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Multidisciplinary management of a Jehovah's Witness patient for the removal of a renal cell carcinoma extending into the right atrium

[La prise en charge multidisciplinaire d'un patient Témoin de Jéhovah pour le retrait d'un hypernéphrome s'étendant dans l’oreillette droite]

David M. Moskowitz, MD^*, Seth I. Perelman, MD^*, Katherine M. Cousineau, CCP, James J. Klein, MD, Aryeh Shander, MD^*, Eric J. Margolis, MD, Steven A. Katz, MD, Henry L. Bennett, PhD^*, Nate E. Lebowitz, MD and M. Arisan Ergin, MD

^* From the Department of Anesthesiology, Division of Cardiothoracic Anesthesia, Critical Care Medicine, Pain Management and Hyperbaric Medicine,
the Department of Cardiothoracic Surgery,
the Department of Urology, and
the Division of Cardiology and Department of Internal Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey, USA.

Dr. David Moskowitz, Director, Cardiothoracic Anesthesia Department of Anesthesiology, Critical Care Medicine, Pain Management and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey 07631, USA. Phone: 201-894-3238; Fax: 201-894-0585; E-mail: david.moskowitz{at}ehmc.com

Purpose: To highlight the management of a Jehovah's witness surgical patient presenting for cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest.

Clinical features: A 47-yr-old male, Jehovah's Witness, with renal cell carcinoma was admitted for left radical nephrectomy and excision of tumour thrombus extending into the junction of the inferior vena cava (IVC) and right atrium (RA). The preoperative goals were to maximize red blood cell mass, delineate the extent of tumour extension and develop a surgical plan incorporating blood conservation strategies to minimize blood loss. A midline abdominal incision was made to optimize removal of the non-caval portion of the tumour from the intra-abdominal region. CPB and deep hypothermic circulatory arrest were instituted to aid in removing the tumour from the IVC and RA. Intraoperative blood conservation strategies included the use of acute normovolemic hemodilution, antifibrinolytics, cell salvage, point-of-care monitoring of heparin and protamine blood concentrations, leukocyte-depleting filter, and meticulous surgical techniques. The patient was successfully weaned from CPB and was transported to the cardiothoracic intensive care unit without complication. The patient was discharged home one week after the operation with a hemoglobin of 10.2 g•dL^-1 and a hematocrit of 31.2%.

Conclusion: Multiple blood conservation techniques were employed to manage this Jehovah's Witness patient through complex cardiac surgery, which was previously denied to him at other institutions. The successful outcome of this patient, while respecting the right to refuse allogeneic blood products, is a result of a multidisciplinary collaboration as well as the application of established blood conservation techniques.

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