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| There is not a transfusion trigger (1). | A 41-year-old Jehovah's Witness in her sixth pregnancy presented at
32 weeks with obstructive jaundiance. Ultrasound showed dilated intrahepatic
and common bile ducts. Labour was induced at 35 weeks and she was delivered
of a normal, healthy baby girl. Eleven days later, an endoscopic retrograde
cholangiopancreatogram demonstrated a stone in the biliary tree and endoscopic
sphincterotomy was performed. Unfortunately, bleeding occurred from the
sphincterotomy site, wich necessitated an emergency laparotomy. Pre-operatively,
the hemoglobin was decreased to 9,8 g/dlitre;
the prothrombin time was normal. The arterial blood pressure was 80/65
mmHg and the pulse was 100 beats/minute.
Cholecistectomy was performed, ine stone was removed from the common bile duct and a large retroduodenal hematoma was evacuated. At the end of the procedure the patient was transferred, anaesthetised, intubated and ventilated, to intensive care unit. The pulse rate was 110 beats/minute in sinus rhytm, blood pressure 100/60 mmHg. The hemoglobin was 3.1 g/dlitre and her clotting screen was within expected limits for the degree of haemodiluition. |
| Discuss consequences with the patient, including the potential for life-threatening hemorrage and possible death if not transfused (2) | Discussion with both the patient and her husband before the
operation had made it clear that they did not wish either blood or blood
products to be administred under any circumstances and a disclaimer was
signed to this effect. Despite the patient's critical postoperative state,
her husband could not be persuased to change his views, wich were respected.
Discussion with the local Blood Transfusion Service confirmed
that there were non synthetic oxygen-carrying substances available
in this country.
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| Others Authors reduced the oxygen consumption by surface cooling, muscle paralysis, controlled ventilation and a barbiturate infusion. | It was therefore decided to continue intermittent positive pressure
ventilation to maintain optimal oxygenation and to reduce the risk
of pulmonary oedema. Gelatin solution was used to maintain her circulating
volume. She was given vitamin K, cimetidine and cefuroxime, with midazolam
and fentanyl for sedation and analgesia.
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The average increase in haemoglobin concentration was approximately 2g/weeks without recombinant erythropoietin. |
Postoperatively, in the first 13 hours she received a total of 4750
ml of intravenous fluid, of wich 4150 ml was gelatin solution and
balance crystalloid. Over the next 24 hours she received 5565 ml (4950
ml gelatin solution) but she was unable to mantain her blood pressure and
therefore on the third day a dopamine infusion was started and increased
to a rate of 9 mcg/Kg/minute to achieve a systolic blood pressure of 100
mmHg. On the fifth day she received 3787 ml (2380 ml gelatin solution),
but her blood pressure was still only 70-80 mmHg systolic and her central
venous pressure +10 cm H2O. She had passed 3330 ml
of urine in the preceding 24 hours. It was considered that to increase
her fluid input in an attempt to raise her central venous pressure and
blood pressure , but without using plasma protein, would put her at risk
of developing pulmonary oedema (serum albumin at this time was 10 g/dlitre).
An infusion of amino acid and glucose solution (Vamin/Glucose) was
started to provide a substrate for the syntesis of albumin. She developed
oedema of her hands and forearms and so was started on regular diuretic
therapy. The chest X ray remained free from signs of pulmonary oedema.
The dopamine requirement over the next several days increased, so that by the twelfth day it had reached 15 mcg/kg/minute. Dobutamine was therefore introduced and the dopamine decreased to 5 mcg/kg/minute. The blood pressure increased in the succeeding 24 hours and permitted a slow withdrawal of dobutamine. After admission to the intensive care unit, her haemoglobin fell to a minimum of 1.8 g/dlitre on the fifth day, and thereafter began to increase steadily (fig.1).  She was treated with parenteral iron sorbitol and folic acid. Minisamples of blood were used throughout to minimize iatrogenic blood loss. Ventilation of the lungs was maintained with 60% inspired oxygen, and reduced to 50% on day 10. She developed severe hypernatriemia with a serum concentration of 168 mmol/litre on the sixth day. The sodium content of the gelatin solution is 145 mmol/litre and so the infusion was stopped. Within a few hours her blood pressure has decreased to 70 mmHg systolic and so the infusion was restarted. She had periods of pyrexia, up to 39°C and persistent, moderate abdominal pain. On the eighteenth day a sudden increase in the white cell count to 36800/cu mm and the loss of the T-tube drain within abdomen prompted further surgical intervention. At laparotomy, the drain was recovered and a large collection of bile was drained from the right upper quadrant of the abdominal cavity, from wich coliform bactera were grown. She returned to the general ward after the operation. The haemoglobon value was 7,1 g/dlitre and albumin 22 g/dlitre. Thirty-four days after the initial surgery, she returned home with a haemoglobin value of 7,7 g/dlitre. |