AUCTORES
Globalize your Research
Case Report | DOI: https://doi.org/10.31579/2690-4861/221
1 Hospital das clínicas de Belo Horizonte, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
*Corresponding Author: Marina Delgado, Hospital das clínicas de Belo Horizonte, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
Citation: Marina Delgado. (2022) Conservative Blood Management and Anesthetic Considerations in A Jehovah’s Witness Patient Undergoing Pancreatoduodenectomy. A Case Report. International Journal of Clinical Case Reports and Reviews. 11(2); DOI: 10.31579/2690-4861/221
Copyright: © 2022 Marina Delgado, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 09 May 2022 | Accepted: 13 May 2022 | Published: 19 May 2022
Keywords: jehovah’s witness; anesthesia; blood conservation; transfusion; cell salvage
Major surgery in a Jehovah's Witness patient represents a challenge for the anesthetic and surgical team not only because of the ethical dilemma, but also because it creates a major obstacle to the rapid control of hemorrhage in a surgical setting. We present a case report of a pancreatoduodenectomy in a Jehovah's Witness patient who refused to be transfused with the use of the principles of bloodless surgery and maintenance of cell savage as a backup, if necessary. The advances in our understanding of hemostatic agents and available techniques for managing patient bleeding represent options for avoiding blood transfusion in this patient population and all patients undergoing major surgery
The Jehovah’s Witness (JW) is a Christian religion that believe that life, which is held as sacred is represented by the blood, thus blood acquires a sacred status. The believe that taking into their bodies, the blood of another creature violates biblical law. The prohibition of blood transfusion is a deeply held core value and is a sign of respect for the sanctity of life [8]. The beliefs of the JW are based on their interpretation of biblical passages that transfusion of whole blood, packed red cells platelets and plasma are unacceptable health treatment. Depending on individual interpretation, transfusion of secondary blood components such as albumin, cryoprecipitate, clotting factors and erythropoietin may be allowed. Many JW also accept acute normovolemic hemodilution and cell salvage machines if the apparatus maintain the continuity of the drainage with the circulation [6]. Blood conservative methods consist of techniques that minimize blood loss and improve patients' own supply with better outcomes and it should be the first effort during any surgery, especially in Jehovah's Witness [9].
The present case illustrates a successful pancreatoduodenectomy surgery in a patient who refused to be transfused and highlighted the complexity in a case of a major surgery with bleeding potential in a Jehovah’s witness patient.
R.P.S., 70 years old, Jehovah witness, female, Brazilian, 40 kg, 1,50m, diagnosed with pancreatic adenoma presented herself for tumor resection and pancreatoduodenectomy (Whipple surgery). Once proposed for surgery, patient firmly deny the possibility to receive transfusions of whole blood, packed erythrocytes, platelets and plasma. She also rejected auto transfusion with blood pre-deposit. She accepted the use of pro-thrombotic drugs such as Tranexamic Acid, plasma derived fractions such as Albumin and
Cryoprecipitate and the use of intraoperative blood conservative techniques as cell salvage and acute normovolemic hemodilution. Preoperative laboratory test showed hemoglobin of 12,3 g/dl with no B12 or iron deficiency.
She was continuously monitored with cardioscopy, peripheral oxygen saturation, invasive blood pressure and bispectral index. A 16G vein catheter was inserted and she was sedated with midazolam 5mg. An epidural anesthesia was performed at T10-T11, using loss of resistance technique, 10ml of 0,2% ropivacaine was injected with 2mg morphine. An epidural catheter was introduced and maintained in the postoperative period. Anesthesia induction and maintenance was performed with continuous infusion of remifentanil (0,2mcg/Kg/min), propofol 2,5mg/kg, Ketamine 0,3mg/kg, Rocuronium 0,6mg/kg and Lidocaine 1mg/kg. A central venous catheter was placed in the right jugular vein with ultrasound guidance and left radial artery cannulation was performed. A Flotrac® was used to calculate the cardiac output and stroke volume, using a left radial arterial line. The systemic vascular resistance could be calculated from the values of central venous pressure (CVP), cardiac index and invasive blood pressure. Tranexamic acid 10 mg/kg was administered before the incision.
During surgery, no major bleeding was observed. 3000ml lactated ringer’s solution and norepinephrine solution 0,05mcg/kg/min were administrated in order to maintain a normal hemodynamic status. Care was taken during the procedure to maintain immobility, normothermia, stable blood pressure and euvolemic state. As there was no profuse bleeding, the cell salvage did not need to be used. Postoperative analgesia was granted by ropivacaine continuous infusion via epidural catheter.
JW are a religious group that do not accept blood transfusion in any manner, even in life threatening situation and so, it become a dilemma for surgeons and anesthesiologists in surgeries with the possibility of substantial blood loss. It is possible to carry out major surgeries without receiving blood with optimum preoperative preparation, meticulous and fast surgery and adequate monitoring [5]. Numerous strategies and technologies allow the reduction of blood product transfusion. Before surgery, a meticulous coagulopathy research and hemodynamic optimization are useful to prepare the patient for surgery tranexamic acid intraoperatively has been reported to reduce blood loss and for that, can be beneficial for JW patients [8].
One of the most important intraoperative blood conservation techniques is the autologous cell salvage, a strategy in which perioperative team collects blood lost on the surgical field and prepares it for transfusion back into the patient. The process begins with aspiration of blood, citrate or heparin is added to prevent clotting, until the moment of separation and washing of the red blood cells (removal of anticoagulant, free hemoglobin and cellular debris). Finally, the solution is centrifugated and a packed red blood cells from autologous blood is produced [6] [1].
Cell Saver is one of the main techniques used to reduce the need for allogeneic blood transfusion in major surgery. The National Institute for Health and Care Excellence (NICE) recommends the use of a cell saver in surgeries if is expected a blood loss greater than 500 ml, such in major cardiac, vascular, urologic surgeries, thoracic surgery, abdominal and pelvic trauma, transplants, obstetric and orthopedic surgery. In addition, it can also be considered in the presence of coagulopathy, in patients with rare blood type or multiple erythrocyte antibodies, and when the patient refuses allogeneic blood transfusion [4]. Wang et al demonstrated the benefits of autologous cell salvage during cardiac surgery. The authors concluded that autologous cell salvage reduced red blood cell transfusion [5]. A 2010 systematic review that pooled 75 clinical trials, including orthopedic, cardiac, and vascular surgery, showed a 21% reduction in the use of allogeneic blood. In 2015, a Cochrane systematic review found a reduction in transfusion of 4.7 units of blood [2]
Situations such as infection, potential for contamination and the presence of tumor cells in the blood collected must be evaluated on a case-by-case basis and therefore constitute relative contraindications [4,5] Autologous cell salvage is controversial in cancer surgery due to the possibility of dissemination of malignant cells. However, recent developments such as leukocyte depletion filtering and blood irradiation may remove the contaminating tumor cells and had shown to be safe and efficacious in oncologic surgeries [3]. Moreover, it is well known that metastatic process is not simple and require adequate number and viability of circulating tumor cells. [7] supported that the salvaged blood is devoid of tumor cell and safe for transfusion. The authors found that the fewer tumor cells in the filtered salvaged blood is significantly lower than the number of circulating tumor cells in the patient own blood. Tumor cells in the salvaged blood are not as potent as in the circulating blood and that is why it is incapable of metastatic seeding. During the filtration steps, the tumor cells membrane loses their integrity, become dysfunctional with no replicative capacity [7].
Although we did not used the cell salvage in this case, this approach potentially could be used in a JW patient to reduce transfusions, particularly during profuse bleeding. Patients who received salvaged blood had no significant difference in distant metastasis rate or tumor recurrence compared to those who received other forms of blood transfusion [4,5]. Overall, salvaged blood in cancer patient should be considered as an alternative to avoid blood transfusion and consequently, the potential risks related to blood transfusion, i.e., immunomodulation, infections and transfusion reaction [2].
Major surgery in a JW patient requires exceptional perioperative management and monitoring as it can last long and may involve significant blood loss. JW patients should not be rejected, but adequately counseled for the successfully of the procedure. In addition, blood supplies could be not always available and present high cost. Strategies to avoid transfusions are therefore desirable. These principles are likely to gain popularity and become standard practice for all patients.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
