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GENERAL ARTICLES

Bilateral Total Knee Replacement with Tourniquets in a Homozygous Sickle Cell Patient

From the King Fahd Hospital of the University, Al-Khobar, King Faisal University, Saudi Arabia

Address correspondence and reprint requests to Dr. Abdulmohsin Al-Ghamdi, PO Box 40052, Al-Khobar 31952, Saudi Arabia. Address email to mohsenkfu{at}hotmail.com

	Abstract

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A 27-yr-old male patient, with homozygous sickle cell disease was scheduled for bilateral total knee replacement under tourniquet. The use of tourniquet in sickle cell patients is not without hazard. After preoperative exchange transfusion, total knee replacement was performed. The patient tolerated the procedure well. Patients with sickle cell disease should not be denied the benefit of a tourniquet if hematological correction has been undertaken.

IMPLICATIONS: The use of a tourniquet in patients with sickle cell is controversial. The author describes a case of bilateral total knee replacement performed using a tourniquet in a patient with sickle cell disease.

	Introduction

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A 27-yr-old male (165 cm, 62 kg) was scheduled for a cemented bilateral total knee replacement with the use of tourniquets. The patient had a long history of severe attacks of osteonecrosis as a complication of homozygous sickle cell disease. His preoperative hemoglobin was 9.3 gm/dL, hematocrit (Hct) was 30%, and hemoglobin electrophoresis was as follows: HbS, 82.6%; HbF, 16%; HbA2, 1.4%. A preoperative exchange transfusion resulted in the following values: Hb, 11.8 g/dL; Hct, 36%; HbS, 47%; HbA, 52.8%; HbA2, 0.2%.

An infusion of lactated Ringer’s solution was started at 120 mL/h the night before. Cefazidime 1.0 gm IV and diazepam 10 mg orally were given 60 min preoperatively. The operating room (OR) was warmed and a heating mattress was used to adjust the body temperature at 37°C. The usual monitoring was used.

Anesthesia was induced with fentanyl 150 µg and propofol 150 mg IV. Endotracheal intubation was accomplished after administration of vecuronium 6 mg. Maintenance of anesthesia with 1%–2% sevoflurane given in 50% nitrous oxide in oxygen and vecuronium and fentanyl were used as necessary. The operation was started on the patient’s worse side, the right knee. After preparation the tourniquet was inflated to 300 mm/Hg (ATS 2000; Zimmer Patient Care Division, Dover, OH). Tourniquet application lasted 97 min, after which it was deflated and the surgeon immediately moved to the left knee, for which tourniquet application lasted 69 min. Throughout the procedure, the patient was stable. After the surgery, the neuromuscular blockade was satisfactory reversed, and the trachea extubated.

Two units of packed red blood cells (PRBC) were given in the postanesthesia care unit (PACU). Approximately 800 mL of blood had been accumulated by the time the patient left the PACU. In the PACU, his temperature was maintained by an artificial warming device (Bair Hugger; Arizant Healthcare, Eden Prairie, MN). The patient received oxygen via a facemask and IV meperidine. He continued to be cardiovascularly stable. He was discharged to the general ward after satisfying discharge criteria and there received the second unit of PRBC, supplemented oxygen and analgesia.

During his stay in the OR, six arterial blood samples taken during inflation and deflation of the tourniquet were sent for manual counting of sickled cells, which showed no significant increase over his preoperative sample nor any major changes in blood gas values. Complete blood count the next morning showed hemoglobin of 9.7 gm/dL and Hct of 29%.

The patient made an uneventful recovery and started physiotherapy 10 days later. He was last seen 6 mo later in the outpatient clinic doing very well.

	Discussion

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Sickle cell disease is a genetically determined chronic hemolytic hemoglobinopathy. The sickle-shaped red blood cells increase blood viscosity, slow blood flow, and subsequently plug small blood vessels (1). Complications related to sickling result from thromboembolic tissue infarction secondary to terminal vascular occlusion (2). The disease is not confined to the African black race but is widely distributed in south Italy, Greece, Turkey, the Arabian Gulf (especially Saudi Arabia), and the Indian subcontinent (3,4). Anesthesiologists working in these regions must be aware of the disease. Bony manifestations are among the commonest presentations of the disease (2,4). These include a vascular necrosis, osteomyelitis (2,5,6). Many of the required orthopedic operative procedures require the use of tourniquet. The application of a tourniquet helps to maintain a bloodless field during the operative procedure and reduces the need for blood transfusion. Unfortunately, however, the use of a tourniquet is not without risk (7). Some authors have noted that vasoocclusive crisis can result in severe postoperative pain and have warned against the routine use of tourniquet (8,9).

Investigators have been searching for methods to reduce the risks of tourniquet application. Adu-Gyamfi et al. (10) suggested that it is safe to use a tourniquet in patients with sickle cell disease provided that optimum acid-base status and oxygenation are maintained throughout the procedure. Furthermore, Vipond and Caldicott (11) have shown a reduction in thromboembolic complications in the presence of a low HbS level in the perioperative period. Other important considerations include hydration, normothermia, and prevention of acidosis and hypoxemia (10,11). In vitro studies have documented that a progressive decrease in oxygen tension provokes a reciprocal increase in sickling (10). However, acute increases in sickling after tourniquet release do occur (12). Perhaps mild hyperventilation during the operative procedure would expedite the return of PaCO₂ and pH to normal levels (10,11).

We report a case of severe sickle cell disease in which a bilateral tourniquet was used with no sequelae. Several factors resulted in decreasing the risk of sickling during and immediately after the period of tourniquet application. First, the patient had an exchange transfusion preoperatively to reduce his Hbs to <50%. Second, the patient was kept well hydrated to ensure good circulation of the temporary occluded vessels at the tourniquet site. Third, mild hyperventilation was applied to keep the ETCO₂ at approximately 30 mm/Hg. Fourth, the surgical team kept the surgical time to a minimum.

This is the first report in the medical literature that describes the successful use of a tourniquet in a sickle cell disease patient. Based on our experience with one patient, such patients should not be denied an operative procedure under tourniquet if this is deemed vital when attention to minimize sickling is taken.

	Acknowledgments

 
The author would like to thank professor Mirghani A. M. Ahmed, MD for his hematological expertise and help.

	References

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This article has been cited by other articles:

				J. M. Sarjeant, J. L. Callum, and A. A. Al-Ghamdi The Use of Tourniquets in Patients with Sickle Cell Disease * Response Anesth. Analg., August 1, 2004; 99(2): 630 - 630. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Abdulla Al-Ghamdi, A. Search for Related Content PubMed PubMed Citation Articles by Abdulla Al-Ghamdi, A. Related Collections Blood Surgery Complications