PIG Meeting: 1st July 2021

49-year-old lady for Laparotomy and Hysterectomy for fibroid uterus and menorrhagia      

Background:

• Very large multi-fibroid uterus
• Menorrhagia – Fe deficiency anaemia in past requiring Iron infusion
• Fit and healthy lady
• Active, normal BMI

Issues

• Jehovah’s witness, Provided advanced care directive regarding acceptable blood products
• Inconsistency between products listed on ACD and those available for use in Australia, for example, haemoglobin

Discussion

Consent for Blood Products

• Frequently find ACD from Jehovah’s witness patients that list products not available in Australia
• Helpful strategy is to direct patients to the Red Cross website, explain available blood products and ask them to discuss with relevant advisors as to which they are happy to accept
• Essential that patients are adequately informed and consented preoperatively
• Jehovah’s witness website has many resources, may be helpful for anaesthetists to review information that patients are provided by church
• Majority of people agreed that they document patient’s wishes with regards to blood products in the event of a life-threatening emergency.
• This is best done at the perioperative consult as patient may need time to consult with family and church

Clinical Strategies to avoid Blood transfusion in this case

Preoperatively:

• Optimising Haematinics, anaemia screen and replacement as appropriate
• Consider use of tranexamic acid or Mirena in menorrhagia
• Fibroids – embolization, Zoladex – reduces size, takes 6 months to work and undesirable side effects.
• Nutrition advice and weight loss if appropriate

Intraoperatively:

• Liaise with surgical team regarding expected blood loss/difficult of surgery
• Consider use of cell salvage
• Intraoperative tranexamic acid to be considered

Plan:

• All above strategies employed
• Liaise with surgeon and procedural anaesthetist
• Consider update of clinic guideline/proforma – ongoing