What are the anesthetic considerations for a reproductive-aged woman with adenomyosis, anemia, and cardiovascular symptoms, including bipedal edema and orthopnea, undergoing total hysterectomy with bilateral salpingectomy?

Anesthetic Considerations for Total Hysterectomy with Bilateral Salpingectomy in Adenomyosis with Recent Severe Anemia

This patient requires meticulous hemodynamic monitoring with invasive arterial blood pressure measurement before induction, given her recent profound anemia (Hb 5.6 g/dL), cardiovascular symptoms (orthopnea, bipedal edema), and requirement for 8 units of packed red blood cells within the past month. 1

Critical Preoperative Anesthetic Factors

Recent Severe Anemia and Cardiovascular Compromise

• Although current hemoglobin is optimized at 113 g/L, this patient had profound anemia (Hb 5.6 g/dL) just one month ago with associated cardiovascular symptoms (orthopnea, bipedal edema), indicating recent myocardial stress. 2

• Preoperative anemia with hemoglobin ≤10 g/dL is associated with significantly increased perioperative mortality, particularly in patients with cardiovascular disease or symptoms. 2

• The presence of orthopnea and bipedal edema suggests possible anemia-induced high-output cardiac failure or myocardial ischemia from chronic severe anemia. 2

• Establish invasive arterial blood pressure monitoring before induction of anesthesia to diagnose and prevent significant hypotension, as recommended for high-risk patients. 1

Hemodynamic Management Targets

• Maintain mean arterial pressure (MAP) ≥60 mmHg at all times, avoiding decreases >20% from baseline for cumulative durations >30 minutes. 2, 1, 3

• Decreases in MAP >20% or values <60 mmHg for >30 minutes are significantly associated with myocardial infarction, stroke, and postoperative death. 2, 3

• Beat-to-beat arterial monitoring reduces hypotensive episodes that occur between non-invasive measurements in high-risk patients. 1

Anesthetic Technique Selection

• Consider neuraxial anesthesia (spinal or epidural) if no contraindications exist (normal coagulation profile confirmed: PT 15.6 sec, INR 1.20, PTT 28.4). 2, 4

• When epidurals or spinals completely replace general anesthesia, there is a 29% decrease in mortality risk and 55% reduction in pneumonia compared to general anesthesia alone. 2, 1, 4

• If general anesthesia is chosen, use volatile anesthetics with opioid supplementation as standard technique. 1

• Avoid high-dose opioid techniques as they may increase hypotension risk in this already cardiovascularly compromised patient. 1

Blood Loss and Transfusion Planning

• Adenomyosis is associated with significant intraoperative blood loss during hysterectomy, and this patient has demonstrated massive transfusion requirements (8 units pRBC total). 2, 5

• Ensure adequate intravenous access (minimum two large-bore peripheral IVs or consider central venous access) before induction. 2

• Have blood products immediately available in the operating room given recent transfusion history. 2

• Maintain hemoglobin >70 g/L intraoperatively; consider transfusion threshold of 75 g/L given recent cardiovascular symptoms. 2

• Consider cell salvage to reduce allogeneic blood transfusion requirements. 2

Intraoperative Monitoring Requirements

Essential Monitoring

• Invasive arterial blood pressure monitoring before induction 1, 3
• Standard ASA monitors (ECG, pulse oximetry, capnography, temperature)
• Urinary catheter for fluid balance monitoring
• Consider central venous pressure monitoring if significant blood loss anticipated or cardiovascular instability develops 3

Avoid Pulmonary Artery Catheter

• Routine use of pulmonary artery catheters is not recommended in low-to-moderate risk patients, as it increases interventions and costs without improving outcomes. 3

Fluid and Hemodynamic Management

Goal-Directed Therapy

• Use goal-directed fluid therapy with stroke volume optimization to maintain adequate tissue perfusion while avoiding fluid overload in a patient with recent bipedal edema. 3, 4

• Monitor markers of adequate oxygen delivery including lactate and central venous oxygen saturation if central access is placed. 2

Vasopressor/Inotrope Preparation

• Have vasopressors immediately available (phenylephrine, norepinephrine) to maintain MAP targets without excessive fluid administration. 1, 3

• Avoid prolonged hypotension through early intervention with vasopressors rather than relying solely on fluid boluses. 2, 1

Specific Anesthetic Concerns for Adenomyosis Surgery

Surgical Bleeding Risk

• Adenomyosis causes diffuse myometrial involvement making surgical planes less distinct and increasing bleeding risk compared to standard hysterectomy. 6, 7, 5

• The patient's history of consuming 3-4 pads/day for 12 weeks and requiring 8 units of transfusion demonstrates severe disease. 5

• Hysterectomy remains the definitive treatment for adenomyosis with completed childbearing and failed medical therapy. 2, 6, 5

Coagulation Status

• Current coagulation parameters are acceptable (PT 15.6 sec, INR 1.20, PTT 28.4) for neuraxial anesthesia if chosen. 2

• Platelet count is adequate at 433 × 10⁹/L. 2

Postoperative Considerations

ICU vs. Ward Admission

• Consider postoperative ICU or high-dependency unit admission given recent severe anemia, cardiovascular symptoms, and high-risk surgery. 2

• Patients with cardiovascular risk factors undergoing major surgery benefit from intensive hemodynamic monitoring and goal-directed therapy. 4

Pain Management

• Implement multimodal analgesia to minimize opioid requirements and associated hypotension. 4

• Consider neuraxial analgesia continuation postoperatively if epidural placed. 4

• Avoid NSAIDs if any concern for cardiovascular disease given recent symptoms. 4

Monitoring for Complications

• Monitor postoperative cardiac biomarkers (high-sensitivity troponin) given recent cardiovascular symptoms and high-risk surgery. 4

• Continue hemoglobin monitoring postoperatively given bleeding risk. 2

• Monitor for venous thromboembolism given adenomyosis association with hypercoagulability (though rare, adenomyosis can cause thromboembolism through elevated CA125 and D-dimer). 8

Common Pitfalls to Avoid

• Do not underestimate cardiovascular risk based solely on current normal hemoglobin—recent profound anemia (Hb 5.6 g/dL) with orthopnea indicates significant myocardial stress that may not have fully resolved. 2

• Do not rely on non-invasive blood pressure monitoring alone—beat-to-beat arterial monitoring is essential in this high-risk patient. 1

• Do not allow prolonged hypotension—even brief episodes of MAP <60 mmHg or >20% decrease from baseline increase risk of myocardial infarction and stroke. 2, 1, 3

• Do not assume standard blood loss for hysterectomy—adenomyosis significantly increases bleeding risk and this patient has demonstrated massive transfusion requirements. 2, 5