Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942005000500009
Brazilian Journal of Anesthesiology
Clinical Information

Manuseio de grave diminuição de hemoglobina em paciente jovem, testemunha de Jeová, submetido à proctocolectomia total: relato de caso

Extreme intraoperative hemodilution in Jehovah’s witness patient submitted total proctocolectomy: case report

Luiz Eduardo Imbelloni; Lúcia Beato; Arídio Ornellas; Carlos Roberto Junqueira Borges

http://dx.doi.org/10.1590/S0034-70942005000500009 Braz J Anesthesiol, vol.55, n5, p.538-545, 2005
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Resumo

JUSTIFICATIVA E OBJETIVOS: Os riscos de transfusão homóloga de sangue são bem conhecidos e alguns pacientes recusam esta transfusão por motivos religiosos. O objetivo foi relatar um caso de proctocolectomia total em Testemunha de Jeová onde o nível de hemoglobina foi de 4 g/dL. RELATO DO CASO: Paciente do sexo masculino, 17 anos, história de polipose intestinal familiar. Iniciada aos oito anos, caracterizada por sangramento. Aos 13 anos colectomia total. Aos 17 anos proctocolectomia total. Preparado com eritropoietina, ácido fólico, infusão de ferro e vitamina B12. Hemograma revelou: hemácias 4.200.000/mm³, hemoglobina 10,5 g/dL e hematócrito de 37%. Plaquetas 273.000/mm³, tempo de protrombina normal. Monitorização com PANI, oximetria de pulso, capnografia e ECG continuamente. Anestesia com propofol, sufentanil, pancurônio e enflurano em circuito fechado. Infusão de 7.000 mL de solução de Ringer com lactato e 150 mL de albumina humana a 20%. Diurese de 2.900 mL. Duração de 10 horas e 30 minutos. Na UTI Ht de 20%, hemácias 2.300.000/mm³, Hb de 4,2 g/dL e mantido com propofol e atracúrio. Exame no dia seguinte revelou: Ht de 18%, hemácias de 2.050.000/mm³, Hb de 4 g/dL. Extubado 18 horas após o término da cirurgia. Segundo dia encaminhado para o quarto. Quarto dia iniciada alimentação por via oral. Alta hospitalar no décimo dia de PO. No 30º PO Ht de 35%, hemácias de 4.000.000/mm³ e Hb de 9,5 g/dL. Seis meses após, fechamento da ileostomia. Submetido a 12 cirurgias sem transfusão sangüínea. CONCLUSÕES: Um planejamento de toda a equipe (clínico, cirurgião, anestesiologista e médicos de terapia intensiva) permite realizar procedimentos cirúrgicos associados com importantes perdas sangüíneas, sem administração de sangue.

Palavras-chave

COMPLICAÇÕES, DOENÇAS, TRANSFUSÃO

Abstract

BACKGROUND AND OBJECTIVES: Homologous blood transfusion risks are well known and some patients may refuse blood transfusions on religious grounds. This report aimed at describing a case of total proctocolectomy in Jehovah’s Witness patient with 4 g/dL hemoglobin. CASE REPORT: Male patient, 17 years old, with family history of adenomatous polyposis. The disease was manifested at eight years of age, characterized by bleeding. At 13 years of age he was submitted to total colectomy. At 17 years of age he was submitted to total proctocolectomy. Patient was prepared with erythropoietin, folic acid, infusion of iron and vitamin B12. Red blood cell count revealed He = 4,200,000/mm³, hemoglobin = 10.5 g/dL, hematocrit = 37% platelets = 273,000/mm³ and normal prothrombin time. Patient was continuously monitored with NIBP, pulse oximetry, capnography and ECG. Anesthesia was induced with propofol, sufentanil, pancuronium and enflurane in closed system. Patient received 7,000 mL lactated Ringer’s and 150 mL of 20% human albumin. Total diuresis was 2,900 mL. Surgery lasted 10 hours and 30 minutes. Patient was referred to the ICU with 20% hematocrit, 2,300,000/mm³ red cells, 4,2 g/dL hemoglobin and was maintained with propofol and atracurium. Next day evaluation revealed 18% hematocrit, 2,050,000/mm³ red cells and 4 g/dL hemoglobin. Patient was extubated 18 hours after surgery and was referred to the ward. Patient started eating four days after surgery and was discharged the 10th postoperative day. Thirty days later patient presented 35% hematocrit, 4,000,000/mm³ red cells and 9.5 g/dL hemoglobin. Six months later he returned for ileostomy closing. Patient was submitted to 12 surgeries without a single blood transfusion. CONCLUSIONS: A good planning of the whole team (clinician, surgeon, anesthesiologist, intensive care staff) allows us to perform surgical procedures associated to major blood losses without administering blood.

Keywords

COMPLICATIONS, DISEASES, TRANSFUSION

References

Spahn DR, Leone BJ, Reves JG. Cardiovascular and coronary physiology of acute isovolemic hemodilution: a review of monoxigen-carrying and oxygen-carrying solutions. Anesth Analg. 1994;78:1000-1021.

A report by the American Society of Anesthesiology Task Force on Blood Component Therapy: Practice for blood component therapy. Anesthesiology. 1996;84:732-747.

Leone BJ, Spahn DR. Anemia, hemodilution, and oxygen delivery. Anesth Analg. 1992;75:651-653.

Viele MK, Weiskopf RB. What can we learn about the need for transfusion from patients who refuse blood? The experience with Jehovah’s Witnesses. Transfusion. 1994;34:396-401.

Zollinger A, Hager P, Singer T. Extreme hemodilution due to massive blood loss in tumor surgery. Anesthesiology. 1997;87:985-987.

Spahn DR, Casutt M. Eliminating blood transfusion: new aspects and perspectives. Anesthesiology. 2000;93:242-255.

Whitaker DK. Transfusion strategy. Eur J Anaesthesiol. 2001;18:493-494.

Strang T, Whitaker DK. Blood conservation strategies in cardiac anaesthesia. Curr Opin Anaesthesiol. 1994;7:53-58.

Van der Linden P. Transfusion strategy. Eur J Anaesthesiol. 2001;18:495-498.

Weiskopf RB, Viele MK, Feiner J. Human cardiovascular and metabolic response to acute, severe isovolemic anemia. JAMA. 1998;279:217-221.

Spahn DR. Perioperative transfusion triggers for red blood cells. Vox Sang. 2000;78:(Suppl2):163-166.

Hardy JF, Belisle S, Janvier G. Reduction in requirements for allogeneic blood products: nonpharmacologic methods. Ann Thorac Surg. 1996;62:1935-1943.

Goldman M, Remy-Prince S, Trepanier A. Autologous donation error rates in Canada. Transfusion. 1997;37:523-527.

Goodnough LT, Brecher ME, Kanter MH. Transfusion medicine. Second of two parts - blood conservation. N Engl J Med. 1999;340:525-533.

Goodnough LT, Despotis GJ, Parvin CA. Erythropoietin therapy in patients undergoing cardiac operations. Ann Thorac Surg. 1997;64:1579-1580.

Goodnough LT, Brecher ME, Kanter MH. Transfusion medicine. First of two parts - blood transfusion. N Engl J Med. 1999;340:438-447.

Hebert PC, Wells G, Blajchman MA. A multicenter randomized controlled clinical trial of transfusion requirements in critical care: Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340:409-417.

Carson JL, Terrin ML, Barton FB. A pilot randomized trial comparing symptomatic vs. hemoglobin-level-driven red blood cell transfusions following hip fracture. Transfusion. 1998;38:522-529.

McIntyre L, Hebert PC, Wells G. Is a restrictive transfusion strategy safe for resuscitated and critically ill trauma patients?. J Trauma. 2004;57:563-568.

McAlister FA, Clark HD, Wells PS. A Perioperative allogeneic blood transfusion does not case adverse sequelae in patients with cancer: a meta-analysis of unconfounded studies. Br J Surg. 1998;85:171-178.

Carson JL, Duff A, Poses RM. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. Lancet. 1996;348:1055-1060.

Fitzgerald RD, Martin CM, Dietz GE. Transfusing red blood cells stored in citrate phosphate dextrose adenine-1 for 28 days fails to improve tissue oxygenation in rats. Crit Care Med. 1997;25:726-732.

Macuco MV, Carrenho JMX, Zambonato JF. Immediate effect of acute preoperative isovolemic hemodiluition on adult patients hematocrit. Rev Bras Anestesiol. 1998;48:475-487.

Oliveira GS, Tenorio SB, Cumino DO. Acute normovolemic hemodilution in children submitted to posterior spinal fusion. Rev Bras Anestesiol. 2004;54:84-90.

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