Bloodless Surgery ...

[coccygodynia]

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I was wondering if I could get some of your opinions on bloodless surgery ... specifically, how many of the hospitals you work at implement this? And if they do, what is the lowest Hgb usually allowed? Are you doing any ABD's before potentially bloody surgeries?

Dr. Aryeh Shander (Englewood Hospital - New Jersey) visited our hospital recently to talk about his program and it sounded intriguing ... any experience with this?

 

[UTSouthwestern]

I was wondering if I could get some of your opinions on bloodless surgery ... specifically, how many of the hospitals you work at implement this? And if they do, what is the lowest Hgb usually allowed? Are you doing any ABD's before potentially bloody surgeries?

Dr. Aryeh Shander (Englewood Hospital - New Jersey) visited our hospital recently to talk about his program and it sounded intriguing ... any experience with this?

None that I have been to in Dallas have a specific program implemented in the sense that a cutoff number would have to be provided. Clinical judement has to supersede cutoff values as your patients' comorbidities will determine if you feel the need for a higher degree of O2 carrying capacity is needed. For example, a patient with known 4 vessel coronary disease and stable angina isn't someone I would let drift too far as their O2 supply/demand curve may already be optimized for that particular patient, all other variables being controlled.

Autologous blood donations will require a significant amount of time for the patient's body to replenish the lost volume and the sicker patients tend to be the ones that would not tolerate having a significant amount of blood being taken out of them over a short period of time. If this carefully planned in advance, it is possible to minimize the hemodynamic consequences on those patients with serious illnesses.

A number of other factors would also have to be considered when determining whether or not a patient is a candidate for bloodless surgery protocols (ex. patient with metastatic cancer).

 

[jwk]

Are you doing this because of religious concerns or as part of an overall blood-conservation program?

 

[f_w]

It is my understanding that 'bloodless surgery' programs are typically linked to certain religious groups (Jehovas Witnesses and some Pentecostals are the only ones I can remember off hand).

 

[sevoflurane]

In a helathy adult going into surgery, deliberate hypotension is an option if you want to conserve blood loss. In someone with triple vessel dz, this wouldn't be an option for fear of MI, stroke and the like. Deliberate hypotension is pretty cool when you implement it on the young patient that won't accept blood products due to religious reasons.

 

[coccygodynia]

Are you doing this because of religious concerns or as part of an overall blood-conservation program?

I was curious for a couple of reasons. The Jehovah's Witness factor is one ... the other was regarding literature about the increased risk of infection post-transfusion (surgical infection, not Hep C or HIV). It seems like a novel approach to medicine and didn't know how many of you employed its use.

Thanks for the responses.

 

[f_w]

I know of a couple of hospitals in NY who offer this as an option, the two that come to mind are staten island university hospital and long island college hospital. Both cater to the Jehovas witness and other religious communities.

It seems like a novel approach to medicine and didn't know how many of you employed its use.

'deliberate hypotension' sounds more like the old surgical quip: all bleeding stops

I value my braincells, if I ever have to go under the knive I'll look for a team of surgeons/anesthesiologists who subscribe to the 'optimal patient outcome' principle.

That said, I do believe that it is a good idea to offer autotransfusion as an option for patients undergoing elective procedures. I am just sceptical if religion gets too much of a say in medical decisions.

 

[UTSouthwestern]

Bloodless surgery programs would NOT apply to Jehova's Witness patients as ABD is not acceptable to JW patients. It doesn't matter that it is the patient's own blood. Once it leaves the body, it cannot be returned to the JW patient.

They will even refuse CPB volume that is not in continuous circulation with their own vasculature (i.e., after the venous lines are clamped).

Deliberate hypotension is a necessity for these patients, although antifibrinolytics and now NovoSeven/factor VII concentrate have emerged as powerful adjuncts.

 

[jetproppilot]

In a helathy adult going into surgery, deliberate hypotension is an option if you want to conserve blood loss. In someone with triple vessel dz, this wouldn't be an option for fear of MI, stroke and the like. Deliberate hypotension is pretty cool when you implement it on the young patient that won't accept blood products due to religious reasons.

and isovolemic hemodilution is cool too. Get a citrate bag from the blood bank, hook it up to your big peripheral IV line or cordis after induction, drain off a coupla units of the patients blood before the case starts. Keep it on top of your anesthesia machine/drug cart and turn it over every once in a while. Replenish the drained off blood with Hespan 500-1000ml. Now the pt's HCT is lower so the amount of RBCs they lose per mL of volume lost is lower. Towards the end of theoperation, replenish the pt with their own blood, RBCs, clotting factors, and all.

 

[seattledoc]

there are some Jahovah witnesses that will allow isovolemic hemodilution as long as the line and blood are in continuous contact with their body, i.e. don't disconnect the autologous units, rather just hang them up on a slow drip. There are probably different levels of JWness, much like there are Jewish people that occasionally eat bacon double cheeseburgers, or Catholics that use condoms, Muslims that drink on special occasions...the list goes on.

 

[Tenesma]

deliberate hypotension used to be a big buzz word for hip replacements where the surgeons used to lose 3-4 liters of blood!!!! now that the surgical technique has improved and they only lose 300-400cc, who needs the "deliberate hypotension"

all i know, is that the last time i provided deliberate hypotension my patient went into ARF and was anuric for 4 days.... kinda makes you rethink things....

in my honest opinion i don't care what your religion is... but if you refuse to receive blood should your body need it then I ain't doing your surgery... Can you imagine if a religion came along that said anything over 22% O2 is against their religion???

we need to be sensitive to cultural issues, but don't put me in a situation where i have to watch another 23 year old girl die on the table for no good reason...

 

[UTSouthwestern]

deliberate hypotension used to be a big buzz word for hip replacements where the surgeons used to lose 3-4 liters of blood!!!! now that the surgical technique has improved and they only lose 300-400cc, who needs the "deliberate hypotension"

all i know, is that the last time i provided deliberate hypotension my patient went into ARF and was anuric for 4 days.... kinda makes you rethink things....

in my honest opinion i don't care what your religion is... but if you refuse to receive blood should your body need it then I ain't doing your surgery... Can you imagine if a religion came along that said anything over 22% O2 is against their religion???

we need to be sensitive to cultural issues, but don't put me in a situation where i have to watch another 23 year old girl die on the table for no good reason...

Similar situation a few nights ago when I was called in to do a ruptured but contained ascending TAA. Lady was a Jehova's Witness and a very unpleasant individual. Explained every aspect of the anesthesia and surgery to her and told her that she needed to have blood because of the location of the dissection, probable need for an AVR, etc. Starting Hct 28. Told me that she refused blood at which time I assured her that she would die and that she should go ahead and tell her family that this was the last time they would see her.

She became angry, threatened a law suit, etc., but I told her that I wasn't pressuring her or forcing her to accept blood, just stating facts: University CT service, DHCA for at least 40 minutes, high probability of coagulopathy, hemodilution with non blood products only and consequences of that, etc. She would die unless God fixed her rupture or used a miracle to improve the surgeons' speed and efficiency. Her choice. Wrote everything down in her chart and asked her to sign a statement showing that she refused blood in this high risk surgery.

She relented and accepted blood: 20 units of PRBC's, 16 of FFP, 2 platelets, 2 cryo.

So we basically saved her life and sent it to hell at the same time.

 

[VentdependenT]

Similar situation a few nights ago when I was called in to do a ruptured but contained ascending TAA. Lady was a Jehova's Witness and a very unpleasant individual. Explained every aspect of the anesthesia and surgery to her and told her that she needed to have blood because of the location of the dissection, probable need for an AVR, etc. Starting Hct 28. Told me that she refused blood at which time I assured her that she would die and that she should go ahead and tell her family that this was the last time they would see her.

She became angry, threatened a law suit, etc., but I told her that I wasn't pressuring her or forcing her to accept blood, just stating facts: University CT service, DHCA for at least 40 minutes, high probability of coagulopathy, hemodilution with non blood products only and consequences of that, etc. She would die unless God fixed her rupture or used a miracle to improve the surgeons' speed and efficiency. Her choice. Wrote everything down in her chart and asked her to sign a statement showing that she refused blood in this high risk surgery.

She relented and accepted blood: 20 units of PRBC's, 16 of FFP, 2 platelets, 2 cryo.

So we basically saved her life and sent it to hell at the same time.

Friggen awsome

 

[f_w]

I have seen it the other way around. Patients mom would not allow us to give blood to a sickler in the ICU because they were jehovas witnesses. Although we absolutely minimized our blood draws, his crit continued to slowly drop until he got arrythmias and died. Hospitals lawyers told us that according to the state laws, there wasn't a f)$@(* thing we could do about it. Oh, just before he died, his dad managed to make is way back from Haiti. When in a family conference it was explained to the dad that in all likelihood the anemia will do his son in and that due to his religious beliefs we couldn't give him any blood products the dad had a bit of a suprised look on his face and said: 'My son is catholic, I didn't think that this is a problem for us'. Gracefully, the kid died before the parents could duke it out in family court.

 

[sevoflurane]

Similar situation a few nights ago when I was called in to do a ruptured but contained ascending TAA. Lady was a Jehova's Witness and a very unpleasant individual. Explained every aspect of the anesthesia and surgery to her and told her that she needed to have blood because of the location of the dissection, probable need for an AVR, etc. Starting Hct 28. Told me that she refused blood at which time I assured her that she would die and that she should go ahead and tell her family that this was the last time they would see her.

She became angry, threatened a law suit, etc., but I told her that I wasn't pressuring her or forcing her to accept blood, just stating facts: University CT service, DHCA for at least 40 minutes, high probability of coagulopathy, hemodilution with non blood products only and consequences of that, etc. She would die unless God fixed her rupture or used a miracle to improve the surgeons' speed and efficiency. Her choice. Wrote everything down in her chart and asked her to sign a statement showing that she refused blood in this high risk surgery.

She relented and accepted blood: 20 units of PRBC's, 16 of FFP, 2 platelets, 2 cryo.

So we basically saved her life and sent it to hell at the same time.

I wonder how she was when she woke up? Pissed off or thankful? Probably just hurting. Hmmm... 😕 Either way, I can't wait 'til I get in the OR. I must walk the land of the intern before I get into those glorious shoes on a permenant basis. Unitl then I will fantisize about such experiences.

 

[UTSouthwestern]

I wonder how she was when she woke up? Pissed off or thankful? Probably just hurting. Hmmm... 😕 Either way, I can't wait 'til I get in the OR. I must walk the land of the intern before I get into those glorious shoes on a permenant basis. Unitl then I will fantisize about such experiences.

She is awake and extubated, but brain freeze just takes a lot of time to come back from. I suspect she'll be a little more pleasant than preoperatively, if only because she may not remember that aspect of her personality.