What anesthetic precautions are recommended for patients of Venezuelan ancestry, considering possible sickle‑cell disease/trait, glucose‑6‑phosphate dehydrogenase deficiency, pseudocholinesterase deficiency, and higher prevalence of hypertension, diabetes, and obesity?

Anesthetic Precautions for Patients of Venezuelan Ancestry

Screen all patients of Venezuelan ancestry for sickle cell disease/trait preoperatively, as this is the single most critical anesthetic consideration that can significantly impact morbidity and mortality if unrecognized. 1

Pre-operative Screening and Assessment

Mandatory Hemoglobinopathy Screening

• All patients of Venezuelan ancestry should undergo pre-operative hemoglobinopathy screening to identify sickle cell disease or trait, as Venezuela has populations with African, Mediterranean, and Middle Eastern ancestry where these conditions are prevalent 1
• Avoid unnecessary repeat screening if recent results are available 1
• Document baseline hemoglobin type, HbS percentage, and baseline oxygen saturation 1

Additional Enzyme Deficiency Screening

• Screen for glucose-6-phosphate dehydrogenase (G6PD) deficiency, particularly given the geographic distribution overlapping with Venezuelan ancestry 2, 3
• Consider pseudocholinesterase deficiency testing if family history suggests prolonged neuromuscular blockade 1

Cardiovascular and Metabolic Assessment

• Evaluate for hypertension, diabetes, and obesity given higher prevalence in this population 4
• Document end-organ dysfunction affecting cardiovascular, pulmonary, renal, and neurological systems if sickle cell disease is present 1

Intra-operative Management for Sickle Cell Disease

Anesthetic Technique Selection

• Regional anesthesia (spinal or epidural) may reduce sickle-related complications compared to general anesthesia due to excellent postoperative analgesia and improved peripheral blood flow from sympathetic blockade 1
• If regional anesthesia is used, treat hypotension early and aggressively with vasopressors and IV fluids to prevent hypoperfusion 1
• For male patients receiving regional anesthesia, counsel about priapism risk and examine regularly, as altered sensation may prevent detection 1

Critical Physiological Parameters to Maintain

Avoid the five key triggers of sickling:

• Hypoxia: Pre-oxygenate before induction; maintain SpO2 >96% or above baseline (whichever is higher) for 24 hours postoperatively 1
• Dehydration: Encourage clear fluids up to 1-2 hours preoperatively; start IV fluids early if oral intake inadequate; measure and replace all fluid losses meticulously 1
• Hypothermia: Maintain normothermia throughout the perioperative period 1, 4
• Acidosis: Use controlled ventilation to achieve normocarbia if intubated 1
• Hypotension: Avoid and treat promptly 1

Monitoring Requirements

• Standard ASA monitoring plus neuromuscular monitoring if neuromuscular blocking drugs are used—ensure complete reversal before extubation 1
• Consider near-infrared spectroscopy for cerebral oxygenation monitoring 1
• Monitor urine output; consider central venous pressure and cardiac output monitoring for major surgery 1

Scheduling and Timing

• Schedule early in the operating day to minimize fasting time and avoid prolonged starvation, which increases dehydration risk 1
• Postpone elective surgery if patient is febrile or experiencing a painful crisis 1

G6PD Deficiency Considerations

Safe Anesthetic Agents

• Benzodiazepines, propofol, fentanyl, ketamine, sevoflurane, and codeine/codeine derivatives are safe and do not cause hemolytic crises in G6PD-deficient patients 3, 5
• Avoid oxidative stressors including certain medications that can trigger hemolysis 2, 3

Perioperative Monitoring

• Monitor for signs of hemolysis: jaundice, dark urine, falling hemoglobin, elevated bilirubin 3, 5
• Minimize surgical stress and hypothermia, which can trigger hemolysis 5

Pain Management Strategy

Multimodal Analgesia Planning

• Document baseline opioid use and continue long-acting opioids throughout the perioperative period 1
• Note that opioid sensitivity is more common than opioid dependency in sickle cell patients 1
• Implement multimodal techniques: regional blocks, patient-controlled analgesia, nurse-controlled analgesia, and oral analgesics 1
• Notify the acute pain team preoperatively for major surgery 1
• Encourage patients to report pain similar to their usual sickle pain (distinct from surgical pain) 1

Multidisciplinary Coordination

Essential Team Communication

• Inform the haematology team when any patient with sickle cell disease requires surgery (emergency or elective) 1
• Communicate with the transfusion laboratory regarding potential transfusion needs 1
• Document sickle cell diagnosis clearly throughout the patient pathway 1

Postoperative Care

• Maintain a low threshold for high dependency or intensive care unit admission based on surgical risk and comorbidities 1
• Continue IV fluids until adequate oral intake is established 1
• Continue oxygen therapy to maintain SpO2 >96% or above baseline for 24 hours 1
• Encourage early mobilization and physiotherapy 1

Common Pitfalls to Avoid

• Do not prolong fasting unnecessarily—this is a common scenario leading to dehydration 1
• Do not give continuous oxygen therapy unless necessary preoperatively, but do pre-oxygenate before induction 1
• Do not use epinephrine in local anesthesia for G6PD-deficient patients according to some sources 6
• Do not discharge day surgery patients until standard criteria are met, and schedule them early to allow time for complication identification 1