Coagulopatia em Testemunha de Jeová

Coagulopathy After Cardiopulmonary Bypass in Jehovah’s Witness Patients: Management of and for the Individual Rather than the Religious Institution
[Editorial]
Elder, Lee
Address correspondence and reprint requests to Lee Elder, Associated Jehovah's Witnesses for Reform on Blood, Boise, ID. Address e-mail to leeelder@ajwrb.org.
Jehovah's Witnesses read with interest the case study by Sniecinski et al. (1) concerning advances in treating patients who refuse certain products made from blood. Some Jehovah's Witnesses fit this profile. Accordingly, we are grateful to medical science for advances facilitating safe perioperative care for patients with this preference.
Sniecinski et al. (1) report the cases of two Jehovah's Witness patients, both of whom accepted transfusions from the donated and stored blood supply. This transfusion of products made from donor blood naturally leads one to question claims, made by some Jehovah's Witnesses, of abstaining from donor blood. This difficulty is amplified when reading power of attorney documents published by the Watchtower stating that Jehovah's Witnesses have the option of accepting literally everything from a given unit of donated blood so long as it is sufficiently fractionated beforehand. Understandably, health care providers are left wondering how a person can lay claim to abstaining from blood as an underlying tenet of faith and yet at the same time declare a preference to accept literally anything and everything from donated blood so long as it has been sufficiently fractionated. An added distraction for physicians trying to understand the Jehovah's Witness patient is the Watchtower organization's marketing of itself as representing Jehovah's Witnesses when it comes to medical use of blood.
In the report by Sniecinski et al. (1) it is important to point out the distinction between treating Jehovah's Witnesses as individuals rather than as part of a population within a religious institution that has strict proclamations on treatment options. In their presentation, Sniecinski et al. (1) treat official Watchtower teaching as though it represents the conviction of all individuals within the Jehovah's Witness population. In fact, the Watchtower organization no more represents the entire population of Jehovah's Witnesses in respect to blood than the Roman Catholic Church represents the entire population of Roman Catholics in relation to birth control techniques. A difference between these two religious institutions is that one interjects itself as representing an entire population with respect to a specific teaching while the other makes no claim that its position reflects the convictions of its members. Despite Watchtower's religious teaching, physicians experience many Jehovah's Witness patients willing to conscientiously accept transfusion of any donated blood product (including whole blood, red cells, white cells, platelets, or plasma) so long as the choice is kept confidential. This is based on a conscientious conviction that the choice is consistent with biblical imperatives. Furthermore, these individuals desire autonomy rather than having the Watchtower organization deciding for them what they can and cannot accept medically as a matter of conscience.
A little advertised fact is that the entire population of Jehovah's Witnesses has never universally assented to the Watchtower organization's religious position on blood transfusion. From the teaching's inception until today, individual Jehovah's Witnesses have lobbied the Watchtower to allow all uses of donor blood for medical purposes. Again, the point here is that the doctrine issued by the Watchtower organization is representative of its own hierarchy, and not of the entire population of Jehovah's Witnesses.
Members of Associated Jehovah's Witnesses for Reform on Blood applaud efforts such as those depicted by Sniecinski et al. (1) to advance medical practices in an effort to improve medical therapies and outcomes for patients with peculiar religious convictions. However, we also remind medical doctors to treat Jehovah's Witnesses patients as each individual prefers rather than as a religious organization prefers them to be treated. In this respect clinicians should take the necessary measures to ensure that choices are autonomous personal decisions rather than transposing organizational religious ideology as though it represents individual conviction. At a minimum, treating physicians should arrange for a private meeting with patients so they have an opportunity to speak for themselves, free from religious pressure and in the absence of family members who are also Jehovah's Witnesses. Again, doctors are looking to confirm an individual's preference regarding blood product transfusion and not the preference of family members or a religious organization. Clinicians should likewise avoid pressuring the patient to act contrary to his or her own convictions.

Testemunha de Jeova-editorial

Optimal Care for Patients Who Are Jehovah’s Witnesses
[Editorial]
Schiller, Harvey Jon MD
Conflict of Interest: Dr. Schiller is an unpaid volunteer staff member of Watchtower.
Address correspondence and reprint requests to H. Jon Schiller, MD, 100 Watchtower Dr., Patterson, NY 12563. Address e-mail to Joschill@jw.org.
The article by Sniecinski et al. (1) on the treatment of two Jehovah's Witnesses with coagulopathy presents a laudable approach toward improved communication with patients who may offer a rather unique medical challenge. Three aspects of this paper merit comment.
First, the paper highlights how far we have come in the past few decades in the treatment of Jehovah's Witnesses. Notice, for example, that the postoperative hematocrit in these two patients were 23% and 20% respectively, and that both patients had “good outcomes.” Actually, this is not unusual in the reports on patients who are Jehovah's Witnesses. Yet, it was not that long ago that some physicians generally applied the “10/30” rule as a transfusion trigger. We have learned much about alternatives for treating anemia and now coagulopathy, as this paper shows.
Second, the authors commendably capture the issue here that the decision on whether to receive these processed blood fractions was up to the two patients. This is not, though, some recent “official” change of position. The decision on blood fractions for Jehovah's Witnesses has long been understood to be up to the individual. For example, in a 1981 position paper in JAMA, Dixon and Smalley (2) reported: “While these verses [Genesis 9:3, 4; Leviticus 17:13, 14; Acts 15:19–21] are not stated in medical terms, Witnesses view them as ruling out transfusion of whole blood, packed RBCs, and plasma, as well as WBC and platelet administration. However, Witnesses' religious understanding does not absolutely prohibit the use of components such as albumin, immune globulins, and hemophiliac preparations; each Witness must decide individually if he can accept these” (2). That is still the basic position of Jehovah's Witnesses.
Third, in their paper reporting two good outcomes, Sniecinski et al. (1) conclude that their use of blood fractions “likely contributed to the good outcomes of these patients.” That may be true, but one can never say for sure. Would the patients have survived and done well had they elected not to take these fractions? Over the years, countless papers across all medical specialties have documented good outcomes for Jehovah Witness patients, even when they seemed contrary to expectations. With Witness patients, as the authors rightly note, each individual decides whether to accept minor blood fractions. That decision may be based partly on the information we physicians provide. We need to take care not to “talk a patient into something.” Both these patients received cryoprecipitate, a product pooled from many patients. Though the safety of such products has improved markedly with viral detection and inactivation methods, review of the literature reveals that there is, and will likely continue to be, some element of hazard (3–6). What if a Witness patient received a blood-borne pathogen or had another severe effect (West Nile, Creutzfeldt-Jakob disease, etc.) from our conscientious care? If we had not carefully explained this possibility, he or she might think it was worse than ironic.
Despite our enlightened medical opinion, we know that, morally and legally, the decision about the risks of any procedure must rest with the patient. The article rightly concludes that the physician should “thoroughly discuss what processed blood fractions are acceptable to each individual in this patient population.”
Occasionally, this may seem frustrating. The physician may find that a particular medical procedure or fraction is acceptable to one Witness patient but not to another. Still, is that not what the patient's faith and conscience call on him to do, to make his own decision? And is not the physician's responsibility to help inform the patient and then to do our best within the boundaries defined by the patient's faith and conscience?

PCV x VCV

Pressure-Controlled Versus Volume-Controlled Ventilation During One-Lung Ventilation for Thoracic Surgery.[Miscellaneous]
Source
Anesthesia & Analgesia. 104(5):1029-1033, May 2007.
Abstract
BACKGROUND: Pressure-controlled ventilation (PCV) has been suggested as a tool to improve oxygenation during one-lung ventilation (OLV) for patients undergoing thoracic surgery. In this study we investigated whether PCV results in improved arterial oxygenation compared with volume-controlled ventilation (VCV) during OLV.METHODS: Fifty-eight patients with good preoperative pulmonary function scheduled for thoracic surgery were prospectively randomized into two groups. Those in group A underwent OLV initially with VCV for 30 min followed by PCV for a similar period of time. Those in group B underwent OLV initially with PCV for 30 min followed by VCV for a similar duration. Airway pressures and arterial blood gases were obtained during OLV at the end of each ventilatory mode.RESULTS: There were no differences during OLV in arterial oxygenation between VCV (Pao2, 206.1 +/- 62.4 mm Hg) and PCV (Pao2, 202.1 +/- 56.4 mm Hg; P = 0.534). Peak airway pressure was lower with PCV than with VCV (24.43 +/- 3.42 cm H2O vs. 34.16 +/- 5.21 cm H2O; P < 0.001).CONCLUSIONS: The use of PCV during OLV does not lead to improved oxygenation during OLV compared with VCV for patients with good preoperative pulmonary function, but PCV did lead to lower peak airway pressures. Further study is needed for patients with severe obstructive or restrictive pulmonary disease.

Preexisting Cognitive Impairment in Patients Scheduled for Elective Coronary Artery Bypass Graft Surgery.
Source
Anesthesia & Analgesia. 104(5):1023-1028, May 2007.
Abstract
BACKGROUND: An accurate assessment of the prevalence of cognitive impairment in patients scheduled for coronary artery bypass graft (CABG) surgery is necessary if valid assumptions regarding cognitive change are to be made. Such an assessment requires the use of a healthy control group free of cardiovascular disease.METHODS: In a retrospective observational study, 349 patients scheduled for CABG surgery underwent neuropsychological testing. We compared the results with those from a group of 170 healthy controls without cardiovascular disease and containing more female patients who were matched for age and IQ score. Cognitive impairment was defined as test scores >=2 sd less than the controls on two or more of the seven tests.RESULTS: The CABG surgery patients performed significantly worse than the control group on all tests except the Grooved Pegboard test (nondominant). When analyzed by group, performance on the verbal learning test was the most impaired. Cognitive impairment was present in 122 (35%) of CABG surgery patients before their procedure. Prior myocardial infarction, age, and IQ were independent predictors of cognitive impairment.CONCLUSIONS: Cognitive impairment is prevalent in patients presenting for CABG surgery. Impaired cognition before surgery must be considered when assessing the effects of CABG surgery on cognitive performance.

Gender Differences in Stroke Risk Among the Elderly After Coronary Artery Surgery
Anesthesia & Analgesia. 104(5):1016-1022, May 2007.
Abstract
BACKGROUND: Previous studies have shown that women are at higher risk than men for stroke after coronary artery bypass graft (CABG) surgery, but gender differences in systemic atherosclerosis have not been studied adequately. We investigated gender differences in the incidence of craniocervical and ascending aortic atherosclerosis and other risk factors for stroke in elderly patients (age >=60 yr) undergoing CABG surgery.METHODS: Data were prospectively collected on 720 patients (31.8% women) undergoing CABG surgery. All patients underwent preoperative brain magnetic resonance imaging and angiography to assess for prior cerebral infarctions, carotid artery stenosis, and intracranial arterial stenosis. Epiaortic ultrasound was performed at the time of surgery to assess for atherosclerosis of the ascending aorta. Cognitive status was measured using the Hasegawa-dementia score in all patients before surgery and on the seventh postoperative day.RESULTS: Women were older and had more hypertension and intracranial arterial stenosis than did men. Men had significantly higher rates of hyperlipidemia, peripheral vascular disease, abdominal aortic aneurysm, smoking history, severe carotid artery stenosis, and severe aortic atherosclerosis than did women. Although there were no differences in prior cerebral infarction or preoperative cognitive impairment, the rate of perioperative stroke was marginally higher in men than in women (3.9% vs 1.3%, P = 0.066). Univariate predictors of perioperative stroke were prior cerebral infarctions, ascending aortic atherosclerosis, preexisting cognitive impairment, and peripheral vascular disease. Stepwise logistic regression analysis demonstrated that significant independent predictors of perioperative stroke were prior cerebral infarctions and aortic atherosclerosis.CONCLUSIONS: These data suggest that men are more likely than women to have risk factors for stroke, including severe carotid artery stenosis, severe aortic atherosclerosis, and peripheral vascular disease. The rates of prior cerebral infarction and preoperative cognitive impairment were similar between genders.

Coagulopatia e CEC

Coagulopathy After Cardiac Surgery May Be Influenced by a Functional Plasminogen Activator Inhibitor Polymorphism.
Source
Anesthesia & Analgesia. 104(6):1343-1347, June 2007.
Abstract
BACKGROUND: Cytokine-mediated inflammation and coagulopathy may occur after cardiac surgery. In this study we investigated the temporal pattern of plasminogen activator inhibitor-1 (PAI-1) gene expression after cardiac surgery and its relation with PAI genotype, and obtained preliminary data regarding its relation to perioperative morbidity.METHODS: The relative change in PAI-1 mRNA 1, 6, and 24 h after cardiopulmonary bypass (CPB) was measured from mononuclear cells in 82 patients undergoing elective cardiac surgery. DNA was analyzed for carriage of the 4G/5G PAI-1 polymorphism.RESULTS: PAI-1 gene expression decreased after CPB in all patients. A larger reduction in PAI-1 gene expression was observed in homozygous carriers of the 5G allele. Homozygous carriers of the 5G allele were also more likely to receive transfusion of coagulation blood products. There was no relation between change in PAI-1 gene expression and duration of CPB.CONCLUSIONS: PAI-1 gene expression decreased over time after CPB. We found a link between PAI-1 genotype, PAI gene expression, and transfusion of coagulation products after cardiac surgery

Morfina e Fentanil x resposta inflamatoria na CEC

The Effects of Morphine and Fentanyl on the Inflammatory Response to Cardiopulmonary Bypass in Patients Undergoing Elective Coronary Artery Bypass Graft Surgery
Source
Anesthesia & Analgesia. 104(6):1334-1342, June 2007.
Abstract
BACKGROUND: Experimental data suggest that morphine has unique antiinflammatory properties. We hypothesized that morphine, when compared with fentanyl, would attenuate the perioperative inflammatory response to cardiopulmonary bypass (CPB) when administered as part of a balanced anesthetic technique.METHODS: Thirty patients undergoing elective coronary artery bypass graft surgery were randomized to receive, in a double-blind manner, either morphine (40 mg) or fentanyl (1000 [mu]g) as part of a standardized opioid-isoflurane anesthetic. Serum concentrations of interleukin (IL)-6 and IL-8 and expression of neutrophil surface adhesion molecules (CD 11a, CD 11b, CD 11c, and CD 18) were measured perioperatively as indicators of the inflammatory response to surgery. Core temperatures were monitored in the intensive care unit to determine the incidence of postoperative hyperthermia (temperature >38.0[degrees]C).RESULTS: IL-6 and IL-8 concentrations increased in all patients after CPB. The increase in serum IL-6 levels was significantly attenuated in the morphine group compared to the fentanyl group at 3 and 24 h post-CPB (P < 0.05). Reductions in expression of neutrophil adhesion molecules were observed in both groups 15 min and 3 h post-CPB; however, a significantly larger reduction in CD 11b and CD 18 expression was noted in patients receiving morphine (P < 0.05). The incidence of postoperative hyperthermia was more frequent in the fentanyl group (73%) compared to the morphine group (0%, P < 0.05).CONCLUSIONS: Compared with fentanyl, the administration of morphine as part of balanced anesthetic technique suppressed several components the inflammatory response (IL-6, CD 11b, CD 18, postoperative hyperthermia) to cardiac surgery and CPB.(C) 2007 by International Anesthesia Research Society.