Heretider Methemoglobinemili Hastada Off-Pump Koroner By-Pass Cerrahisinde Anestezi Yönetimi
Özet
Methemoglobinemi (MetHb) eritrosit içindeki demirin ferröz (Fe+2) olan formunun çeşitli faktörler sonucu ferrik (Fe+3) olarak indirgenmesi sonucu oluşur. MetHb kanda artmış olan hemoglobin M düzeyi sonucunda dokulara yeterince oksjien sunumu yapılamaması sonucunda siyanoz, solunum yetmezliği, kardiyak aritmi ve ölüme kadar ilerleyebilen ciddi bir klinik sorundur. Tablonun ciddiyeti MetHb yüzdesine, MetHb seviyelerindeki artış hızına, hastanın bunu temizleme yeteneğine ve hastanın altta yatan fonksiyonel durumuna bağlıdır. Sıklıkla toksik ilaçlar (sülfonamidler, aminosalisilik asit, klorokin, dapson, metoklopramid, lokal anestezik) bu duruma sebep olurken nadiren kalıtsal olarak da görülebilir. Oksijen sunumunda kusurun olması dokuların oksijenizasyonu olumsuz yönde etkiler. Oksjien uygulanması ile oksijenizasyon takibi için pulse oksimetre yerine ko oksimetre ya da arteriyel kan gazı ile takip edilmesi ve oksidatif ajanlardan kaçınılması operasyon öncesi MetHb düzeyinin düşük tutulmaya çalışılması her türlü kanamaya karşı hazırda kan ürünlerinin rezerve edilmesi kalıtsal MetHb hastalarında preoperatif hazırlık için önemli hususlardır.
Peroperatif dönemde hastanın oksijenizasyonu ve MetHb düzeyinin yakın takip edilmesi herhangi bir kanama anında cell saver yerine taze kan ürünlerinin kullanılması, MetHb düzeyine göre basamak tedavilerinin bilinip uygulanması, hastanın anestezik ajanlara daha az maruziyeti ve erken ekstübasyonun planlanması hastanın oksijenizasyonuna olumlu katkıda bulunacaktır.
Postoperatif dönemlerde hastaların analjezisinin iyi sağlanması hastanın hem solunum eforunu hem de mobilizasyonunu artırarak erken dönemde taburculuk için kolaylık sağlar. Özellikle torakotomi yapılan ve drenler takılan hastalarda solunum eforunu kolaylaştırma amacıyla preoperatif olarak rejyonel uygulamalar yapılmaktadır. Fakat lokal anestezi ile artan MetHb düzeyi uygulamada kısıtlayıcı olup diğer analjezik yöntemleri uygulamamıza neden olmuştur. Bu olgumuzda karın ağrısı ve nefes darlığı ile acil servise başvuran 59 yaşındaki tanısı olmayan heretider MetHb’li hastanın kardiyak by-pass süreci hazırlıktan taburculuğa kadar olan süreci paylaşılmıştır.
Referanslar
Iolascon A, Bianchi P, Andolfo I, Russo R, Barcellini W, Fermo E, Toldi G, Recommendations for diagnosis and treatment of methemoglobinemia. Am J Hematol. 2021 Dec 1;96(12):1666-1678. doi: 10.1002/ajh.26340. Epub 2021 Sep 23.
Wright RO, Lewander WJ, Woolf AD. Methemoglobinemia: etiology, pharmacology, and clinical management. Ann Emerg Med. 1999 Nov;34(5):646-56. doi: 10.1016/s0196-0644(99)70167-8. PMID: 10533013.
Khan M, Paul S, Farooq S, Oo T, Ramshesh P, Jain N. Rasburicase-Induced Methemoglobinemia in a Patient with Glucose-6- Phosphate Dehydrogenase Deficiency. Curr Drug Saf. 2017;12(1):13-18. doi:10.2174/1574886312666170111151246
Solheim L, Brun AC, Greibrokk TS, Jacobsen D, Fossum C. Methemoglobinemi--årsaker, diagnostikk og behandling [Methemoglobinemia--causes, diagnosis and treatment]. Tidsskr Nor Laegeforen. 2000 May 20;120(13):1549-51. Norwegian. PMID: 10916478.
Mansouri A, Lurie AA. Concise review: Methemoglobinemia. Am J Hematol 1993; 42: 7-12. DOI: 10.1002/ajh.2830420104
Beutler E; Methemoglobinemia and other causes of cyanosis: Williams Hematology, 6 th ed. In Beutler E, Litchman MA, Coller BS, Kipps TJ, Seligsohn U. (eds): New York: McGrawHill, Inc, 2001: 611-7.
Tobias JD, Ramachandran V. Intraoperative diagnosis of unsuspected methemoglobinemia due to low pulse oximetry values. J Int Care Med 2009; 24: 273-7. DOI: 10.1177/0885066609335732
Percy MJ, Lappin TR. Recessive congenital methaemoglobinaemia: cytochrome b(5) reductase deficiency. Br J Haematol 2008; 141: 298-308 DOI: 10.1111/j.1365-2141.2008.07017.x
Ewenczyk C, Leroux A, Roubergue A, et al. Recessive hereditary methaemoglobinaemia, type II: delineation of the clinical spectrum. Brain. 2008 Mar;131:760-1. doi: 10.1093/brain/awm337. Epub 2008 Jan 17. PMID: 18202104.
Anderson ST, Hajduczek J, Barker SJ. Benzocaine-induced methemoglobinemia in an adult: Accuracy of pulse oximetry with methemoglobinemia. Anesth Analg 1998; 67: 1099-1101. PMID: 3189900
Groeper K, Katcher K, Tobias JD. Anesthetic management of a patient with methemoglobinemia. South Med J 2003; 96: 504-509. DOI: 10.1097/01.smj.0000051342.99317.99
Somervaille T. Disorders of Hemoglobin: Genetics, Pathophysiology, and Clinical Management. J R Soc Med. 2001;94(11):602–3. PMCID: PMC1282256.
Cortazzo JA, Lichtman AD. Methemoglobinemia: a review and recommendations for management. J Cardiothorac Vasc Anesth. 2014;28(4):1043–7. DOI: 10.1053/j.jvca.2013.02.005
Sahu KK, Dhibar DP, Gautam A, Kumar Y, Varma SC. Role of ascorbic acid in the treatment of methemoglobinemia. Turk J Emerg Med. 2016;16(3):119‐120 doi: 10.1016/j.tjem.2016.07.003
Rino PB, Scolnik D, Fustinana A, Mitelpunkt A, Glatstein M. Ascorbic acid for the treatment of methemoglobinemia: the experience of a large tertiary care pediatric hospital. Am J Ther. 2014;21(4):240‐243. DOI: 10.1097/MJT.0000000000000028
Rehman A, Shehadeh M, Khirfan D, Jones A. Severe acute haemolytic anaemia associated with severe methaemoglobinaemia in a G6PD‐deficient man. doi: 10.1136/bcr-2017-223369
Patnaik S, Natarajan MM, James EJ, Ebenezer K. Methylene blue unresponsive methemoglobinemia. Indian J Crit Care Med. 2014;18(4):253‐255. doi: 10.4103/0972-5229.130582
Golden PJ, Weinstein R. Treatment of high‐risk, refractory acquired methemoglobinemia with automated red blood cell exchange. J Clin Apher. 1998;13(1):28‐31 DOI: 10.1002/(sici)1098-1101(1998)13:1<28::aid-jca6>3.0.co;2-b
Liao YP, Hung DZ, Yang DY. Hemolytic anemia after methylene blue therapy for aniline-induced methemoglobinemia. Vet Hum Toxicol 2002; 44:19-21. PMID: 11824767
Kiziltepe U, Eyileten ZB, Sirlak M, Tasoz R, Aral A, Eren NT, Uysalel A, Akalin H. Antiarrhythmic effect of magnesium sulfate after open heart surgery: effect of blood levels. Int J Cardiol. 2003;89:153-8. doi: 10.1016/s0167-5273(02)00449-7. PMID: 12767537.
Ho-Hsiang Chen, Yi-Shian Chub, Ya-ChiHua, Rong-Tsung Lin. An occupational hazard emergency that presented as methemoglobinemia. Journal of Acute Medicine 2012; 2: 58-61;89:153-8. doi: 10.1016/s0167-5273(02)00449-7. PMID: 12767537
Farzam K, Jan A. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Dec 27, 2022. Beta Blockers. [PubMed] PMID: 30422501
Guay J. Methemoglobinemia related to local anesthetics: A Summary of 242 Episodes. Anesth Analg 2009;108: 837-845 DOI: 10.1213/ane.0b013e318187c4b1
Hurford WE, Kratz A. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 23-2004. A 50-year-old woman with low oxygen saturation.N Engl J Med 2004; 351: 380-387. DOI: 10.1056/NEJMcpc049013
Alexander CM, Teller LE, Gross JB. Principles of pulse oximetry: the oretical and practical considerations. Anesth Analg 1989; 68: 368-376. PMID: 2645811
Referanslar
Iolascon A, Bianchi P, Andolfo I, Russo R, Barcellini W, Fermo E, Toldi G, Recommendations for diagnosis and treatment of methemoglobinemia. Am J Hematol. 2021 Dec 1;96(12):1666-1678. doi: 10.1002/ajh.26340. Epub 2021 Sep 23.
Wright RO, Lewander WJ, Woolf AD. Methemoglobinemia: etiology, pharmacology, and clinical management. Ann Emerg Med. 1999 Nov;34(5):646-56. doi: 10.1016/s0196-0644(99)70167-8. PMID: 10533013.
Khan M, Paul S, Farooq S, Oo T, Ramshesh P, Jain N. Rasburicase-Induced Methemoglobinemia in a Patient with Glucose-6- Phosphate Dehydrogenase Deficiency. Curr Drug Saf. 2017;12(1):13-18. doi:10.2174/1574886312666170111151246
Solheim L, Brun AC, Greibrokk TS, Jacobsen D, Fossum C. Methemoglobinemi--årsaker, diagnostikk og behandling [Methemoglobinemia--causes, diagnosis and treatment]. Tidsskr Nor Laegeforen. 2000 May 20;120(13):1549-51. Norwegian. PMID: 10916478.
Mansouri A, Lurie AA. Concise review: Methemoglobinemia. Am J Hematol 1993; 42: 7-12. DOI: 10.1002/ajh.2830420104
Beutler E; Methemoglobinemia and other causes of cyanosis: Williams Hematology, 6 th ed. In Beutler E, Litchman MA, Coller BS, Kipps TJ, Seligsohn U. (eds): New York: McGrawHill, Inc, 2001: 611-7.
Tobias JD, Ramachandran V. Intraoperative diagnosis of unsuspected methemoglobinemia due to low pulse oximetry values. J Int Care Med 2009; 24: 273-7. DOI: 10.1177/0885066609335732
Percy MJ, Lappin TR. Recessive congenital methaemoglobinaemia: cytochrome b(5) reductase deficiency. Br J Haematol 2008; 141: 298-308 DOI: 10.1111/j.1365-2141.2008.07017.x
Ewenczyk C, Leroux A, Roubergue A, et al. Recessive hereditary methaemoglobinaemia, type II: delineation of the clinical spectrum. Brain. 2008 Mar;131:760-1. doi: 10.1093/brain/awm337. Epub 2008 Jan 17. PMID: 18202104.
Anderson ST, Hajduczek J, Barker SJ. Benzocaine-induced methemoglobinemia in an adult: Accuracy of pulse oximetry with methemoglobinemia. Anesth Analg 1998; 67: 1099-1101. PMID: 3189900
Groeper K, Katcher K, Tobias JD. Anesthetic management of a patient with methemoglobinemia. South Med J 2003; 96: 504-509. DOI: 10.1097/01.smj.0000051342.99317.99
Somervaille T. Disorders of Hemoglobin: Genetics, Pathophysiology, and Clinical Management. J R Soc Med. 2001;94(11):602–3. PMCID: PMC1282256.
Cortazzo JA, Lichtman AD. Methemoglobinemia: a review and recommendations for management. J Cardiothorac Vasc Anesth. 2014;28(4):1043–7. DOI: 10.1053/j.jvca.2013.02.005
Sahu KK, Dhibar DP, Gautam A, Kumar Y, Varma SC. Role of ascorbic acid in the treatment of methemoglobinemia. Turk J Emerg Med. 2016;16(3):119‐120 doi: 10.1016/j.tjem.2016.07.003
Rino PB, Scolnik D, Fustinana A, Mitelpunkt A, Glatstein M. Ascorbic acid for the treatment of methemoglobinemia: the experience of a large tertiary care pediatric hospital. Am J Ther. 2014;21(4):240‐243. DOI: 10.1097/MJT.0000000000000028
Rehman A, Shehadeh M, Khirfan D, Jones A. Severe acute haemolytic anaemia associated with severe methaemoglobinaemia in a G6PD‐deficient man. doi: 10.1136/bcr-2017-223369
Patnaik S, Natarajan MM, James EJ, Ebenezer K. Methylene blue unresponsive methemoglobinemia. Indian J Crit Care Med. 2014;18(4):253‐255. doi: 10.4103/0972-5229.130582
Golden PJ, Weinstein R. Treatment of high‐risk, refractory acquired methemoglobinemia with automated red blood cell exchange. J Clin Apher. 1998;13(1):28‐31 DOI: 10.1002/(sici)1098-1101(1998)13:1<28::aid-jca6>3.0.co;2-b
Liao YP, Hung DZ, Yang DY. Hemolytic anemia after methylene blue therapy for aniline-induced methemoglobinemia. Vet Hum Toxicol 2002; 44:19-21. PMID: 11824767
Kiziltepe U, Eyileten ZB, Sirlak M, Tasoz R, Aral A, Eren NT, Uysalel A, Akalin H. Antiarrhythmic effect of magnesium sulfate after open heart surgery: effect of blood levels. Int J Cardiol. 2003;89:153-8. doi: 10.1016/s0167-5273(02)00449-7. PMID: 12767537.
Ho-Hsiang Chen, Yi-Shian Chub, Ya-ChiHua, Rong-Tsung Lin. An occupational hazard emergency that presented as methemoglobinemia. Journal of Acute Medicine 2012; 2: 58-61;89:153-8. doi: 10.1016/s0167-5273(02)00449-7. PMID: 12767537
Farzam K, Jan A. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Dec 27, 2022. Beta Blockers. [PubMed] PMID: 30422501
Guay J. Methemoglobinemia related to local anesthetics: A Summary of 242 Episodes. Anesth Analg 2009;108: 837-845 DOI: 10.1213/ane.0b013e318187c4b1
Hurford WE, Kratz A. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 23-2004. A 50-year-old woman with low oxygen saturation.N Engl J Med 2004; 351: 380-387. DOI: 10.1056/NEJMcpc049013
Alexander CM, Teller LE, Gross JB. Principles of pulse oximetry: the oretical and practical considerations. Anesth Analg 1989; 68: 368-376. PMID: 2645811
