P045: WHEN BLOOD ISN'T A MATCH: PERI-INTUBATION RISKS AND ANESTHESIA MANAGEMENT IN HEMORRHAGIC SHOCK
Ashley R Bouzon, BA1; Gisele Wakim, MD2
1University of Miami Miller School of Medicine; 2Department of Anesthesiology, Miller School of Medicine
Background: Sickle cell disease (SCD) is a hereditary hemoglobinopathy in which hemoglobin S leads to erythrocyte sickling and vaso-occlusion. Perioperative management requires prevention of sickling triggers, including hypoxia, acidosis, hypothermia, and hypotension, and careful attention to transfusion strategy. The risk of alloimmunization to minor antigens like Rh, Kell, S, is significantly elevated in SCD patients, complicating massive hemorrhage management. In emergent settings where antigen-matched units are unavailable, anesthesiologists may need to administer unmatched blood, increasing the risk of acute and delayed hemolytic reactions, acute chest syndrome (ACS), and ongoing hemodynamic instability postoperatively. This case describes the anesthetic considerations in a patient with SCD who required an emergent unmatched transfusion due to complicated hemorrhagic shock.
Methods: A retrospective review of perioperative anesthetic management, transfusion decisions, and postoperative course was performed for a single patient with SCD undergoing emergent neurovascular intervention.
Results: A 45-year-old female with SCD presented with a sudden severe “worst headache of life” (WHOL) followed by syncope. Imaging suggested subarachnoid hemorrhage from multiple intracranial aneurysms. Cerebral angiography confirmed a large right internal carotid artery (ICA) dorsal wall aneurysm, a trilobed anterior communicating artery aneurysm, and a large left ICA dorsal wall aneurysm.
Over several hospital days, she underwent staged embolization procedures, including coil embolization of the right ICA aneurysm, pipeline stent placement, and stent-assisted coil embolization of the anterior communicating artery aneurysm. Subsequent embolization of the left ICA dorsal wall aneurysm was performed via transfemoral access.
Shortly after this procedure, the patient developed hemorrhagic shock due to a large right retroperitoneal hematoma. Hemoglobin decreased from 9.2 g/dL to 5.3 g/dL. An institutional massive transfusion protocol was activated; however, O-negative units were unavailable. Due to hemodynamic instability, she was transfused with O-positive unmatched blood after receiving premedication with intravenous corticosteroid, antihistamine, and acetaminophen. Hematology evaluation noted exposure to Rh-positive and S-positive blood, but no alloantibodies were detected. Serial hemolysis labs, including bilirubin, were monitored.
The patient remained intubated for continued hemodynamic and ventilatory control and underwent emergent vascular surgery for repair of a right external iliac artery injury, requiring additional transfusion. After intervention, she stabilized in the neurosurgical intensive care unit, was weaned off vasopressors, and remained under surveillance for delayed hemolytic transfusion reactions and sickle-related complications.
Discussion: This case highlights the anesthetic complexities of caring for patients with SCD experiencing hemorrhage requiring rapid transfusion when fully matched blood is unavailable. Anesthesiologists must simultaneously manage transfusion-related risks and prevent physiologic conditions that promote erythrocyte sickling. Postoperative continuation of mechanical ventilation may be appropriate to optimize oxygenation, ventilation, and temperature regulation. Close multidisciplinary coordination between anesthesia, hematology, and vascular surgery is essential in managing acute hemodynamic instability, minimizing transfusion-related complications, and preventing perioperative sickling events.