Abstract PR017

Abstract

Background: Jehovah’s Witnesses (JWs) do not accept blood transfusions of whole blood, although they may accept some blood plasma fractions at their own discretion. Members can specify which allowable fractions and treatments they will personally accept. Though some JWp may accept Normovolemic Hemodilution (NHD) if blood is attached to a return line that is connected to their body, our patient declined that alternative so we proposed Hypervolemic hemodilution (HHD). HHD means infusing extra fluid into the patient. Their circulating blood volume is thus increased, therefore they can afford to lose quite a lot more blood during surgery than they would otherwise. Case Report: 54y-o female, 60kg, with no comorbidity was scheduled to undergo total abdominal hysterectomy. She presented a Hb level of 12g/dl. Her baseline HR was 80 bpm, BP 120/70mmHg and SaO2 99% on room air. Anesthesia was induced with etomidate, fentanyl, cisatracurium, and maintained with sevoflurane, remifentanyle, cisatracurium. After induction we administered slowly 500cc Voluven and 1000cc Physiologic Serum. CAM 1´5-3 needed to keep controlled hypotension with a mean BP of 50-60mmHg. 60minutes after induction when HR was 70bpm, mean BP 55mmHg and SaO2 99%, the patient suffered a sudden ST segment depression in II,III,AVF (2mm) and tachycardia 105bpm. We suspected subendocardial injury caused by a decrease in the Hb level so we proceed to administer diuretics and decreased the CAM of sevofluorane. Results: 30minutes later, with 500ml diuresis and mean BP of 60mmHg, ST segment recovered normality. No increase of CPK & TroponineI were found and the patient had no chest pain after surgery. The patient presented a subendocardial injury due to intraoperative bleeding which was solved with hemoconcentration and decreasing the CAM of sevofluorane with no necessity of nitroglicerine or vasoactive drugs. Conclusions: HHD is an important technique that helps to avoid the need for homologous blood transfusions in JWs patients. We have to take into account the side effects of both hemodilution and hypervolemia: hemodiluting a patient risks acute anemia and hipoxemia. Hypervolemia risks pulmonary and cerebral edema, hyponatremia and congestive heart failure; therefore some relative contraindications for HHD are coronary and cerebral vascular disease, myocardial disfunction, hypertension and coagulopathy. Strict monitoring of fluid balance, diuresis, EKG, Sa02 and invasive blood pressure are mandatory.