the feasibility and physiological aspects of anesthesia and surgery without homologous blood ...

142 Pages·2012·2.61 MB·English

THE FEASIBILITY AND PHYSIOLOGICAL ASPECTS OF ANESTHESIA AND
SURGERY WITHOUT HOMOLOGOUS BLOOD TRANSFUSIONS
PROEFSCHRIFT
TER VERKRIJGING VAN DE GRAAD VAN DOCTOR IN OE
GENEESKUNDE
AAN DE ERASMUS UNIVERSITEIT ROTTERDAM
OP GEZAG VAN DE RECTOR MAGNIFICUS
PROF. DR. J. SPERNA WEILAND
EN VOLGENS BESLUIT VAN HET COLLEGE VAN DEKANEN.
DE OPENBARE VERDEDIGING ZAL PLAATSVINOEN OP
WOENSDAG 1 JUNI 1983 DES NAMIDDAGS
TE 2.00 UUR
DOOR
RONNY LAPIN
GEBOREN TE TEL AVIV
PROMOTOREN PROF. DR. J. JEEKEL
PROF. DR. W. ERDMANN
CO-REFERENTEN PROF. DR. C. HILVERING
PROF. DR. G. CORSSEN
This manuscript is dedicated
with 1a ve to my son Ari.

LIST OF CONTENTS
CHAPTER I INTRODUCTION .................................................. 1
CHAPTER I I SURGERY WITHOUT BLOOD TRANSFUSIONS ............................ 9
I I -i The perfonnance of major surgery in Jehovah 1 s
Witnesses ..•.....•••.•.••••.•.•••.••.••....•••.•••... 9
11-ii The surgical approach to the Jehovah1S Witness patient
bleeding from oesophageal varices .................... 18
!!-iii Internal iliac artery ligation analysis of fifty
cases ................................................ 28
CHAPTER III GENERAL ANAESTHESIA FOR THE ANEMIC PATIENT WITHOUT BLOOD
THERAPY ...................................................... 34
CHAPTER IV METHODS OF AVOIDING BLOOD TRANSFUSION ........................ 41
I V-i Intraoperative reinfusion •••••••..••.•...•.•••••••.•. 41
!V-ii The use of intravenous iron dextran .................. 55
CHAPTER V FLUOROCARBONS ................................................ 59
V-i Introduction ......................................... 59
Y-i-1 Historical evolution of the use of perf1uorochemicals
as blood substitutes ................................. 59
V-i-2 Pathophysiology of Fluosol-DA 20% .................... 66
V-ii The experimental use of Fluorocarbons •••....•••••••.. 79
Fluorocarbon mediated changes in oxygen supply in the
ischemically hypoxic myocardium- preliminary report.
V-iii The clinical use of perfluorocarbons ................. 90
The preoperative treatment of severely anemic patients
with a perfluorochemical oxygen transport medium
F1uosol-DA 20%.
CHAPTER VI DISCUSSION .................................................. 111
CHAPTER VII SUMMARY ..................................................... 115
REFERENCES .................................................................... 119
ACKNOWLEDGEMENTS
CURRICULUM VITAE

'The credit belongs to the man who is actually
in the arena whose face is marred by dust and
sweat and blood; who at best knows in the end
the triumph of high achievements and who at
worst if he fails at least fails while daring
greatly so that his place shall never be with
those cold and timid sou1s who know neither
victory not defeat. 1
Franklin T Roosevelt

1
CHAPTER I
INTRODUCTION
The modern practice of medicine has an ever-increasing dependency on the
blood bank industry. Indeed, on many occasions there is an unwarranted and
inappropriate use of hemotherapy.
The first recorded blood transfusion was given to Pope Innocent VIII in 1492
(Narengo-Rowe, 1982). This treatment was unsuccessful, and the patient and all
three blood donors died as a result of the experiment. Since then physicians
have been mesmerized by the 10mnipotent1 powers of extraneous blood in reversing
disease processes, regardless of the inherent complications or the logical
indications for such blood transfusions.
It has been estimated that 12 million units of blood are transfused yearly
into patients in the United States. This blood comes primarily from volunteer
sources, but paid donors must necessarily be used, in order to make up for
shortages created by the ever increasing demand. In addition, the cost of whole
blood has risen steadily to $100.00 per unit in some hospitals and frozen blood
is double this price. On average 2.5 units of blood are used for each trans
fusion and retrospective data analyses of the need for individual blood trans
fusions have unifonnly demonstrated that at least half of all blood transfusions
were unnecessary.
The risks of using homologous blood include disseminated
isosensitization~
intravascular coagulopathy, febrile reactions, bacterial contamimation, thrombo
phlebitis, hepatitis, cytomegalic viruses infection, syphilis~ herpes, malaria,
trypanosomiasis, thrombocytopenia, and reduced factor-VIII mediated coagulopathy.
Cardiac arrhythmias may occur as a result of vascular overload and hemosiderosis.
Blood, mismatched as a result of technical errors has also sometimes
contributed to catastrophies. The risk of hepatitis is 20-46% with paid donors,
2
and ranges from 10-15% when volunteers are used for the provision of donor blood.
Since only one-third of the patients become clinically jaundiced, it is difficult
to detennine the total incidence without performing liver enzymes tests and
antigen screening studies in all cases. The exact number of deaths directly
related to the transfusion of blood is also difficult to determine due to various
factors (including the failure of many hospitals to report such occurrences). Of
the deaths which have been attributed to blood transfusion, 60% '"ere related to
mismatched blood and 30% resulted from serum hepatitis (Myhre, 1980).
A number of methods can be employed in order to avoid the use of blood
transfusions. For additional information the reader is referred to Fig. 1 in
which the subject is dealt with schematically.
Surgical techniques may be improved, in order to avoid blood loss, by
employing hypotension, hypothermia, autotransfusion, intravenous iron therapy,
Folic Acid, and intravenous hyperalimentation to increase the rate of natural
hemoglobin production. Reassessment of the concept of the 1 need' for a
hemoglobin of 10 gm%, exploring the full potential of perfluorochemicals, and the
use of erythopoietin will greatly reduce the costs, risks, and shortages which
are associated with autologous blood transfusions.
Grant (1921) reported the first peroperative autologous blood transfusion.
Milles (1963) documented a similar procedure and Cowell (1974) presented a report
on a series of pediatric orthopaedic patients who were treated using this method
of autologous transfusion. The safety of preoperative blood collection for
subsequent retransfusion into patients with coronary insufficiency was
demonstrated by Cove (1976) and Ebert (1941) showed that plasma volume will
increase over 72 hours to compensate for the loss of red blood cells. Finch
(1950) showed that the limiting factor to effective hematopoesis after blood loss
is the depletion of iron-stores. Total dose infusion of intravenous Iron was
shown to replace these stores quite rapidly.
Mallory (1976) and Eckhardt (1978) reported two series of patients undergoing
hip replacement utilizing preoperative blood harvesting. The average blood