Perioperative Management of the Jehovah s Witnesses Patient

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1 Perioperative Management of the Jehovah s Witnesses Patient Jeanette Harrington, MD Department of Anesthesia The University of Iowa Disclosures No financial conflicts of interest Society for the Advancement of Blood Management, SABM >15 years UIHC Transfusion Sub-committee >12 years UIHC Implementation of Blood Management Program >3 years 1

2 Educational Objectives Improve awareness of unique needs of Jehovah s Witnesses patients Discuss optimal perioperative management of Jehovah s Witnesses patients, surgicalanesthetic Understand the key importance of preoperative individual planning Describe intraoperative strategies Acknowledge safety considerations of strategies Ultimate objective: Understand the importance of coordination of 3 key pillars of JW patient care 2

3 3 Key Pillars of Jehovah s Witnesses Patient Care Optimizing RBC mass, preoperatively Minimizing actual blood loss intraoperatively Appropriate tolerance of anemia, during surgery and postoperatively How many of us have provided the perioperative care of one or more Jehovah s Witnesses patients? 3

4 Experienced refusal to provide care? Jehovah s Witnesses and their wishes toward blood: never accepted Blood that has been stored outside whole blood, preop autologous donation Red cells White cells Platelets Plasma 4

5 Jehovah s Witnesses Patient What is Accepted Crystalloids, colloids Erythropoietin Recombinant clotting factors Perfluorocarbons Surgical devices to achieve hemostasis More, individualized each patient What is accepted by some and not by others (matters of conscience) Fractions Albumin (as volume substitute, part of drugs) Sera (vaccinations, Rh incompatibility), Hgb based solutions Coagulation factor concentrates (factor VIII, IX, III, cryoprecipitate) 5

6 What is accepted by some and not by others (matters of conscience) Plasma protein solutions Fibrin Glues containing blood derivatives Bone marrow, stem cells Methods, with or without closed circuit What is accepted by some and not by others (matters of conscience) Heart-lung machine Extracorporeal oxygenation Dialysis (continuous venovenous hematocrit) Cell salvage with or without irradiation Peri-operative platelets and plasma apheresis Acute normovolemic hemodilution 6

7 Recent UIHC Jehovah s Witnesses Patient 30 y/o female, C/S x 5, chronic dental decay, chronic uterine blood loss due to fibroids, per patient, lifelong Desires hysterectomy; noncompliant with meds to control uterine bleeding Hemoglobin= 7.7 g/dl; hematocrit = kg, BMI 40 7

8 Your Plan? Recent UIHC Jehovah s Witnesses Patient Medical management: surgery delayed 2-3 months Provera (medroxyprogesterone) 10 mg PO QID to control uterine bleeding Oral iron supplementation, ferrous sulfate: 325 mg (65 mg Fe) one tablet TID Norethindrone 5 mg PO (hormonal imbalance) 8

9 Recent UIHC Jehovah s Witnesses Patient Follow up visit: hemoglobin 10.2 g/dl Serum ferritin 21.5 ng/ml ( ng/ml) Iron 93 mcg/dl (72-130) Total iron binding capacity 398 ( ) Iron saturation 23 (27-44%) 2 months later, Hgb= 12.2 g/dl, Hct = 37% Okay to proceed now? 9

10 Recent UIHC Jehovah s Witnesses Patient Robotic laparoscopic hysterectomy Extensive adhesions, concern for open Bilateral salpingectomies Cystoscopy EBL 50 ml Discharged POD#1 Hgb=11.3 g/dl Hct 35% 10

11 What was done right? What was done right preoperatively? Postponing elective surgery Strongly encouraging compliance to medical regimen: optimizing RBC mass with iron, folic acid, B12, hormonal replacement F/u visit(s), verification of compliance 11

12 What was done right intraoperatively? Surgical procedure choice: laparoscopic, robotic Contingency plan for open, due to adhesions, previous surgeries x 5, weight Anesthesia, adequate volume via crystalloid, (albumin, available, if needed) What about more complex surgeries, coexisting diseases? 12

13 Complex surgeries, coexisting diseases Cardiac Spine Total joints Transplants Trauma Obstetrics Pediatrics ACD, anemia of chronic disease Cancer Oncology Same principles: optimize RBC mass, minimize blood loss, tolerate anemia 13

14 Cardiac, other complex surgeries: optimize RBC mass, erythropoietin + iron Society for Thoracic Surgery 2011 Guidelines Class IIa It is reasonable to use preoperative erythropoietin(epo) plus iron, given several days before cardiac operation, to increase red cell mass in patients with preoperative anemia, in candidates for operation who refuse transfusion (eg, Jehovah s Witness), or in patients who are at high risk for postoperative anemia. 14

15 Minimizing Blood Loss If expected blood loss >1000 ml, consider acute normovolemic hemodilution, ANH (explanations to follow including simulation lab demonstration) Importance of patient positioning Induced hypotension Meticulous surgical techniques Hemostatic agents: gels, glues, tranexamic acid Importance of normothermia, clotting Cell saver, if patient allows 15

16 Acute Normovolemic Hemodilution Acute Normovolemic Hemodilution (ANH) Simulation Laboratory Set-up to View Volume expander 1-4 collection CPDA-1 blood bags 450 ml AABB and FDA guidelines for sterility and transfusion Peripheral vein, g preferred BP cuff 50=60 mm Hg 16

17 Caution Acute Normovolemic Hemodilution Induced hypotension All Procedures, Optimal Temperature Acid-base Hemostasis Communication of team 17

18 Summary, Objectives Awareness of unique needs of Jehovah s Witnesses patients Optimal perioperative management of Jehovah s Witnesses patients, surgical-anesthetic Key importance of preoperative individual planning Describe intraoperative strategies Acknowledge safety considerations of strategies Summary, Objectives Describe intraoperative strategies, acute normovolemic hemodilution Acknowledge safety considerations of strategies: iron, erythropoietin + iron 18

19 3 Pillars Jehovah s Witnesses Patient Care Optimizing RBC mass, preoperatively Minimizing actual blood loss intraoperatively Appropriate tolerance of anemia, during surgery and postoperatively Medical Legacy of Jehovah s Witnesses Patients 19

20 Resources Seeber P, Shander A: Basics of Blood Management, Blackwell Publishing, 2007 Waters, Jonathan H: Blood Management: Options for Better Patient Care, AABB, 2008 Waters, Jonathan H: Perioperative Blood Management, A Physician s Handbook, AABB, and Questions? 20

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