Gender-affirming Care via HRT and Difficult Anesthetization, a Critical Care Transport Consideration

Background

With gender-affirming care seeing an 11-fold, five year availability increase in some states, patients being prescribed hormone replacement therapy (HRT) have increased. Research from greater than five years ago finds that puberty suppression treatment or gender-affirming hormone therapy and anesthesia medicines have no instances of drug-drug interaction. This case study examines difficult anesthetization of a transgender female prescribed hormone replacement therapy.

Objective

We aim to examine the anesthesia requirements of a transgender, post cardiac arrest patient during interfacility critical care transport who is prescribed hormone replacement and steroid therapy for gender affirming care.

Methods

Case Study describing a transgender female and her requirement for an unusual amount of sedation and analgesia.

Results

The patient is a 56-year-old transgender female with a history of coronary artery disease, coronary vasospasm, ventricular tachycardia, internal defibrillator placement, hypertension and gender dysphoria who receives Progesterone and Estradiol Valerate (E2V). The patient experienced an in-hospital VT arrest, received ACLS medications, defibrillation, and intubation. ROSC was achieved and prior to CCT arrival, the patient received a total of 525mcg of fentanyl, 10mg of vecuronium, 11mg of midazolam, 1mg of Dilaudid, and a 150mcg/hr fentanyl infusion for post-intubation sedation. Following CCT arrival, the patient is conscious, obviously uncomfortable, and follows commands while still being ventilated as well as restrained to the hospital bed. IV patency is ensured. To achieve a RASS of -3/-4 and appropriate ventilator compliance, she required a total of 10mg of midazolam, 200mcg of fentanyl, and 345mg of ketamine, in less than 20 minutes. It is noted that this patient does not have a significant history of alcoholism, drug use, or any conditions that would increase metabolic demand. She has relatively unremarkable CMP, CBC, and blood gas values. The patient was successfully transported 30 minutes by ground to a cardiac ICU, requiring redosing of analgesia and initiation of an infusion of ketamine at 4mcg/kg/min. Upon moving the patient to the hospital bed at the receiving, she required additional PRN analgesia and sedation doses post-transfer of care.

Conclusion

With limited, dated research on the effects of anesthesia requirements of patients receiving HRT for gender-affirming care, further studies should evaluate the need for increased anesthesia requirements for patients receiving progesterone and E2V. Critical care transport providers should be aware of the possibility of difficult anesthetization within this population.