Anaesthesia in Patients with Sickle-cell Anaemia.

Sir,—We were very interested to read Dr. R. A. Browne's article on this subject (Brit. J. Anaesth. (1965), 37, 181) and feel that a case which we were requested to anaesthetize might be worthy of comment in this connection. The patient was a West Indian woman, age 27 years, gravida-4 with a long history of sickle-cell anaemia, for which she had received alkalis plus blood transfusions. She was admitted following an episode of sickling, with multiple pulmonary thromboses, at the 36th week of pregnancy, and had such poor respiratory function that she had to be nursed in an oxygen tent. It was felt that her only hope of survival was an immediate Caesarean section plus sterilization. The patient, when first seen by the anaesthetists, was in an oxygen tent and, despite the presence of obvious respiratory distress, her mucous membranes were pink. At this stage it was very difficult to decide whether the respiratory troubles were due to a sup;radded cardiac failure or solely due to thrombotic phenomena in the lungs. This case posed a nurnb;r of grave problems from the anaesthetic point of view: (i) The enormous reduction in functioning lung volume. (ii) There were recurrent crises due to further pulmonary thrombosis. (iii) The need to avoid anoxia in any form for even a short period, as this would precipitate further sickling and embarrass an already anoxic woman and baby. (iv) The added difficulties in controlling respiration due to the abdominal mass (pregnant uterus), (v) The need to maintain blood pressure due to danger of local thrombosis. (vi) Whether blood transfusion would be advantageous or not, balancing the advantages of adding haemoglobin against the disadvantages of overloading the circulation in the presence of anaemia and potential or actual cardiac failure. In the case under discussion, as very little haemorrhage occurred during the Caesarean section, no blood was given.