Outcomes of cardiac surgery in Jehovah's Witness patients: A review.

OBJECTIVE: To review current literature evidence on outcomes of cardiac surgery in Jehovah's Witness patients. METHODS: A comprehensive electronic literature search was done from 2010 to 20th August 2020 identifying articles that discussed optimisation/outcomes of cardiac surgery in Jehovah's Witness either as a solo cohort or as comparative to non-Jehovah's Witnesses. No limit was placed on place of publication and the evidence has been summarised in a narrative manner within the manuscript. RESULTS: The outcomes of cardiac surgery in Jehovah's Witness patients has been described, and also compared, to non-Witness patients within a number of case reports, case series and comparative cohort studies. Many of these studies note no significant differences between outcomes of the two groups for a number of variables, including mortality. Pre-, intra and post-operative optimisation of the patients by a multidisciplinary team is important to achieve good outcomes. CONCLUSION: The use of a bloodless protocol for Jehovah's Witnesses does not appear to significantly impact upon clinical outcomes when compared to non-Witness patients, and it has even been suggested that a bloodless approach could provide advantages to all patients undergoing cardiac surgery. Larger cohorts and research across multiple centres into the long term outcomes of these patients is required.

Bloodless surgery and gynecological patients among Jehovahs Witnesses.

OBJECTIVE: The aim of this research is to present our experiences with the surgical treatment of gynecological patients among Jehovahs Witnesses. Moreover, the medical, moral, and ethical problems in this regard have been highlighted. METHODS: 75 Jehovahs Witnesses patients were operated on for various benign and malignant gynecological diseases between 2007 and 2018. All of these patients were operated on according to the rules of blood-sparing surgery. RESULTS: The operations were assessed according to the dia-gnosis, mode of surgery, estimated blood loss, and disease outcome. Excessive blood loss did not occur during any of these operations, and the estimated blood loss for the same procedure was 10 to 550 mL. CONCLUSION: Jehovahs Witnesses gynecological patients is a group of high-risk patients because they refuse to undergo blood transfusion. Nevertheless, the principles of blood-sparing surgery should be applied to not only Jehovahs Witnesses patients but also to all patients in general. Even if a blood transfusion is the last resort to solve issues pertaining to excessive blood loss during complicated operations, the said procedure always carries certain risks. Therefore, blood transfusion should be performed only on rare occasions. Jehovahs Witnesses patients categorically refuse blood transfusion even if it is the only way to save ones life. Even though the legislation of the Czech Republic deals with this problem, there are other moral and ethical aspects that need to be addressed in this regard.

Pancreatic resections in patients who refuse blood transfusions. The application of a perioperative protocol for a true bloodless surgery.

BACKGROUND: The refusal of blood transfusions compels surgeons to face ethical and clinical issues. A single-institution experience with a dedicated perioperative blood management protocol was reviewed to assess feasibility and short-term outcomes of true bloodless pancreatic surgery. METHODS: The institutional database was reviewed to identify patients who refused transfusion and were scheduled for elective pancreatic surgery from 2010 through 2018. A protocol to optimize the hemoglobin values by administration of drugs stimulating erythropoiesis was systematically used. RESULTS: Perioperative outcomes of 32 Jehovah's Witnesses patients were included. Median age was 67 years (range, 31-77). Nineteen (59.4%) patients were treated with preoperative erythropoietin. Twenty-four (75%) patients underwent pylorus-preserving pancreaticoduodenectomy, 4 (12.5%) distal pancreatectomy (DP) with splenectomy, 3 (9.4%) spleen-preserving DP, and 1 (3.1%) total pancreatectomy. Median estimated blood loss and surgical duration were 400 mL (range, 100-1000) and 470 min (range, 290-595), respectively. Median preoperative hemoglobin was 13.9 g/dL (range, 11.7-15.8) while median postoperative nadir hemoglobin was 10.5 g/dL (range, 7.1-14.1). The most common histological diagnosis (n = 15, 46.9%) was pancreatic ductal adenocarcinoma. Clavien-Dindo grade I-II complications occurred in fourteen (43.8%) patients while one (3.1%) patient had a Clavien-Dindo grade IIIa complication wich was an abdominal collection that required percutaneous drainage. Six (18.8%) patients presented biochemical leak or postoperative pancreatic fistula grade B. Median hospital stay was 16 days (range, 8-54) with no patient requiring transfusion or re-operation and no 90-day mortality. CONCLUSIONS: A multidisciplinary approach and specific perioperative management allowed performing pancreatic resections in patients who refused transfusion with good short-term outcomes.

Bloodless Arterial Switch Operation in a 2.7-kg Jehovah's Witness Patient.

Bloodless pediatric cardiac surgery requiring the use of cardiopulmonary bypass (CPB) remains a challenge for the entire operating room (OR) team. The amount of circulating blood volume to pump prime volume mismatch of small patients results in hemodilution that frequently results in transfusion of allogeneic blood products. Patients of families of the Jehovah's Witness (JW) faith reject the use of these products because of religious beliefs. Our institution is a referral center for children of JW families because we have developed techniques to minimize blood loss with the hope of performing bloodless pediatric cardiac surgery whenever possible. These techniques include preoperative treatment with erythropoietin, intraoperative acute normovolemic hemodilution, CPB circuit miniaturization, ultrafiltration during and after CPB, limiting blood gas analyses or other unnecessary blood draws, and using hemostatic agents during and after CPB. We present the case of a 4-day-old patient of the JW faith weighing 2.7 kg with transposition of the great arteries and an intact ventricular septum who underwent an arterial switch operation. The patient received no allogeneic blood product administration throughout the entire hospitalization. The patient's first hematocrit in the OR was 43%, lowest hematocrit on bypass was 15%, and first hematocrit in the cardiothoracic intensive care unit post-procedure was 21%. The patient was discharged on post-op day nine with a hematocrit of 36%.

Adolf Lorenz and the Lolita Armour Case.

Almost 120 years ago, in 1902, the American multimillionaire J. Ogden Armour invited the Austrian orthopaedic surgeon Adolf Lorenz, professor at the University of Vienna, to treat his daughter Lolita. Lolita was born premature in 1896 and spent the first months of her life in an incubator. Later she was diagnosed with congenital dislocation of both hips. Lorenz had developed a "bloodless" treatment method and was invited by the Armour family to Chicago to "operate" on Lolita. Both hips had already been treated by an American orthopaedic surgeon before but without a satisfactory result. Lorenz should achieve a better one. The operation was performed in Chicago on 12 October 1902 and was accompanied by a very large media spectacle. This article is mainly based on contemporary newspaper reports.

Multidisciplinary strategies in bloodless medicine and surgery for patients undergoing pancreatectomy.

BACKGROUND: Bloodless pancreatic surgery (BPS) is rarely performed and/or reported. We aim to characterize perioperative and anesthetic strategies in BPS. MATERIALS AND METHODS: A literature search was performed on MEDLINE looking for case reports/case series using search terms ("Jehovah's Witness" [All Fields]) AND ("Pancreatic Surgery" [All Fields] OR "Pancreaticoduodenectomy" [All Fields] OR "Distal Pancreatectomy" [All Fields]). Data regarding categorical variables are reported as proportions and quantitative continuous variables as medians with ranges or means with standard deviation. Forty-one patients requiring BPS are reported in the literature with three additional cases from our institution (n = 44). The data analyzed included clinicopathologic factors, BPS strategies, patient complications, and in-hospital mortality. RESULTS: The most common procedure and diagnosis were pancreaticoduodenectomy (n = 34, 77.3%) and pancreatic ductal adenocarcinoma (n = 12, 27.3%), respectively. Transfusion reduction strategies in BPS fell into three categories: preoperative, intraoperative, and postoperative. Preoperative strategies included iron supplementation (n = 24, 54.5%) and erythropoietin administration (n = 14, 41.2%). Intraoperative strategies included acute normovolemic hemodilution (n = 30, 68%) and cell saver (n = 4, 9.1%). Postoperative strategies included erythropoietin (n = 16, 48.5%) and iron supplementation (n = 16, 48.5%). Complications occurred in 21 (60%) patients. There was no in-hospital mortality among the 44 patients in this cohort. CONCLUSIONS: A broad spectrum of bloodless medicine and surgery practices were used based on patient selection, multidisciplinary practice, and preference. With careful perioperative and anesthetic management, BPS can be performed with good outcomes.

Open Cardiac Surgery without Blood and Blood Products Transplantation.

BACKGROUND: Blood transfusions are the most common type of tissue and organ transplantation. Perioperative and postoperative transfusions may cause morbidity and mortality and transfusion should based on only hematocrit values but also on hemodynamic and clinical parameters of the patient, which cannot be ignored. METHODS: A prospective study was conducted between January 2015 and October 2016 with adult patients undergoing elective open heart surgery. In these patients, a protocol was established, and patients were divided into two groups as transfusion (-) and transfusion (+). In the first 24 hours in the intensive care unit, patients' drainage, 24-hours urine output, awakening and extubation times, and lactate and bilirubin levels in arterial blood gases were recorded. Thirty-day mortality and morbidity, and hemodynamic and clinical data were compared between these two groups. RESULTS: We have performed a total of 138 cases; no blood and blood products were transfused in 71% (n = 98), and in 29.0% (n = 40) blood and blood products were transfused. Thirty-day mortality and morbidity (arrhythmia, infectious and pulmonary morbidity, myocardial infarction, cerebrovascular accident, renal dysfunction, sternal revision) were compared between these two groups and no statistically significant difference was observed. Patients' awakening, extubation time, cardiopulmonary bypass period, cross-clamp time, and days in intensive care unit and hospital were compared, and there was no statistically significant difference between the two groups. Conclusion: In this study, we conclude that open heart surgery without blood transfusion may be accomplished with decent peri/postoperative management. The patients who did not receive any blood or blood products were not compromised clinically or hemodynamically. No extra morbidity and mortality were seen in the non-transfusion group. Transfusion decision was based on clinical and hemodynamic parameters such as persistent hypotension or tachycardia, hyperlactatemia, low urine output, and anemic symptoms.

Perioperative Management of a Child with Hypoplastic Left Heart Syndrome of the Jehovah's Witness Faith Presenting for Hybrid Comprehensive Stage II Procedure.

Over the years, there has been a growing recognition of the potential negative sequelae of allogeneic blood products on postoperative outcomes following cardiac surgery. In addition, followers of the Jehovah's Witness (JW) faith have a religious restriction against receiving blood or blood components. Advances in perioperative care, cardiopulmonary bypass (CPB), and surgical technique have minimized the need for allogeneic blood products. Specific blood conservation strategies include maximizing the preoperative hematocrit and coagulation function as well as intraoperative strategies, such as acute normovolemic hemodilution and adjustments of the technique of CPB. We report a 7-month-old patient whose parents were of the JW faith who underwent a comprehensive stage II procedure for hypoplastic left heart syndrome without exposure to blood or blood products during his hospital stay. Perioperative techniques for blood avoidance are discussed with emphasis on their application to infants undergoing surgery for congenital heart disease.

Encouraging results of blood conservation in neonatal open-heart surgery.

OBJECTIVE: To report early outcomes of blood conservation in neonatal open-heart surgery. METHODS: Ninety-nine patients undergoing neonatal open-heart surgery during the implementation of a blood conservation program between May 2021 and February 2023 were reviewed. Patients either received traditional blood management (blood prime, n = 43) or received blood conservation strategies (clear prime, n = 56). Baseline characteristics and outcomes were compared between groups. RESULTS: There was no difference in body weight (median, 3.2 kg vs 3.3 kg; P = .83), age at surgery (median, 5 days vs 5 days; P = .37), distribution of The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories categories or duration of cardiopulmonary bypass. Patients in the clear prime group had higher preoperative hematocrit (median, 41% vs 38%; P < .01), shorter postoperative mechanical ventilation time (median, 48 hours vs 92 hours; P = .02) and postoperative intensive care unit length of stay (median, 6 days vs 9 days; P < .01) than patients in the blood prime group. Fourteen patients (25%) in the clear prime group, including 1 Norwood patient, were discharged without any transfusion. Among patients within the clear prime group, hospitalizations without blood exposure were associated with higher preoperative hematocrit (median, 43% vs 40%; P = .02), shorter postoperative mechanical ventilation times (median, 22 hours vs 66 hours; P = .01) and shorter postoperative hospital stays (median, 10 days vs 15 days; P = .02). CONCLUSIONS: Bloodless surgery is possible in a significant proportion of neonates undergoing open-heart surgery, including the Norwood operation, even in the early stages of experience. Early clinical results are favorable but long-term follow-up and continued efforts are warranted to prove safety and reproducibility.

Bloodless Gynecological Surgery in Blood Products Refusing Patients: Experience of a Single Institution.

Propose: This pilot study aimed to apply the central tenets of bloodless surgery and to analyze the effectiveness of specific preoperative, intraoperative, and postoperative strategies to minimize the risk for blood transfusion after gynecological surgery in a specific group of patients who refused blood products. Methods: A total of 83 patients undergoing gynecological surgery were included in the study. Forty-two patients received preoperatively oral iron, acid folic, and vitamin B12 supplementation in the 30 days before surgery, and 41 patients did not receive therapy. Results: No significant differences were found when comparing the two study groups. The implementation of all procedures to maintain a bloodless surgery has been helpful, in association with the other available procedures, in achieving optimal management and maintenance of hemoglobin levels, even in the most critical situations. Conclusion: In conclusion, implementing the bloodless approach as much as possible could guarantee the patient better and safer clinical and care management. Furthermore, well-designed research is required to clarify further the effects of bloodless surgery in gynecological patients.

Treating Osteoarthritis in Jehovah's Witness Patients.

This article addresses the challenges surrounding hip and knee osteoarthritis (OA) treatment in Jehovah's Witnesses (JWs), focusing on the complexities arising from their refusal of blood products and transfusions. Acknowledging the heightened risk of blood loss anemia during joint replacement surgery, this review explores documented strategies that enable safe elective joint arthroplasty in JW patients, emphasizing comparable initial diagnostic methods and non-operative treatments up until the pre-operative stage. Special considerations should be taken in the perioperative and intraoperative stage. Despite these challenges, safe arthroplasty is feasible with satisfactory outcomes through a combination of careful preoperative optimization, blood saving protocols, and cultural sensitivity.

Fatal Hemoptysis With Pleural Effusions Secondary to Superior Vena Cava Obstruction as a Complication of Central Venous Catheterization.

This report outlines a rare case of superior vena cava (SVC) syndrome presenting with hemoptysis in a 33-year-old female Jehovah's Witness patient with a complex medical history, including systemic lupus erythematosus (SLE) and chronic hemodialysis dependency due to end-stage renal disease and a failed renal transplant. The SVC syndrome was attributed to occlusion from a right subclavian dialysis catheter. The management of this case was particularly challenging due to the patient's severe anemia and the development of a tension hemothorax following thoracentesis, compounded by her refusal of blood transfusions in adherence to her religious beliefs. A multidisciplinary approach, incorporating bloodless medical techniques such as erythropoietin and iron infusions alongside surgical interventions without blood transfusion, was successfully employed. This case sheds light on the evolving etiology of SVC syndrome and highlights the uncommon but potentially fatal occurrence of hemoptysis as a complication. It also emphasizes the importance of respecting patient values in complex medical decisions.

Enhancing bariatric surgery safety for patients refusing blood transfusions: a specialized protocol with comprehensive technical measures.

Bariatric surgery has become a leading treatment for obesity, with techniques such as Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) demonstrating notable success in sustained weight loss and improved quality of life. Technological advancements and improved techniques have enhanced the safety of these procedures. The surgical procedures of Jehovah's Witnesses, who refuse blood transfusions as part of their beliefs, pose unique challenges and have rarely been addressed in the context of bariatric surgery. This report aimed to investigate the safety of bariatric surgery in patients who refuse blood transfusion, with an established protocol to minimize the risk of bleeding. We examined the prospectively collected data of Jehovah's Witness patients who underwent bariatric surgery from 2019 to 2023. The surgeries were conducted following a protocol that included specific measures to prevent bleeding. Data were reviewed for demographics, anthropometrics, comorbidities, preoperative medications, operative time, blood loss, length of hospital stay, hemoglobin level, drainage volume, tranexamic acid use, and postoperative 30-day complications. Eleven Jehovah's Witness patients underwent bariatric surgery, including 10 LSG and 1 LRYGB. A patient with iron deficiency anemia underwent intravenous iron treatment before the surgery. There were no intraoperative complications or major postoperative complications. All patients maintained stable hemodynamics postoperatively. Only one patient encountered nausea-vomiting, classified as a minor complication. One patient experienced a small amount of hemorrhagic drainage, which transitioned to serous after tranexamic acid infusion. Bariatric surgery can be performed safely with established protocols in patients who refuse blood transfusions.

Successful Heart Transplantation Without Blood Transfusion in a Jehovah's Witness Patient With Congenitally Corrected Transposition of the Great Arteries: A Case Report.

We report a case of heart transplantation in a 68-year-old Jehovah's Witness patient with congenitally corrected transposition of the great arteries (ccTGA) who developed heart failure due to right ventricular dysfunction. The patient underwent successful heart transplantation without the use of blood products, employing meticulous hemostasis and careful surgical planning. This case highlights the anatomical considerations and challenges in transplanting a heart in a patient with ccTGA, including the reversed positions of the pulmonary artery and the ascending aorta. It also emphasizes the importance of tailored surgical strategies to achieve hemostasis and avoid blood transfusion in Jehovah's Witness patients. This case adds to the limited literature on heart transplantation in patients with ccTGA and demonstrates that heart transplantation can be successfully performed without blood transfusion in Jehovah's Witness patients.

Spinal deformity surgery in patients for whom blood transfusion is not an option: a single-center experience.

OBJECTIVE: Spinal deformity surgery is associated with significant blood loss, often requiring the transfusion of blood and/or blood products. For patients declining blood or blood products, even in the face of life-threatening blood loss, spinal deformity surgery has been associated with high rates of morbidity and mortality. For these reasons, patients for whom blood transfusion is not an option have historically been denied spinal deformity surgery. METHODS: The authors retrospectively reviewed a prospectively collected data set. All patients declining blood transfusion who underwent spinal deformity surgery at a single institution between January 2002 and September 2021 were identified. Demographics collected included age, sex, diagnosis, details of any prior surgery, and medical comorbidities. Perioperative variables included levels decompressed and instrumented, estimated blood loss, blood conservation techniques used, length of surgery, length of hospital stay, and complications from surgery. Radiographic measurements included, where appropriate, sagittal vertical axis correction, Cobb angle correction, and regional angular correction. RESULTS: Spinal deformity surgery was performed in 31 patients (18 male, 13 female) over 37 admissions. The median age at surgery was 41.2 years (range 10.9-70.1 years), and 64.5% had significant medical comorbidities. A median of 9 levels (range 5-16 levels) were instrumented per surgery, and the median estimated blood loss was 800 mL (range 200-3000 mL). Posterior column osteotomies were performed in all surgeries, and pedicle subtraction osteotomies in 6 cases. Multiple blood conservation techniques were used in all patients. Preoperative erythropoietin was administered prior to 23 surgeries, intraoperative cell salvage was used in all, acute normovolemic hemodilution was performed in 20, and perioperative administration of antifibrinolytic agents was performed in 28 surgeries. No allogenic blood transfusions were administered. Surgery was staged intentionally in 5 cases, and there was 1 unintended staging due to intraoperative blood loss from a vascular injury. There was 1 readmission for a pulmonary embolus. There were 2 minor postoperative complications. The median length of stay was 6 days (range 3-28 days). Deformity correction and the goals of surgery were achieved in all patients. Two patients underwent revision surgery during the follow-up period: one for pseudarthrosis and the other for proximal junctional kyphosis. CONCLUSIONS: With proper preoperative planning and judicious use of blood conservation techniques, spinal deformity surgery may be performed safely in patients for whom blood transfusion is not an option. The same techniques can be applied widely to the general population in order to minimize blood loss and the need for allogeneic blood transfusion.

Short and long-term outcomes after cardiac surgery in Jehovah's Witnesses patients: a case-control study.

Cardiac surgery in Jehovah's Witnesses (JW) patients who refuse blood transfusion is challenging requiring dedicated strategies. We aimed to analyze non-selected JW patients undergoing cardiac surgery and to compare with matched controls both perioperative outcomes and long-term survival. We retrospectively analyzed JW patients undergoing cardiac surgery from January 2016 to March 2021 and compared them with matched controls. The primary outcome was a composite of in-hospital perioperative adverse events and in-hospital mortality. The secondary outcome was all-cause mortality at long-term follow-up. A total of 113 JW patients and 113 controls were included. Baseline clinical characteristics, including laboratory parameters were comparable. Overall, there were no statistical differences between JW vs controls in terms of in-hospital mortality (2.7% vs 1.8%, p = 1.00) but mortality was remarkably high (40%) in JW patients with post-op hemoglobin < 8 g/dl. Logistic regression analysis found that the JW group was not associated with a higher occurrence of the composite outcome (adjusted odds ratio 0.91, 95% confidence interval [CI] 0.54-1.57). After a median follow-up of 1397 [IQR 922.7-1723.5] days, JW patients were not associated with a significantly higher all-cause mortality (adjusted hazard ratio 0.77, 95% CI 0.24-2.42). Cardiac surgery can be safely performed in non-anemic JW patients despite the refusal of blood transfusions. Favorable clinical outcomes can be achieved by the use of specific perioperative strategies for bloodless surgery with no differences as compared to control patients except in JW patients with a very low level of post-operative hemoglobin not supported by immediate transfusions.

High Radiofrequency Surgery and Chromoendoscopy: A Novel Surgical Technique for the Treatment of Respiratory Papillomatosis.

Recurrent Respiratory Papillomatosis is a highly recurrent and residual disease. The use of indigo-carmine chromoendoscopy increases the early detection of nonvisible disease and reduces the possibility of leaving residual lesions. The best chances of papillomatosis being eradicated depend upon a surgical shallow epitheliolysis approach applied to patients who have never been surgically damaged before. We developed a novel surgical technique based upon the use of a time controlled High Radiofrequency (HRF) energy output. We applied a three-step bloodless HRF-surgical technique, that is, epitheliolysis, angiolysis and peeling without the aid of adjunct therapies. It acts according to differences in the water density of the tissues. We use it to remove the epithelial viral reservoir thus preserving subepithelial layers. For this purpose, we designed and manufactured a custom-made HRF electrodes set for office and O.R. use. From 2005 to 2018, 39 patients (100%) with recurrent respiratory papillomatosis participated in the present prospective work. Twenty-five (64,10%) achieved complete postsurgical remission, 6 (15,38%) were lost to follow up, and 8 (20,51%) present partial remissions. Thirty-six patients had laryngeal papillomatosis. Follow-up was possible in 30 of the 36 patients with laryngeal papillomatosis with a success remission rate of 83,33% (25 of 30). Eleven of those 36 (30,55%) entered this study without previous surgical treatment and 9 of 11 (81,81%) were cured. Indigo-carmine chromoendoscopy, a visualization solution for papillomatosis detection, together with a bloodless HRF-surgical technique proved to be effective tools to eradicate papillomatosis. Voice restoration to normal or near normal levels was achieved in all patients.

Evolution of Bloodless Surgery: A Case for Bloodless Suprapubic Prostatectomy.

Allogeneic blood transfusion is commonly prescribed to patients undergoing suprapubic prostatectomy for benign prostatic hyperplasia as a treatment option to replace blood loss. Historically, suprapubic prostatectomy has been perceived as an extremely high hemorrhagic surgery, and this has led to the association of suprapubic prostatectomy with a high rate of allogeneic blood transfusion. However, the outcome of suprapubic prostatectomy has significantly improved over the years and has become less hemorrhagic in many hands - creating the opportunity to consistently avoid allogeneic blood transfusion. On the other hand, the efficacy of blood transfusion has come under more stringent scrutiny as many clinical studies have reported inconsistent effects of blood transfusion on patient outcome. In contemporary practice, a more conservative/bloodless approach in the perioperative management of anemia in surgical patients is strongly being advocated with convincing evidence that many surgical patients can be routinely and safely managed without allogeneic blood transfusion. There is no large-scale discussion on bloodless surgery in urology in the contemporary literature, especially in the area of suprapubic prostatectomy that has been historically associated with a high rate of blood transfusion. This review article will discuss the evolution of bloodless surgery including the ongoing controversies surrounding blood transfusion in general, and then the relatively small but ongoing penetration of bloodless surgical approach in the field of suprapubic prostatectomy. Furthermore, the authors' approach to bloodless suprapubic prostatectomy will be highlighted, and in doing so, it can be emphasized that suprapubic prostatectomy is no more as hemorrhagic as was historically perceived, but rather a routine bloodless suprapubic prostatectomy is now possible in many hands.

Major thoracic surgery in Jehovah's witness: A multidisciplinary approach case report.

INTRODUCTION: A bloodless surgery can be desirable also for non Jehovah's witnesses patients, but requires a team approach from the very first assessment to ensure adequate planning. PRESENTATION OF THE CASE: Our patient, a Jehovah's witnesses, was scheduled for right lower lobectomy due to pulmonary adenocarcinoma. Her firm denies to receive any kind of transfusions, forced clinicians to a bloodless management of the case. DISCUSSION: Before surgery a meticulous coagulopathy research and hemodynamic optimization are useful to prepare patient to operation. During surgery, controlled hypotension can help to obtain effective hemostasis. After surgery, clinicians monitored any possible active bleeding, using continuous noninvasive hemoglobin monitoring, limiting the blood loss due to serial in vitro testing. The optimization of cardiac index and delivery of oxygen were continued to grant a fast recovery. CONCLUSION: Bloodless surgery is likely to gain popularity, and become standard practice for all patients. The need for transfusion should be targeted on individual case, avoiding strictly fixed limit often leading to unnecessary transfusion.

[Single intravenous tranexamic acid dose to reduce blood loss in primary total knee replacement]. / Dosis única intravenosa de ácido tranexámico como medida de ahorro transfusional en prótesis total primaria de rodilla.

OBJECTIVE: To evaluate the effectiveness and safety of a single intravenous dose of tranexamic acid in order to reduce blood loss in total knee replacement. MATERIALS AND METHODS: Prospective observational study of the administration of tranexamic acid in patients undergoing primary total knee arthroplasty from November 2013 to February 2015, in which an autologous blood recovery system was used. The study included 98 patients, distributed into two groups of 49 patients according to whether or not they received intravenous tranexamic acid. The primary endpoint was the number of patients requiring autologous transfusion from the recovery system autologous blood recovery system. RESULTS: No drop-outs were recorded during follow-up. There were no significant differences between groups as regards the preoperative and hospital variables. The mean preoperative haemoglobin and haematocrit at 24 and 48 hours postoperatively were similar in both groups. The average volume of bleeding in the autologous blood recovery system and estimated average blood loss was lower in patients who had been administered tranexamic acid, with significant differences. No patients in the group that was administered tranexamic acid required blood autotransfusion. The transfusion rate was zero in the two groups. No adverse events related to the administration of tranexamic acid were recorded. CONCLUSIONS: Intravenous administration of tranexamic acid, according to the described protocol, has presented a non-autotransfusion or allo-transfusion rate of 100%, with no increased incidence of thrombotic events. Thus, its use in this group of patients is recommended. The indication should be individualized, its use justified in the patient medical records, and informed consent is mandatory.