is scheduled for surgery, the patient should be seen or reviewed
by an in-house hematologist to establish and ensure continuity of care. A patient’s
hemoglobinopathy should be ascertained since some forms of SCD are more severe
https://t.me/med1917
388 C. Iradukunda
than others [13]. Ascertaining the genotype of patients from endemic areas of the
world [5, 24] is essential in guiding individualized postoperative analgesia plans and
appropriating resources as determined by the disease severity [13, 25, 26] Addi-
tionally, the expertise of the Hematologist is also crucial to guide the timely initia-
tion of sickle disease-modifying therapies such as hydroxyurea, crizanlizumub, L-
glutamine and voxelotor [7].
6 Individualized Pain Plan
Optimizing postoperative pain management in patients with sickle cell disease
requires that the provider be familiar with the complex manifestations of the disease
in situations of increased stress that may be encountered in the perioperative period.
Goal setting is pivotal in managing postoperative pain in SCD patients with a focus
on return to baseline functional status which may mean complete pain resolution for
some versus baseline chronic pain state in others.
Postoperative pain management in SCD patients begins in the preoperative period
with a focused pain history and an assessment of analgesic elements (Table 1) perti-
nent to SCD patients followed by the drafting of an individualized pain management
plan [27, 28]. In general, a multimodal analgesic approach to postoperative pain
is suitable for most surgical patients, however, SCD patients present several chal-
lenges and may require additional resources. Distinctive in patients with SCD are
several factors that impact and compound the presentation of postoperative pain in
the perioperative period as outlined in the following paragraphs.
7 Early Recognition and Management of an Acute Painful
Crisis
A vaso-occlusive painful crisis in the perioperative period is often multifactorial in
etiology [2, 12]. In the postoperative period, an acute painful crisis often presents as
a new severe acute pain and may be localized to a non-surgical site often with precip-
itating factors that should be identified and treated promptly [29, 30]. Maintaining
adequate hydration status by allowing clear fluid intake up to 2 h before surgery and
careful intravenous fluid maintenance for those who are strict NPO status is advised
[31]. Throughout the perioperative period, vigilant monitoring of a patient’s input
and output should be performed and this can provide valuable information about the
patient’s hydration status [29]. To prevent hypoxia, supplemental oxygen may be
required during the intraoperative and postoperative periods to maintain an oxygen
saturation > 95%. Incentive spirometry is encouraged in patients with SCD under-
going surgery to mitigate pulmonary complications and the use of CPAP in patients
with Obstructive Sleep Apnea may be necessary [23, 26].
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана