The Complicated OB Patient

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MommyMD

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35 y Female, pregnant with identical twins came for anesthesia consult
recent diagnosis of hereditary angioedema (3 events at dentist, one related to food, one related to new makeup - mainly facial and tongue with some feelings of difficulty breathing). never intubated with these events. does not know type of hereditary angioedema yet. no preventative meds
hx of uterine fibroids (had open myomectomy 2 yrs ago- prior to dx of hereditary angioedema)


hx of uterine bleeding with Hg as low as 4...never had transfusion for religious beliefs
Social: Jehovah’s Witness
Meds: prenatal vitamins, carries an epi-pen (even though it wont help with hereditary angioedema)
Allergies: Latex (tongue tingles, lips swelling) Reglan (EPS)
Airway - class II, 5feet 170lb (pregnant with twins)
Hg is 11

OB plans to do a planned c-section at 38 weeks...what is your plan? (pt will accept albumin but no other blood products) is possibly considering cell salvage if the cell saver is primed and connected back to her so there is continuous flow.

What happens when she comes in at 37 weeks in labor at night? what do you do then?​
 
MommyMD said:
is possibly considering cell salvage if the cell saver is primed and connected back to her so there is continuous flow.

​
Click to expand...

I have never understood this. Who's been lying to JW patients? How can there be a "continuous" column of blood when you have a RESERVOIR that PERIODICALLY gets DUMPED into a centrifuge, hence getting intermittent volumes of blood back?



BTW,

pent sux tube...
 
MommyMD said:
35 y Female, pregnant with identical twins came for anesthesia consult
recent diagnosis of hereditary angioedema (3 events at dentist, one related to food, one related to new makeup - mainly facial and tongue with some feelings of difficulty breathing). never intubated with these events. does not know type of hereditary angioedema yet. no preventative meds
hx of uterine fibroids (had open myomectomy 2 yrs ago- prior to dx of hereditary angioedema)


hx of uterine bleeding with Hg as low as 4...never had transfusion for religious beliefs
Social: Jehovah’s Witness
Meds: prenatal vitamins, carries an epi-pen (even though it wont help with hereditary angioedema)
Allergies: Latex (tongue tingles, lips swelling) Reglan (EPS)
Airway - class II, 5feet 170lb (pregnant with twins)
Hg is 11

OB plans to do a planned c-section at 38 weeks...what is your plan? (pt will accept albumin but no other blood products) is possibly considering cell salvage if the cell saver is primed and connected back to her so there is continuous flow.

What happens when she comes in at 37 weeks in labor at night? what do you do then?​
Click to expand...

a spinal
 
urge said:
I have never understood this. Who's been lying to JW patients? How can there be a "continuous" column of blood when you have a RESERVOIR that PERIODICALLY gets DUMPED into a centrifuge, hence getting intermittent volumes of blood back?
Click to expand...

Even sillier are the ones who want an organ transplant.
 
Arch Guillotti said:
Even sillier are the ones who want an organ transplant.
Click to expand...

That one always amazed me as well. I have done extensive reading on this issue in the past. The whole belief system regarding blood transfusions is soooo contrived. If you follow the church's history, you will see that they changed their stance on organ transplants and have made revisions on the stance about blood and blood product transfusions. Interestingly, I believe it was around 2000 when the church was set to reverse their stance against blood transfusions. The pamphlets even went to the printer and a few were out there to be viewed. They had a change of heart and reverted, calling back all of the pamphlets. At one time, I was able to find one posted on the internet and read it. It was very interesting.
In addition, there is a faction of the church that does not agree with this practice and several years ago, one of the leaders of that group wrote an article in A&A published under the name "Elder" so that he could not be identified for fear of retribution and being "disfellowshipped" from the church. The issue of A&A had several articles on the subject and it was interesting reading.
It would really not shock me if the "no blood transfusion" policy was gone before my career in medicine is over. It will be weird that people will have died for this belief that will be discarded by the church. I think the policy's time has come to be discarded. If you have not read the details about what IS allowed and what IS NOT allowed, you will be amazed. It is based on nothing at all and the difference between what some will accept and not accept are comical at best.

Here are links to a couple of articles by "Elder" who really sums up nicely the importance of finding out how each individual patient feels about transfusions and not just what the church doctrine is:

http://www.anesthesia-analgesia.org/content/104/4/757.long

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1733296/pdf/v026p00375.pdf

Important point, speak to the patient alone, without their family or church members present. The church is quick to send an "elder" there to help them be strong in their commitment.
 
I have no problem taking care of JW patients and not transfusing them if that is their wish. But they damn well are going to tell me that they would rather die than have me give them someone else's blood.


And yes, I fully believe it is a complete load of BS that their wishy-washy religious leaders would allow people to die for this.
 
Potentially more complicated than the classic P/S/T since intubation can induce an episode of edema, and then she remains intubated until airway edema subsides. She's had recurrent angioedema, so I suppose it really does not matter what type - for the elective CSX I would plan to pretreat her with C1 esterase inhibitor concentrate. Pharmacy can dose it for me. I agree with the spinal anesthesia plan, and would go for this even if she comes in urgently at 0300. Emedicine says that a couple of units of FFP can give enough factor to treat a angioedema crisis, and I would consider this if an angioedema crisis occurred. Assuming experienced and talented obstetricians, it's unlikely she'll drop to a Hb of 4, even with a dilated uterus from twins. Obviously many other factors to consider, but there's the gist.
 
gtb said:
I would plan to pretreat her with C1 esterase inhibitor concentrate... Emedicine says that a couple of units of FFP can give enough factor to treat a angioedema crisis, and I would consider this if an angioedema crisis occurred.
Click to expand...

Would she accept either?

- pod
 
gtb said:
I would plan to pretreat her with C1 esterase inhibitor concentrate....a couple of units of FFP can give enough factor to treat a angioedema crisis
Click to expand...

Read carefully - Jehovah's Witness; As has been commented upon in aforementioned posts. Your "fabulous" complicated Emedicine-sanctioned plan has just bought you a lawsuit you will lose.
 
Jay K said:
Read carefully - Jehovah's Witness; As has been commented upon in aforementioned posts. Your "fabulous" complicated Emedicine-sanctioned plan has just bought you a lawsuit you will lose.
Click to expand...

Maybe, maybe not. It depends on what the individual will accept. The policy and beliefs can be fluid. If it is fractionated enough, some may accept it. Other JW's who believe the policy is not correct will accept all products, but in confidentiality so as not to be disfellowshipped (a pretty big deal where family and friends must shun them or risk being disfellowshipped themselves).

19451.jpg


Thus, the importance of the private conversation.

In addition to the mom, you have two other patients in this scenario who are not getting a say in the matter of whether the mom should receive blood or products. This issue makes it a bigger deal to me. Similar to parents saying that their 5 year old having a brain tumor resection can not have a blood transfusion if needed. Not as straightforward as the simple case of a non-pregnant JW having surgery. Is it fair to put the babies at risk? Is it fair to force them to grow up motherless if disaster occurred and the babies were salvaged but the mom was not?

There are a lot of layers of consideration that make this complicated.
 
proman said:
It's a non issue with children. No state permits parents from withholding transfusion for their children.
Click to expand...

I agree, but it will involve a court order and some legal hoops. Do you know if any states address a pregnant JW who needs a blood transfusion in which the fetus is at risk? I suspect it does not come into play until the baby is born, but I know some have serious ethical issues with this scenario.
 
Gern Blansten said:
I agree, but it will involve a court order and some legal hoops. Do you know if any states address a pregnant JW who needs a blood transfusion in which the fetus is at risk? I suspect it does not come into play until the baby is born, but I know some have serious ethical issues with this scenario.
Click to expand...

I don't know about pregnancy, but you don't need a court order to transfuse a JW child. You can treat the child immediately. The JW parents I've dealt with have all understood.
 
proman said:
I don't know about pregnancy, but you don't need a court order to transfuse a JW child. You can treat the child immediately. The JW parents I've dealt with have all understood.
Click to expand...

We have a similar situation. We can go ahead and provide the treatment and the legal team cleans up the details later. I think the parents are frequently actually relieved. They got to say they refused it and be in good graces with the church but they also get to keep their child alive. I believe this is how it is most of the time. You occasionally hear about those who grab their kid and flee the hospital, but I believe that is rare.
 
I think we should all find out just how serious the JW patients are when all their support system is gone and the conversation becomes private.

I also think that except for urgent/emergent situations that a JW should have to fill out a detailed standardized forum regarding exactly what products they can receive since there are so many weird beliefs and interpretations as well as permutations of products and factors that you can give.
 
Gern Blansten said:
We have a similar situation. We can go ahead and provide the treatment and the legal team cleans up the details later. I think the parents are frequently actually relieved. They got to say they refused it and be in good graces with the church but they also get to keep their child alive. I believe this is how it is most of the time. You occasionally hear about those who grab their kid and flee the hospital, but I believe that is rare.
Click to expand...

If I recall, my school's hospital had a form that JW parents would sign that was a pseudo-consent; it basically said that the parents were absolving themselves of decision-making with regards to treatment of the child, so that they did not have to explicitly give permission to give them blood products.

Or something equally confusing...
 
She was willing to accept c1 esterase inhibitors (not prior to c-section but after c-section if had an angioedema crisis)
 
The patient did come in labor to hospital prior to planned c-section date. Locum tenem ob on call that night. case done in general OR under GA. Rapid sequence, easy intubation. Took close to 2 mins for delivery of twins after incision. Boggy uterus despite hemabate, methergine, cytotek. Hg when leaving OR was 5. Pt continued to bleed to Hg of 3.5.
Patient in ICU for 5 days (no need for pressors) extubated after day 1 (+cuff leak, no signs of angioedema crisis)- just tachy and orthostatic.
Babies did well.
(pt plans for tubal ligation in future)
 
MommyMD said:
The patient did come in labor to hospital prior to planned c-section date. Locum tenem ob on call that night. case done in general OR under GA. Rapid sequence, easy intubation. Took close to 2 mins for delivery of twins after incision. Boggy uterus despite hemabate, methergine, cytotek. Hg when leaving OR was 5. Pt continued to bleed to Hg of 3.5.
Patient in ICU for 5 days (no need for pressors) extubated after day 1 (+cuff leak, no signs of angioedema crisis)- just tachy and orthostatic.
Babies did well.
(pt plans for tubal ligation in future)
Click to expand...

VERY Close call. No need for pressors? Did you guys think of tying off the uterine arteries as she is not going to be having any more babies? Good thing she was youngish.
 
sure would have been nice to not have that volatile anesthetic on board. so cell saver wasnt used? sounds like 3-4 L blood loss, would have been nice...
 
sevoflurane said:
VERY Close call.
Click to expand...

Indeed dangerously close to the physiological limits:
Arterial oxygen content (equation) =
(Hgb x 1.36 x SaO2) + (0.0031 x PaO2)
= 47.6ml O2/L + 9.3 (assuming a PaO2 of 400mmHg) = 57ml O2/L

With a cardiac output of 6L/min you're at 342ml O2 delivery/min with an extraction ratio of 75% you get 256ml O2/ min Yikes 😱
 
Normal O2 consumption being 250 ml/min in a resting state.... I bet her tachycardia and anemia got her periods of cyanosis despite high dissolved oxygen content.

Way to apply equations to real life scenerios professor DHB. :prof: 👍
 
urge said:
I have never understood this. Who's been lying to JW patients? How can there be a "continuous" column of blood when you have a RESERVOIR that PERIODICALLY gets DUMPED into a centrifuge, hence getting intermittent volumes of blood back?



BTW,

pent sux tube...
Click to expand...


Where do you get your pent? The back room of some laundromat? 🙂 We are low on phenylephrine. Will likely run out of sux and tubes next week.
Tuck
 
no more pent to tell you the truth.

Pent sux tube, more than a drug combo, is a way of life.
 
Last edited:
Boops. Hypoxia not cyanosis. Good catch.
Dissolved part of the O2 content equation plays a very minute role in actual oxygen content.

You need at least 3-5gm/dl of deoxygenated/reduced Hgb to cause cyanosis.
 
Pt needed pushed of phenyleprhine (she did have a Right IJ cordis placed before start of surgery to give fluid fast).

DHB- thanks for the math! Her 02 sat was 100% the entire time
 
Regarding the Jehovah's Witness with angioedema issue, there is now a non-blood product derived drug called ecallantide which has been approved by the FDA for hereditary angioedema. It's a kallikrein inhibitor. There was an issue of the NEJM about a year ago with several papers on alternatives to C1INH that were equally efficacious, although I think this is the only one that is both available in the US now, and doesn't come from blood products.

Now, whether your hospital pharmacy will have this on hand when your patient presents acutely, I don't know, but for a planned section, this may be useful to know about, especially if your OBs have the foresight to contact you in advance.
 
Idiopathic said:
except when hemoglobin is 3
Click to expand...

Agree.

Anemia to a hgb of 3 can cause hypoxia because you are not meeting metabolic needs at the cellular level (specifically the electron transport chain and no 02 being there as a final electron acceptor thereby leading to anaerobic respiration and development of lactic acidosis).

As DHB calculated, the contribution to dissolved oxygen is significant when your Hgb (major carrier of O2 in the blood) gets this low.

Otherwise, it contributes very little. It goes back to investing 2 ATP's to get 36 ATP's + H20.

cr-fig-2.jpg
 
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