[ ] bloodless_surgery1.pp

Bloodless Surgeryand

The Jehovah’s Witness Patient

Dr. Christopher Ray M.D. &Dr. Evan Pivalizza M.D.

Morbidity and Mortality Conference

Case Presentation #1

Mrs. HM was a 51 year-old Jehovah’s Witness patient who was involved in a MVC with a large dump truck on 2-24-03. The patient’s car was T-boned during the accident.

She was life-flighted to HH as a code III and arrived in the ER with a GCS of 15

She indicated in the ER that she did not want any blood even if it resulted in her own death.

Injures discovered included: Grade IV liver laceration Large splenic laceration Multiple open head lacerations 3 rib fractures Pulmonary contusions

The patient subsequently deteriorated in the ER and was emergently intubated with 22mg Etomidate and 120mg of Sux. for signs of shock.

ER stated that the pulse ox would not picked up.

The remainder of the patient’s PMH was noted to be negative.

Anesthesia Pre-op

Anesthesia OR Record

Anesthesia OR Record

Anesthesia Post-op

Post-op Events

Patient taken to STICU with unstable VS

She was declared DNR by the surgeon

The patient later developed bradycardia and subsequent cardiopulmonary arrest. No CPR was performed and she was pronounced dead at 5:14pm

Cause of death was not stated but appears to have been cardiac arrest as a result of severe internal hemorrhage.

Treatments Used

Cell Saver 1250Hextend 1500Albumin 1500Lactated Ringer’s 4000Aprotinin inf.Tham inf.Epinephrine inf. (low dose)Hypothermia (Unintentional)

Jehovah’s Witness

This religion was founded in 1872 by Charles Russell in Pittsburgh, Pennsylvania. He later introduced The Watch Tower.

Witness’s officially adopted the policies of no blood transfusions in 1945 as a church decision.

Bible chapters that reference their beliefs include: Genesis 9:3-4 Leviticus 17:10-16 Acts 15:19-21

Name changed to Jehovah’s Witness in 1931

Leviticus 17:10-12

10 " 'Any Israelite or any alien living among them who eats any blood-I will set my face against that person who eats blood and will cut him off from his people. 11 For the life of a creature is in the blood, and I have given it to you to make atonement for yourselves on the altar; it is the blood that makes atonement for one's life. 12 Therefore I say to the Israelites, "None of you may eat blood, nor may an alien living among you eat blood."

The JW religion and patient believes that by receiving blood products they will be cut off from having everlasting life after their death.

Interpretation by Believers

Ethical Issues

Competent Adult: Has the legal right to self-determination.

Incompetent Adult (emergency): Need a court direct BT

Minor (emergency): Need a court direct BT

Minor (elective): Need a court direct BT

Hermann Hosp. ProcedurePediatric patient (<18 years old) with parents acting on the

child’s behalf. In need of a blood transfusion

Pediatric Social Worker is contacted immediately

SW contacts Child Protective Services

CPS contacts a judge who grants temp. custody to CPS

Blood Transfusion(s) then takes place

Custody is then transferred back to parents after the transfusion(s).

Acceptability of Blood Products

Acceptable Not Acceptable Questionable

Crystalloids Whole Blood Albumin

Colloids Red Cells Immunoglobins

Gelatins (Europe) Platelets Vaccines

G-CSF (most) White Cells Coagulation Factors

Epo. (most) Plasma (FFP) Hemodilution

Cell Saver

Organ TRP

What JW Patient’s Desire

Treatment without the use of any blood products.

Many of these patients are willing to die rather than receive blood.

Patient’s request that alternative treatments be used.

This group of patients continue to pose ethical and clinical challenges for surgeons and anesthesiologist.

If any autologous blood is used it must stay in continuity with the body.

Anesthesia for Elective Surgery

Cardiac and vascular surgery have mortality.

Other high risk procedures/conditions include: repeat cardiac surgery severe LV dysfunction HCT <24 on post-op day 1

Acute BL > 500ml in anemic patient’s have mortality

Pre-op Hct < 18% have an mortality, irrespective of BL

Outpatient Elective SurgeryPreoperative Management

1. Erythropoietin

Glycosylated polypeptide released by the kidney in response to hypoxia. It increases erythropoietic precursors in the bone marrow.

Recombinant product made from Chinese hamster ovarian cell line.

Treatment should be organized by the patient’s surgeon, anesthesiologist, and hematologist.

While treating the patient with Epo. simultaneous treatment with:

1. Iron 6mg/kg/day2. B123. Folate

ErythropoietinDosing

600U/kg per week SC for 3 week on days (21, 14, 7, and day of surgery)

Alternatively the patient can get:300U/kg per day SC for 10 days before surgery and 4 days after surgery

Complications/Side Effects include:1. Seizures2. Hypertension3. Hyperviscosity

Erythropoietin

A study in ’93 by Viele & Weiskopf found that of 61 JW patients with a Hgb <8 and their cause of death was noted to be anemia the patient’s Hgb was less than 5.

Darbepoetin Alfa (Aranesp)Novel Erythropoiesis-Stimulating Protein (NESP)

Similar to Epo. but has a slight modification. Half-life is 3 times longer with greater potency Can be administered less frequently

Approved in 2001 for Renal Failure and 2002 for anemia Research currently underway for surgical use

Intraoperative Strategies1. Acute Normovolemic Hemodilution

Acute normovolemic hemodilution is the process of removing one or more units of blood at the beginning of surgery (prior to surgical incision) for transfusion to the patient either during or at the end of the operation.

ANH reduces or eliminates the need for allogeneic blood, and is one of the least costly method of autologous blood procurement.

ANH can be implemented during cardiac, major general, hepatic, neurologic, orthopedic, and urologic procedures.

Acute Normovolemic Hemodilution During ANH, whole blood is drawn from a patient prior to surgery, while restoring the circulating blood volume with acellular fluid.

The collected blood is anticoagulated with a citrate based anticoagulant and stored in the operating room at room temperature to preserve platelet, clotting factor, and white blood cell function.

This procedure results in: O2 carrying capacity viscosity SNS stimulation VR, SV, CO # of RBC’s lost during surgery

Volume Removed

How Much Volume of Blood Can Be Drawn?

ANH is usually limited to a volume of 2,000 mL or a target hematocrit (Hct) of 28%, which ever comes first.

V = EBV x (HI-HF)/HAV

Must remember that with a JW patient the blood must stay in continuity with the body.

Acute Normovolemic HemodilutionIndications for Acute Normovolemic Hemodilution (ANH)1. The anticipated intraoperative blood loss is 1 liter or more. 2. Any type of surgery associated with significant blood loss. 3. The desire for the patient not to receive previously donated autologous/donor blood products.  

Relative Contraindications for ANH 1. Anemia 2. renal function & cannot excrete large amounts of fluid. 3. When an in cardiac output is undesirable. (A.S., CAD)4. Limitations of cardiac or pulmonary function

Acute Normovolemic Hemodilution

Cost Savings Reduction in total transfusion costs ($100/unit with ANH) compared with ($269 with autologous).

Underutilized? Time Consuming Requires additional equipment/knowledge The mean duration of hemodilution was 60.6 minutes, with 1 unit (500 mL’s) of blood removed every 17.8 minutes.

Some studies suggest that significant (including economic) benefit only for redo hip surgery and radical prostatectomy

Intraoperative Strategies

2. Hypervolemic Hemodilution

3. Regional anesthesia

No blood is withdrawn Blood volume is expanded aggressively Decreased # of RBC’s lost during surgery Postop diuresis and recovery

Epidurals performed for orthopedic procedures including Hip and Knee

Intraoperative Strategies

4. Controlled hypotensionMAP 50-65 mmHGDo not use if the patient has CVS, CNS, Renal, or Liver dysfunction

5. Controlled HypothermiaO2 consumption is decreased 6% for each C Increased O2 solubility in the plasma via a left shift of the oxyhemoglobin dissociation curve.

Must maintain temp > 33 C (arrhythmia, coag.)

Intraoperative Strategies

9. Aprotinin

Aprotinin is a naturally occurring proteolytic enzyme inhibitor that was discovered in the 1930’s and launched in Germany as Trasylol in 1959.

Trasylol is indicated for prophylactic use to reduce perioperative blood loss and the need for blood transfusion in patients undergoing cardiopulmonary bypass (CPB).

Overall effect is antifibrinolytic and platelet protection

Aprotinin

PHARMACOLOGICAL ACTION:Trasylol forms reversible stoichiometric enzyme inhibitor-complexes with: Human Trypsin Plasmin Plasma Kallikrien Tissue Kallikrien Elastase Urokinase Thrombin

DecreaseTheirAffinity

Aprotinin

The effects of aprotinin results in a reduction in systemic inflammatory response, fibrinolysis, and thrombin generation, which translates into a decreased, need for allogeneic blood transfusions and reduced bleeding.

By inhibiting pro-inflammatory cytokine release Aprotinin helps maintains glycoprotein homeostasis.

Platelets: reduces glycoprotein loss (e.g., GpIb/GpIIb/IIIa)

Granulocytes: prevents the expression of pro-inflammatory adhesive glycoproteins. (e.g., CD11b)

Aprotinin

Dose: By slow intravenous infusion Open heart surgery, loading dose is 2,000,000 units (200 mL) after induction of anesthesia and before sternotomy. Maintenance dose, by intravenous infusion 500,000 units (50 mL) every hour until end of operation.

Anaphylactic reactions are possible.

Europe: wider applications to orthopedics, spine, and liver transplant procedures.

Intraoperative Strategies

10. Cell Saver

Collected blood is citrated, filtered, washed with saline, concentrated, and returned to the patient.

Frequently used when blood loss is expected to more than one liter

Contamination by bacterial or malignant cells are relative contraindications.

Remember with a JW patient to maintain continuity

Cost: $1600

Intraoperative Strategies11. DDAVP (Desmopressin)

A synthetic analogue of ADH (Vasopressin)

Plasma levels of Factor VIII and vWF in deficient and healthy patients. Platelet adhesion to the vessel wall. (No effect on platelet count or aggregation) PTT and Bleeding Time

M.O.A. Not completely understood

Used for Hemophilia A, vWD, DI, and bed wetting

DDAVP

Medication if given IV or SC

Dose of .3mcg/kg over 30 min. will help prevent tachycardia, flushing, tremors, or chest pain.

Observe for signs of water retention and hyponatremia esp. if given with loop diuretics.

Clinical studies show bleeding after cardiac surgery in selected patient’s with platelet dysfunction.

Intraoperative Strategies12. Artificial Oxygen Carries

Artificial oxygen carries are grouped into hemoglobin-based O2 carriers and perflourocarbon emulsions. These drugs are still undergoing extensive clinical testing

Flourocarbons

In the June '03 of Anes. a study found the use of perfluron emulsion as a artificial oxygen carrier was shown to improve hepatocellular injury after hemorrhagic hypotension when compared to using blood, colloid, or combo of blood and colloid.

Flourocarbons

In the Dec.'02 issue of Anes. a European phase II trial suggested that when perfluron emulsion was used in high blood loss non-cardiac surgery there was a decreased allogenic blood transfusion requirement. There were more adverse events in the PFC group 86% vs. 81% and more serious events 32% vs. 21%. Mortality was the same. (cardiac/digestive/nervous)

Intraoperative Strategies

13. Recombinant Factor VIIa (NovoSeven) Produced by baby hamster kidney cell lines and free of human protein.

Is indicated for the treatment of bleeding episodes in hemophilia A or B patients with inhibitors to Factor VIII or Factor IX.

There are 2 case reports in this month’s issue of Anes. that report on two patients who underwent MVR with the use of Aprotinin in the CPB. Both were treated with rFVIIa after bleeding was noted at the end of the case and had significant improvement within 3 and 8 minutes.

Novoseven

A study out of Europe by Levy et al. using a single dose of rFVIIa verses placebo in patient’s undergoing transabdominal prostatectomy found an reduction in blood loss from 2,450 to 1,400.

Novoseven

Recombinant FVIIa is a factor VIII and/or IX bypassing agent and initiates hemostasis through the tissue factor (TF) dependent coagulation pathway. 

When complexed with tissue factor: Activates Factor X to Factor Xa Activates Factor IX to Factor IXa Factor Xa, with other factors, then converts prothrombin to thrombin, which leads to the conversion of fibrinogen to fibrin

Consider a TEG

Review of Coagulation Cascade

Postoperative Strategies

1. Increase CaO2 (Arterial O2 content)

CaO2 = SaO2 (Hgb x 1.34) + (PaO2 x 0.0031)

As RBC vol. the normal 2% of O2 that is dissolved in blood increases to as much as 25% FiO2

Possible with Hyperbaric O2, but prolonged use would lead to toxicity.

Postoperative Strategies

2. Decrease CMRO2

Sedation, Analgesia PPV, muscle relaxation controlled hypothermia

3. Minimize Phlebotomy

Tromethamine Tham

A buffer that can be used to treat metabolic acidosis when concerns exist regarding CO2 accumulation from the metabolism of administered sodium bicarbonate.

Tham is 0.3 M solution adjusted to a pH of approximately 8.6 with glacial acetic acid.

Acts as a proton acceptor and corrects acidosis by binding hydrogen ions (H+) and increases in HCO3

Contraindicated:Tham Solution is contraindicated in anuria and uremia

Cleared by the kidneys

Tham

The following formula is a general guide:

(mL of 0.3 M) = Wt(kg) X Base Deficit (mEq/liter) X 1.1

For example a 100 kg pt. with a buffer base deficit (negative base excess) of 5 mEq/liter

would require 100 x 5 x 1.1 = 550 ml of Tham Solution

Case Report #2

47 y/o JW patient with Hep. C, pancytopenia, and splenic lymphoma presented to HH as an outpatient for an elective splenectomy.

Preoperatively he was severely anemic and was referred to the hematologist where he was started on 10,000 U/d SC Epo. for six weeks. Before his surgery his hgb was 5.3g/dL, PT 13.8, and PTT 41.5.

Preoperatively the patient underwent splenic embolization by IR

Case #2Intraoperatively

Patient was given a loading dose of Aprotinin along with an infusion. Cell Saver and Albumin used for volume.

Anes. was induced with STP, Fent., Roc/Panc. and maintained with Isoflurane (0.7%-1.2%)

EBL was 500

The surgery went uneventful and the patient was extubated within 15 hours and later discharged.