Bleeding in a Jehovah's Witness patient undergoing a redo aortic valve replacement controlled with cryoprecipitate and a prothrombin complex concentrate.

PURPOSE: This is a case report involving a middle-aged Jehovah's Witness patient who underwent a redo aortic valve replacement, coronary artery bypass graft, and Maze procedure facilitated by cardiopulmonary bypass. The consent process included a discussion of the management of bleeding and hemostasis in the perioperative period in the context of the patients' religious choice and the possible consequences of avoiding transfusion in massive bleeding. The medical team agreed to abide by the patient's wishes with respect to the blood and blood products deemed unacceptable by the patient irrespective of the consequences. The consent included a discussion of manufactured hemostatic agents that are designated by the Hospital Liaison Committee Network for Jehovah's Witnesses as subject to personal decision. There was also a discussion of recombinant agents available, all of which are acceptable to Jehovah's Witness patients. The patient accepted the use of cryoprecipitate, prothrombin complex concentrate, and recombinant factor VIIa. CLINICAL FEATURES: After separation from cardiopulmonary bypass and protamine administration, blood loss was 350 mL over a ten-minute period. The international normalized ratio (INR) was 3.5 at that time. Cryoprecipitate 15 U, 1-deamino-8-D-arginine vasopressin 16 U, and a prothrombin complex concentrate, Octaplex®, 60 mL were administered. Blood loss improved significantly. The INR in the cardiac surgical intensive care unit was 1.3. The sample was taken approximately one hour following the administration of the hemostatic agents. The patient's chest was closed, and chest tube drainage was 310 mL over the next 12 hr. CONCLUSION: This is a novel case involving the use of prothrombin complex concentrate in the setting of a Jehovah's Witness patient undergoing a complex operative procedure.

Urgent replacement of a mechanical mitral prosthesis in an anticoagulated patient with Bombay red blood cell phenotype.

PURPOSE: Bombay red blood cell phenotype is an extremely rare blood type for which patients can receive only autologous or Bombay phenotype red blood cells. We report a case of urgent repeat sternotomy for replacement of a mechanical mitral prosthesis in a patient with Bombay phenotype anticoagulated with warfarin, to emphasize the transfusion challenges in such patients. CLINICAL FEATURES: A male of Indian descent presented to hospital with New York Heart Association IV symptoms. His medical history revealed previous mitral valve replacement with a mechanical prosthesis in 2005 and Bombay phenotype blood. Preoperative transthoracic echocardiography demonstrated thrombus obstruction of the mitral prosthesis despite anticoagulation with warfarin. Right ventricular systolic pressure was >100 mmHg with 3+ tricuspid regurgitation. The patient's condition was temporized with diuretics, bronchodilators, and bi-level positive airway pressure ventilation while transfusion medicine and cardiac surgery were consulted for urgent surgery. The patient received vitamin K and prothrombin complex concentrate prior to repeat sternotomy and successful mitral prosthesis replacement. After cardiopulmonary bypass, heparinization was corrected with protamine and followed by a second dose of prothrombin complex concentrate and recombinant activated factor VIIa. Postoperatively, the patient received four units of packed red blood cells, two autologous units and two units of Bombay specific red blood cells. Right ventricular pressures stabilized at 40 mmHg following surgery. The patient recovered following several days of inotropic support with milrinone, diuretics, and bronchodilators. CONCLUSION: Patients with Bombay phenotype red blood cells present as type O, but they are unable to receive red blood cells from any phenotype other than Bombay phenotype. They are able to receive all other blood products, including fresh frozen plasma, cryoprecipitate, platelets, prothrombin complex concentrate, and recombinant activated factor VIIa. Coordination between Canadian Blood Services, transfusion medicine, surgery, and anesthesia is important in managing these patients.

Empirically grounded clinical interventions clients' and referrers' perceptions of computer-guided CBT (FearFighter).

BACKGROUND: Computer-guided CBT has been shown to be a potentially useful way of closing the gap between the demand and supply for CBT. Moreover, this approach has additional benefits in terms of less travel times for treatment, accessibility in remote and unusual locations, increased confidentiality, easier disclosure of sensitive information, and more egalitarian therapist-client interactions. Research on computerized CBT has concentrated on clinical outcomes, but the views of clients on this treatment approach have been relatively neglected. AIMS: The aims were to assess client satisfaction, professionals' views, and ease of programme use after completion of treatment via an internet-based CBT programme for panic and phobic anxiety (FearFighter). METHOD: A feasibility and effectiveness study of FearFighter was conducted in remote and rural areas of Scotland. Treatment data are available for 35 clients at post-treatment, of whom 29 completed an 18-item set of rating scales designed to assess satisfaction, including ease of use, accessibility, how far needs were met, whether changes to the programme were required, the benefits and drawbacks of not having a therapist, and quality of support. Open-ended questions were included. Referring agencies were also asked to rate their views on FearFighter. RESULTS: Clients reported moderate to high levels of improvement and of overall satisfaction; very few difficulties in logging on to and using the programme were encountered. Similar levels of satisfaction with the programme were reported by referrers. CONCLUSIONS: It is concluded that computer-guided CBT is acceptable to clients and to professionals, and that it could play a valuable part in a "stepped care" system of delivering CBT.

Reference intervals for anion gap and strong ion difference in pregnancy: a pilot study.

OBJECTIVE: Acid-base status and electrolyte levels change in normal pregnancy. We hypothesized that these physiological changes affect both anion gap and strong ion difference (SID). METHODS: A cross-sectional study of normal pregnant women (6 in the first trimester, 47 in the second trimester, 59 in the third trimester, and 13 postpartum). RESULTS: The anion gap in pregnancy (8.5 +/- 2.9 mEq/L) was less, compared to postpartum values (10.7 +/- 2.5 mEq/L), (p < 0.005). The SID, too, was lower (pregnancy, 38.3 +/- 2.9 mEq/L, postpartum 43.5 +/- 2.3 mEq/L, p < 0.001), reflecting the combined influence of changes in albumin, SID, and PCO(2). CONCLUSION: Anion gap and SID both decrease in pregnancy, events which must be taken into account when managing acid-base disorders in gestation.