Here’s how readers responded to a You Make the Call question about a patient with sickle cell disease undergoing bariatric surgery.
Disclaimer: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is solely at your own risk.
I would propose to transfuse the patient with two to three units of RBC concentrates at about weekly intervals, starting 4 weeks before the planned surgical intervention. This will suppress her own production of erythrocytes, and she will have enough HbA before surgery.
Bernhard Lämmle, MD
Center for Thrombosis and Hemostasis, University Medical Center Mainz
Patient should have repeated partial exchange transfusions to reduce HbS+C to <50% and phlebotomy to keep total Hb <10.5 as needed.
Stephen H. Embury, MD
Vanguard Therapeutics, Inc.
San Francisco, CA
I would do exchange transfusions as her Hgb is adequate for a major surgery (<10 g/dL). If it is above 10 g/dL, thrombotic complications are high. If there is no facility available to perform the exchange, simply remove as much volume as what is transfused to keep target Hgb around 10 g/dL pre-operatively. She has to be well hydrated and be on thromboprophylaxis for VTE with LMWH. She should do well. She may need a little more vigilant post-op care to take care of nutrition and hydration.
A. Saifudeen, MBBS, MD
Sultan Qaboos Hospital
Since this is an elective procedure, I would do serial blood transfusions, with removal of 150-200 mL prior to transfusion every two weeks for one month. The goal would be to get Hb S and Hb C to less than 25 percent. Why? This patient is likely to have compromised respiration due to abdominal surgery and every effort should be made to avoid post-op chest syndrome. Whatever is done, simple transfusion should not exceed a Hb of 12-14 to prevent hyperviscosity syndrome.
George J. Dover, MD
Johns Hopkins University School of Medicine
I don’t think there is great data suggesting that an exchange transfusion is necessary, but if you would like to do one, you don’t need any special equipment. See Blood Banking and Transfusion Medicine, ed Hillyer, 1st ed 2003, p.353 for instructions on how to do a manual red blood cell exchange transfusion.
Ann Zimrin, MD
University of Maryland Greenebaum Cancer Center