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  1. Lola Garcia of Hemet, California, was the smallest infant in North America to undergo such a procedure. Physicians at Lucile Packard Children’s Hospital Stanford have performed open-heart surgery without a blood transfusion on the smallest infant ever to undergo such a procedure in North America. The surgery was done on a 10-day-old baby girl born in Hemet, California, with a serious congenital heart defect. Meticulous planning and execution of the surgery, an arterial switch procedure, allowed the medical team to surmount daunting technical challenges of treating a 7-pound open-heart patient without giving her a blood transfusion. It is the first “bloodless” open-heart surgery performed on an infant in the Western United States. “If you can do surgery safely and effectively without transfusion, there are several medical benefits,” said Frank Hanley, MD, chief of pediatric cardiac surgery at the hospital’s Betty Irene Moore Children’s Heart Center and one of two surgeons who performed the procedure. He said patients who do not receive blood products have fewer post-surgical complications, provided they do not lose too much blood. “You have to be able to do the surgery safely and not have the patient’s red blood cell count drop too low,” added Hanley, who is he Lawrence Crowley, MD, Professor in Child Health at the Stanford School of Medicine. A severe heart defect From the moment of her birth on Oct. 21, little Lola Garcia struggled to breathe. She and her parents, Felisa and Jared Garcia, were rushed to a children’s hospital near the family’s home. Lola was diagnosed with transposition of the great arteries, a rare condition in which the heart’s major arteries are not connected correctly. Normally, the blood follows a single, figure-eight-shaped circuit through the heart and lungs, then back to the heart and out to the body to supply oxygen to organs. In Lola’s heart, the blood made two separate circuits — from the heart to the lungs and back, and from the heart to the body and back. The normal figure-eight was separated into two poorly connected loops. Her brain and other organs were not getting enough oxygen. “They said she would definitely need heart surgery, and most likely a blood transfusion, to correct the problem,” said Felisa. “We were happy there was a solution, but when they said ‘transfusion,’ my heart dropped.” The Garcias are Jehovah’s Witnesses; they requested that Lola’s surgery be done without a blood transfusion because of their religious beliefs. Although many hospitals now offer bloodless surgery for adults, the challenges of avoiding transfusion are much greater in newborns who need open-heart procedures. Several hospitals around the country turned the family down. But the pediatric cardiothoracic surgery team at Packard Children’s offered to attempt baby Lola’s arterial switch procedure without transfusing blood. “Very few people have the technical expertise to do this,” said Vamsi Yarlagadda, MD, a clinical associate professor of pediatrics at the School of Medicine and the cardiologist at Packard Children’s who cared for Lola. Technical hurdles During surgery, Lola needed to be connected to a heart-lung machine, which would pump her blood through a circuit of tubing and membranes for re-oxygenation. The machine’s tubing is primed with saline that mixes with the patient’s blood. For an adult, the volume of saline in a standard heart-lung machine does not dilute the blood enough to be dangerous, but a 7-pound newborn has less blood to begin with. Connecting Lola to a standard heart-lung circuit would have dangerously lowered her red blood cell count. In the past, the problem has been solved by transfusing blood. For Lola, the Packard Children’s team took a different approach. Read more: http://med.stanford.edu/news/all-news/2018/02/newborn-first-in-western-us-to-have-bloodless-open-heart-surgery.html
  2. Highlights •Neurosurgical outcomes in patients who refuse blood products are similar to control patients when blood management protocols are followed •No significant differences in mortality or morbidity were identified •No significant differences in hospital length of stay or readmission rates were identified Abstract Background Jehovah's Witnesses (JW) are a Christian faith with > 1 million members in the United States who do not accept autologous blood transfusions. The optimal management of these patients undergoing neurosurgical procedures is not well defined. Here, we examined the feasibility and safety of JW undergoing neurosurgery in a blood management program. Study Design and Methods Sixty-eight JW patients including 23 males and 45 females (mean age 53 +/- 12 years) who underwent a variety of cranial (n=19) and spinal (n=49) neurosurgical procedures over a 5-year period were identified retrospectively and their hospital charts, anesthetic records and operative reports reviewed. A concurrent cohort of sex - age- and procedure-matched non-JW controls also was identified. Results Among JW patients a cell-saving system was used in 27 cases, with blood re-transfused in 13 cases. Lactated Ringers solution was used extensively intra-operatively; albumin was given to 15 patients. The median decrease in Hgb was 2.1 g/dL. One patient had a postoperative Hgb value < 7 g/dL. One patient returned to the operating room to revise a lumbar pedicle screw, and one patient had postoperative seizures. No cardiopulmonary complications, sepsis, pneumonia, or wound infection were observed. When compared to the matched control group, similar outcome results were observed. Blood loss and operative time also were similar in JW patients and controls. Conclusions Neurosurgical procedures in Jehovah's Witnesses are feasible, safe, and have similar outcomes to patients willing to accept transfusion when managed within a multidisciplinary blood management program. http://www.worldneurosurgery.org/article/S1878-8750(16)30854-3/abstract
  3. Much has changed as doctors have come to understand the risks of blood transfusions and the ways to avoid them — helped in part by studies of Jehovah's Witnesses. Michael Anderson, a Jehovah’s Witness minister who underwent a bloodless emergency bypass procedure after a heart attack earlier this month, was visited in his hospital room by Syl Jones, a fellow Jehovah’s Witness and an administrative resident/fellow at Hennepin County Medical Center. Dr. Daniel DiBardino didn’t have much time for niceties on Sept. 8 as he consulted patient Michael Anderson about the emergency cardiac bypass he needed. Anderson is a Jehovah’s Witness — opposed to donor blood transfusions — and DiBardino needed to know if he could breach that religious conviction during the procedure. “What if he’s bleeding to death, which occasionally can happen in cardiac surgery?” he recalled asking Anderson and his wife. “A lot of things can go wrong.” “Absolutely not,” was the reply. A decade ago, that answer might have touched off a doctor-patient argument or the kind of ethics crisis featured in medical TV shows. But as doctors have come to understand the risks of blood transfusions and the ways to avoid them — helped in part by studies of Jehovah’s Witnesses — much has changed. Hospitals such as Hennepin County Medical Center (HCMC), where DiBardino practices, have become more accommodating — and more adept at conserving patients’ own blood during surgeries. “When I was in medical school, honestly, that was never a thing; people didn’t talk about blood conservation,” DiBardino said. “You just used blood because that’s what you did. And that has changed.” Today, for example, surgeons understand that one unit of blood often works as well as two and that excessive blood from donors can result in transfusion-related complications and even deaths. As a result, HCMC has reduced the use of donated red blood cells by 32 percent since 2009. Other Twin Cities hospitals have reduced their use of blood products as well. HCMC has taken the approach a step further through its Bloodless Surgery and Medicine Program, including a firewall in its computerized medical records system that prevents doctors from ordering donor blood products once patients have refused them. The computer system gives doctors alternatives, such as medications that stimulate more blood production in the body, which they can consider even when preparing for emergency surgeries, said Dr. Jed Gorlin, who directs transfusion medicine at HCMC and is the medical director for Memorial Blood Centers, a regional donor agency. “In the heat of battle, you won’t remember all of those,” Gorlin said, “so it’s a checklist to go through all of that stuff.” The Jehovah’s Witnesses’ objection to receiving donor blood comes in part from interpretations of the Bible, including a passage in Acts that calls on people to “abstain from pollutions of idols, and from fornication, and from things strangled, and from blood.” Practical interpretations vary somewhat, Gorlin said. Some members of the religion accept the experimental use of a substitute made from cow’s blood, while others refuse it. A few object to the use of a machine that recycles a patient’s own blood once it has exited the body. But almost all reject transfusions of red blood cells from donors. Anderson, 66, has walked hundreds of miles visiting homes in southwest Minneapolis to teach his religion. He carried a medical directive with him for just such emergencies. Then, driving from his home in Robbinsdale to his Kingdom Hall on Sept. 8, the minister knew something was wrong. “All the way there, I had pain and it wouldn’t go away, and it wouldn’t go away and it wouldn’t go away,” he recalled. Medics determined that he was having a heart attack and gave him aspirin and nitroglycerin pills, which had eased his pain by the time DiBardino sat with him to discuss his surgery: a triple bypass to reroute blood flow around blockages to the heart. “There was no question ... transfusion would not be an option,” Anderson said in an interview from his hospital bed last week. Hemoglobin levels HCMC’s policy is to accommodate such objections for adult patients, when they are conscious and able to communicate their wishes, but not necessarily for parents acting on behalf of pediatric patients. A 1944 child labor decision in Massachusetts still governs such cases, stating that “parents are free to become martyrs themselves. But it does not follow that they are free ... to make martyrs of their children.” Once viewed harshly by the medical establishment, Jehovah’s Witnesses have taught doctors much about the body’s ability to survive surgeries without transfusions, Gorlin said. He gave a lecture in South Dakota this month titled “Management of blood: What we can learn from Jehovah’s Witnesses.” A key measure is the patient’s hemoglobin, the protein in red blood cells that carries oxygen from the lungs. Doctors once thought a hemoglobin measure of 10 grams per deciliter was the key threshold at which patients needed a transfusion. Now, they have found that patients are just as likely to survive if their levels drop to seven. In one local case, a woman who hemorrhaged after childbirth survived despite her hemoglobin dropping to 2.3. “Nobody really knows for any given person how much blood loss they’ll tolerate,” DiBardino said. “You just have to kind of put your faith into it.” ‘Every red blood cell matters’ Still, the odds of surviving the triple bypass that Anderson underwent are substantially lower without transfusions, DiBardino said. As a result, surgeons make it a priority to conserve blood, from the initial step — severing a leg vein to serve as a bypass line around a clogged artery — to connecting that bypass line to the heart. “It’s on your mind that every red blood cell matters for this guy,” DiBardino said. “You’re operating on the biggest structures filled with the most blood in the human body.” At the end of the four-hour operation, Anderson’s hemoglobin level stood at seven. But with rest, iron pills and other medications, it rose to 12. One week later, Anderson had fewer IV tubes and was standing and eating solid food. Two weeks later, he was back home. He believes his clean living helped him survive the surgery and said he is eager to ease back into walking and his door-to-door ministry. “It’s just a matter of pacing myself,” he said, “as I go.” http://www.startribune.com/minneapolis-hospital-embraces-bloodless-surgery/394648141/
  4. When preparing a patient for safe bloodless spine surgery, a comprehensive evaluation is recommended. This ensures “no surprises” in the operating room. In this book, the factors that govern blood loss and blood transfusion are discussed. This manuscript presents the comprehensive preparation of a patient for bloodless spine surgery, techniques for diminishing blood loss in the operating room, postoperative considerations, and includes case reports of patients who have undergone surgery using the blood management methods outlined. Digital images and illustrations are incorporated throughout the book to show important concepts, and a dictionary is provided to thoroughly explain the important factors in bloodless surgery. An effort was made to ensure that the information is provided for readers who come from a non-medical background, with adhering to the basics. Jehovah’s Witness: It is estimated that there are more than 2 million Jehovah’s Witnesses in the United States. Followers of this religion believe that the Bible prohibits blood or blood product transfusion (Acts 15:28-29). Typically, patients of this religion do not accept transfusions of whole blood, packed cells, white blood cells, platelets, or plasma or autotransfusion of predeposited blood. Some witnesses may permit infusion of albumin, clotting factor solutions, or dextran or other plasma expanders and intraoperative autotransfusion, done under closed loop technique. Even though a transfusion may be necessary to save a patient’s life, the administration of blood and/or blood products in the face of refusal after informed consent can be legally considered a violation of a patient’s right to control what is done to his or her body. In the awake and otherwise competent adult, courts have ruled that physicians cannot be held liable if they comply with a patient’s directive and withhold life-saving blood administration following specific and detailed informed consent of the consequences of such an omission of treatment. The issue becomes diificult when patients are unconscious (most Jehovah’s witnesses carry cards informing medical personnel of their religious beliefs), or minors “Tweet this!” Bloodless Advice & Strategies For Jehovah’s Witnesses Jehovah’s witnesses suffer from herniated discs, spinal stenosis and require spine surgery, bloodless spine surgery, spinal decompression surgery, spinal fusion surgery, and revision spine surgery. These bloodless techniques are great for Jehovah’s Witnesses and for non-witnesses too. http://realspinesurgery.com/2016/08/05/fyi-bloodless-spine-surgery-jehovahs-witnesses/
  5. Dana Edson was talking with a friend from her church in Kerrville, TX. Her friend’s son was in need of a kidney transplant. Edson offered to be tested to see if she was a match for Mark Ridgaway, whom she’d never met. Ridgaway had been given a kidney transplant from his mother 16 years ago, but he was in need of another transplant and had been on a wait list for over a year. It turned out that Edson was match, but instead of donating a kidney to Ridgaway, Dr. Osama Gaber – director of the J.C. Walter Jr. Transplant Center at Houston Methodist – asked her to enter a swap program. She agreed on one condition: “I wouldn’t want to give my kidney if Mark had to wait three years for his, and that’s when (Dr. Gaber) gave me the guarantee that Mark would get his the same day as I gave mine,” says Edson. When it was all said and done, Edson’s willingness to enter the program resulted in a six-way kidney swap. 71-year old Rudyne Walker was the last of the six to receive a kidney. She was in stage five renal failure when she received, Edson’s. “I got from Dana a kidney that is young and vigorous and excited about life. I haven’t had a kidney like that in 40-years. It moves me when I’m not ready to go,” said Walker. In order for a recipient to receive a kidney, they must have a donor willing to enter the swap program. Kellie Canaday worked with Walker at Exxon. Canaday had offered to donate a kidney for Walker but they weren’t a match. Maria Coronado ended up receiving Kellie’s kidney. Juan Coronado shed 30 pounds to help his wife. Maria had been dealing with dialysis for two years. Juan’s kidney went to Steve Miller, whom Coronado had never met. Miller had been battling with diabetes for 43 years and like Ridgaway, was in need of a second transplant. Olivia Miller wanted to help her husband, but she was not a match. So instead she helped Esmerelda Guerrero. Guerrero and her husband Cesar are Jehovah’s Witnesses from New Mexico. They had been turned down in their effort to receive a kidney transplant for Esmerelda because they refuse to have blood transfusions. Fortunately for them, Houston Methodist is one of a select few hospitals that perform bloodless transfusions. “We have a program for Jehovah’s Witness transplants. We do actual lung transplants with Jehovah’s Witnesses. So, we give them hormones to raise their blood count, we prepare them differently for the transplant,” says Dr. Gaber. While Cesar didn’t provide a kidney for his wife, he was still able to help. Felix Rodriguez received Cesar’s kidney. Sandra Izquierdo wanted to help her brother, Felix, but couldn’t because she wasn’t a match. Instead her kidney went to Mark Ridgaway. Six donors and six recipients, all thanks to the kindness of strangers, though they all consider themselves family now. Dr. Gaber says months of preparation went into performing the “six-way” organ swap. “You actually need 12 operating rooms and it is hard on the hospital because of the complexity, you don’t want to make mistakes. The kidney needs to go to the right place,” said Dr. Gaber. With more than 1,400 people on the Methodist kidney transplant wait list, the hospital hopes more people will participate in the program. http://www.houstonpublicmedia.org/articles/news/2016/08/01/162583/houston-methodist-performs-six-way-kidney-swap/

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