a 37-year - old female patient ( 161 cm , 49 kg ) was admitted with sickle cell syndrome ( sca ) , s / beta (  ) positive thalassemia . hemoglobin electrophoresis showed an hbs count of 58.5% , hba count of 23.5% , hba2 count of 7% , and an hbf count of 11% . due to crohn 's disease and liver dysfunction , the patient was scheduled for elective laparoscopic cholecystectomy ( lc ) to treat acute cholecystitis . it was decided to perform the operation with thoracic epidural anesthesia ( tea ) due to severely impaired liver function and hematologic problems . the patient had been diagnosed as having crohn 's colitis ten years prior to our clinic admission , following several episodes of abdominal pain and bloody diarrhoea . the diagnosis had been confirmed by radiology , endoscopic examination and biopsy of the gastrointestinal tract . seven years ago the patient underwent successful elective cesarean surgery . during the diagnosis of sca disease , plasma exchange occurred 7 times . the reports of hemoglobin ( hb ) level and liver function tests are shown in table 1 and 2 . noninvasive monitoring ( ekg , arterial blood pressure and pulse oximetry ) was initiated on patient arrival . all data were recorded at 5 minutes intervals . during the monitoring , 500 ml of isolyte s was infused . tea was performed with a 20-g tuohy needle and epidural catheter that was inserted 5 cm in the cephalic direction from t9/t10 for perioperative anesthetic management and postoperative 
 pain control . the patient received oxygen at a rate of 4 l / min through a facemask attached to an end tidal co2 monitor . during the operation the patient was given a 10 - 25 microgram / kg / min propofol infusion for sedation , 2 mg midazolam for hypnotic , and 100 microgram fentanyl for shoulder pain . surgery time was approximately 105 minutes with co2 insufflations pressure  12 mmhg and was eventful . there was no need for intraoperative blood transfusion and our patient was taken to the intensive care unit without experiencing any problem during the surgical procedure . throughout surgery , the patient remained hemodynamically stable with a pulse rate 64 - 78/min and a systolic blood pressure of 104 - 126 mmhg . after the operation during the 2nd and 4th hours , 0.5% bupivacaine was administered for postoperative pain control . we describe the first case of sickle cell anemia ( sca ) , beta ( + ) thalassemia , and crohn 's disease , in which the patient was effectively anesthetized for laparoscopic cholecystectomy using thoracic epidural anesthesia , with particular attention to hemodynamics , especially in liver dysfunction . the primary pathology in thalassemia stems from the quantity of globin production , whereas the primary pathology in sickle cell disease is related to the quality of globin produced . the sickle cell syndromes are caused by a genetic mutation in the -globin chain of the hemoglobin molecule , where glutamic acid is substituted by valine at the sixth position and includes the prototype sickle cell anemia ( homozygous ) , sickle cell carrier ( heterozygous ) , hemoglobin sc disease , and sickle  thalassemia ( s/ thalassemia and s/ thalassemia ) . the thalassemias share with the sickle haemoglobinopathies characteristics such as accelerated hemoglobin denaturation and degradation , excess free iron release , heightened oxidative stress , a hypercoagulable state , and widespread vascular damage . common clinical features include chronic hemolytic anemia , pulmonary damage and hypoxemia , progressive neurological damage , intracranial hemorrhage , thrombotic stroke , deep vein thrombosis , arterial occlusion , leg ulcers , and shortened life expectancy [ 1 - 3 ] . thus anesthetic management in the case we observed is critical and needs to be monitored carefully . general anesthesia and surgical trauma add an additional risk of complication because of changes in temperature , ph , oxygen tension , and fluid volume . careful perioperative and postoperative monitoring should allow the avoidance of hypoxemia , hypovolaemia , hypothermia , acidosis and over - transfusion since the erythrocytes undergo sickling . epidural anesthesia , no special postoperative complications , may be applicable for lc . however , the incidence of intraoperative referred shoulder pain is high , and so careful patient recruitment and management of shoulder pain should be considered . thus we decided that our patient with sickle cell anemia , beta ( + ) thalassemia , and crohn 's disease , who demonstrated liver dysfunction would undergo anesthetic management using the thoracic epidural anesthesia ( tea ) technique . during the operation , hemodynamics and postoperative liver function test parameters were stable . nevertheless intraoperative shoulder pain was a major event and was controlled effectively with small doses of opioid analgesia administered intravenously . the effect of general anesthesia using isoflurane and epidural anesthesia using ropivacaine was shown on hemostasis in hepatic patients . thus epidural ropivacaine anesthesia provided better hemostatic stability , especially in hepatic patients . in our case , the epidural anesthesia did not affect liver enzyme parameters . we presented the first case of sickle cell anemia ( sca ) , beta ( + ) thalassemia , and crohn 's disease , which was effectively anesthetized for laparoscopic cholecystectomy using thoracic epidural anesthesia . according to our experience , the results were excellent without severe complications . ultimately , we considered laparoscopic cholecystectomy using thoracic epidural anesthesia that resulted in a shorter hospital stay with rare postoperative complications rather than an open operation using general anesthesia in patients with sickle cell disease . we suggest that this may be the procedure of choice in the treatment of cholelithiasis in such patients .
a 37-year - old woman diagnosed with sickle cell anemia ( sca ) , beta ( + ) thalassemia , crohn 's disease , and liver dysfunction was scheduled for laparoscopic cholecystectomy ( lc ) due to acute cholecystitis with gall bladder . 
 regional anesthesia was performed . 
 an epidural catheter was inserted into the 9 - 10 thoracal epidural space and then 15 ml of 0.5% bupivacaine was injected through the catheter . the level of sensorial analgesia tested with pinprick test reached up to t4 . 
 here we describe the first case of the combination of sickle cell anemia ( sca ) , beta ( + ) thalassemia , and crohn 's disease successful anesthetic management with attention to hemodynamics , particularly with regards to liver dysfunction .