Optimization of oxygen delivery in a Jehovah's Witness with severe anaemia after postpartum haemorrhage

Abstract

Summary:The delivery of a 25-year-old Jehovah's Witness was complicated by postpartum haemorrhage with a nadir haematocrit of 3%. To improve oxygen delivery without blood transfusion, FiO 2 was increased to maximize dissolved oxygen delivery. Central venous oxygen saturation was used to assess tissue oxygenation. When blood products are refused, successful management of severe anaemia is possible with supportive medical care to achieve haemostasis, optimize oxygen delivery and promote haematopoiesis.Keywords: postpartum haemorrhage, ScvO 2 , blood product refusal CASE HISTORYA 25-year-old primipara dedicated to Jehovah's Witness faith developed preeclampsia at 37 weeks with a haematocrit of 35%. She received magnesium sulphate and delivered a 2555 g infant via vacuum. Her postpartum course was complicated by postpartum haemorrhage due to uterine atony and retained products of conception for which she was treated with operative curettage and uterotonics. Her postoperative haematocrit was 6.2%. She was transferred to the ICU and received vitamin K, iron sucrose and hespan. She became increasingly hypotensive and received norepinephrine, dopamine and albumin. She demonstrated acute neurological changes, was intubated and transferred to our facility.The patient's record documented a 21-year recognition of Jehovah's Witness practice and an advanced directive executed during pregnancy. Her family confirmed these sentiments. The office of the Attorney General reviewed the directive and concluded its execution while pregnant acted as a surrogate expression of her preferences including her consideration of her pregnancy. Medical providers approached her case respecting her advanced directive.Initial laboratory values included an elevation of troponin of 5.43 ng/mL (,0.4), ALT of 266 U/L (8 -49), AST of 210 U/L (10 -44) and serum creatinine of 1.2 mg/dL (0.3-1.2), venous lactate of 10.7 mmol/L (0.5-2.1), platelet count of 156,000/mL (150-400) and HCO 3 of 17 mEq/L (22 -32). Blood draws were obtained from peripheral and peripherally inserted central catheter (PICC) line access. Her electrocardiogram demonstrated sinus tachycardia with a heart rate of 130 beats per minute. A transthoracic echo obtained on postpartum day 3 revealed normal ventricular size and function without detectable regional wall motion abnormality, normal valve function and a very small, circumferential pericardial effusion.To decrease oxygen consumption, she remained mechanically ventilated with spontaneous assist control and positive end-expiratory pressure of 5 cm H 2 O. Her FiO 2 (fraction of inspired oxygen) was increased from 50% to 100% despite O 2 saturations of 100% to optimize oxygen carrying capacity (Figure 1). Tissue oxygenation was assessed with central venous oxygen saturations (ScvO 2 ) obtained via a PICC with the line tip in the superior vena cava just above the cavoatrial junction. At a FiO 2 of 100%, ScvO 2 improved from 40% to 90%, lactate and HCO 3 normalized, each suggesting improved oxygen delivery. Her PaO 2 ranged from 126 to 1...

Therapie einer extremen Anämie mit vernetztem Rinderhämoglobin

“…Etliche Fallberichte beschreiben eine erfolgreiche Therapie extrem niedriger Hb-Werte bei jungen (maximales Alter 44 Jahre), kardiovaskulär gesunden ZJ, einige davon aus Europa [ 4 , 21 , 22 ], die meisten aus den USA [ 5 , 7 , 10 , 20 , 23 , 24 , 28 ]. Sowohl akute postpartale [ 21 , 23 , 24 ], postoperative [ 7 , 22 , 28 ] oder posttraumatische Anämien [ 20 ] als auch langsame Hb-Abfälle bei hämolytischer Anämie [ 10 ] oder Chemotherapie bei Leukämien [ 4 , 5 ] wurden überlebt. Die niedrigsten dokumentierten Hb-Werte reichen von 3,9 bis 1,3 mg/dl [ 4 ] sowie in einem Fall „nicht mehr messbar“ bei einem Hämatokrit von 3 % [ 23 ].…”

“…Sowohl akute postpartale [ 21 , 23 , 24 ], postoperative [ 7 , 22 , 28 ] oder posttraumatische Anämien [ 20 ] als auch langsame Hb-Abfälle bei hämolytischer Anämie [ 10 ] oder Chemotherapie bei Leukämien [ 4 , 5 ] wurden überlebt. Die niedrigsten dokumentierten Hb-Werte reichen von 3,9 bis 1,3 mg/dl [ 4 ] sowie in einem Fall „nicht mehr messbar“ bei einem Hämatokrit von 3 % [ 23 ].…”

“…Als Gründe werden Infekte, Nebenwirkung der Chemotherapie, aber auch die anämiebedingte Hypoxie des Knochenmarks selbst angeführt. In einem Fall konnten Kreislaufparameter (Laktacidose, zentralvenöse Sättigung und Herzfrequenz) durch Erhöhung der F I O 2 auf 100 % verbessert werden [ 23 ], in einem anderen Fall zeigten wiederholte Zyklen einer hyperbaren Sauerstofftherapie keinen messbaren Effekt [ 24 ].…”

Caring for Pregnant Women for Whom Transfusion is Not an Option. A National Review to Assist in Patient Care

“…While the data is conflicting, case reports document survival in JW patients with extremely low Hb levels (down to 10 g/L) with aggressive use of ESAs and/or other supportive measures 15,16 . The use of ESAs are at the discretion of the local unit, requiring local hospital drug committee authorisation and informed consent explaining the risks of hypertension and thrombosis.…”

Caring for pregnant women for whom transfusion is not an option. A national review to assist in patient care

“…There is no role for routine ESA use, but they may be considered in high‐risk patients. While the data are conflicting, case reports document survival in JW patients with extremely low Hb levels (down to 10 g/L) with aggressive use of ESAs and/or other supportive measures . The use of ESAs is at the discretion of the local unit, requiring local hospital drug committee authorisation and informed consent explaining the risks of hypertension and thrombosis.…”