From the Guidelines
Patients with Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency require special anesthetic considerations to prevent hemolytic crises during surgery, and it is crucial to avoid medications that can trigger oxidative stress, including antimalarials (primaquine, chloroquine), sulfonamides, nitrofurantoin, rasburicase, methylene blue, and certain analgesics like aspirin at high doses, as supported by studies such as 1 and 1.
Key Considerations
- Safe anesthetic agents include propofol, etomidate, ketamine, benzodiazepines, opioids, and most modern inhalational anesthetics (sevoflurane, desflurane) as they do not trigger oxidative stress.
- Regional anesthesia techniques are also safe when appropriate, but caution is advised due to potential coagulation disturbances.
- Preoperatively, checking G6PD enzyme levels and hemoglobin status to establish baseline values is essential, as noted in guidelines such as those mentioned in 1 and 1.
- During surgery, maintaining normothermia, avoiding acidosis, and preventing hypoxia are critical as these conditions can exacerbate hemolysis, a point emphasized in studies like 1 and 1.
Monitoring and Management
- Postoperatively, monitoring for signs of acute hemolysis including jaundice, dark urine, and unexplained anemia is vital.
- The underlying pathophysiology involves reduced G6PD enzyme activity, which normally protects red blood cells from oxidative damage by maintaining glutathione levels, as discussed in 1.
- Without adequate G6PD, oxidative stressors can cause hemolysis, potentially leading to anemia, jaundice, and in severe cases, renal failure, highlighting the importance of careful management and monitoring, as suggested by evidence from 1 and other studies.
From the Research
Significance of G6PD Deficiency in Anesthesia
- G6PD deficiency is the most common enzymatic disorder of red blood cells in humans, affecting approximately 400 million people worldwide 2.
- Patients with G6PD deficiency lack the ability to protect red blood cells against oxidative stresses from certain drugs, metabolic conditions, infections, and ingestion of fava beans, which can lead to hemolytic anemia 2, 3.
Anesthetic Management in G6PD-Deficient Patients
- The most effective management strategy is to prevent hemolysis by avoiding oxidative stressors, such as certain medications and infections 2, 4.
- Safe anesthetic agents for G6PD-deficient patients include benzodiazepines, codeine/codeine derivatives, propofol, fentanyl, and ketamine, as they do not cause hemolytic crises 2.
- Dexmedetomidine, an anesthetic agent with antioxidant actions, may be useful for reducing the risk of hemolysis after surgery in G6PD-deficient patients 3.
- Regional anesthesia, such as ultrasound-guided axillary brachial plexus block with bupivacaine, can be a safe and effective technique in G6PD-deficient patients 5.
Perioperative Considerations
- Patients with G6PD deficiency should be screened and informed of the risks and signs of hemolytic crisis 2.
- Anesthetic management should focus on reducing surgical stress, monitoring for hemolysis, and treating it if it occurs 4, 6.
- The combination of sevoflurane inhalation anesthesia with sufentanil can be safe and effective in managing G6PD-deficient patients 6.