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ANESTHETIC MANAGEMENT OF THE PATIENT WHO REFUSES BLOOD TRANSFUSION

ANESTHETIC MANAGEMENT OF THE PATIENT WHO REFUSES BLOOD TRANSFUSION. Article by Jacques F. Dupuis; DY Tien Nguyen, Department of Anesthesiology and Critical Care, The University of Texas M.D, Anderson Cancer Center, Houston, Texas. PREPARED BY: AHMAD SHAFWAN BIN ABDULLAH SUPERVISOR:

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ANESTHETIC MANAGEMENT OF THE PATIENT WHO REFUSES BLOOD TRANSFUSION

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  1. ANESTHETIC MANAGEMENT OF THE PATIENT WHO REFUSES BLOOD TRANSFUSION Article by Jacques F. Dupuis; DY Tien Nguyen, Department of Anesthesiology and Critical Care, The University of Texas M.D, Anderson Cancer Center, Houston, Texas PREPARED BY: AHMAD SHAFWAN BIN ABDULLAH SUPERVISOR: DR ROHANI RAMLIY

  2. 2 MAJOR REASONS: • FEAR OF DISEASE TRANSMISSION -agree for autologous blood tranfusion 2. RELIGIOUS BELIEFS

  3. MEDICAL CHALLENGES • LIMITATION IN MAINTAINANCE OF OXYGEN TRANSPORT, HEMOSTASIS AND COAGULATION UNDER CONDITION WHICH ELEMENTS PROGRESSIVE DEPLETED, HOWEVER UNABLE TO REPLACE OXYGEN DELIVERY IT IS NECESSARY TO MATCH OXYGEN CONSUMPTION CRITICAL OXYGEN DELIVERY DEFINES AS POINT AT WHICH OXYGEN DELIVERY IS INSUFFICIENT TO OXYGEN CONSUMPTION DELIVERY OXYGEN LIMITED > LIMITED IN TISSUE OXYGENATION > ORGAN DAMAGE > DEATH HEMOSTASIS, COAGULATION DEPENDS ON PERIPHERAL VASCULATURE INTEGRITY, PLATELET NUMBER & FUNCTION, COAGULATION FACTORS Ott & Cooley report – 542 patient who underwent cardiovascular surgery with 12 deaths related to blood loss.

  4. PHYSIOLOGY AND LIMITS OF OXYGEN TRANSPORT 1. HYPOVOLEMIA > ANEMIA > INADEQUATE OXYGEN DELIVERY BY REDUCTION OF CARDIAC OUTPUT 2. MAINTAIN NORMAVOLAEMIA > COMPENSATORY INCREASE IN CARDIAC OUTPUT UP TO LIMIT ALLOWABLE HB REDUCTION 3. HEMODILUTION > REDUCED BLOOD VISCOCITY > DECREASE IN PERIPHERAL VASCULAR RESISTANCE > TRIGGER SYMPATHETIC PATHYWAY TO INCREASE CARDIAC OUTPUT

  5. BALANCE BETWEEN OXYGN DELIVERY & CONSUMPTION EXPRESSED BY OXYGEN EXTRACTION RATIO O2 EXTRACTION RATIO = O2 CONSUMPTION/ O2 DELIVERY ADEQUATE COMPENSATION OCCURS UNTIL RATIO IS 0,5. IF RATIO > 0.5 – METABOLIC & HEMODYNAMIC DISTURBANCE ENSUES

  6. MECHANISM FOR COMPENSATION • INCREASE IN CARDIAC OUTPUT & ORGAN BLOOD FLOW • INCREASE IN O2 EXTRACTION from THE BLOOD • DECREASE IN HEMOGLOBIN AFFINITY FOR OXYGEN

  7. INCREASE IN CARDIAC OUTPUT & ORGAN BLOOD FLOW • DECREASE IN BLOOD VISCOCITY > DECREASE IN SYSTEMIC VASCULAR RESISTANCE > INCREASE IN VENOUS RETURN • INCREASE IN PLASMA LEVEL OF CATECHOLAMINES INCREASE IN O2 EXTRACTION FROM THE BLOOD MYOCARDIUM HAS THE HIGHEST EXTRACTION RATIO (0.5-0.7) >> AEROBIC GLYCOLYSIS & LIMITED METABOLIC RESERVE

  8. DECREASE IN HEMOGLOBIN AFFINITY FOR OXYGEN Van Woerkens report -case of acutely anemic Jehovah’s witness -position of oxygen dissociation, corrected for pH & pCO2 shifted to the right, not before HCT reach at 8%

  9. Wilkerson et al Anemia was tolerated to hematocrit of 15%, severe deterioration in cardiac output occurs <10% Arterial lactate start rising at HCT 10% Left ventricular extraction ratio (0.5-0.6) does not change from HCT 20% to 4%.

  10. Gerd report • Evidence in clinical setting of chronic anemia in 7 children (aged 7months – 11 years) • Average Hb: 3.3 , with the lowest 1.9g/dL • All patients had elevated cardiac index, heart rate and stroke volume and decreased systemic vascular resistance that reverted to normal after blood tranfusion

  11. Van Woerkens report In a fully monitored Jehovah’s witness under anesthesia – acute hemodilution from 31% hematocrit (10.1g/dL) to Hct :20% (Hb 6.1) induced a decrease in systemic vascular resistance of 53% & increase in cardiac output of 54% Critical oxygen delivery after which oxygen consumption gradually decreased at 184mL/m2/min or 4.9ml/kg/min at Hb 4. Oxygen extraction was 0.44 (mixed venous PaO2 34mm Hg, mixed venous saturation 56%) Death postoperatively at Hb 1.6g/dL.

  12. In subjects with restricted coronary flow , some studies indicate that cardiac function is maintained or improved with moderate hemodilutiondue to flow & increase in oxygen extraction. However, few factors eg degree of stenosis, metabolic demands of myocardium, myocardial dysfunction affects in oxygen extraction. Singbarti et al report ASA I : patient who undergoing hip arthroplasty showed evidence of ischemia based online ST segment at Hb 4.5 ASA II-III : Hb 6.6

  13. In term of age, elderly patient shows similar compensatory increase in cardiac output younger patient.

  14. THERAPEUTIC OPTIONS • Preservation for oxygen transport & reduction of oxygen consumption • Reduction of oxygen consumption • Preservation of hemostasis and coagulation

  15. Hemodilution (normovolemia/hypervolemia) – nonoxygen- carrying solutions, colloids, crystalloids, oxygen-carrying solutions, fluorocarbon emulsion, Hb solutions B. Reduction of blood loss due to invasive monitoring & instrumentation • Controlled hypotension, pharmacologic interventions, coagulation factor stimulation, topical hemostatics, intraoperative positioning, surgical techniques, non surgical approach, radiologic techniques (embolization), avoidance of iatrogenic blood loss, avoidance of negative interference with hemostasis & coagulation (dextrans, starch

  16. C. Autologous transfusion • Preoperative storage(liquid/ frozen) • Intraoperative/ postoperative blood salvage – passive systems (unprocessed blood) & active systems (cell separator/ saver, cardiopulmonary bypass machine) D. Increase in erythopoeisis E. Increase in oxygen-carrying capacity of Hb – increase FiO2, avoidance of agents that limit FiO2 such as Desflurane or limitation of concentration, avoidance of negative interferencewith O2 carrying capacity of blood, control of factors responsible for Hb affinity for O2 (pH, pCO2, temperature)

  17. F. Increase in oxygen-carrying capacity of plasma – hyperbaric O2, hypothermia G. Increase cardiac output (inotrope eg, dobutamine) & avoidance of negative interference with tissue oxygen uptake (cyanide ion toxicity) Reduction of oxygen consumption Hypothermia, Artificial ventilation, Sedation Preservation of hemostasis and coagulation Plateletpharesis/ plasmapharesis Reduction of blood loss

  18. ANESTHETIC IMPLICATIONSMONITORING • COMMON PARAMETERS OXYGEN SATURATION, HB LEVEL, ARTERIAL AND MIXED VENOUS BLOOD GASES, CARDIAC OUTPUT – CALCULATION OF OXYGEN DELIVERY AND OXYGEN CONSUMPTION & OPTIMAL TIMING OF REINFUSION OF PREOPERATIVELY HARVESTING RBC • ARTERIAL LINE & PUMONARY ARTERY CATHETER • MONITORING OF HEMOSTASIS & COAGLATION - ALLOW FOR CORRECT TIMING OF PLASMA AND PLATELET TRANFUSION

  19. SPECIAL REQUIREMENTS FOR INTRAOPERATIVE BLOOD HARVESTING • A CIRCUIT, WHICH H INFLOW TO RESERVOIR FROM ARTERIAL/ VENOUS AND OUTFLOW FROM RESERVOIR IS VENOUS. SIMPLEST METHOD IS BLOOD WITHDRAWAL BY GRAVITY INTO COLLECTION BG WITH ANTICOAGULANT • CELL PROCESSOR – ALLOWS FOR TEMPORARY SEPARATION & REINFUSION OF PLATELETS/ PLASMA – USUALLY FOR OPERATION WHICH INVOLVED EBL >25% FROM BLOOD VOLUME • ATRIOVENOUS LOOP – FOR INCIRCULATION & REINFUSION

  20. MANAGEMENT OF ANESTHESIA • MODE OF ANESTHESIA – ALONE OR COMBINED REGIONAL / GENERAL ANESTHESIA • INDUCED HYPOTENSION • HEMODILUTION WITH MINIMAL DEPRESSION OF CARDIAC FUNCTION • INHALATIONAL AGENT – DESFLURANE LIMITS FIO2 • FIO2 1.0 – MAXIMIZE HB SATURATION & DISSOLVED OXYGEN IN PLASMA • MODERATE HYPOTHERMIA • REDUCE O2 CONSUMPTION – AVOID SHIVERING & RESTLESSNESS POSTOPERATIVELY, THUS ARTIFICIAL VENTILATION, SEDATION, & MUSCLE RELAXANT CAN BE USED

  21. CASE REPORT 39 YEARS OLD WHITE WOMA (170CM, 89KG) WITH DIAGNOSIS OF HUGE OSTEOSARCOMA OF RIGHT FEMUR WITH LUNG METASTASIS FOR 3 YEARS BACKGROUND OF: CHILDHOOD RHEUMATIC FEVER & ANEMIA SOCIAL HX: JEHOVAH’S WITNESS REFUSED TRANSFUSION OF BLOOD, BUT AGREED FOR BLOOD HARVEST INTRAOPERATIVELY

  22. PATIENT WAS GIVEN HEMATINICS AND ERYTHROPEITIN 8 WEEKS PRIOR OPERATION PRIOR HEMATINICS & E-PO : HB 9.7, HCT 27.6 A DAY PRIOR SURGERY: HB 10.5, HCT 33.4 ON DAY OF SURGERY: HB 9.7, HCT 31 ECG: SINUS TACHYCARDIA, HR: 118/MIN, LV HYPERTROPHY CXR: POORLY AERATED LUNG AT RIGHT LUNG BASE CT PELVIS: “GIGANTIC OSTEOSARCOMA” OF RIGHT FEMUR, EITHER DIRECTLY EXTENDING OR METASTASIZING TO RIGT ACETABULUM WITH MARKED ENLARGEMENT OF RIGHT ILIC VEIN & VENA CAVA ECHO: MILD DILATED CARDIOMYOPATHY WITH MILD DIFFUSE HYPOKINESIS, EF 0.59, MILD MITRAL REGURGITATION, LA AND LV ENLARGEMENT, SMALL PERICARDIAL EFFUSION MONITORING: PULMONARY ARTERY CATHETER, CONTINOUS MIXED VENOUS OXYMETRY

  23. PATIENT ANESTHESIZED WITH NARCOTIC AND ISOFLURNE TECHNIQUE. PATIENT THEN HEMODILUTED WITH CRYSTALLOIDS IN TOTAL VOLUME OF 3L, THEN BLOOD RESTORED IN BLOOD CELL PROCESSOR. POSTHEMODILUTION – HB 6.6, HCT 21.4%. HB 4.5 – RAPID REINFUSION OF HARVESTED BLOOD INTIATED DUE TO DETERIORATING HAEMODYNAMICS (INCREASE PULM CAPILLARY WEDGE PRESSURE & HYPOTENSION) & WORSENING TISSUE OXYGENATION (DECREASED MIXED VENOUS OXYGENATION OPERATIVE TIME: 14H, 10MINS OPERATIVE SPECIMEN: 29.4KG (1/3 PATIENT WEIGHT)

  24. COAGULATION TEST: PT 15.6, PTT 39.3, PLT 245.000/MM3 OXYGEN DELIVERY 551ml O2/min at Hb 4.8 compared to prehemodiluton 1067 ml O2/min OXYGEN CONSUMPTION at Hb 4.8 110 ml O2/min VS 108.5 at Hb 9.7 LOWEST MICES VENOUS O2 SATURATION – 52% AT HB 4.5 AND HIGHEST LACTATE 3.1 AT HB 6.0 FLUID BALANCE *INTAKE AUTOLOGOUS BLOOD – 2875ML CRYSTALLOID – 30,600ML *OUTPUT EBL: 3600MLS URINE OUTPUT: 20,600ML MONITORING: LOWEST HB 4.8, HCT 14.6 AT COMPLETION OF SURGERY HB 6.9, HCT 21%

  25. POSTOP ADMITTED TO SURGICAL ICU & EXTUBATED POD1. POST OP XRAY: BILATERAL PLEURAL EFFUSION, INCREASED PULMONARY VASCULAR CONGESTION, POSSIBL CONSOLIDATION IN RIGHT AND LEFT LUNG BASES. REPEATED X RAY – CLEARING PULMONARY EDEMA PATIENT THEN DISCHARGED ON 38TH POSTPERATIVE DAY WITH HB 11.1, HCT 32.6

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