Abstract
Purpose
To highlight the management of a Jehovah’s witness surgical patient presenting for cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest.
Clinical features
A 47-yr-old male, Jehovah’s Witness, with renal cell carcinoma was admitted for left radical nephrectomy and excision of tumour thrombus extending into the junction of the inferior vena cava (IVC) and right atrium (RA). The preoperative goals were to maximize red blood cell mass, delineate the extent of tumour extension and develop a surgical plan incorporating blood conservation strategies to minimize blood loss. A midline abdominal incision was made to optimize removal of the non-caval portion of the tumour from the intra-abdominal region. CPB and deep hypothermic circulatory arrest were instituted to aid in removing the tumour from the IVC and RA. Intraoperative blood conservation strategies included the use of acute normovolemic hemodilution, antifibrinolytics, cell salvage, point-of-care monitoring of heparin and protamine blood concentrations, leukocyte-depleting filter, and meticulous surgical techniques. The patient was successfully weaned from CPB and was transported to the cardiothoracic intensive care unit without complication. The patient was discharged home one week after the operation with a hemoglobin of 10.2 g·dL−1 and a hematocrit of 31.2%.
Conclusion
Multiple blood conservation techniques were employed to manage this Jehovah’s Witness patient through complex cardiac surgery, which was previously denied to him at other institutions. The successful outcome of this patient, while respecting the right to refuse allogeneic blood products, is a result of a multidisciplinary collaboration as well as the application of established blood conservation techniques.
Résumé
Objectif
Présenter la prise en charge d’un opéré Témoin de jéhovah pendant la circulation extracorporelle (CEC) et l’arrêt circulatoire hypothermique profond.
Éléments cliniques
Un homme de 47 ans, Témoin de Jéhovah, atteint d’un hypernéphrome, devait subir une néphrectomie radicale gauche et l’excision d’un thrombus tumoral qui s’étendait à la jonction de la veine cave inférieure (VCI) et de l’oreillette droite (OD). Les objectifs préopératoires étaient d’augmenter la masse des globules rouges, de préciser l’extension de la tumeur et d’élaborer un plan chirurgical comprenant des stratégies de conservation du sang afin d’en réduire les pertes. Une incision abdominale médiane a été faite pour optimaliser le retrait, de la région intraabdominale, de la portion de la tumeur hors de la veine cave. La CEC et l’arrêt circulatoire hypothermique profond ont été établis pour faciliter le dégagement de la tumeur de la VCl et de l’OD. Les stratégies peropératoires de conservation du sang ont comporté l’usage d’hémodilution normovolémique aiguë, d’antifibrinolytiques, de récupération des cellules, de monitorage de chevet pour les concentrations sanguines d’héparine et de protamine, de filtre pour la déplétion leucocytaire et de techniques chirurgicales méticuleuses. Le sevrage de la CEC a été réussi et le patient a été transporté à l’unité des soins intensifs cardiothoraciques, sans complication. Il a reçu son congé une semaine après l’opération. Son hémoglobine était alors de 10,2 g·dL− 1 et l’hématocrite à 31,2%.
Conclusion
Diverses techniques de conservation du sang ont été employées pour la prise en charge d’un patient Témoin de Jéhovah au cours d’une intervention cardiaque complexe, laquelle avait été refusée précédemment dans d’autres hôpitaux. Tout en respectant le droit au refus de produits sanguins allogéniques, l’intervention a été bien réussie chez ce patient grâce à une collaboration multidisciplinaire et à une application des techniques de conservation du sang.
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References
Helm RE, Klemperer JD, Rosengart TK, et al. Intraoperative autologous blood donation preserves red cell mass but does not decrease postoperative bleeding. Ann Thorac Surg 1996; 62: 1431–41.
Huyzen RJ, Harder MP, Huet RC, Boonstra PW, Brenken U, van Oeveren W. Alternative perioperative anticoagulation monitoring during cardiopulmonary bypass in aprotinin-treated patients. J Cardiothorac Vasc Anesth 1994; 8: 153–6.
Staehler G, Brkovic D. The role of radical surgery for renal cell carcinoma with extension into the vena cava. J Urol 2000; 163: 1671–5.
Polascik TJ, Partin AW, Pound CR, Marshall FF. Frequent occurrence of metastatic disease in patients with renal cell carcinoma and intrahepatic or supradiaphragmatic intracaval extension treated with surgery: an outcome analysis. Urology 1998; 52: 995–9.
Kuczyk MA, Bokemeyer C, Köhn G, et al. Prognostic relevance of intracaval neoplastic extension for patients with renal cell cancer. Br J Urol 1997; 80: 18–24.
Hatcher PA, Anderson EE, Paulson DF, Carson CC, Robertson JE. Surgical management and prognosis of renal cell carcinoma invading the vena cava. J Urol 1991; 145: 20–4; discussion 3–4.
Giberti C, Oneto F, Martorana G, Rovida S, Carmignani G. Radical nephrectomy for renal cell carcinoma: long-term results and prognostic factors on a series of 328 cases. Eur Urol 1997; 31: 40–8.
Glazer AA, Novick AC. Long-term followup after surgical treatment for renal cell carcinoma extending into the right atrium. J Urol 1996; 155: 448–50.
Wilkinson CJ, Kimovec MA, Uejima T. Cardiopulmonary bypass in patients with malignant renal neoplasms. Br J Anaesth 1986; 58: 461–5.
Sasaoka N, Kawaguchi M, Sha K, et al. Intraoperative immediate diagnosis of acute obstruction of tricuspid valve and pulmonary embolism due to renal cell carcinoma with transesophageal echocardiography. Anesthesiology 1997; 87: 998–1001.
Plowman AN, Bolsin SN, Patrick AJ. Unusual cause of intraoperative hypotension diagnosed with transoesophageal echocardiography in a patient with renal cell carcinoma. Anaesth Intensive Care 1999; 27: 63–5.
Novick AC, Kaye MC, Cosgrove DM, et al. Experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi. Ann Surg 1990; 212: 472–6; discussion 6–7.
Mejean A, Vogt B, Quazza JE, Chretien Y, Dufour B. Mortality and morbidity after nephrectomy for renal cell carcinoma using a transperitoneal anterior subcostal incision. Eur Urol 1999; 36: 298–302.
Rodriguez-Rubio FI, Abad JI, Sanz G, et al. Surgical management of retroperitoneal tumors with vena caval thrombus in the inferior cava using cardiopulmonary bypass, arrested circulation and profound hypothermia. Eur Urol 1997; 32: 194–7.
Almassi GH. Surgery for tumors with cavoatrial extension. Semin Thorac Cardiovasc Surg 2000; 12: 111–8.
Welz A, Schmeller N, Schmitz C, Reichart B, Hofstetter A. Resection of hypernephromas with vena caval or right atrial tumor extension using extracorporeal circulation and deep hypothermic circulatory arrest: a multidisciplinary approach. Eur J Cardiothorac Surg 1997; 12: 127–32.
Vogt PR, Ensner R, Prêtre R, et al. Less invasive surgical treatment of renal cell carcinomas extending into the right heart and pulmonary arteries: surgery for renal cell carcinoma. J Card Surg 1999; 14: 330–3.
Kalaycioglu S, Sinci V, Aydin H, Soncul H. Cardiopulmonary bypass technique for treatment of renal cell carcinoma extending into the vena cava. Ann Thorac Cardiovasc Surg 1999; 5: 419–21.
Helm RE, Gold JP, Rosengart TK, Zelano JA, Ison OW, Krieger KH. Erythropoietin in cardiac surgery. J Card Surg 1993; 8: 579–606.
Laupacis A, Fergusson D. Erythropoietin to minimize perioperative blood transfusion: a systematic review of randomized trials. The International Study of Perioperative Transfusion (ISPOT) Investigators. Transfus Med 1998; 8: 309–17.
Kochamba GS, Pfeffer TA, Sintek CF, Khonsari S. Intraoperative autotransfusion reduces blood loss after cardiopulmonary bypass. Ann Thorac Surg 1996; 61: 900–3.
Petry AF, Jost T, Sievers H. Reduction of homologous blood requirements by blood-pooling at the onset of cardiopulmonary bypass. J Thorac Cardiovasc Surg 1994; 107: 1210–4.
Whitten CW, Allison PM, Latson TW, et al. Evaluation of laboratory coagulation and lytic parameters resulting from autologous whole blood transfusion during primary aortocoronary artery bypass grafting. J Clin Anesth 1996; 8: 229–35.
Schönberger JPAM, Bredée JJ, Tjian D, Everts PAM, Wildevuur CRH. Intraoperative predonation contributes to blood saving. Ann Thorac Surg 1993; 56: 893–8.
Gan TJ, Bennett-Guerrero E, Phillips-Bute B, et al. and theHextend Study Group. Hextend®, a physiologically balanced plasma expander for large volume use in major surgery: a randomized phase III clinical trial. Hextend Study Group. Anesth Analg 1999; 88: 992–8.
Lazarchick J, Conroy JM. The effect of 6% hydroxyethyl starch and desmopressin infusion on von Willebrand factor: ristocetin cofactor activity. Ann Clin Lab Sci 1995; 25: 306–9.
Conroy JM, Fishman RL, Reeves ST, Pinosky ML, Lazarchick J. The effects of desmopressin and 6% hydroxyethyl starch on factor VIII:C. Anesth Analg 1996; 83: 804–7.
Lang K, Boldt J, Suttner S, Haisch G. Colloids versus crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery. Anesth Analg 2001; 93: 405–9.
Edelman MJ, Potter P, Mahaffey KG, Frink R, Leidich RB. The potential for reintroduction of tumor cells during intraoperative blood salvage: reduction of risk with use of the RC-400 leukocyte depletion filter. Urology 1996; 47: 179–81.
Levi M, Cromheecke ME, de Jonge E, et al. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet 1999; 354: 1940–7.
Laupacis A, Fergusson D. Drugs to minimize perioperative blood loss in cardiac surgery: meta-analyses using perioperative blood transfusion as the outcome. The International Study of Peri-operative Transfusion (ISPOT) Investigators. Anesth Analg 1997; 85: 1258–67.
Bennett-Guerrero E, Sorohan JG, Gurevich ML, et al. Cost-benefit and efficacy of aprotinin compared with — aminocaproic acid in patients having repeated cardiac operations. A randomized, blinded clinical trial. Anesthesiology 1997; 87: 1373–80.
Hill GE, Pohorecki R, Alonso A, Rennard SI, Robbins RA. Aprotinin reduces interleukin-8 production and lung neutrophil accumulation after cardiopulmonary bypass. Anesth Analg 1996; 83: 696–700.
Stefanou DC, Gourlay T, Asimakopoulos G, Taylor KM. Leucodepletion during cardiopulmonary bypass reduces blood transfusion and crystalloid requirements. Perfusion 2001; 16: 51–8.
Despotis GJ, Joist JH, Hogue CW Jr, et al. The impact of heparin concentration and activated clotting time monitoring on blood conservation. A prospective, randomized evaluation in patients undergoing cardiac operation. J Thorac Cardiovasc Surg 1995; 110: 46–54.
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Moskowitz, D.M., Perelman, S.I., Cousineau, K.M. et al. Multidisciplinary management of a Jehovah’s Witness patient for the removal of a renal cell carcinoma extending into the right atrium. Can J Anesth 49, 402–408 (2002). https://doi.org/10.1007/BF03017330
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DOI: https://doi.org/10.1007/BF03017330