Cesarean hysterectomy in a Jehovah’s Witness with placenta percreta– discussion of two cases

Cesarean hysterectomy in a Jehovah’s Witness with placenta percreta–

discussion of two cases

Tom Archer, MD, MBA

UCSD Anesthesia

Learning objectives– answer following questions:

• What are the alternatives to homologous (allogeneic) blood transfusion?

• What are the techniques and physiology of acute normovolemic hemodilution (ANH)?

• What are the techniques and physiology of intraoperative cell salvage (IOCS)?

Alternatives to “other people’s blood” (allogeneic transfusion)

• Keep patient warm. Bair Hugger. Warm all fluids.

• Good surgical technique (“Factor 6.0”)

• Preoperative erythropoietin (EPO)

• Preoperative autologous donation (PAD)

• Acute normovolemic hemodilution (ANH)

• Intraoperative cell salvage (IOCS)

Alternatives to “other people’s blood” (allogeneic transfusion)

• Elective hypotension– global (drop the MAP)

• Elective hypotension– local (elevate the surgical site)

• Accept lower postoperative Hb (Hb = 8.5 was average ICU transfusion threshold in Europe in 2002. 7.0 was threshold in TRICC study).

Is allogeneic blood transfusion bad for patients?

• Infection– bacteria, viruses

• Immunomodulation– wound infections and tumor recurrence?

• Allergic reactions / TRALI

• Unknown junk?

• Non-functional, damaged RBCs?

• White cells?

Is fresh allogeneic blood better than old allogeneic blood?

• Better 2,3-DPG levels?

• Less debris and damaged cells?

• We don’t really know yet.

Case 1

• 42 y.o. G6P4 s/p 4 previous cesarean deliveries.

• Sent to UTHSCSA at 34 weeks due to placenta previa.

• Ultrasound suggestive of placenta percreta with bladder involvement.

Case 1

• JW, refusing transfusion. Interviewed alone multiple times. Signed paperwork.

• EPO 30,000 U / day from 4 days prior to surgery until 9 days after. +FeSO4

• At 34 4/7 weeks with Hct 33.8 surgery scheduled for next day when most experienced surgeon and cellsaver tech both available.

Case 1

• 16 g PIV x 2 (Each arm).

• Sodium citrate 30 cc po, metoclopramide 10 mg IV and famotidine 20 mg IV, midazolam 2 mg before OR.

• In OR 20 g right radial arterial line PulseCO monitor

• 8.5 right IJ sheath for ANH and re-transfusion

Case 1

• Lower body Bair Hugger during ANH. Upper body added after induction.

• All fluids warmed.

Case 1

• 1200 cc blood removed over 15 minutes, replaced with hetastarch 500 cc and Normosol 2000 cc.

• Phenylephrine 25-50 mcgm to maintain MAP as needed.

• No change in FHTs, monitored during ANH.

Case 1

• Hgb pre-ANH = 11.7

• Hgb post-ANH = 10.2

• Pre-O2 + fentanyl 100 mcgm

• RSI GA with propofol 100 mg, ketamine 50 mg, sux 100 mg.

• Maintenance: desflurane in O2 and air.

Case 1

• Difficult surgical dissection.

• Rocuronium 30 mg for muscle relaxation.

• Separate suction system used for amniotic fluid, which did not go to cellsaver suction cannister.

• 3450 gm male infant apgars 7/ 8.

Case 1

• Oxytocin 5 U given at urgent request of surgeon, despite continued presence of placenta and plan for hysterectomy with no attempt to remove placenta.

• Severe hypotension (MAP = 38) after oxytocin bolus.

Case 1

• MAP = 38 after oxytocin, treated with phenylephrine, crystalloid and hetastarch.

• Boggy, bleeding uterus. Difficult removal of uterus and part of bladder. Attempt to visualize ureteral orifices with IV methylene blue. Left ureteral orifice not seen.

• Due to heavy bleeding, further attempts to see left ureter were abandoned.

• Hemostasis sub-optimal ANH blood started.

• Hemostasis improved closure begun.

Case 1• EBL = 5500 cc. Cellsaver received 4824 cc of

shed blood.

• 1769 cc of washed, packed cells given back to patient. Patient also received 3500 cc crystalloid, 1000 cc hetastarch.

• Lungs clear, patient extubated at end of case.

• Hgb in ICU post op = 7.8

Case 1

• Creatinine day of surgery = 0.5

• Creatinine POD #1 = 0.9.

• IVP did not show left ureter

Case 1

• Left percutaneous nephrostomy under epidural on POD #2 when Hgb = 6.5

• Patient sent home on POD #7 with Hgb = 6.2

• POD #29 Hgb = 11.0

FIGURE 1

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Minutes after 0800

MA

P (

mm

Hg

) a

nd

HR

(b

ea

ts /

min

ute

)

HR MAP

ANH0840-0855

Induction 0901

Incision 0915

Delivery + oxytocin bolus

0935

Nadir of MAP 0936

Crystalloid, hetastarch, phenylephrine, ANH and cellsaver blood 0937-1100

FIGURE 2

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Arterial line minutes

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R (

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(ri

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is)

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SVR

CO

Skin incision(min 59)

Induction(min 45)

delivery and oxytocin(min 79)

Nadir of BP(min 81)

CO falls, despite low SVR

FIGURE 3

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90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110

Minutes after 0800

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SVR CO

Bolus oxytocin is dangerous!

• Dilates both resistance arterioles and capacitance veins.

• Has the potential for catastrophic hypotension if both SVR and CO (venous return) fall at the same time.

Another patient: bolus oxytocin decreases SVR dramatically, SV and CO increase in a compensatory manner.

Another patient: bolus oxytocin decreases SVR dramatically, SV and CO increase in a compensatory manner.

FIGURE 3

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90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110

Minutes after 0800

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xis)

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13.5

14

SVR CO

In this Jehovah’s Witness patient, oxytocin bolus caused decreases in BOTH the SVR and the CO, causing a severe drop in MAP.

Take home lesson about arteriolar vasodilators:

• If cardiac output cannot increase, MAP may crash.

• CO cannot increase in:– Hypovolemia

– Stenotic cardiopulmonary lesions (e.g. MS, AS, increased pulmonary resistance)

Erythropoietin (EPO)

• 10,000 – 30,000 U / day SQ.

• Not everyone responds.

• Important mediator of cerebral protection?

• Stay tuned to EPO story.

Nicolas Jabbour, MD,*Annals of Surgery • Volume 240, Number 2, August 2004

Preoperative Rx with EPO increases Hct in JW liver recipient patients prior to living donor liver transplant.

Intraoperative cell salvage (IOCS)

Run animation on desktop(then go to Slide 29)

Intraoperative cell salvage (IOCS)

• Pure, washed red cell product.

• Platelets, debris, K+, junk is washed out.

• RBC’s 2,3-DPG stays good.

• RBC deformability stays good

• Earlier worries about coagulation problems were due to using unwashed cells.

Wash volume can be varied depending on the “dirtiness” of the surgery, from 1-3 liters of normal saline or plasmalyte per unit of RBCs.

Intraoperative cell salvage (IOCS)

• Hct of resulting product is 60-70%, depending on RPM and duration of packing phase of “wash cycle”.

• Economics of IOCS can be favorable, compared to homologous transfusion.

• Out-sourcing of IOCS vs. in-house training.

MURPHY ET AL Ann Thorac SurgPERIOPERATIVE CELL SALVAGE AND AUTOTRANSFUSION 2004;77:1553–9

In CABG, IOCS reduces % of patients receiving homologous blood.

MURPHY ET AL Ann Thorac SurgPERIOPERATIVE CELL SALVAGE AND AUTOTRANSFUSION 2004;77:1553–9

In CABG, IOCS reduces average amount of homologous blood transfused per patient.

Intraoperative cell salvage (IOCS) reduces allogeneic transfusion in

revision hip arthroplasty

J.P. Bridgens,THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORGVOLUME 89-A · NUMBER 2 · FEBRUARY 2007

Downside of IOCS:

• Best global recovery of RBCs is 50%.

• In other words, of1000 RBCs bled out, at best, 500 RBCs can be returned o the patient.

• In orthopedics, the figure is 33%.

Contraindications to IOCS?

• OB? (“Amniotic fluid embolus”)– NO!– Use separate suction system for amniotic fluid.– Use “leukocyte” reduction filter if possible.

• Cancer surgery?– Maybe not.– Much evidence to show that this is safe (RRP,

radical cystectomy, etc.)

• Bacterial contamination?– Maybe not.– Much evidence to show that this is safe (trauma).

IOCS in cesarean delivery

• Hundreds of reported cases of cell salvage used successfully in cesarean delivery.

• Best practice is to use abundant wash (2-3 L) to remove essentially all debris.

• Best to not suction amniotic fluid into the reservoir.

• Best to re-administer blood through “leukocyte” reduction filters (the purpose of which is to eliminate fetal squamous cells)

Radical retropubic prostatectomy:

Use of IOCS does not increase recurrence rate of cancer.

(retrospective study)

ALAN M. NIEDER UROLOGY 65: 730–734, 2005

Alan M. Nieder UROLOGY 69: 881–884, 2007.

Radical cystectomy:

Use of IOCS does not increase risk of tumor recurrence

(retrospective study)

“Leukocyte” reduction filter

• Rationale in OB IOCS is to decrease fetal squamous cell administration to mother.

• Rationale in other settings is to remove WBCs and / or tumor cells.

“Leukocyte” reduction filter

Do leukodepletion filters improve outcomes?

• No one really knows.

Case 2

• 34 y.o. JW G3 P2 referred at 32 weeks due to placenta previa / percreta.

• 12 day pre-op course of EPO and FeSO4, despite which Hgb stayed at 10.9 pre-op.

• Similar monitoring and plan: Keep patient warm, arterial line, PulseCO, right IJ, 16 x 2 PIV, ANH and ICOS.

Case 2

• 2100 cc of blood taken off for ANH.

• Post-ANH Hgb = 7.8

• No FHT changes during 71 minutes of ANH

• GA after ANH complete

• Uneventful delivery of Apgar 7/8 infant.

• No oxytocin given.

Case 2• Uneventful hysterectomy. EBL 1000cc.

• Furosemide given to facilitate re-transfusion of ANH blood.

• Bolus furosemide causes transient arteriolar dilation and decrease in MAP.

• Ureteral orifices visualized with indigo carmine transient arteriolar constriction and MAP increase. (NO scavenger)

• Patient extubated at end of case.

• Post-op Hgb = 9.0

RIJ placement pain and inc SVR. ANHinc CO. Incision inc SVR.

Acute normovolemic hemodilution

• Preserves platelets and clotting factors as well as RBCs.

• Takes time and effort.

• Requires a big line to get blood out (doesn’t have to be central line, but it helps).

• Give all fluids through warmers (hypothermia interferes with hemostasis).

Acute normovolemic hemodilution

The CPD bag from the blood bank has a NEEDLE on it!

Needle needs to come off and Luer-lock connector needs to go on.

Acute normovolemic hemodilution

Blood bank has a splicing machine to put Luer-lock tubing onto CPD bag.

Acute normovolemic hemodilution

A sterile splice

Acute normovolemic hemodilution

Now CPD bag can be hooked up to a

3-way stopcock

Acute normovolemic hemodilution

• How much blood can / should be taken off prior to cesarean delivery?

• No one knows.

• This case is lowest reported Hb (7.8) after ANH for placenta previa.

• Was this justified?

Acute normovolemic hemodilution

• Justification was that exposure of fetus to significant maternal anemia would be brief (30-60 minutes) and FHTs would be monitored with patient in LUD and getting 100% O2 by mask.

• Justification was that prior case had EBL = 5500 cc and discharge Hb = 6.2.

Acute normovolemic hemodilution

• Normovolemic anemia is well tolerated.

• Cardiac output increases due to decreased SVR.

• Decreased SVR is due to arteriolar dilation, capillary recruitment and decreased blood viscosity.

Marina Jamnicki, MD et al. Journal of Cardiothoracic and Vascular Anesthesia, Vol 17, No 6 (December), 2003: pp 747-754

In ANH, anemia is compensated by increases in both CO and O2 extraction.

Delivery of O2 decreases, but O2 consumption stays constant.

Marina Jamnicki, MD et al. Journal of Cardiothoracic and Vascular Anesthesia, Vol 17, No 6 (December), 2003: pp 747-754

Dogs tolerate ANH down to a Hb of 20% of baseline.

In dogs undergoing extreme ANH, O2 consumption falls and lactate levels rise only after extreme ANH (Hb < 20% of baseline).

ANH causes increased CO and SV and decreased SVR

Case 2: Approximate nominal changes in CO with ANH: 4.8 6.2, very roughly 30%.

Summary

• What is the best transfusion strategy for a case with high EBL and with no homologous transfusion option?

Alternatives to “other people’s blood” (allogeneic transfusion)

• Good surgical technique• Preoperative erythropoietin (EPO)• Preoperative autologous donation (PAD)• Acute normovolemic hemodilution (ANH)• Elective hypotension– global (drop the MAP)• Elective hypotension– local (elevate the surgical

site)• Intraoperative cell salvage (IOCS)• Accept lower postoperative Hb (Hb = 8.5 was

average ICU transfusion threshold in Europe in 2002. 7.0 was threshold in TRICC study).

Homologous Transfusion- Free Surgery

• Accept lower post-op Hct (TRICC study).• Consider pre-operative EPO / FeSO4 /

folate.• Consider pre-operative autologous

donation (PAD)– not option with JWs.• Consider acute normovolemic

hemodilution (ANH).• Consider intra-operative cell salvage

(IOCS).

Homologous Transfusion- Free Surgery

• Keep patient warm. Use Bair-Hugger. Warm all fluids.

• Consider elective hypotension.

• Consider elevating site of surgery.

Final thought

• Due to the increasingly apparent problems associated with homologous transfusion, should we be using more “transfusion-free” techniques even when homologous transfusion IS an option?

The End