Department of Anesthesiology, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109-1998, USA.
Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, USA.
Adv Anesth. 2021 Dec;39:77-96. doi: 10.1016/j.aan.2021.07.005. Epub 2021 Sep 29.
With more than 1 million people identifying as transgender in the United States alone, the likelihood of encountering a transgender patient and their family of choice in the perioperative setting is very high. A lack of data exists to equitably inform transgender-specific issues, as well as the associated morbidity during the transgender reassignment perioperative period. Anaesthesiologists should actively acquire the knowledge and skills needed to inclusively and respectfully manage these patients and be aware of their unique physiological and psychosocial needs. The pre-operative approach includes a detailed history, focusing on the patients cross-sex hormone treatment (CSHT) regimen and associated medical conditions. An in-depth understanding of commonly used hormones such as estrogen and testosterone and their effect in the perioperative periods is essential. The physical examination should be relevant to the anatomy that is currently present while taking into consideration feminising and masculinising procedures (e.g., genioplasty, thyroid cartilage augmentation), how these interventions alter the anatomy, and potential airway complications. Laboratory results should be interpreted with care – and with expert assistance if needed - as hormone therapy might affect reference values. In addition, risk assessment tools should be used with caution since they often include sex in their scoring system but do not account for the use of CSHT. Intraoperative considerations include urethral catheter placement, drug dosing, and drug interactions that are commonly encountered in the transgender patient. Special attention should be taken in transgender females who have undergone vocal feminization, as case reports have described unexpected difficult airway management. A multimodal approach, which includes regional blocks and attention to pre-existing chronic pain conditions, should be employed as part of the post-operative pain management plan. The post-operative nausea and vomiting risk has not yet been established in this population, requiring appropriate anti-emetic prophylaxis. Despite societal advances that improve transgender health, the medical community still lacks empirical evidence to effectively mitigate the distinctive challenges confronted by this at-risk population.
仅在美国，就有超过 100 万人认同自己的跨性别身份，因此在围手术期环境中遇到跨性别患者及其选择的家庭的可能性非常高。由于缺乏数据，无法公平地告知跨性别特定问题，以及在跨性别重新分配围手术期期间相关的发病率。麻醉师应积极获取知识和技能，以包容和尊重的方式管理这些患者，并了解他们独特的生理和社会心理需求。术前方法包括详细的病史，重点关注患者的跨性别激素治疗（CSHT）方案和相关疾病。深入了解常用激素，如雌激素和睾酮及其在围手术期的作用至关重要。体格检查应与当前存在的解剖结构相关，同时考虑到女性化和男性化手术（例如，颏成形术，甲状软骨增强术），这些干预措施如何改变解剖结构以及潜在的气道并发症。应谨慎解读实验室结果-如有必要，请寻求专家协助-因为激素治疗可能会影响参考值。此外，应谨慎使用风险评估工具，因为它们通常在评分系统中包含性别，但不考虑 CSHT 的使用。术中考虑因素包括尿道导管放置，药物剂量和在跨性别患者中常见的药物相互作用。对于已经进行过声音女性化的跨性别女性，应特别注意，因为病例报告描述了意外的困难气道管理。应采用多模式方法，包括区域阻滞和注意先前存在的慢性疼痛状况，作为术后疼痛管理计划的一部分。在该人群中尚未确定术后恶心和呕吐的风险，需要适当的止吐预防措施。尽管社会进步改善了跨性别者的健康状况，但医学界仍然缺乏有效的证据来有效缓解这一高危人群所面临的独特挑战。
