Perioperative Management of Sickle Cell Disease in Complex Congenital Cardiac Surgery: A Compilation of Two Cases

Preoperative exchange transfusion is frequently recommended in patients with homozygous sickle cell anemia (homozygous SS) who undergo cardiopulmonary bypass to reduce the concentration of circulated sickle hemoglobin. The information regarding the ideal level of sickle hemoglobin for sickle cell disease (SCD) patients who require surgery is still divergent in the literature. We present the successfully managed cases of two children aged 11 months and three years with homozygous SS who underwent cardiopulmonary bypass for double-outlet right ventricle and cor-triatriatum sinistrum, respectively. In both cases, we performed preoperative blood and exchange transfusion, as well as strict intraoperative invasive monitoring. We also maintained normothermia, avoided hypoxia and acidosis, and offered effective pain management.

Modifying priming techniques in cardiopulmonary bypass circuit in known case of sickle-cell trait undergoing open heart surgery

Modifying cardiopulmonary bypass (CPB) circuit’s priming technique before the onset of CPB in cardiac patients known with sickle-cell disease or sickle cell trait has been observed to be of substantial significance in dealing with such challenges without having any life-threatening consequences. We modified our routine heparinized crystalloid priming of the CPB circuit with partial exchange transfusion by adding donor blood (packed red blood cells), fresh frozen plasma (FFP), and bicarbonate. This has helped us bring down the overall sickle cell hemoglobin in the blood thereby reducing its risk of sickling.

Outcomes of Patients with Sickle Cell Disease and Trait Following Congenital Heart Disease Surgery

BACKGROUND

Sickle cell disease (SCD) is a hemoglobinopathy which can cause multi-organ dysfunction. The objective of our paper was to assess the perioperative outcomes of patients undergoing surgery for congenital heart disease who had either SCD or sickle cell trait (SCT).

METHODS

We performed a retrospective review of patients with SCD and SCT who had records in the Society of Thoracic Surgeons Congenital Heart Surgery Database between 2014 and 2019. The primary outcome was operative mortality; secondary outcomes included post-operative complications. One-to-one propensity score matching was performed between the SCD and SCT groups and the control group for further analysis.

RESULTS

Our study population consisted of 73, 411, and 36501 patients in the SCD, SCT, and control groups respectively. Median age at surgery in years (25-75% interquartile range) was 2.8(0.4, 9.7), 0.60(0.2, 3.1), and 0.70(0.2, 6.4) years in the SCD, SCT, and control cohort respectively. Operative mortality, surgery duration, cardiopulmonary bypass time, and cross clamp time were not significantly different among the three groups. The SCD group had a higher rate of post-surgical cardiac arrest than its propensity score matched control group (5.5% vs 0%, p<0.05); otherwise there were no statistically significant differences in the outcomes between the SCD and SCT groups and their respective matched control groups.

CONCLUSIONS

Operative mortality following cardiothoracic procedures in patients with SCD and SCT appeared similar to our control patients. While these patients may require unique peri-operative management, they can undergo cardiac surgery without an observed increase in mortality.

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.

Red Blood Cell Disorders: Perioperative Considerations for Patients Undergoing Cardiac Surgery

Disorders affecting red blood cells (RBCs) are uncommon yet have many important physiologic considerations for patients undergoing cardiac surgery. RBC disorders can be categorized by those that are congenital or acquired, and further by disorders affecting the RBC membrane, hemoglobin, intracellular enzymes, or excessive RBC production. A foundational understanding of the physiologic derangement for these disorders is critical when considering perioperative implications and optimization, strategies for cardiopulmonary bypass, and the rapid recognition and treatment if complications occur. This review systematically outlines the RBC disorders of frequency and relevance with an emphasis on how the disorder affects normal physiologic processes, a review of the literature related to the disorder, and the implications and recommendations for patients undergoing cardiac surgery.

Perioperative considerations in a sickle cell patient undergoing cardiopulmonary bypass

An 11-year-old child, a known case of sickle cell anaemia with a history suggestive of sickling crisis in the past was scheduled for surgical pulmonary valvotomy. Pre-operative blood transfusion and hydroxyurea were administered. Pre-operative blood transfusion is indicated in sickle cell disease patients to raise the haematocrit level and lower sickle haemoglobin (HbS) levels. Before the start of cardiopulmonary bypass (CPB), exchange transfusion was performed to reduce HbS level and raise adult haemoglobin level. Hypothermia was prevented by employing normothermic CPB.