2024 FSA Podium and Poster Abstracts
P002: EXTRACORPOREAL MEMBRANE OXYGENATION IN JEHOVAH'S WITNESS PATIENT.
Madina Akhmetkaliyeva, MD1; Kylie Schmitt2; Gian Paparcuri1; Tyler Chonis1; 1HCA Florida Kendall Hospital; 2Nova Southeastern University
Introduction: Ethical dilemmas can arise often in the field of anesthesiology. One such scenario that can impact the anesthetic plan of a patient is when their religious beliefs preclude the use of blood products. When challenges like this arise, anesthesiologists must be equipped with other techniques to cater the anesthetic plan to the specific patient, while providing optimal care. This case report examines how to approach Jehovah’s Witness patients with high acuity cases such as cardiogenic shock.
Methods: A 56-year-old female with a past medical history of type 2 diabetes mellitus presented to the ED as STEMI alert leading to massive myocardial infarction. The patient went straight to the Cath lab for percutaneous stent placement to the LAD and percutaneous intra-aortic balloon pump insertion through the femoral artery. While in the Cath lab, the patient started to vomit and became hypoxic secondary to aspiration. The Anesthesia team was called for emergent intubation. Despite being on mechanical ventilation patient's condition continued to deteriorate and the decision was made to place her on VA ECMO support to allow her lungs and heart time to heal. Being a Jehovah’s Witness and refusing blood products created an additional challenge to the management of acute cardiogenic shock with respiratory failure.
The Anesthesia team transported the patient from the ICU to the operating theater on mechanical ventilation with high FiO2 and PEEP requirements, with an Impella device and multiple pressors. Patient hemodynamic stability was continuously monitored using Arterial Line, Central Venous Pressure, and Pulmonary Artery Pressure. Arterial Blood Gas was taken throughout the procedure to control hemoglobin levels, perfusion, and ventilation. We used transesophageal echo to monitor the correct placement of ECMO cannulas and assess cardiac function. The patient required multiple drips including epinephrine, vasopressin, amiodarone, dopamine, norepinephrine, and insulin. In addition to 5L of albumin, the patient received 7L of crystalloid solutions.
Conclusion: The patient underwent successful placement on ECMO and was transferred back to ICU in satisfactory condition without a major drop in hemoglobin levels. Unfortunately, shortly after surgery, the patient developed critical dilutional coagulopathy due to lysis from Impella and cannulation bleeding on ECMO. The intensivists were unable to optimize the patient’s condition due refusal of blood products. Ultimately, the patient was placed on a morphine drip, extubated with all measures stopped and the patient shortly passed away after.
Discussion: This case highlights the complexities in managing critically ill patients with distinctive cultural and medical preferences. The clash between medical interventions and individual beliefs poses challenges in optimizing care and necessitates collaborative decision-making and open communication with the family to allow for informed decision-making to respect patient autonomy while also conducting evidence-based medical interventions.