11.3 Blood transfusion + Jehovah's Witness Flashcards
A 57-year-old patient is scheduled for resection of a colonic carcinoma in 3 weeks’ time.
The haemoglobin is 10.1 g/dl at time of referral to the pre-assessment clinic.
a) What intraoperative methods can be used to minimise allogeneic blood transfusion? (35%)
Surgical:
» Senior surgical team.
> > (Staged) laparoscopic surgery.
> > Meticulous haemostasis, diathermy.
> > Biological haemostats, e.g. Kaltostat (cellulose), fibrin glues (Tisseel).
> > Cell salvage
(leucocyte depletion filter in view of malignancy).
(In other types of surgery, the use of a tourniquet and positioning to avoid venous stasis will also help minimise blood loss).
Anaesthetic:
» Senior anaesthetic team.
> > Avoid venous congestion:
adequate relaxation, avoid high intrathoracic
pressures, avoid hypercapnia.
> > Patient warming:
avoid the coagulopathy associated
with hypothermia.
> > Flow monitoring: optimise tissue
oxygen delivery by appropriate fluid and
vasopressor use.
> > Regional anaesthesia.
> > Keep blood pressure low –
depends on comorbidities.
> > Near patient monitoring of coagulation.
Pharmacological:
» Recombinant clotting factors VIII, IX, VIIa.
» Antifibrinolytics, e.g. tranexamic acid.
» Desmopressin promotes von Willebrand’s factor release.
b) What steps constitute the final check required by the National Patient Safety Agency’s ‘Right Patient,
Right Blood’ guideline? (25%)
At the patient’s bedside, the person responsible for transfusion must:
» Ask the patient to state
name, surname and date of birth (if able).
> > Check those details against identity wristband.
> > Check those details against label/tag on blood unit.
c) What are the additional preoperative preparations that must be made if this patient is a Jehovah’s
Witness. (40%)
Preoperative:
> > Advance decision:
full discussion with patient
(in absence of family,
with time for the patient
to make decisions)
regarding what, if any,
blood components are acceptable.
Check acceptability of cell salvage.
Discussion about increased risk of morbidity and mortality if blood transfusion refused.
Appreciation that there are no true blood
alternatives.
Understanding that the patient is free
to change mind until
they are unable to do so due to anaesthesia,
and that no one else is able
to change the directive on their behalf.
Can have another conversation in
the presence of family/member
of Hospital Liaison Team if desired.
> > Haematology advice:
consideration of
preoperative erythropoietin,
iron (may be intravenous),
folate,
B12
(effect likely to be limited by the
existence of malignancy
and short time available).
*» Stop anticoagulants and antiplatelets if possible.
*» Plan for intraoperative care to
ensure that senior teams (who are willing to
comply with the patient’s refusal of blood products), cell salvage etc. are all available on day of surgery.
> > Plan for postoperative care
and discuss rationale with the patient:
• Higher dependency postoperative care,
possibly ventilation on ICU
depending on blood loss.
• Supplemental oxygen.
• Careful monitoring to optimise
cardiac output and, therefore, oxygen
delivery, but also to check for postoperative bleeding.
• Consideration of hyperbaric oxygen if haemoglobin very low and facility permits.
