Strategic and operational aspects of a transfusion-free neonatal arterial switch operation

Schweiger, Martin; Dave, Hitendu; Kelly, Janet; Hübler, Michael

doi:10.1093/icvts/ivt010

Cited by 4 publications

(3 citation statements)

References 5 publications

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“…In the recent literature, other groups (4-7) have also reported cardiovascular surgery on Jehovah's Witness patients with this class of BW. Results in respect to hemodilution, however, showed lower values of hematocrit than those we are presenting here (6).…”

Section: Discussioncontrasting

confidence: 73%

Complex Cardiac Surgery on Patients with a Body Weight of Less Than 5 kg without Donor Blood Transfusion

Boettcher¹,

Dehmel²,

Redlin³

et al. 2017

J Extra Corpor Technol

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Performing safe cardiac surgery in neonates or infants whose parents are Jehovah's Witnesses is only possible in a coordinated team approach. An unconditional prerequisite is a cardiopulmonary bypass (CPB) circuit with a very low priming volume to minimize hemodilution. In the past decade, we have developed a functional blood-sparing approach at our institution. The extracorporeal circuit was miniaturized. This had to be recently adapted, faced with a challenge associated with the switch to high-volume crystalloid cardioplegia. A filtration circuit was added. Here, we report an open heart surgery on three consecutive children of Jehovah's Witness parents with a body weight of 2.7, 4.5, and 4.8 kg, respectively. Procedures consisted of one arterial switch operation and two repairs of complete atrioventricular septal defects. Our static priming volume of less than 90 mL resulted in a nadir hematocrit during CPB of 27.7% (Hb 8.9 g/dL) in a patient which happened to have the lowest body weight of 2.7 kg. The two other patients had their lowest hematocrit at 31.4% (Hb 10.2 g/dL). The three children could be treated without any kind of transfusion of blood which had left the circulation or its extensions, in accordance with the parents' wishes, and enjoy favorable outcomes without transfusion of blood products during their entire hospital stay.

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Section: Discussioncontrasting

confidence: 73%

Complex Cardiac Surgery on Patients with a Body Weight of Less Than 5 kg without Donor Blood Transfusion

Boettcher¹,

Dehmel²,

Redlin³

et al. 2017

J Extra Corpor Technol

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show abstract

“…The Jehovah’s Witness population has encouraged development of techniques with a goal of bloodless surgery for neonates undergoing cardiopulmonary bypass surgery. In term Jehovah’s Witness neonates and small children, case reports of transfusion-free surgeries with cardiopulmonary bypass have been reported, including a 3.55-kg neonate with correction of tetralogy of Fallot with absent pulmonary valve and aneurysm of the left pulmonary artery (lowest hemoglobin 8.5 g/dL) and a 3.5-kg infant who received an arterial switch operation for dextro-transposition of the great arteries (lowest hemoglobin 7.2 g/dL) [ 27 – 31 ]. But in most retrospective studies of bloodless surgeries with cardiopulmonary bypass, infants less than 5–6 kg received blood or blood products during their hospitalization or were excluded from the protocols [ 30 , 32 ].…”

Section: Discussionmentioning

confidence: 99%

Attempting to Honor Beliefs of Jehovah’s Witnesses at the Edge of Viability in an Infant Born at 23 Weeks’ Gestational Age

Sauer

Marc-Aurele

2016

Am J Case Rep

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Patient: Male, 23 weeks’ gestational age newbornFinal Diagnosis: 23 weeks’ extreme prematurity • intraventricular hemorrhage • anemia • respiratory distress syndromeSymptoms: Hypotension • metabolic acidosis • tachycardiaMedication: —Clinical Procedure: Transfusion of packed red blood cellsSpecialty: Pediatrics and NeonatologyObjective:Rare diseaseBackground:Infants born at 23 weeks’ gestation have a poor prognosis and require intensive care, including blood transfusions, to survive. Generally speaking, the decision to forgo life support is acceptable. Jehovah’s Witnesses believe that life is sacred and want lifesaving interventions except for blood transfusions. Therefore, an ethical dilemma exists when a baby is born on the edge of viability to parents that are Jehovah’s Witnesses. In this case, if parents and healthcare professionals disagree on the best interests of the child, the medical team should obtain a court order from the state to intervene.Case Report:We present the case of an infant born at 23 weeks’ gestation to parents who are Jehovah’s Witnesses. The parents wanted full life-support, except for blood transfusions, to be given. The clinical team obtained a court order to transfuse the infant. The infant unfortunately died despite all efforts.Conclusions:Currently, it is nearly impossible to honor the beliefs of Jehovah’s Witnesses to provide lifesaving treatments without blood transfusions for infants born at the border of viability. If the goal is to prolong life, the standard of care for a premature infant is for a doctor to obtain a court order to override the beliefs and wishes of Jehovah’s Witness parents and transfuse blood products as medically indicated. Although bloodless techniques for high-risk surgeries are under development, care for premature infants at 23 weeks’ gestation necessitates red cell transfusions.

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“…Several groups have demonstrated and recommend transfusion-free cardiac surgery, even in neonates and infants [42][43][44][45]. Data suggest a bypass hematocrit of greater than or equal to 24% is desirable for certain congenital cardiac defects.…”

Section: Hematocrit Managementmentioning

confidence: 99%

The bypass plan

Matte

2015

Perfusion for Congenital Heart Surgery

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The perfusionist must be familiar with the patient's original diagnosis, catheterization lab interventions, previous surgeries, and current needs when developing the bypass plan. The following are major considerations for management of the patient during cardiopulmonary bypass. Please refer to Chapter 6 for defect-specific considerations.The care team must have a reasonably standardized communication plan for the bypass run [1][2][3]. This includes standardizing to closed-loop communication for certain anesthesia, surgical, and cardiopulmonary bypass (CPB) commands, notifications, and/or concerns. Each communication should be verbally acknowledged per the team standard (either repeated back or with another affirmation) to ensure the information is properly delivered and handled. This technique is essential for bypass safety and is used at most centers to announce checkpoints during the case.Common bypass-related checkpoints where closedloop communication among the team is essential include the following: • Heparin in • ACT running • Bypass lines clamped and ready for division at the field • Pump suckers on (with suckers and vent line tested under saline at field)

show abstract

Strategic and operational aspects of a transfusion-free neonatal arterial switch operation

Cited by 4 publications

References 5 publications

Complex Cardiac Surgery on Patients with a Body Weight of Less Than 5 kg without Donor Blood Transfusion

Complex Cardiac Surgery on Patients with a Body Weight of Less Than 5 kg without Donor Blood Transfusion

Attempting to Honor Beliefs of Jehovah’s Witnesses at the Edge of Viability in an Infant Born at 23 Weeks’ Gestational Age

The bypass plan

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