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 MAJOR REASONS:
1. FEAR OF DISEASE TRANSMISSION
-agree for autologous blood tranfusion
2. RELIGIOUS BELIEFS
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.
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
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
MECHANISM FOR COMPENSATION
1. INCREASE IN CARDIAC OUTPUT & ORGAN
BLOOD FLOW
2. INCREASE IN O2 EXTRACTION from THE
BLOOD
3. DECREASE IN HEMOGLOBIN AFFINITY FOR
OXYGEN
INCREASE IN CARDIAC OUTPUT & ORGAN BLOOD FLOW
1. DECREASE IN BLOOD VISCOCITY > DECREASE IN
SYSTEMIC VASCULAR RESISTANCE > INCREASE IN
VENOUS RETURN
2. 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
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%
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%.
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
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.
In subjects with restricted coronary flow , some
studies indicate that cardiac function is maintained
or improved with moderate hemodilution due 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
In term of age, elderly patient shows similar
compensatory increase in cardiac output
younger patient.
THERAPEUTIC OPTIONS
• Preservation for oxygen transport & reduction
of oxygen consumption
• Reduction of oxygen consumption
• Preservation of hemostasis and coagulation
A. 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
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)
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
ANESTHETIC IMPLICATIONS
MONITORING
• 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
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
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
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
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
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)
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%
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
TIME
INTAKE
OUTPUT
HB/ HCT
OR DAY
34, 930 ML
27, 040 ML
6.9/ 21.0
POD1
2, 146 ML
5, 988 ML
8.2/ 25.3
POD2
1, 609 ML
6, 390 ML
8.1/ 25.2
POD3
2, 185 ML
PATIENT THEN DISCHARGED ON
WITH HB 11.1, HCT 32.6
4, 640 ML
8,2/25.7
38TH POSTPERATIVE DAY