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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 7  |  Issue : 1  |  Page : 17-21

Preoperative blood transfusion in adults with sickle cell disease undergoing elective surgical procedures: A survey of practice and outcome in Zaria, Nigeria


1 Department of Surgery, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
2 Department of Orthopedics and Trauma, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
3 Department of Hematology and Blood Transfusion, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria

Date of Web Publication4-Apr-2018

Correspondence Address:
Dr. Dauda M Maigatari
Department of Surgery, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_45_17

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  Abstract 


Background: Preoperative blood transfusion, which decreases the proportion of sickle red blood cells and improves anemia, has been associated with decreased risk of perioperative complications. The aim of this study was to retrospectively review our experience in the management of adult patients with sickle cell anemia undergoing elective surgery, and to determine blood transfusion requirement and surgery-related perioperative complications.
Patients and Methods: Patients were divided into two groups: Group A had top-up transfusion and Group B received a partial exchange transfusion. Four surgical procedures were analyzed: open cholecystectomy, total hip replacement, total knee replacement, and split thickness skin grafts. Postoperative complications were categorized into three groups – (1) SCD-related, (2) non-SCD-related, and (3) transfusion-related perioperative complications.
Results: Twelve (12) patients received top-up transfusion before surgery (Group A) while 20 patients (Group B) received partial exchange transfusions. There were 6 (18%) postoperative complications; two occurred in group A patients who received top-up transfusion and four occurred in group B patients who had partial exchange transfusion. Sickle cell disease-related complications consisted of acute vaso-occlusive pain in two patients (6%). Four patients (12%) had episodes of postoperative fever secondary to atelectasis, urinary tract infection, and wound infection. Only one (3%) patient in group A (top up) had a mild hemolytic transfusion reaction.
Conclusion: This study showed that preoperative blood transfusion was associated with a reduced risk of perioperative complications in patients with sickle cell disease who underwent low and medium-risk surgery.

Keywords: Elective surgery, partial exchange blood transfusion, sickle cell disease, top up blood transfusion


How to cite this article:
Maigatari DM, Abdulrasheed I, Lawal DI, Hassan A, Augustine B, Muhammad PK. Preoperative blood transfusion in adults with sickle cell disease undergoing elective surgical procedures: A survey of practice and outcome in Zaria, Nigeria. Arch Int Surg 2017;7:17-21

How to cite this URL:
Maigatari DM, Abdulrasheed I, Lawal DI, Hassan A, Augustine B, Muhammad PK. Preoperative blood transfusion in adults with sickle cell disease undergoing elective surgical procedures: A survey of practice and outcome in Zaria, Nigeria. Arch Int Surg [serial online] 2017 [cited 2021 May 15];7:17-21. Available from: https://www.archintsurg.org/text.asp?2017/7/1/17/229180




  Introduction Top


Sickle cell disease (SCD) is the most common genetic hematological disease worldwide.[1],[2] Over the last decade, sub-Saharan Africa accounted for two-third of global SCD births, making it the most burdened region.[3],[4] Nigeria has the largest prevalence of SCD in sub-Saharan Africa, with a projected exponential growth in the next decade.[4],[5] The most severe SCD syndrome, homozygous hemoglobin S disease (HbSS) or sickle cell anemia (SCA), is the phenotype in over 90% of Nigerian patients.[5]

Patients with SCD are more likely than the general population to undergo surgical procedures during their lifetime.[6],[7],[8] In addition, patients with SCD having general anesthesia for surgical procedures have a greater risk for SCD and non-SCD-associated perioperative complications.[9],[10],[11] These increased risks are secondary to acute tissue injury and chronic organ damage produced by vaso-occlusion from sickle red blood cells.[12],[13] Preoperative blood transfusion, which decreases the proportion of sickle red blood cells and improves anemia, has been associated with decreased risk of complications related to SCD.[14],[15],[16] Preoperative blood transfusion can be by top-up (simple) transfusion to raise the hemoglobin level to approximately 10 g/dL, with about 50% reduction in hemoglobin S (HbS), or by exchange blood transfusion (aggressive) in which the HbS is replaced by healthy red blood cells with a goal of reducing HbS to below 30%.[2],[4],[8],[14]

Despite increased recognition of the importance and efficacy of preoperative blood transfusion in the prevention and treatment of SCD complications, there is a paucity of literature from Nigeria and sub-Saharan Africa.[4] The purpose of this study is to retrospectively review our experience in the management of adult patients with SCA who had elective surgery, and to evaluate blood transfusion requirements and surgery-related perioperative complications.


  Patients and Methods Top


This is a retrospective review of the medical records of SCD patients who underwent elective surgical procedures between June 2010 and December 2016. Inclusion criteria were adult patients (>18 years) with a diagnosis of SCA determined by the presence of HbSS on hemoglobin electrophoresis. Patients with incomplete records were excluded. Recorded information included patient demographics, clinical and laboratory data, preoperative blood transfusion regimen, and perioperative course.

Perioperative management was standardized in all patients, and included the administration of intravenous fluids, general anesthesia, antibiotics, and supplemental oxygen. The patients were divided into two groups – Group A underwent top-up blood transfusion and Group B received a partial exchange blood transfusion. Partial exchange blood transfusion in this study is the transfusion of 15 mL/kg of packed erythrocytes into an antecubital vein while simultaneously removing 20 mL/kg of whole blood by gravity from the opposite antecubital vein.[16]

Four surgical procedures in adults were analyzed – open cholecystectomy, total hip replacement, total knee replacement, and split thickness skin grafts. The procedures were further classified as low risk (split thickness skin grafts) and medium risk (cholecystectomy, total hip, and total knee replacement) in accordance with the Cooperative Study of Sickle Cell Disease criteria.[17] Postoperative complications were categorized into three groups: (1) SCD-related, (2) non-SCD-related, and (3) transfusion-related perioperative complications. The results are presented in tables and analyzed using simple frequency distribution.


  Results Top


During the study period, 32 SCA patients (18 males and 14 females) with a mean age of 26.6 years underwent elective surgical procedures at the Ahmadu Bello University Teaching Hospital Shika Zaria, Kaduna state. Preoperative hematocrits ranged from 7 g/dL to 11.2 g/dL. The mean preoperative hemoglobin was similar in groups A and B; 9 g/dL and 10.5 g/dL, respectively [Table 1]. Twelve patients received top-up transfusion before surgery (Group A), with the amount of blood given ranging from 1 to 3 units, while 20 patients (Group B) received partial exchange transfusions ranging from 1 to 4 units [Table 1].
Table 1: Demographic and clinical characteristics of patients assigned to top-up transfusion (Group A) or partial exchange blood transfusion (Group B)

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Eleven (34%) of the 32 surgical procedures were classified as low risk and 21 (65%) were moderate risk [Table 2]. There were 6 (18%) postoperative complications; two occurred in group A patients who received top-up transfusion and four occurred in group B patients who had partial exchange transfusion [Table 3]. SCD-related complications consisted of acute vaso-occlusive pain in 2 patients (6%). Four patients (12%) had episodes of postoperative fever secondary to atelectasis, urinary tract infection, and wound infection. Only 1 (3%) patient in group A (top-up) had a hemolytic transfusion reaction.
Table 2: Surgical procedures and surgical risk category of patients

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Table 3: Postoperative complications

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  Discussion Top


The perioperative management of patients with SCD poses unique challenges due to the profound morbidity of SCD and the vulnerability of the patients to the physiologic stresses of surgery and anesthesia.[14],[15] This is particularly relevant in the developing world where resources and equipment are limited.[16],[17],[18]

This study was limited to cholecystectomy, hip, and knee replacement, as well as split thickness skin graft for chronic leg ulcers, which are the most common elective surgical procedures in adult patients with SCD in our hospital. A similar study by Adam et al.[19] in the United States found cholecystectomy to be the most common surgical procedure in adults with SCD followed by hip replacement. A study from the UK in all populations observed that ear, nose, and throat procedures were the most common in children followed by hip replacement and cholecystectomy in adults.[2] Chronic leg ulcers have been a long-recognized complication of SCD and were present in the first four reported patients with SCD. A recent study in our institution reported a chronic leg ulcer prevalence of 3.1% among adults with SCA.[20]

In this study majority of the patients who had split thickness skin grafts received top-up transfusion, while exchange blood transfusion was predominantly in patients undergoing cholecystectomy and hip replacement.[14],[21],[22] This is consistent with the recent guidelines on red cell transfusion in SCD proposed by Davis et al.[23] The authors advocate top-up transfusion for low and moderate-risk surgery to achieve a post-transfusion Hb of 10 g/dL. They recommended an exchange transfusion for patients undergoing medium and high-risk surgery in patients with severe SCD and those with significant comorbidities.[23]

Top-up transfusion is more convenient, easier to administer, and has historically been more frequently used for acute transfusion in hospitalized SCD patients.[6],[14],[21],[22] It raises the hematocrit and hemoglobin A (HbA) while at the same time diluting the HbS. The oxygen-carrying capacity of the blood is increased as well. Top-up transfusions also suppress the generation of sickle cell by the bone marrow if performed several days before surgery.[17],[18] The disadvantages are the possibility of prolonged marrow suppression leading to an aplastic crisis and a theoretic increase in blood viscosity that may precipitate a crisis.[18] Exchange blood transfusion can be accomplished by automated exchange transfusion or partial exchange transfusion.[6] The advantages include rapid removal of sickle cells from the circulation, reduction of viscosity, less volume overload, and prevention of hemosiderosis resulting from repeated transfusions.[16],[18] It is also believed that exchange transfusions in patients with overwhelming infection may provide immunologic components at the site of infection, remove bacteria and endotoxins, and improve microcirculation.[18] Some disadvantages of both top-up and exchange transfusions inherent to transfusions are hepatitis, transfusion reactions, development of atypical antibodies, and acquired immune deficiency syndrome (AIDS).[18] The overall postoperative complication rate for SCD patients undergoing elective surgery in this study was 18%. This is similar to the 15% observed in the preoperative transfusion group study by Howard et al.[15] This is, however, lower than 31–33% reported by Vichinsky et al.[13] This might have been due to our study including only SCD patients who underwent low-risk and medium-risk operations.[14],[15],[18] Only one episode (3%) of transfusion reaction was seen, which compares favorably with a previously reported rate of 7.5% in the study by Vichinsky et al.[16] The rates of non-SCD-related complications in this study (12%) were lower than rates reported in previous studies by Buck [14] and Koshy.[17] This difference could be due to improvements in surgical and anesthesia techniques.[15]

The prevention of SCD and non-SCD related complications is essential in the perioperative management of these patients. It is generally accepted that meticulous attention must be given to all aspects of perioperative care including adequate hydration and warmth, as well as anesthetic and surgical technique.[15],[18] In this study, a close liaison between the anesthetist, surgeon, and hematologist was crucial in ensuring good postoperative outcomes. All patients received intravenous fluids at least 2 hours before surgery, which was continued after surgery until oral administration of fluids could be tolerated.[15],[18],[22] The patients were also kept warm and well-oxygenated throughout the perioperative period to avoid conditions that could lead to relative or regional hypoxia, increase sickling, and compromised oxygen delivery to tissues. Several authors agree with these approach in the perioperative treatment of SCD.[18],[22],[23]

Limitations

The limitations of this study include the nature of the study, being a retrospective study. Retrospective studies are usually based on clinic records and are subject to underreporting. The true incidence of SCD may, thus, be higher due to poor adherence to health care delivery protocols that facilitate prompt and appropriate referrals to tertiary institutions. The interpretation and application of the results of this study must be considered from this standpoint. Second is the relatively small number of patients. Further studies regarding the benefits of preoperative blood transfusion prior to elective surgical procedures should be undertaken in adults as well as children. This study should also be replicated in more tertiary institutions in Nigeria to glean a larger sample size and facilitate the coordination and development of a perioperative transfusion protocol in SCD on a national level.


  Conclusion Top


This study showed that preoperative blood transfusion was associated with a reduced risk of perioperative complications in patients with SCD who underwent low-risk or medium-risk surgery. Top-up transfusion and partial exchange transfusion are important in preventing complications and should be a part of the standard management of these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Aziz AM, Meshikhes AW. Blood Transfusion in Patients with Sickle Cell Disease Requiring Laparoscopic Cholecystectomy. JSLS 2011;15:480-5.  Back to cited text no. 1
    
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Diaku-Akinwumi IN, Abubakar SB, Adegoke SA, Adeleke S, Adewoye O, Adeyemo T, et al. Blood transfusion services for patients with sickle cell disease in Nigeria. Int Health 2016;8:330-40.  Back to cited text no. 5
    
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Wahl S, Quirolo KC. Current issues in blood transfusion for sickle cell disease. Curr Opin Pediatr 2009;21:15-21.  Back to cited text no. 6
    
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Ould Amar AK, Delattre O, Godbille C, Béra O, Halbout PA, Catonné Y. Assessment of the use of transfusion therapy and complications in orthopedic surgery in patients with sickle-cell anemia: Retrospective study. Transfus Clin Biol 2003;10:61-6.  Back to cited text no. 7
    
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Buck J, Davies SC. Surgery in sickle cell disease. Hematol Oncol Clin North Am 2005;19:897-902.  Back to cited text no. 8
    
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Suell MN, Horton TM, Dishop MK, Mahoney DH, Olutoye OO, Mueller BU. Outcomes for children with gallbladder abnormalities and sickle cell disease. J Pediatr 2004;145:617-21.  Back to cited text no. 9
    
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Alotaibi GS, Alsaleh K, Bolster L, McMurtry MS, Wu C. Preoperative transfusion in patients with sickle cell disease to prevent perioperative complications: A systematic review and meta-analysis. Hematology 2014;19:463-71.  Back to cited text no. 10
    
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Fisher L. Perioperative care of the patient with sickle cell disease. AORN J 2011;93:150–9.  Back to cited text no. 11
    
12.
Fu T, Corrigan NJ, Quinn CT, Rogers ZR, Buchanan GR. Minor elective surgical procedures using general anesthesia in children with sickle cell anemia without pre-operative blood transfusion. Pediatr Blood Cancer 2005;45:43-7.  Back to cited text no. 12
    
13.
Vichinsky EP. Current issues with blood transfusions in sickle cell disease. Semin Hematol 2001;38:14-22.  Back to cited text no. 13
    
14.
Buck J, Casbard A, Llewelyn C, Johnson T, Davies S, Williamson L. Preoperative transfusion in sickle cell disease: A survey of practice in England. Eur J Haematol 2005;75:14-21.  Back to cited text no. 14
    
15.
Howard J, Malfroy M, Llewelyn C, Choo L, Hodge R, Johnson T, et al. The Transfusion Alternatives Preoperatively in Sickle Cell Disease (TAPS) study: A randomised, controlled, multicentre clinical trial. Lancet 2013;381:930-8.  Back to cited text no. 15
    
16.
Vichinsky EP, Haberkern CM, Neumayr L, Earles AN, Black D, Koshy M, et al. A Comparison of Conservative and Aggressive Transfusion Regimens in the Perioperative Management of Sickle Cell Disease. N Engl J Med 1995;333:206-13.  Back to cited text no. 16
    
17.
Koshy M, Weiner SJ, Miller ST, Sleeper LA, Vichinsky E, Brown AK, et al. Surgery and anesthesia in sickle cell disease. Cooperative Study of Sickle Cell Diseases. Blood 1995;86:3676-84.  Back to cited text no. 17
    
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Bischoff RJ, Williamson A, Dalali MJ, Rice JC, Kerstein MD. Assessment of the use of transfusion therapy perioperatively in patients with sickle cell hemoglobinopathies. Ann Surg 1988;207:434-8.  Back to cited text no. 18
    
19.
Adam S, Jonassaint J, Kruger H, Kail M, Orringer EP, Eckman JR, et al. Surgical and obstetric outcomes in adults with sickle cell disease. Am J Med 2008;121:916-21.  Back to cited text no. 19
    
20.
Hassan A, Gayus DL, Ibrahim A, Musa AU, Dahiru LI, Babadoko AA. Chronic leg ulcers in sickle cell disease patients in Zaria, Nigeria. Arch Int Surg 2014;3:141-5.  Back to cited text no. 20
    
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Yawn BP, Buchanan GR, Afenyi-Annan AN, Ballas SK, Hassell KL, James AH, et al. Management of Sickle Cell Disease. JAMA 2014;312:1033-48.  Back to cited text no. 21
    
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Stanley AC, Christian JM. Sickle cell disease and perioperative considerations: Review and retrospective report. J Oral Maxillofac Surg 2013;71:1027-33.  Back to cited text no. 22
    
23.
Davis BA, Allard S, Qureshi A, Porter JB, Pancham S, Win N, Cho G, et al. Guidelines on red cell transfusion in sickle cell disease Part II: Indications for transfusion. Br J Haematol 2017;176:192-209.  Back to cited text no. 23
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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