Abstract
Purpose: Orthotopic liver transplantation is typically associated with large volume blood loss. Technological and pharmacological advances permit liver transplantation in patients who formerly were not candidates for this surgery because of strict limitations on blood product administration. We describe a liver transplant in a Jehovah’s witness with ankylosing spondylitis.
Clinical features: A 49-yr-old Jehovah’s Witness with ankylosing spondylitis and end stage liver disease secondary to sclerosing cholangitis underwent orthotopic liver transplantation. Recombinant human erythropoietin (4,000 IU sc every two days for four weeks, then 4,000 IU sc every week) established a normal hemoglobin concentration preoperatively (>140 g·L−1 compared with 120 g·L−1 baseline). Intraoperatively, strategies for reducing risk of blood product transfusion included avoidance of hypothermia (T >35°C), minimal blood sampling (four 1 ml samples), normovolemic hemodilution (two units), administration of Aprotinin (2 million units bolus dose followed by infusion of 500,000 u·hr−1), and return of blood (1,500 ml) scavenged from the operative field. Estimated blood loss was 2,200 ml. The preoperative and postoperative hemoglobin concentration was 1 47 g·L−1 (hematocrit 0.45) and 123 g·L−1 (hematocrit 0.37), respectively. No blood products were required and he was discharged three weeks postoperatively without complication.
Conclusion: Technological and pharmacological advances allow patients to undergo surgery traditionally associated with large volume blood loss with reduced risk of blood product administration.
Résumé
Objectif: La transplantation du foie orthotopique est typiquement associée à une perte de sang importante. Les progrès technologiques et pharmacologiques permettent de réaliser une transplantation hépatique chez des patients qui n’auraient pu subir cette opération auparavant à cause de limitations rigoureuses d’administration des produits sanguins. Nous décrivons une greffe hépatique chez un témoin de Jéhovah qui présente une spondylarthrite ankylosante.
Éléments cliniques: Un témoin de Jéhovah de 49 ans souffrant de spondylarthrite ankylosante et d’une maladie hépatique terminale secondaire à une cholangite sclérosante a subi une greffe hépatique. L’administration d’érythropoïétine recombinante humaine (4 000 UI sc aux deux jours pendant quatre semaines, puis 4 000 UI sc chaque semaine) a établi une concentration d’hémoglobine préopératoire nomrale (>140 g·L−1 comparée à 120 g·L−1 au départ). Les stratégies peropératoires adoptées pour réduire le risque lié à la transfusion de produit sanguin comprenaient l’absence d’hypothermie (T >35 °C), le prélèvement minimal de sang (quatre échantillons de 1 ml), l’hémodilution normovolémique (deux unités), l’administration d’aprotinine (des bolus de deux millions d’unités suivis de perfusion de 500 000 u·h−1) et le retour du sang épuré (1 500 ml) provenant du champ opératoire. Le perte sanguine a été de 2 200 ml. La concentration préopératoire et postopératoire d’hémoglobine a été de 1 47 g·L−1 (hématocrite 0,45) et 123 g·L−1 (hématocrite 0,37), respectivement. Aucun produit sanguin n’a été nécessaire et le patient a quitté l’hôpital trois semaines après l’opération sans complication.
Conclusion: Les progrès technologiques et pharmacologiques permettent de réduire les risques liés à l’administration de produit sanguin et de réaliser des opérations traditionnelement associées à d’importantes pertes sanguines.
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Baldry, C., Backman, S.B., Metrakos, P. et al. Liver transplantation in a Jehovah’s Witness with ankylosing spondylitis. Can J Anaesth 47, 642–646 (2000). https://doi.org/10.1007/BF03018997
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DOI: https://doi.org/10.1007/BF03018997