Anesthetic Management of a Rare Case of a Lactating Mother with Congenital Methemoglobinemia Undergoing Laparoscopic Surgery: A Case Report
Article Sidebar
Main Article Content
Abstract
Background: Methemoglobinemia is an uncommon hematological condition in which hemoglobin contains iron in an oxidized (Fe³+) state with limited oxygen-carrying ability. It can be congenital or acquired. Anesthetic management of methemoglobinemia poses a great challenge, as there is a risk of refractory hypoxemic crisis in the perioperative period.
Case: Here, we present a case of a 24-year-old female with congenital methemoglobinemia who presented with gallstone disease for laparoscopic cholecystectomy under general anesthesia. She had a deficiency of cytochrome B5 reductase, which contributed to 26% of methemoglobin levels on co-oximetry. Despite taking considerable precautions to avoid hypoxemic episodes and metabolic acidosis, an episode of desaturation happened at the end of the procedure, which was managed with intravenous methylene blue. The patient recovered without any hypoxemic insult.
Conclusion: Anesthetic management of patients with moderate (20% - 30%) methemoglobinemia can be successful with extreme precautions to avoid events that can increase the methemoglobin levels and adequate preparation and availability of intravenous methylene blue.
Article Details
Copyright (c) 2025 Sanjeev Kumar S, et al.
This work is licensed under a Creative Commons Attribution 4.0 International License.
Lin CY, Yang JM, Chen CT, Hsu YW, Huang CJ, Chen CC, et al. Anesthetic management of a patient with congenital methemoglobinemia. Acta Anesthesiol Taiwan. 2009;47(3):143−146. Available from: https://doi.org/10.1016/s1875-4597(09)60042-4
Hall DL, Moses MK, Weaver JM, Yanich JP, Voyles JW, Reed DN. Dental anesthesia management of methemoglobinemia-susceptible patients: A case report and review of literature. Anesth Prog. 2004;51(1):24-27. Available from: https://pubmed.ncbi.nlm.nih.gov/15106687/
Guay J. Methemoglobinemia related to local anesthetics: A summary of 242 episodes. Anesth Analg. 2009;108(3):837-845. Available from: https://doi.org/10.1213/ane.0b013e318187c4b1
Chowdhary S, Bukoye B, Bhansali AM. Risk of topical anesthetic-induced methemoglobinemia – a 10-year retrospective case-control study. JAMA Intern Med. 2013;173(9):771-776. Available from: https://doi.org/10.1001/jamainternmed.2013.75
Opera AD. Hematological disorders. In: Hines RL, Marschall KE, editors. Stoelting’s Anesthesia and Coexisting Disease. 7th ed. Philadelphia: Elsevier; 2018. p. 486. Available from: https://shop.elsevier.com/books/stoeltings-anesthesia-and-co-existing-disease/marschall/978-0-323-40137-1
Karimbanakkal F, Rajesh MC, Kuriakose S, Veetil PP, Puzhakkal S. Anesthetic management of a patient with methemoglobinemia: Case report and review of literature. BMH Med J. 2023;11(1):9-13. Available from: https://www.babymhospital.org/BMH_MJ/index.php/BMHMJ/article/view/376/762
Iolascon A, Bianchi P, Andolfo I, Russo R, Barcellini W, Fermo E, et al. Recommendations of diagnosis and treatment of methemoglobinemia. Am J Hematol. 2021;96(12):1666-1678. Available from: https://doi.org/10.1002/ajh.26340
Baraka AS, Ayoub CM, Kaddoum RN, Maalouli JM, Chehab IR, Hadi UM. Severe oxyhemoglobin desaturation during the induction of anesthesia in a patient with congenital methemoglobinemia. Anesthesiology. 2001;95(5):1296-97. Available from: https://doi.org/10.1097/00000542-200111000-00041
Naik S, Jaiswal A, Agarwal M, Goel A. Anesthetic concerns of patients planned for urgent surgery with incidental diagnosis of methemoglobinemia in Hansen’s disease: A case report. J Anesth Clin Res. 2022;13(8):1-3. Available from: http://dx.doi.org/10.35248/2155-6148.22.13.1078
Manchikalapati A, Webb L, Waddell K, Newman J. A near miss: Anesthetic-induced methemoglobinemia leading to near extracorporeal cannulation. Crit Care Med. 2003;51(1):161.
Verhovsek M, Henderson MP, Cox G, Luo H-Y, Steinberg MH, Chui DHK. Erratum to: Unexpectedly low pulse oximetry measurements associated with variant hemoglobins: A systematic review. Am J Hematol. 2011;86(8):722–725. Available from: https://doi.org/10.1002/ajh.22074
Tandale S, Dave NM, Garasia M. Methemoglobinemia: What the anesthetist must know. Indian J Anesth. 2013;57(4):427–428. Available from: https://doi.org/10.4103/0019-5049.118525
Butterworth JF, Mackey DC, Wasnick JD, Morgan GE, Mikhail MS, editors. Morgan & Mikhail’s Clinical Anesthesiology. 6th ed. McGraw-Hill Education; 2018. p. 216-217, 462-463. Available from: https://accessmedicine.mhmedical.com/content.aspx?bookid=2444§ionid=189634642
Cho SS, Park YD, Noh JH, Kang KO, Jun HJ, Yoon JS. Anesthetic experience of methemoglobinemia detected during general anesthesia for gastrectomy of advanced gastric cancer – a case report. Korean J Anesthesiol. 2010;59(5):340-343. Available from: https://doi.org/10.4097/kjae.2010.59.5.340
Williams L, Wilkins. Pao₂, Sao₂, O₂ content. Dr. Martin’s is all you really need to know to interpret arterial blood gases. 2nd ed.