Anesthesia in obstetric patient with sickle cell anemia and thalassemic trait after plasmapheresis: case report

Plasmapheresis is the technique of choice for severe hemolytic anemia patients. A consequence is plasma cholinesterase depletion, which interferes with metabolism of some neuromuscular blockers currently used in anesthesiology. Pregnant patient, 26 years old, physical status ASA IV, 30 weeks and 3 days gestational age, with sickle cell anemia, thalassemic trait and allo-immunization for high frequency antigens. Patient presented sickling crisis being transfused with incompatible blood. Patient evolved with massive hemolysis being admitted with 3 g/dL hemoglobin and 10% hematocrit, severe jaundice, tachycardia, apathic and pale. Hematological evaluation has concluded for the inexistence of compatible blood for transfusion. Patient was treated with steroids, immunoglobulins and plasmapheresis. In the second admission day patient evolved with acute renal failure and pulmonary edema, general state worsening and hemodynamic instability. Gestation resolution was indicated due to patient's clinical conditions and consequent acute fetal suffering. Patient was admitted to the operating room conscious, pale, with dyspnea, jaundice, 91% SpO2 in room air, heart rate of 110 bpm and blood pressure of 110 x 70 mmHg, under dopamine (1 microg.kg-1.min-1) and dobutamine (10 microg.kg-1.min-1). We decided for balanced general anesthesia with alfentanil (2.5 mg), etomidate (14 mg), atracurium (35 mg) and isoflurane. There were no anesthetic-surgical intercurrences. Patient was referred to ICU after surgery completion under tracheal intubation and vasoactive drugs, being extubated 3 hours later. This case was a challenge for the team since patient was hemodynamically instable with coagulogram abnormalities counterindicating regional anesthesia. In addition, plasmapheresis potentially depletes plasma cholinesterase reserves, interfering with anesthesia. However, available drug armamentarium has allowed for the safe management of this situation.