Jehovah's Witness/preop Type and Screen and CBC

[Twiggidy]

Thoughts?

Why?

Edit: this is for a c/s btw, so i can understand CBC for plt count for regional anesthesia

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[pgg]

Did she decline blood products? All of them, or just some of them? Rhogam might be acceptable to her, if indicated.

She might change her mind.

 

[22031 Alum]

Some only refuse whole blood.

Some only refuse pRBCs.

Some will change their minds about refusing as you update them on their continued blood loss and the seriousness of their condition - especially if there's a new baby in the room that they want to live for.

I've seen all of the above, and would prefer having a T&S to not.

 

[ryanjmy]

Cbc could change your management. You might cancel the case plus you have an idea of how much blood a pt can lose before it gets critical. Communicating with the surgeon how bad things are is important. A lot of jw pt wil take cell saver and hemodilution auto transfusions.

As for t&s, I've heard of pt's families consenting for blood products when it's life or death.

Edit: Just saw this is a c/s so I guess canceling and cell saver are out.

 

[caligas]

Doesn't matter what family "consents" to, if patient said no blood and is now asleep, no transfusion.

 

[Gern Blansten]

In this situation, there is a different twist to the ethical dilemma that needs to be addressed with the mother so that she can make an informed decision. You must inform her that if she hemorrhages during the procedure, the baby will likely survive, but she may not. So, this new baby, who has no say in the matter, will be forced to grow up without the benefit of their mother's love and guidance. You should likely determine if the mom has considered this and does it impact her decision at all.

 

[Twiggidy]

thanks peeps. these are all things i didn't consider. i admittedly approach these patients a little to conservatively sometimes so my initial reaction this morning was, "why the heck are we drawing labs on this person we're not giving blood to anyway?"

All responses are great and will help me in the future. Thanks

 

[22031 Alum]

Doesn't matter what family "consents" to, if patient said no blood and is now asleep, no transfusion.

Luckily for cesareans, the patient is usually awake. When I get to the decision point of more intense interventions (ie hysterectomy) and putting the patient to sleep, we're having a frank discussion about what may happen without transfusion. I've had some patients remain adamant that they won't take any blood products, and sadly, I've seen some of them die because of that decision. (It's sad to me, but there have been families quite at peace with their loved one making that decision, even with a new motherless baby left behind.) But other times, the conviction becomes a lot weaker once the concept of bleeding to death becomes less abstract.

 

[dhb]

I've had some patients remain adamant that they won't take any blood products, and sadly, I've seen some of them die because of that decision.

hard to believe

 

[Mman]

hard to believe

I've had 1 Jehovah's Witness die from bleeding in the OR. We kept them alive to the ICU with a Hct in the single digits but they died a day or two later. It happens. The vast majority of the time they do fine.

 

[BuzzPhreed]

Uncrossmatched blood if they change their mind. Not a good use of resources, but keeps your ass out of court.

And I too have seen a patient die who was being coded in the unit with a hemoglobin of < 4. The family said "no blood". How the enforcement of some silly superstitious by proxy belief doesn't constitute homicide is beyond me.

 

[Shimmy8]

Did a C/S today on JW, did a type and screen with the CBC for neuraxial.

She was potentially abrupting and failed to progress so we went with C/S. Had perfusion in room with cell saver, luckily didn't have to use it.

Butthole was a little tight until things were under control.

 

[kingcer0x]

"Intraoperative cell salvage is a strategy to decrease the need for allogeneic blood transfusion. Traditionally, cell salvage has been avoided in the obstetric population because of the perceived risk of amniotic fluid embolism or induction of maternal alloimmunization. With advances in cell salvage technology, the risks of cell salvage in the obstetric population parallel those in the general population. Levels of fetal squamous cells in salvaged blood are comparable to those in maternal venous blood at the time of placental separation. No definite cases of amniotic fluid embolism have been reported and appear unlikely with modern equipment. Cell salvage is cost-effective in patients with predictably high rates of transfusion, such as parturients with abnormal placentation."

Cell Salvage in Obstetrics
Goucher, Haley MD; Wong, Cynthia A. MD; Patel, Samir K. MD; Toledo, Paloma MD, MPH
Anesthesia & Analgesia
August 2015
Vol. 121 - Issue 2: p 465–468

http://mobile.journals.lww.com/anes...cle=00027&ContextualNavigationType=mostviewed

 

[Docuronium]

"Intraoperative cell salvage is a strategy to decrease the need for allogeneic blood transfusion. Traditionally, cell salvage has been avoided in the obstetric population because of the perceived risk of amniotic fluid embolism or induction of maternal alloimmunization. With advances in cell salvage technology, the risks of cell salvage in the obstetric population parallel those in the general population. Levels of fetal squamous cells in salvaged blood are comparable to those in maternal venous blood at the time of placental separation. No definite cases of amniotic fluid embolism have been reported and appear unlikely with modern equipment. Cell salvage is cost-effective in patients with predictably high rates of transfusion, such as parturients with abnormal placentation."

Cell Salvage in Obstetrics
Goucher, Haley MD; Wong, Cynthia A. MD; Patel, Samir K. MD; Toledo, Paloma MD, MPH
Anesthesia & Analgesia
August 2015
Vol. 121 - Issue 2: p 465–468

http://mobile.journals.lww.com/anes...cle=00027&ContextualNavigationType=mostviewed

Keeping up---hot off the presses there