prof. mridul panditrao's peri-operative management of jehovah's witness patient

PERI-OPERATIVE PERI-OPERATIVE MANAGEMENT OF AMANAGEMENT OF A

“JEHOVAH’S WITNESS”“JEHOVAH’S WITNESS”PATIENT POSTED FOR AN PATIENT POSTED FOR AN

EMERGENCY EMERGENCY EXPLORATORY EXPLORATORY LAPAROTOMY:LAPAROTOMY:

A CASE REPORT, SERIES ANDA CASE REPORT, SERIES ANDA PROPOSED PROTOCOLA PROPOSED PROTOCOL

Dr. M.M. PANDITRAODr. M.M. PANDITRAODr.(Mrs.) M.M. PANDITRAODr.(Mrs.) M.M. PANDITRAO

Dr.(Mrs.) B.B. SHAHDr.(Mrs.) B.B. SHAHDr.(Mrs.) M. BANNERJEE*Dr.(Mrs.) M. BANNERJEE*

Dr. S. DAS Dr. S. DAS

Department of Anaesthesiology & Critical CareDepartment of Anaesthesiology & Critical CarePadmashree Dr. D. Y. Patil Medical CollegePadmashree Dr. D. Y. Patil Medical College

(Deemed University)(Deemed University)Pimpri, Pune Pimpri, Pune

INTRODUCTIOINTRODUCTIONN

The members of “Jehovah’s witness”, a group of

believers in Christianity, who refuse to accept

“BLOOD TRANSFUSION”,

even auto transfusion, blood products and albumin,

pose a special challenge to the Anaesthesiologists/

Clinicians and are often turned down by hospitals.

The basis of this belief is according to the dictate

given in the Gospels.

THE BIBLE: NEW TESTAMANT: (Acts: Chapter THE BIBLE: NEW TESTAMANT: (Acts: Chapter

15:verses 28/29)15:verses 28/29)

2828"For it seemed good to the Holy "For it seemed good to the Holy

Spirit and to us to lay upon you no Spirit and to us to lay upon you no

greater burden than these greater burden than these

essentials: essentials: 2929 that you abstain that you abstain

from things sacrificed to idols and from things sacrificed to idols and

from blood from blood and from things and from things

strangled and from fornication; if strangled and from fornication; if

you keep yourselves free from such you keep yourselves free from such

things, you will do well. Farewell.“things, you will do well. Farewell.“THE BIBLE: NEW TESTAMANT: (Acts: Chapter 15:verses 28/29)THE BIBLE: NEW TESTAMANT: (Acts: Chapter 15:verses 28/29)

For elective procedure:For elective procedure:

Preventive and precautionary measures- Preventive and precautionary measures-

• Building up of HaemoglobinBuilding up of Haemoglobin

• Use of torniquettesUse of torniquettes

• Better surgical skills Better surgical skills

(electro-cautery, managing Haemostasis)(electro-cautery, managing Haemostasis)

• Other alternatives of blood loss:Other alternatives of blood loss:

COLLOIDS COLLOIDS – – Polygelins, starches or Polygelins, starches or Dextrans. Dextrans.

CASE REPORTCASE REPORTA 65 year old male A 65 year old male Occupation - mechanic Occupation - mechanic Complaints - distention of abdomen & Complaints - distention of abdomen &

pain in abdomen since 4-5dayspain in abdomen since 4-5days

Past HistoryPast HistoryLump in abdomenLump in abdomenOperated case for the same one month Operated case for the same one month

backback

Personal historyPersonal history

Appetite - Appetite - decreased decreased

Sleep - Sleep - decreased decreased

Stool - Stool - not passed not passed

Bladder- Bladder- normalnormal

Family historyFamily history - - Not Not

significantsignificant

Drug historyDrug history - - Not Not

significantsignificant

GENERAL GENERAL EXAMINATIONEXAMINATIONAveragely built, cachexic maleAveragely built, cachexic male

AfebrileAfebrilePallor ++Pallor ++Decreased response to oral Decreased response to oral

commandcommandPulsePulse-98/min-98/minBP-140/80 mm HgBP-140/80 mm HgR/RR/R-24/ min-24/ minMPC- Grade IIMPC- Grade II

SYSTEMIC SYSTEMIC EXAMINATIONEXAMINATION

• CNS-Decreased response to verbal commandsCNS-Decreased response to verbal commands

• Rest Examination was essentially normalRest Examination was essentially normal

PROVISIONAL ΔPROVISIONAL Δ

? Ac.INTESTINAL OBSTRUCTION ? Ac.INTESTINAL OBSTRUCTION

SEPTICAEMIASEPTICAEMIA

INVESTIGATIOINVESTIGATIONSNS

HB - HB - 8 gm%,8 gm%,

TLC - 9900,TLC - 9900,

DLC (%) DLC (%) N-86N-86, L-08, M-03, E-03, , L-08, M-03, E-03,

ESR - ESR - 60 mm/hr60 mm/hr..

BT/CT - 01’30”/05’15” Mins.BT/CT - 01’30”/05’15” Mins.

BSL® - 86mg%,BSL® - 86mg%,

Sr. Cr - 1.4mg%, BUL - 31mg%,Sr. Cr - 1.4mg%, BUL - 31mg%,

Sr. Electrolyte - NaSr. Electrolyte - Na++-143 meq/lit, -143 meq/lit,

KK++- - 2.7 meq/lit, 2.7 meq/lit,

ClCl- - 106 meq/lit106 meq/lit

Urine Examination:Urine Examination:

Routine - Routine - Albumin: +3Albumin: +3, Sugar - , Sugar - absentabsent

Microscopic - Pus cells 8-10/hpf,Microscopic - Pus cells 8-10/hpf,

Epi.cells 1-2/hpf, Epi.cells 1-2/hpf, RBC 10-RBC 10-12/hpf.12/hpf.

LFTLFT : Sr.Bilirubin (T) 0.5mg%, : Sr.Bilirubin (T) 0.5mg%, (Dir)0.1mg% (Dir)0.1mg% ALT-30 IU/lit, ALP-ALT-30 IU/lit, ALP-

47IU/lit.47IU/lit.

CXR CXR : Normal: Normal

ECG ECG : WNL: WNL

USG (Abdomen) :USG (Abdomen) :

Multiple retro-peritoneal nodes are Multiple retro-peritoneal nodes are seenseen

? Lymphomatous in origin? Lymphomatous in origin

Other possibilities - Other possibilities -

? Retro-peritoneal sarcoma/fibrosis? Retro-peritoneal sarcoma/fibrosis

? Metastases/Secondaries? Metastases/Secondaries

Pancreas-NormalPancreas-Normal

Gall bladderGall bladder-Reveals sludge within.-Reveals sludge within.

Both kidneys are minimally Both kidneys are minimally

swollenswollen..

ANESTHETIC MANAGEMENTANESTHETIC MANAGEMENT

Patient was taken for surgery under Patient was taken for surgery under General Anesthesia , as ASA V (E) at General Anesthesia , as ASA V (E) at 3.45pm. 3.45pm.

• Special consent for “No Blood Transfusion”Special consent for “No Blood Transfusion”

• NBM NBM

• Intravenous lines: CVP & a 18G cannula secured.Intravenous lines: CVP & a 18G cannula secured.

• Pulse rate -100/min,Pulse rate -100/min,

• BP - 140/80 mmHgBP - 140/80 mmHg

• Respiratory rate - 20/min. Respiratory rate - 20/min.

• Pre-induction CVPPre-induction CVP - 12 cm of H - 12 cm of H22O, O,

• SpO2= 100%.SpO2= 100%.

• ECG monitoring with standard lead II was startedECG monitoring with standard lead II was started

INDUCTION:INDUCTION:• Pre-oxygenation with 100% oxygen by Pre-oxygenation with 100% oxygen by

mask for 3 min mask for 3 min

• Induced with IV Propofol sleep dose (12 Induced with IV Propofol sleep dose (12 ml., 1%) and Succinylcholine 100mg.ml., 1%) and Succinylcholine 100mg.

• Sellick’s maneuvere Sellick’s maneuvere

• Intubated with ET tube no. 8.5, cuff Intubated with ET tube no. 8.5, cuff inflated. Air entry checked, Tube fixed.inflated. Air entry checked, Tube fixed.

• N.M.Blockade with AtracuriumN.M.Blockade with Atracurium

• Continuous monitoring of Pulse, Continuous monitoring of Pulse, BP,SaO2%, ECG, CVP, Urine output and BP,SaO2%, ECG, CVP, Urine output and Blood loss.Blood loss.

MAINTANENCEMAINTANENCE::• Maintained on controlled ventilation on OMaintained on controlled ventilation on O22 + +

NN22O (50:50) & Isoflurane- trace conc.O (50:50) & Isoflurane- trace conc.

• IV Pentazocine 15 mg and IV Torsemide 5 mg IV Pentazocine 15 mg and IV Torsemide 5 mg

• CVP CVP ≈ ≈ 12 cm H12 cm H22O maintained upto the resection O maintained upto the resection

of obstructed bowel loop, then went down upto of obstructed bowel loop, then went down upto

≈≈ 2 cmH 2 cmH22O. Third space loss ≈ 2000 ml.O. Third space loss ≈ 2000 ml.

• Prophylactically – Tetrastarch- VoluvenProphylactically – Tetrastarch- VoluvenR R infused, infused,

2packs of 500mi. Given intra-operatively 2packs of 500mi. Given intra-operatively

• IV fluids replaced as per NBM and maintenance IV fluids replaced as per NBM and maintenance

needs.needs.

REVERSALREVERSAL

• Neostigmine 2.5mg+ Atropine 1.2mgNeostigmine 2.5mg+ Atropine 1.2mg

• Patient extubated after suctioningPatient extubated after suctioning

• Patient was shifted to ICU on oxygen Patient was shifted to ICU on oxygen through Ventury maskthrough Ventury mask

• In ICU Voluven continued -3In ICU Voluven continued -3rdrd pack pack

• Uneventful course and recovery within Uneventful course and recovery within a weeka week

4.40 4.40 pmpm

05.00 05.00 pmpm

5.30 5.30 pmpm

6.00 6.00 pmpm

6.30p6.30pmm

7.00 7.00 pmpm

7.30 7.30 pmpm

IV IV drugdrugss

AtracurAtracuriumium

AtracuAtracuriumrium





PentazPentazocineocine

TorseTorsemidemide

IV IV infuinfusionsion

DNSDNS

VoluvVoluvenen

RLRL

VoluvVoluvenen

DNSDNS RLRL

VoluvVoluvenen

DNSDNS

VoluvVoluvenen

SpOSpO22100%100% 100%100% 100%100% 100%100% 100%100% 100%100% 100%100%

CVPCVP +12cm +12cm HH22OO

+12c+12cm Hm H22OO

+12c+12cm Hm H22OO

+12 +12 cm cm HH22OO

+2cm +2cm HH22OO

+2 cm +2 cm HH22OO

+4cm +4cm HH22OO

BPBP 140/80140/80mm.Hgmm.Hg

110/7110/70mmH0mmHgg

100/7100/70mm. 0mm. HgHg

100/7100/70mm. 0mm. HgHg

100/70 100/70 mmHgmmHg

110/7110/70mm. 0mm. HgHg

130/7130/70mm. 0mm. HgHg

PRPR 100/100/minmin

120/120/min.min.

110/110/min.min.

106/106/min.min.

110/110/min.min.

102/102/min.min.

110/110/minmin

DISCUSSIONDISCUSSIONA person who belongs to “Jehovah's Witness” A person who belongs to “Jehovah's Witness” faith, believes that as per directives in faith, believes that as per directives in

The BibleThe Bible ( New Testament: Acts, 15 : 28/29) ( New Testament: Acts, 15 : 28/29) “Keep abstaining “Keep abstaining

from blood,”from blood,”

In patients posted for planned elective In patients posted for planned elective surgery:surgery:

• Consideration to optimize the patients G.C.Consideration to optimize the patients G.C.

• To reduce blood loss intra-operatively.To reduce blood loss intra-operatively.

• Correction of Anaemia by giving oral or Correction of Anaemia by giving oral or parenteral Iron preparation pre-operatively.parenteral Iron preparation pre-operatively.

• Pre-assessment of inevitable blood loss intra-Pre-assessment of inevitable blood loss intra-operatively and planning of surgery according operatively and planning of surgery according to the absolute need.to the absolute need.

Use of proper technique to ensure :Use of proper technique to ensure :

• Meticulous Haemostasis during the surgery.Meticulous Haemostasis during the surgery.

• Minimize duration of surgery by using enlarged Minimize duration of surgery by using enlarged

expert surgical team. expert surgical team.

• Use of Topical haemostatic agents- Ab-gel, Use of Topical haemostatic agents- Ab-gel,

Haemolock or Use of Systemic haemostatic agent Haemolock or Use of Systemic haemostatic agent

– Tranexamic acid– Tranexamic acid

• Use of electro-cautery, thermal balloon, laser.Use of electro-cautery, thermal balloon, laser.

• Mechanical occlusion of blood vessels by ligation Mechanical occlusion of blood vessels by ligation

vascular clips, clamps.vascular clips, clamps.

Controlled Hypotensive Anesthesia Controlled Hypotensive Anesthesia

But our patient for emergency Laparotomy with Hb of 8gm% with high risk of blood loss,who refused for transfusion of blood and all kinds of blood products posed a challenge for the maintenance of cardiovascular stability intraoperatively. The volume replacement with only crystalloids was also unsuitable and risky as patient was also anaemic.

So we decided to use Tetrastarch –Voluven

• It is of vegetative origin & it fulfills the religious It is of vegetative origin & it fulfills the religious criteria of patient of not accepting any blood related criteria of patient of not accepting any blood related productsproducts

• It has a minimal tendency to produce allergic reactionIt has a minimal tendency to produce allergic reaction

• Does not interfere with coagulationDoes not interfere with coagulation

• Remains in the intra-vascular compartment for longer Remains in the intra-vascular compartment for longer duration (6-8hrs)duration (6-8hrs)

• It improves microcirculation.It improves microcirculation.

• It maintains good Oxygen saturationIt maintains good Oxygen saturation

• Does not cause volume overload, especially in Does not cause volume overload, especially in compromised patients.compromised patients.

WITH THIS EXPERIENCEWITH THIS EXPERIENCE& &

AS THE WORD SPREAD AS THE WORD SPREAD AROUND, BY THIS TIME AROUND, BY THIS TIME WE HAVE DONE A SERIES WE HAVE DONE A SERIES OF THESE PATIENTS IN OF THESE PATIENTS IN OUR O.T.OUR O.T.

Sr.NSr.Noo

Type of Type of SurgerySurgery

Elect/Elect/EmergencyEmergency

AnesthesiAnesthesiaa

1.1. Expl. Expl. LaparotomyLaparotomy

EmergencyEmergency GAGA

2.2. SplenectomySplenectomy ElectiveElective GAGA

3.3. LSCSLSCS EmergencyEmergency SASA

4.4. ORIF ORIF (humerus)(humerus)

ElectiveElective GAGA

5.5. ORIF ORIF (Femur)(Femur)

ElectiveElective SASA

6.6. CholecystectCholecystectomyomy

ElectiveElective GAGA

Sr.NSr.Noo

Type of Type of SurgerySurgery

Elect/Elect/EmergencyEmergency

AnesthesiaAnesthesia

7.7. LSCSLSCS EmergencyEmergency GAGA

8.8. HerniorrhaHerniorrhaphyphy


9.9. HerniorrhaHerniorrhaphyphy


10.10. DHS DHS fixationfixation

ElectiveElective CSECSE

11.11. ORIF ORIF (tibia)(tibia)


12.12. ORIF ORIF (femur)(femur)


PROPOSED PROTOCOLPROPOSED PROTOCOL• For elective/ emergency surgeries under For elective/ emergency surgeries under

Regional Anaesthesia:Regional Anaesthesia: Pre loading with a Colloid : Tetra starchPre loading with a Colloid : Tetra starch Intra-op. continued use of colloidIntra-op. continued use of colloid Post-op. colloid upto 30ml/ kg/ 24 hoursPost-op. colloid upto 30ml/ kg/ 24 hours..

• For elective/ emergency surgeries under For elective/ emergency surgeries under General Anaesthesia: General Anaesthesia:

Intra-op. continued use of colloids along with Intra-op. continued use of colloids along with crystalloids crystalloids Post-op. colloid upto 30ml/ kg/24 hoursPost-op. colloid upto 30ml/ kg/24 hours. .

Our experience with this protocol Our experience with this protocol has been very gratifying and our surgical has been very gratifying and our surgical colleagues are quite satisfied !! colleagues are quite satisfied !!

CONCLUSIONCONCLUSION

• ““JEHOVAH’S WITNESS” Patients JEHOVAH’S WITNESS” Patients pose a peri-operative challengepose a peri-operative challenge

• A proper planning and meticulous A proper planning and meticulous pre-op. preparation is neededpre-op. preparation is needed

• If emergency surgery is needed: If emergency surgery is needed: gravity & risk is increased gravity & risk is increased

•We, with our ongoing We, with our ongoing experience have proposed a experience have proposed a protocol which works very well!protocol which works very well!

prof. mridul panditrao's peri-operative management of jehovah's witness patient

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