Cardiopulmonary Bypass without Preoperative Exchange Transfusion in Sicklers

Abstract

The effect of hypothermic cardiopulmonary bypass techniques on the sickling process was evaluated in patients with sickle cell hemoglobin. It was presumed that intraoperative hemolysis, as identified by hemoglobinuria, reflected increased sickling. Data of 43 patients with sickle cell traits and 2 with sickle cell disease, who were operated on under cardiopulmonary bypass and cold cardioplegic arrest in a tertiary center from the beginning of 1995 to the end of 2004, were retrospectively analyzed. A mean nasal temperature of 30.8 degrees C +/- 2.1 degrees C was achieved. Three patients with sickle cell trait developed intraoperative hemoglobinuria, albeit with normal surrogate values for hemolysis. However, they had significantly lower mean hemoglobin levels during cardiopulmonary bypass compared to those sickle cell patients who did not exhibit hemoglobinuria (hemoglobin, 6.0 +/- 0.2 vs. 7.4 +/- 0.9 g x dL(-1), p < 0.01). Total drainage and blood transfusion requirements in patients with normal and sickle cell hemoglobin were similar. It was concluded that hypothermic cardiopulmonary bypass with cold cardioplegia is safe in sickle cell patients. Maintenance of adequate hemoglobin levels during cardiopulmonary bypass may be important to avoid triggering a sickling process.

Preoperative Exchange Transfusion for Sickle Cell Disease Patients Undergoing Open-Heart Surgery: An Exception to the Rule

“…When hemolysis persists, lactic dehydrogenase and serum haptoglobin are the next parameters to rise, followed by an increase in reticulocyte count. There may also be hematuria 7 . These values were normal in our patient indicating that no hemolysis took place during CPB.…”

Perioperative care of children with sickle cell disease: A systematic review and clinical recommendations

“…Some authors advocate for preoperative transfusion without giving a threshold, despite evidence from the abovementioned RCTs. Exchange transfusions (manual and automated) for a leve of HbS <30% is recommended for high risk surgery either preoperatively, or on cardiopulmonary bypass . In cardiac pulmonary bypass, some authors suggest a stricter HbS limit of <5% .…”

“…Intraoperative monitoring varies. Per standard anesthetic care, blood pressure, cardiac rhythm and rate and oxygenation are monitored strictly to avoid hypoxia . Some groups perform more invasive systematic monitoring such as the continuous measurement of central venous pressure, arterial blood pressure, regular arterial blood gas exchange and/or urine output determination (by Foley catheterization) .…”

Perioperative considerations in a sickle cell patient undergoing cardiopulmonary bypass

“…Pre-operative blood transfusion is indicated in SCD patients to raise the haematocrit level and lower HbS levels. [67] Hydroxyurea is the main treatment in symptomatic sickle cell patients because of its beneficial effects. [8] Hydroxyurea increases HbF, which prevents sickling and also has beneficial effects on red blood cells hydration and vascular wall adhesion.…”