Facteurs de morbidité du syndrome de mal-être post-rachianesthésie / Morbidity factors of post-spinal anesthesia disease syndrome

La pratique de la rachianesthésie est motivée par la qualité de l'analgésie post-opératoire qu'elle procure. Cependant, la rachianesthésie reste comme tout acte médical associée à certains accidents. Méthodes : C'est une étude prospective, descriptive et analytique qui s'est déroulée sur une période d'un (01) mois allant du 07 Mai 2022 au 07 Juin 2022 au CHU d'Angré. Résultats : la rachianesthésie a été réalisée dans 188 des cas, soit un taux de 60% de l'ensemble des interventions. Le sexe ratio était de 0,13 et l'âge moyen était de 33 ± 10 ans. L'antécédent le plus retrouvé était l'HTA. La bupivacaine était le seul anesthésique local utilisé avec comme adjuvant la morphine, le fentanyl ou l'association morphine -fentanyl. Les incidents peropératoires étaient dominés par les troubles hémodynamiques à type d'hypotension artérielle (98,7%) et de bradycardie. Les patients ayant présenté un syndrome de mal être post opératoire représentaient 70,8% de notre effectif. Le Syndrome de Mal Etre post opératoires était dominé par les nausées et vomissements suivis des prurits. Tous les patients ayant présenté un syndrome de mal être post rachianesthésie n'avaient pas bénéficié de prise en charge. La survenue du syndrome de mal être post rachianesthésie était statistiquement associé à la présence de la morphine comme adjuvant (p=0,016). Conclusion : La rachianesthésie est une remarquable technique d'anesthésie. Néanmoins la fréquence des évènements per et post opératoires survenant au décours de cette technique n'est pas négligeable, car ils sont la source d'inconforts notables

Challenging the management of bleeding and coagulopathy in ascending aortic surgery in a Jehovah's Witness patient: case report / Desafiando el manejo del sangrado y la coagulopatía en cirugía de aorta ascendente en un paciente testigo de Jehová: Reporte de Caso

Abstract Introduction: Not transfusing in certain medical settings can be a life-threatening decision; however, Jehovah's Witness patients who reject transfusions have led to learning and multiple medical interventions to avoid it. Despite this, heart surgery follows a specialty that is clearly related to the risk of transfusion, making operating on a Jehovah's Witness patient a challenge. Case presentation: An ascending aorta surgery was performed on a Jehovah's Witness patient, where different strategies were applied, both for blood saving and for the prevention and management of coagulopathy. Results: Surgery of the ascending aorta with extracorporeal circulation was successfully performed without requiring administration of blood components. Conclusions: Adequate planning and implementation of bleeding prevention strategies and coagulopathy management may contribute to avoid and/or reduce the administration of blood products, allowing for the absence of transfusions to not be utopia in major cardiac surgery.

Resumen Introducción: No transfundir en algunos escenarios médicos puede ser una decisión que amenaza la vida del paciente, sin embargo, los pacientes testigos de Jehová quienes rechazan las transfusiones, han conducido al aprendizaje y realización de múltiples intervenciones médicas para evitarla. A pesar de ello, la cirugía cardiaca sigue una especialidad claramente relacionada con el riesgo de transfusiones, por lo que operar a un paciente testigo de Jehová constituye un reto. Presentación del caso: Se llevó a cabo una cirugía de aorta ascendente en un paciente testigo de Jehová, donde se aplicaron diferentes estrategias, tanto de ahorro sanguíneo como de prevención y manejo de la coagulopatía. Resultados: Se llevó a cabo exitosamente una cirugía de aorta ascendente con circulación extracorpórea, sin requerir la administración de componentes sanguíneos Conclusiones: La adecuada planeación y realización de estrategias de prevención del sangrado y manejo de la coagulopatía pueden contribuir a evitar y/o reducir la administración de hemoderivados, permitiendo que en cirugía cardiaca mayor la ausencia de transfusiones no sea una utopia.

Medicina y Cirugía sin Sangre La Experiencia de Solca Guayaquil / Medicine and Surgery without Blood The Experience of Solca Guayaquil

Introducción: Los riesgos asociados con las Transfusiones de Sangre Alogénicas (TSA) son ampliamente conocidos y han contribuido a nuevos paradigmas de tratamiento para la medicina y cirugía sin sangre. Por tanto, es importante contar con estrategias terapéuticas efectivas y prácticas que sirvan como alternativas al uso de TSA. Este informe describirá las estrategias aplicadas a los pacientes de este reporte. Métodos: Estudio retrospectivo descriptivo de alternativas a la TSA utilizadas en SOLCA Guayaquil con pacientes que no aceptaron TSA bajo ninguna circunstancia, entre los años 2011 y 2017. La estrategia terapéutica se basó en un diagnóstico temprano y un tratamiento agresivo de la anemia y cualquier tipo de sangrado activo. Se utilizó eritropoyetina, hierro y folato, según requerimientos del paciente. Todos los pacientes quirúrgicos recibieron ácido tranexámico y otros hemostáticos tópicos según necesidad. Resultados: De 73 pacientes oncológicos, el 68.5 % eran no quirúrgicos, de este grupo el 62 % recibió quimioterapia. La hemoglobina aumentó hasta 12.6 g/dL. Por tratamiento global por paciente se administraron hasta 3000 mg de hierro, 140.000 unds de eritropoyetina y megadosis de vitamina C fue aplicada con una media de 24 gramos. Todos los pacientes aumentaron sus niveles de hemoglobina en un promedio de 25 días. Conclusión: Es esencial iniciar un tratamiento temprano, preventivo y coordinado con un equipo multidisciplinario comprometido a estos esquemas. Los pacientes respondieron bien a los medicamentos y las dosis recibidas y no se informaron efectos secundarios. También podemos ver que estas estrategias son efectivas y factibles de aplicar.

Introduction: Risks associated with the Allogeneic Blood Transfusions (ABT) are widely known and have contributed to new treatment paradigms for bloodless medicine and surgery. Therefore, it is essential to have effective therapeutic strategies that serve as alternatives to ABTs. This report describes the strategies applied to patients in this paper. Methods: A Retrospective descriptive study of ABT alternatives used in SOLCA Guayaquil with patients who did not accept ABTs under any circumstances, between 2011 and 2017. The therapeutic strategy was an early diagnosis and an aggressive treatment of anemia and any active bleeding. Erythropoietin, iron, and folate were applied, according to the patient's requirements. All surgical patients received tranexamic acid and other hemostatics as needed. Results: Of 73 cancer patients, 68.5% were non-surgical, 62% of the group received chemotherapy. For global treatment per patient, up to 3000 mg of iron was administered, 140,000 units of erythropoietin and megadoses of vitamin C were applied with an average of 24 grams. All patients increased their hemoglobin levels by an average of 25 days. All patients increased their hemoglobin levels by an average of 25 days. Conclusion: It is essential to start early treatment, prevent and coordinate with a multidisciplinary team committed to these schemes. The patients responded well to the medications, and the doses received, and no side effects were reported. We can also see that these strategies are practical and feasible to apply.

Era of Bloodless Surgery: Spotlights on Hemostasic Materials and Techniques / 한양의대학술지

Ever since mankind has had blood, efforts to stop bleeding have never ceased and so numerous methods for hemostasis have been developed. In recent decades, minimally invasive surgical techniques have led patients to less-bleeding surgery but, hemostatic agents, devices and techniques still play an important role in medical side. A number of hemostatic agents and devices have been developed and they can be classified by their mechanism of action. That classification of the coagulants includes mechanisms with physical, caustic, bio-physical, biologic actions. Hemostatic devices are divided into categories such as dressings, glue, clips, electrocoagulations and so on. Based on the concept of minimally invasive surgical procedures, variously developed surgical techniques are divided by the number of ports used and auxiliary instruments. However, there are advantages and disadvantages to each of the hemostatic agents and minimally invasive methods, and the belief in the classical method also prevents the application of new hemostatic methods. The knowledge and understanding of the benefits and costs of these newly developed hemostatic methods will make it easier for medical personnel to manage patient's blood.

A Paradigm Shift: Perioperative Iron and Erythropoietin Therapy for Patient Blood Management / 한양의대학술지

Allogeneic blood transfusion is often restricted due to its adverse effects, a lack of blood supply, and religious or cultural constraints. As a result, patient blood management (PBM) has been gaining attention. PBM is an evidence-based, patient-centered bundle of technologies that manages perioperative anemia and reduces bleeding during surgery. PBM improves the postoperative prognoses. Perioperative anemia is the main concern in PBM; therefore, to diagnose and treat it is important. This review focuses on the perioperative use of oral or intravenous iron and erythropoietin (EPO), in relevant fields such as cardiac surgery, orthopedics, and neurosurgery. IV administration of iron has been controversial due to safety concerns, such as increased risk of infection. However, using IV iron appropriately is beneficial in most surgical settings. Although recombinant human EPO may increase thromboembolic risks, this can be mitigated through various methods including limiting the target Hb level, using it in combination with IV iron, or prophylaxis for deep venous thrombosis. EPO is recommended in patients undergoing cardiac or orthopedic surgery. As PBM becomes globally implemented, the blood management methods, including tranexamic acid, hemostatic agents, and cell salvage have become more variable as well. Among them, administration of iron and EPO would be the most common pharmacologic choices based on current practice. However, controversy still exists. Therefore, further studies on iron and EPO are needed to ensure better and safer patient care.

Patient Blood Management: Obstetrician, Gynecologist's Perspectives / 한양의대학술지

Obstetricians and gynecologists frequently deal with hemorrhage so they should be familiar with management of patient blood management (PBM). We will review to summarize the alternative measures and interventions used in bloodless surgery in the field of obstetrics and gynecology. In the obstetric field, PBM has been developed as an evolving evidence-based approach with a number of key goals: (i) to identify, evaluate, and manage anemia; (ii) reduce iatrogenic blood loss; (iii) optimize hemostasis; and (iv) establish decision thresholds for transfusion. Transfusion, mechanical method including balloon tamponade and uterine artery embolization, and intraoperative cell salvage were introduced for PBM. In the gynecologic field, PBM is not significantly different from that in the obstetric field. Preoperative managements include iron supplement, erythropoietin administration, autologous blood donation, and uterine artery embolization. Meticulous hemostasis, short operative time, hypotensive anesthetic techniques, hemodilution during operation, blood salvage and pharmacological agents were introduced to intraoperative management. Postoperative measures include meticulous postoperative monitoring of the patient, early detection of blood loss, reduction of blood sampling, appropriate use of hemopoiesis, normalization of cardio-pulmonary function and minimization of oxygen consumption. In conclusion, each obstetrician and gynecologist should be aware about the appropriate method for blood conservation and use in practice. A comprehensive approach to coordinating all members of the bloodless agent and surgical team is essential.

Liver transplantation in Jehovah's Witnesses: two cases report / 대한마취과학회지

Liver transplantation is especially challenging in patients who are Jehovah's Witnesses because their religious beliefs prohibit the receipt of blood products. We present two cases of living donor liver transplantation performed in adult Jehovah's Witnesses in South Korea without the use of blood products. In the first case, preoperative erythropoiesisstimulation therapy increased hemoglobin levels from 8.1 to 13.1 g/dl after 9 weeks. In the second case, hemoglobin levels increased from 7.4 to 10.8 g/dl after 6 months of erythropoiesis-stimulation therapy. With the combination of acute normovolemic hemodilution, intraoperative cell salvage, and use of transfusion alternatives, liver transplantation was successfully performed without transfusion of blood products.

Laparoscopic D1+ Lymph Node Dissection for Gastric Cancer in Jehovah's Witness Patients: a 1:3 Matched Case Control Study

PURPOSE: Laparoscopic gastrectomy in early gastric cancer patients is accepted as standard, but it is sometimes challenging for patients who refuse blood transfusions such as Jehovah's Witness (JW) patients, because of the risk of bleeding related to radical lymph node dissection. This study aimed to confirm the adequacy and safety of laparoscopic gastrectomy with D1+ lymphadenectomy in JW patients. METHODS: From January 2009 to December 2015, 265 gastric cancer patients underwent laparoscopic gastrectomy in our institute. Among them, there were 25 JW, and they were statistically matched with 75 patients from the control groups depending on age, sex, and body mass index (BMI). In a retrospective review, patient laboratory values and their pathology results were analysed. RESULTS: There was no significant difference when comparing the clinical characteristics of JW and control groups. There was no statistically significant difference in blood loss or operation time between the two groups. Mean blood loss was 202.4±172.6 ml in the JW group and 179.7±163.8 ml in the control group (p=0.556). The number of retrieved lymph nodes was 27.8±13.9 in the JW group and 29.3±12.1 in the control group (p=0.607). Haemoglobin and haematocrit were measured after surgery and there was no statistically significant difference between the two groups. CONCLUSION: Laparoscopic D1+ gastrectomy in a JW may be performed with an equivalent risk to the control group. Laparoscopic gastrectomy can be applied to Jehovah's Witnesses if the specialied cancer center has sufficient experience in stomach cancer surgery, even if there is not enough experience in bloodless surgery.

Successful transfusion-free pancreatectomy in Jehovah's Witness patients

BACKGROUNDS/AIMS: Although perioperative therapies have improved greatly, pancreatectomies still often need blood transfusions. However, the morbidity from blood transfusions, the poor prognosis of blood transfused patients, high cost, and decreasing supply of blood products is accelerating transfusion-free (TF) surgery in the patients who have pacreatectomies. The aim of this study was to assess the feasibility of TF pancreatectomies for patients who are Jehovah's Witness. METHODS: We investigated the possibility of TF pancreatectomies for the Jehovah's Witness patients undergoing pancreatectomies between January 2007 and Februay 2014. There were 4 cases of Whipple's operation, 4 of pylorus-preserving pancreaticoduodenectomy, 2 of radical antegrade modular pancreatosplenectomy and 1 of laparoscopic distal pancreatectomy. All were performed by one surgeon. RESULTS: Most of the TF pancreatecomies patients received perioperative blood augmentation and intraoperative acute normovolemic hemodilution (ANH). They received no blood transfusions at any time during their hospitalization, and pre- and intra-operative data and outcomes were acceptably favorable. CONCLUSIONS: To the best of our knowledge, this report is the first successful consecutive pancreatectomy program for Jehovah's Witness not involving blood transfusion. TF pancreatectomy can be performed successfully in selected Jehovah's Witness. Postoperative prognosis and outcomes should be confirmed in follow up studies.

Blood Conservation Strategy during Cardiac Valve Surgery in Jehovah's Witnesses: a Comparative Study with Non-Jehovah's Witnesses / 대한구급학회지

BACKGROUND: We compared the clinical outcomes of cardiac valve surgery in adult Jehovah's Witness patients refusing blood transfusion to those in non-Jehovah's Witness patients without any transfusion limitations. METHODS: From 2005 to 2014, 25 Jehovah's Witnesses (JW group) underwent cardiac valve surgery using a blood conservation strategy. Twenty-five matched control patients (non-JW group) were selected according to sex, age, operation date, and surgeon. Both groups were managed according to general guidelines of anticoagulation for valve surgery. RESULTS: The operative mortality rate was 4.0% in the JW group and 0% in the non-JW group (p = 1.000). There was no difference in postoperative major complications between the groups (p = 1.000). The overall survival rate at 5 and 10 years was 85.6% ± 7.9% and 85.6% ± 7.9% in the JW group, respectively, and 100.0% ± 0.0% and 66.7% ± 27.2% in the non-JW group (p = 0.313). The valve-related morbidity-free survival rates (p = 0.625) and late morbidity-free survival rates (p = 0.885) were not significantly different between the groups. CONCLUSIONS: Using a perioperative strategy for blood conservation, cardiac valve surgery without transfusion had comparable clinical outcomes in adult patients. This blood conservation strategy could be broadly applied to major surgeries with careful perioperative care.

Intraoperative autologous based blood conservation strategies in mitral valve replacement / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate whether intraoperative autologous donation (IAD) can reduce perioperative blood transfusion for patients underwent mitral valve replacement (MVR).</p><p><b>METHODS</b>A total of 318 patients received implementation of IAD from January 2011 to December 2013 were analyzed retrospectively, and compared with 517 patients of the previous 36-month period (from January 2008 to December 2012). The method of small-volume retrograde autologous priming, strict blood transfusion standard along with IAD together constituted a progressive blood-saving strategy. Statistical methods including Students' t-test, Pearson's χ(2) test, Kruskal-Wallis analysis and multivariate Logistic regression model were used for comparisons of the data.</p><p><b>RESULTS</b>There were no significant difference between IAD group and non-IAD group considering preoperative patient demographics, characteristics and preoperative comorbidities. However, IAD group significantly reduced number of patients transfused with intra/post-operative packed red-blood cell (PRBC) (55(17.0%) vs. 215 (42.1%), χ(2)=53.0, P=0.000), and had significantly reduced postoperative chest tube output (150(380) ml vs. 700(660) ml, H=195.648, P=0.000), length of stay ((16±6) d vs. (20±8)d, t=9.60, P=0.000). But hematocrit were lower in IAD group (30%±5% vs.33%±4% at end of operation, t=7.76, P=0.000; 30%±4% vs. 32%±5% at discharge, P=0.000, t=3.86). Multivariate logistic aggression analysis revealed that age, IAD and smoking history were factors influencing the probability of intra or postoperative blood transfusion.</p><p><b>CONCLUSION</b>Implementation of blood conservation strategies based on intraoperative autologous donation in mitral valve replacement surgery can significantly reduce intra/postoperative blood transfusion as well as postoperative complications.</p>

Blood Management Strategies in Total Knee Arthroplasty

A perioperative blood management program is one of a number of important elements for successful patient care in total knee arthroplasty (TKA) and surgeons should be proactive in its application. The aims of blood conservation are to reduce the risk of blood transfusion whilst at the same time maximizing hemoglobin (Hb) in the postoperative period, leading to a positive effect on outcome and cost. An individualized strategy based on patient specific risk factors, anticipated blood loss and comorbidities are useful in achieving this aim. Multiple blood conservation strategies are available in the preoperative, intraoperative and postoperative periods and can be employed in various combinations. Recent literature has highlighted the importance of preoperative Hb optimization, minimizing blood loss and evidence-based transfusion guidelines. Given TKA is an elective procedure, a zero allogenic blood transfusion rate should be the aim and an achievable goal.

Blood Conservation Strategy during Cardiac Valve Surgery in Jehovah's Witnesses: a Comparative Study with Non-Jehovah's Witnesses / 대한중환자의학회지

BACKGROUND: We compared the clinical outcomes of cardiac valve surgery in adult Jehovah's Witness patients refusing blood transfusion to those in non-Jehovah's Witness patients without any transfusion limitations. METHODS: From 2005 to 2014, 25 Jehovah's Witnesses (JW group) underwent cardiac valve surgery using a blood conservation strategy. Twenty-five matched control patients (non-JW group) were selected according to sex, age, operation date, and surgeon. Both groups were managed according to general guidelines of anticoagulation for valve surgery. RESULTS: The operative mortality rate was 4.0% in the JW group and 0% in the non-JW group (p = 1.000). There was no difference in postoperative major complications between the groups (p = 1.000). The overall survival rate at 5 and 10 years was 85.6% ± 7.9% and 85.6% ± 7.9% in the JW group, respectively, and 100.0% ± 0.0% and 66.7% ± 27.2% in the non-JW group (p = 0.313). The valve-related morbidity-free survival rates (p = 0.625) and late morbidity-free survival rates (p = 0.885) were not significantly different between the groups. CONCLUSIONS: Using a perioperative strategy for blood conservation, cardiac valve surgery without transfusion had comparable clinical outcomes in adult patients. This blood conservation strategy could be broadly applied to major surgeries with careful perioperative care.

Transfusion free radical antegrade modular pancreaticosplenectomy of metastatic neuroendocrine tumor of the pancreas in Jehovah's Witness patient

In a popular sense, Jehovah's Witnesses (JW) have their creeds, one of which is refusal of blood transfusion. Such refusal may impinge on their proper management, especially in critical situations. We present a case of successful bloodless multimodality therapy, which was performed for a JW. The patient was a 49-year-old woman and JW who had general weakness 7 days before admission. She was diagnosed with a pancreatic neuroendocrine tumor (PNET) with hepatic metastases. Transcatheter arterial chemoembolization and Sandostatin LAR injection were performed, and then she was given a transfusion-free Radical antegrade modular pancreatosplenectomy sequentially. We gave recombinant human erythropoietin and iron hydroxide sucrose complex daily for five days after surgery. She was discharged at postoperative day 12 without any surgical complications. Multimodality therapy is very important for optimal treatment of PNET. Along with intimate interdepartmental cooperation, careful patient selection and appropriate perioperative management could possibly enhance the surgical outcome.

Preoperative Erythropoietin Administration in Patients With Prostate Cancer Undergoing Radical Prostatectomy Without Transfusion

PURPOSE: In this study, we administered erythropoietin preoperatively to patients who underwent open radical prostatectomy without transfusion to increase their hemoglobin levels and investigated the efficacy of this procedure. MATERIALS AND METHODS: We evaluated 62 patients who underwent open radical prostatectomy performed by the same surgeon between June 2005 and January 2011. The 22 patients who refused transfusion were assigned to group 1; the patients who accepted transfusion were assigned to group 2. Before surgery, we administered erythropoietin beta to group 1 patients whose hemoglobin levels were <12 g/dL and retrospectively compared the clinical data of the two groups. We used the t-test and the chi-square test for statistical analysis. RESULTS: Mean preoperative hemoglobin levels in group 1 after erythropoietin administration (14.5 g/dL) were significantly higher than those in group 2 (13.59 g/dL, p=0.003). Moreover, the difference in the mean hemoglobin levels before and after surgery for group 1 patients (3.55 g/dL) significantly exceeded that for group 2 patients (2.08 g/dL, p=0.000). Additional analysis revealed no statistically significant differences in perioperative complications between the groups. CONCLUSIONS: Preoperative erythropoietin administration increased the safety margin of hemoglobin levels, and this strategy worked sufficiently well in our experience.

A Single-Center Experience of Transfusion Free Surgical Treatment over 13 Years in Korea

OBJECTIVE: Patient' desire of transfusion free surgery has been increasing due to blood transfusion risks. We analyzed the perioperative parameters and perioperative management of transfusion free surgical treatment in Soonchunhyang University Seoul Hospital. METHODS: Operation quantity and blood unstoring count from blood bank between 2000 and 2012 were collected from chronological records. Perioperative parameters including preoperative hemoglobin level, postoperative hemoglobin level, and lowest hemoglobin level were collected from medical records. Perioperative blood management such as acute normovolemic hemodilution, intraoperative blood cell salvage, or hematinic agents and complication were assessed. RESULTS: A total of 3,088 patients underwent transfusion free surgery at Soonchunhyang University Seoul Hospital between 2000 and 2012. Postoperative hemoglobin level <5.0 g/dL were 33 patients. Four patients expired at postoperative period with serious perioperative complications. Average of expired patient's hemoglobin was 3.22 g/dL and overall mortality was 0.12%. Operation was increased as years go by. The amount of blood use bank wasn't increased in general patients with transfusion. CONCLUSION: Careful perioperative blood management for transfusion free surgical treatment was responsible for safety and results in good clinical outcomes. Overall transfusion rate was decreased in spite of increasing operation quantity.

Can Maximum Surgical Blood Order Schedule Be Used as a Predictor of Successful Completion of Bloodless Surgery?

BACKGROUND: The Soonchunhyang University Hospital Bloodless Center was established in 2000, and more than 2,000 bloodless surgeries have been performed there since. In this study, the lowest postoperative Hb/preoperative Hb (Hblow/pre) ratio and mortality rates of patients who underwent bloodless surgery were analyzed for each maximum surgical blood order schedule (MSBOS) category to assess whether MSBOS can be used as a predictor of successful completion of bloodless surgery. METHODS: A total of 971 patients were included. MSBOS was defined as the average number of units of RBCs transfused during each elective surgery. We used the Hblow/pre ratio as an alternative to intraoperative blood loss. Frequency of Hblow/pre ratios < or =0.5, use of transfusion alternatives, and mortality rates were compared across MSBOS categories. RESULTS: Out of the 971 patients, 701 (72.2%) were categorized as type and screen (T&S), 184 (18.9%) as MSBOS 1, 64 (6.6%) as MSBOS 2, and 22 (2.3%) as MSBOS 4. Transfusion alternatives were used by 397 (40.9%) patients. The frequency of the use of simultaneous erythropoietin and iron, hemostatics, acute normovolemic hemodilution, and Cell Saver (Haemonetics corp., USA) was higher in patients in the higher MSBOS categories. Six (0.6%) patients died within 30 days of surgery. Hblow/pre ratios tended to be lower as the level of MSBOS category increased. CONCLUSIONS: Surgeries in the higher MSBOS categories tended to be associated with high blood loss and mortality. Active use of transfusion alternatives is recommended in patients in high MSBOS categories who are scheduled to undergo bloodless surgery.

Ingrown toenail conservative or surgical treatment

To describe the conservative and/or surgical treatment of in growing Toenail at royal Jordanian air force medical facility. A retrospective review of the medical records of a total of 115 patients; during a period of two years June 1999- June 2001 Results: Out of 115 patients presented with ingrown toenail 93 [80%] were males and 23 [20%] were females, aged 15-50 years with mean age of [32.5] years. Out of 115 patients with ingrown toenail, 60 [52%] presented in early stages, complaining of pain, were treated conservatively, with success rate of 73.3% and an average of one week sick leave. While in patients treated surgically, the success rate was 76.4% and an average of four weeks sick leave. Conclusion: Success and recurrence rates were nearly equal, but a marked decrease in workday's absence was obtained

Transfusion Free Kidney Transplantation in Jehovah's Witness Patients / 대한이식학회지

Transfusion free surgery is of increasing interest as more patients are refusing a blood transfusion because of religious belief, infection or fear of a blood-transmitted disease such as AIDS. Patients of the Jehovah's Witness faith generally do not accept transfusions of blood or blood products but some will accept cadaveric organs for transplantation. Recently, it is possible to perform 'bloodless' autologous or reduced-intensity allogeneic transplants in properly selected patients. The success of these procedures depends on the transplantation technique and on meticulous attention to blood conservation and supportive care. In our center, nine Jehovah's Witness received a kidney transplantations and transfusion free surgery. All the patients received erythropoietin injection and iron supplement before kidney transplantation. They were not serious bleeding in surgery and graft dysfunction after surgery. All the recipients are alive and have well functioning grafts. Elective living donor kidney transplantation allows implementation of a transfusion free strategy. We think that various methods replaced blood transfusion reduced risk of postoperative anemia and unnecessary transfusion.

Cardiac Surgeries without Transfusion / 대한마취과학회지

BACKGROUND: Jehovah's Witnesses are well known for their refusal of blood transfusions which, challenges the safety of performing cardiac surgeries. Their stand regarding blood transfusions has garnered criticism from some medical and legal sources, but has also added incentive for the development of many bloodless surgery techniques. To assess the impact on the continuing progress of blood saving protocols and increasing operative risk; herein our results in this specific population are reported. METHODS: The medical records of Jehovah's Witnesses, who underwent cardiac surgeries without blood transfusions, between Feb 1996 and Sep 2005, were retrospectively reviewed. RESULTS: 103 surgical procedures were performed on 102 patients. The age of patients varied from 2 months to 78 years, with a sex ratio of 60:42 (Male:Female). Cardiopulmonary bypass (CPB) was used in 81 cases. The mean hemoglobin (Hb) and hematocrit (Hct) levels were 13.2 g/dl (8.1-17.3), and 39.2% (24.3-52.5) before surgery, and 11.8 g/dl (8.0-16.5), and 35.3% (24-49) after surgery, respectively. Recombinant human erythropoietin (rHuEPO) and iron were used in 95 and 69 cases before and after surgery, respectively. High dose aprotinin (2 million KIU IV loading dose, 2 million KIU into the pump prime volume and 500,000 KIU per hour of surgery as a continuous intravenous infusion) was used in 67 cases. Acute normovolemic hemodilutions were performed in 7 cases. Cell saver was used in all procedures. Re-operations were needed in two cases due to wound infections and one patient died-of arrhythmias on the 2nd post-operative day. CONCLUSIONS: Bloodless cardiac surgery can be performed on Jehovah's Witnesses, but effective care of such patients requires close collaborative team efforts and advance planning to ensure favorable outcomes. At our hospital, preoperative iron and rHuEPO, as well as high dose aprotinin and cell saver are routinely used where indicated.