Jehovah Witness for Revision

[turnupthevapor]

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So I have a patient coming down the pipe who has a starting HCT 30 and needs an explant/revison for a recalled arthroplasty situation (not sure if it is hypersensitivity reaction to the old hardware but the surgeon says its shedding metal or something). I am planning on a CSE, tranexamic acid, and potentially hemodilution.

My question for you brainiacs is two fold.

1. Cell saver ok for a set of hardware that may be shedding cobalt, chromium or God knows what else in to the joint space? I am thinking I will not use it unless it is a life or death situation

2. Is there evidence and safety data for preop procrit and IV iron? Thought procit may have prothrombotic type consequences?

food for thought;

http://www.csosortho.com/pdf/labuttiarticle-epoetin-alfa.pdf

http://bja.oxfordjournals.org/content/110/3/488#

http://www.ncbi.nlm.nih.gov/pubmed/18789632

THANKS Y'ALL

 

[norwood]

The BJA article seems to focus on iron deficiency anemia. Do we know why the pt is anemic?

 

[BLADEMDA]

PUBLIC RELEASE: 6-MAY-2013Single, high-dose erythropoietin given 2 days pre-op reduces need for transfused blood


http://www.eurekalert.org/pub_releases/2013-05/aaft-she050113.php


http://www.kumed.com/~/media/Files/KUMED/pdf/BM Presentation/Using Iron and Epo.ashx

 

[Noyac]

Shouldn't be any issue with cell saver as long as the pt is amendable to it.

 

[deleted171991]

Actually, if you Google it, there are some issues with the cell saver when there is metal in the joint space.

http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&cad=rja&uact=8&ved=0CDMQFjAD&url=http://www.researchgate.net/profile/Koen_Smet/publication/23256036_Does_intraoperative_cell_salvage_remove_cobalt_and_chromium_from_reinfused_blood/links/0deec5208ce6cc3135000000.pdf&ei=EVvtVK6fHvLnsATX_YDADg&usg=AFQjCNFjjo8UjpHsWjKhcbKsQ4CR3fTl9A&bvm=bv.86956481,d.cWc

Abstract: In 12 patients undergoing a revision hip arthroplasty after a failed metal-on-metal primary hip arthroplasty, the effectiveness of intraoperative cell salvage (ICS) in removing metal ions was investigated. Samples of blood collected during surgery were filtered using 2 ICS devices. The samples had the concentrations of cobalt (Co) and chromium (Cr) measured before and after filtration. There was an average reduction of 76.3% for Cr concentration and 78.6% for Co concentration after ICS filtering. The Co-to-Cr ratio before and after filtration was similar. At the present time, these salvage systems should be used with caution in the patient undergoing revision of metal-on-metal bearing surfaces.

http://www.arthroplastyjournal.org/article/S0883-5403(05)80104-4/abstract

The use of Cell Saver blood during revision hip arthroplasty has many benefits, both medical and economic. After a review of the current literature, to our knowledge, no case of metallic debris has been reported in the blood after complete treatment with the Haemonetics Cell Saver (Braintree, MA) and appropriate filter system. A case of total hip revision of a loose, cemented acetabular component with a commercially pure titanium metal backing and a titanium alloy plasma-spray textured surface was undertaken. The titanium alloy femoral component was not visibly loose and was not revised. The joint lining tissues were black. Throughout the procedure, the operative site was suctioned with a double-lumen heparinized catheter that delivered blood and other materials to a Haemonetics Cell Saver 3 Plus. The reservoir and filter unit used were the compatible Bentley BCR-3500 (Baxter, Irvine, CA), a system capable of filtering particulates down to 20 μm. Prior to infusion of the salvaged blood, many large black clumps of material were observed mixed in the blood. Some measured 10 × 5 × 5 mm and could easily be seen macroscopically. Light microscopy demonstrated red blood cells with intermixed neutrophils, and black foreign material scattered as separate particles and within the cytoplasm of the scattered histiocytes. Energy dispersive analysis of the black material confirmed the composition as primarily titanium with minute quantities of copper, iron, phosphorous, and sulfer. A scanning electron photomicrograph of one of the specimens demonstrated a large conglomerate, approximately 2,000 μm in diameter, composed primarily of titanium and organic material. No malfunction in the Cell Saver machine, defects in the Cell Saver disposable components, or defects in the Bentley reservoir and filter were identified. In this case, if the individual titanium fragments did not aggregate into grossly visible particles, the contaminant likely would not have been discovered. Use of the Cell Saver in tissues with gross metallosis is not a reported contraindication. The authors suggest careful observation of the Cell Saver during the portion of revision surgery dealing with grossly blackened tissues in order to avoid aggregates of titanium as encountered in this case. Further, the authors now use a second suction not attached to the Cell Saver when grossly blackened tissues are encountered.

 

[Noyac]

Wait, would the pt be better off if they didn't give them back their own blood which contains metal ions in the first place? I mean are we really doing them any harm? They already had the metal in their system. It's not like we are removing all the metal ions. All of their blood is essentially tainted with metal, right? What's the harm if it's in the cell saver blood.

 

[Gas you down]

seems like the two articles re:metal in blood are at odds with each other. the first says spinning the blood down lowered metal concentrations, which is what I would expect from filtering/centrifuging. the second was a single case which showed grossly visible clots in centrifuged cell saver blood.
I would have no problem giving them back their own blood. but if in doubt, throw it out. just my .02

 

[deleted171991]

But even the first one says "At the present time, these salvage systems should be used with caution in the patient undergoing revision of metal-on-metal bearing surfaces.", just because there is too much metal (from the joint) in the salvaged blood.

Do we really want to reinfuse metallic microscopic splinters?

 

[Noyac]

Probably not.

 

[narcusprince]

Any option for autologous blood donation. Have the patient donate 2 units then store it then give the same units back to the patient during the surgery in addition EPO and FE after collecting the blood? I know that most Jehovahs witness blood donation/transfusion protocals differ based on the temple with which they practice. Sounds like you have some homework.

 

[Gern Blansten]

Any option for autologous blood donation. Have the patient donate 2 units then store it then give the same units back to the patient during the surgery in addition EPO and FE after collecting the blood? I know that most Jehovahs witness blood donation/transfusion protocals differ based on the temple with which they practice. Sounds like you have some homework.

They will likely not accept autologous units. The issue is that the blood must be in continuous circuit with their own blood, which is why CPB and cell saver are usually accepted. Be aware that JW patients have different views on what they will and will not accept.
If you ever have any time to waste, look up the scripture that all of this is based on. It is pretty bogus and far fetched.
In addition, discuss their desires with them in private, away from family and clergy to get their real feelings on what they desire. Rarely, in private, JW patients will say that a blood transfusion is acceptable but no one in their family or church can know about it. It can lead to excommunication from their church and family. The church will require their family to "shun" them. Very sad, actually.
There is a large faction of JW's who are pushing hard for reform of JW policies regarding blood transfusions. If I was a betting man, I would say that this will be a moot issue within our lifetimes and we will look back and wonder what the heck they were thinking.

 

[kbuztravel]

Actually, if you Google it, there are some issues with the cell saver when there is metal in the joint space.

http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&cad=rja&uact=8&ved=0CDMQFjAD&url=http://www.researchgate.net/profile/Koen_Smet/publication/23256036_Does_intraoperative_cell_salvage_remove_cobalt_and_chromium_from_reinfused_blood/links/0deec5208ce6cc3135000000.pdf&ei=EVvtVK6fHvLnsATX_YDADg&usg=AFQjCNFjjo8UjpHsWjKhcbKsQ4CR3fTl9A&bvm=bv.86956481,d.cWc



http://www.arthroplastyjournal.org/article/S0883-5403(05)80104-4/abstract

I know I'm a year late here but I thought I'd post this comment anyway if it's beneficially for future reference.
Centrifuging/washing will NOT eliminate metal debris, it will concentrate it.
There are modifications to the cell saver procedure that can be performed when there is a revision to reduce metal contaminants that neither study used or referenced. Modifications won't eliminate metal debris 100% but it would reduce it even more than the two studies cited making it theoretically insignificant.

1. Use a double suction setup when working on contaminated tissue, irrigate with normal saline, then you can resume cell saver. This would transfer the majority of metal debris to a separate suction, rather than your cell saver system. Don't overload the system. This is recommended by the UK Cell Salvage Action Group. (see the Contraindications sheet attached) NEITHER study implemented this method so it would be reasonable to say that they are already starting out with higher numbers of metal contaminants.
2. Have a dedicated tech running the cell saver. The person running the cell saver needs to pay close attention while the cell saver is filling so that they can monitor the system for premature washing, metal debris can trip the sensor into starting early. If they do not pay attention to this the equipment might wash a partially filled bowl, which would leave more contaminants in the washed blood than a completely filled bowl. http://link.springer.com/article/10.1007/BF02803177
3. Use a 20µm filter after blood has been washed with the cell saver. Again Neither study used these before reinfusion.

 

[sethco]

PUBLIC RELEASE: 6-MAY-2013Single, high-dose erythropoietin given 2 days pre-op reduces need for transfused blood


http://www.eurekalert.org/pub_releases/2013-05/aaft-she050113.php


http://www.kumed.com/~/media/Files/KUMED/pdf/BM Presentation/Using Iron and Epo.ashx

Blade, am I missing something? This makes no sense. EPO simulates RBC production, which takes upwards of 120 days. Yet, this study shows or improves after only two days?

Edit: didn't even see that this was a year old thread, haha

 

[ranvier]

Not PC but IMO taking care of this population is the same as a patient insisting I do the case with my left arm tied behind my back because of their belief system.

 

[drmwvr]

Probably not.

In a JW? Why not? There surely isn't any more than is showered completely unfiltered into the circulation during explantation and debridment. It's a hog slaughter in there, and I'd say careful consideration with a JV IS using caution, as someone said, should the patient accept CS. If it wasn't needed, fine. But I would not hesitate should shove come to push.

 

[Noyac]

In a JV? Why not? There surely isn't any more than is showered completely unfiltered into the circulation during explantation and debridment. It's a hog slaughter in there, and I'd say careful consideration with a JV IS using caution, as someone said, should the patient accept CS. If it wasn't needed, fine. But I would not hesitate should shove come to push.

Well actually it depends. What's the reason for the revision? What's the failed hip components made of? Is it metal on metal, poly or ceramic? When these fail, it is my understanding that they fail for different reasons. One being underlying infection. One being metal on metal allergy with debris or pseudotumor. One being failed ceramic rim with debris, although the this debris is usually larger. There are many reasons for revisions. We do plenty and I haven't transfused one in a long time. They may need transfusion POD# 1or 2 but not so much in the OR in my facility. I would probably rather banked blood of it were me depending on the reason for hip failure.

But you do have a point.

 

[Pooh & Annie]

Not PC but IMO taking care of this population is the same as a patient insisting I do the case with my left arm tied behind my back because of their belief system.

And the costs. I'm fine with "beliefs" requiring interventions that cost more than the standard, but that monetary burden should fall on the believer.

 

[deleted171991]

And the costs. I'm fine with "beliefs" requiring interventions that cost more than the standard, but that monetary burden should fall on the believer.

Good luck with that, in a country where hospitals have to pay for translators.

 

[drmwvr]

And the costs. I'm fine with "beliefs" requiring interventions that cost more than the standard, but that monetary burden should fall on the believer.

Hear, hear. Let's not forget believers in tobacco and alcohol.

 

[pgg]

Hear, hear. Let's not forget believers in tobacco and alcohol.

You sure you want to go down that road?

98% of all injury and disease in adults is self-inflicted.

Not just tobacco and alcohol. Fat and sugar, obesity. Fast cars, contact sports. STDs. Too much sun and too little sunscreen. It's almost all self inflicted.

 

[Noyac]

You sure you want to go down that road?

98% of all injury and disease in adults is self-inflicted.

Not just tobacco and alcohol. Fat and sugar, obesity. Fast cars, contact sports. STDs. Too much sun and too little sunscreen. It's almost all self inflicted.

So let's all wrap ourselves in bubble wrap, drink H2O and only eat fish and chicken.
If anyone does anything different, then it's Hospice care for them.

 

[aneftp]

As physicians for "elective cases" you do have the right to opt out of cases that go against your beliefs.

Say if patient had a starting hemoglobin of 8. With chronic medical problems (usual esrd, cad etc) Elective.

If they don't want a blood transfusion and if it's elective revision. And you don't feel comfortable. Just refuse to do the case. Simple as that.

Now if it weren't elective than it changes the complexity of it all.

 

[pjl]

And the costs. I'm fine with "beliefs" requiring interventions that cost more than the standard, but that monetary burden should fall on the believer.

This seems strongly at odds with your political beliefs.


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[Planktonmd]

Unfortunately most religious and non religious "beliefs" are loads of crap, but they are part of the real world we are forced to live in.
So, if someone believes that they were abducted by aliens, the earth is flat, or that Jesus will be mad at them if they get a blood transfusion you are expected to ignore their stupidity and do your best to take care of them.
This is what differentiates you as a physician and makes you the highly paid nurse extender you thrive to be!
So, let's focus on medicine and leave beliefs, delusions, and religions to those who claim to be experts in these domains!

 

[pgg]

So let's all wrap ourselves in bubble wrap, drink H2O and only eat fish and chicken.
If anyone does anything different, then it's Hospice care for them.

Or we can leave the social engineering to Congress, and they can sin tax the hell out of things according to changing societal whims, and we in the medical professions can just take care of sick and injured people however they hurt themselves.

 

[Pooh & Annie]

This seems strongly at odds with your political beliefs.


Sent from my iPhone using SDN mobile app

I don't think so. I think someone needs a good reason to cost someone else money. I don't generally think "beliefs," in this case at least, are a great reason.
I do think everyone's a hypocrite to some degree though, me included.

 

[drmwvr]

You sure you want to go down that road?

98% of all injury and disease in adults is self-inflicted.

Not just tobacco and alcohol. Fat and sugar, obesity. Fast cars, contact sports. STDs. Too much sun and too little sunscreen. It's almost all self inflicted.

Must've forgotten the 'tongue in cheek' smiley.... sorry.

 

[Pooh & Annie]

You sure you want to go down that road?

98% of all injury and disease in adults is self-inflicted.

Not just tobacco and alcohol. Fat and sugar, obesity. Fast cars, contact sports. STDs. Too much sun and too little sunscreen. It's almost all self inflicted.

Don't insurers ask about some of these lifestyle decisions? And shouldn't they have the right to?

 

[Noyac]

As physicians for "elective cases" you do have the right to opt out of cases that go against your beliefs.

Say if patient had a starting hemoglobin of 8. With chronic medical problems (usual esrd, cad etc) Elective.

If they don't want a blood transfusion and if it's elective revision. And you don't feel comfortable. Just refuse to do the case. Simple as that.

Now if it weren't elective than it changes the complexity of it all.

No. We don't have that luxury.
You either realize that their beliefs are "probably" unfounded and carry on or you get another job.
By the time the pt has made it to us, the anesthesiologist, they have been through all the hoops. The surgeon has agreed to operate, where right or wrong. It's not a good deal. But as Anesthesiologists we can't go around cancelling or refusing to do cases because of "our" beliefs. Or can we?
It's not a good system. I agree.
But Ina case like this,who has actually had someone die because they couldn't give blood? I'm sure there are some of you but the numbers are extremely low. I had a JW go to a hct of 6. She did fine. Sure, we adjusted but it worked.

So I guess you have the right to refuse to do cases that go against your beliefs but do that on a regular basis and you will find yourself jumping from one job to the next. You can't disregard all the work others have done to get to surgery just because it doesn't fit your beliefs.

That's my belief, at least.

 

[drmwvr]

Don't insurers ask about some of these lifestyle decisions? And shouldn't they have the right to?

So JW's should get a rebate for the squeaky clean lives they lead, not popped for not wanting blood.

 

[Pooh & Annie]

No. We don't have that luxury.
You either realize that their beliefs are "probably" unfounded and carry on or you get another job.
By the time the pt has made it to us, the anesthesiologist, they have been through all the hoops. The surgeon has agreed to operate, where right or wrong. It's not a good deal. But as Anesthesiologists we can't go around cancelling or refusing to do cases because of "our" beliefs. Or can we?
It's not a good system. I agree.
But Ina case like this,who has actually had someone die because they couldn't give blood? I'm sure there are some of you but the numbers are extremely low. I had a JW go to a hct of 6. She did fine. Sure, we adjusted but it worked.

So I guess you have the right to refuse to do cases that go against your beliefs but do that on a regular basis and you will find yourself jumping from one job to the next. You can't disregard all the work others have done to get to surgery just because it doesn't fit your beliefs.

That's my belief, at least.

My "beliefs" are irrelevant. It's how THEIR beliefs effect my ability to care for them. And again, people have the right to believe what they want. In fact if it's really a "belief", they couldn't change it even if they wanted. And I f it puts them at risk, that's ok as long as they know it. But if straying from the standard of care will cost someone more, it becomes boutique medicine and the patient themself should be responsible for added costs.

Unfortunately when it comes to things like risky behaviors (smoking, extreme sports, etc...), insurance may cost more (which it probably should), and will make those people less likely to want insurance. It's kind of a catch-22.

 

[Pooh & Annie]

So JW's should get a rebate for the squeaky clean lives they lead, not popped for not wanting blood.

Good point. Epidemiologically they're probably cheaper to the system.

 

[OB1🤙]

JWs are cheaper to care for on average.

Less useless blood tests, costs of blood banking, etc.

We do a lot of JW hearts.

 

[deleted59964]

So, if someone believes that they were abducted by aliens, the earth is flat, or that Jesus will be mad at them if they get a blood transfusion you are expected to ignore their stupidity and do your best to take care of them.

unfortunately you can't just ignore their stupidity - you have to cater to it