Open-Heart Surgery Achieves Success Without Blood Transfusions

<img class="alignnone size-full wp-image-35258" src="" alt=" Teamwork and careful planning allowed successful surgery to treat congenital heart defects in an infant who, for religious reasons, could not receive blood transfusions or blood products. "width =" 805 "height =" 453 "/>

Teamwork and careful planning led to successful surgery to treat congenital heart defects in infants who, for religious reasons, could not receive blood transfusions or blood products.

When RaeLynn Gehrke was born in December 2016 with a complex heart disease called Tetralogy of Fallot her parents knew that they were in a difficult situation.

The family, who lives in Bemidji, Minnesota, learned that an operation was needed to correct the malformations caused by RaeLynn's condition. However, as Jehovah's Witnesses whose faith prevents them from receiving blood transfusions, her parents knew that the standard of care for most patients would not be acceptable to RaeLynn.

Acknowledging the family's concerns and the complex circumstances in which he placed them, pediatric cardiologist Treating RaeLynn in Fargo, North Dakota, linked them to Mayo Clinic Cardiovascular Surgeon ] Sameh Said, MD After months of careful planning and coordinated effort among a team of clinicians on July 17, 2017, the baby was able to undergo open heart surgery at Mayo Clinic Rochester ] using a procedure that was in keeping with the family's beliefs.

"It was really an example of an extraordinary team effort," says Dr. Said about the successful operation – the first of its kind in a Mayo pediatric patient Clinic.

The team work that RaeLynn's parents saw in action and communication between team members assured them that their daughter would receive the highest level of care.

"They understood our fears," says RaeLynn's mother, Summar Gehrke. "We knew how confident and determined they were to not just do the surgery safely, but without any blood."

Perfecting the plan

When Dr. Said received the consultation request on the case of RaeLynn, his first thought was that the operation was technically possible, but this would require careful planning.

"How can we do it and keep the results excellent and make sure that the child is safe?" Dr. Said says. "We thought that if we had the right team and the right preparation, we would be able to do the operation with minimal risk."

Dr. He assembled a team of specialists that included Caitlin Blau, in cardiac perfusion, Paul Stensrud, MD in Cardio-Thoracic Anesthesia, Nurse Practitioner Corissa Hebb, Grace Arteaga. M.D. in pediatric intensive care, and medical secretary Rachel Johnson. The group focused its efforts on developing a surgical strategy for RaeLynn, the team's most important player.

"Cardiac surgery is really a team sport," says Dr. Stensrud. "We normally work in teams and sometimes in teams, depending on what we need to do, focused on the heart surgery team, but there was much more communication than usual."

"We thought that if we had the right team and the right preparation, we would be able to do the operation with a minimum of risk." – Sameh says, M.D.

Babies who require open-heart surgery and are placed on cardiopulmonary bypass – sometimes referred to as the heart-lung machine – receive blood products during surgery. Blood is added to the heart-lung machine to maintain hemoglobin levels and decrease the hemodilution that can result from the machine, especially in babies, because of their small blood volume.

People undergoing cardiac surgery often receive blood transfusions to counteract the blood lost during the operation and the necessary blood samples for laboratory measurements used to guide therapy during and after the operation.

"We had to change every step during this period," says Dr. Said.

The development of a surgical plan involving no blood products or transfusions began by determining what was acceptable for RaeLynn's parents.

"The parents were very competent and very accurate," says Dr. Said. "His mother asked me to write the protocol exactly as we were going to do it, and we e-mailed it, even before we met face-to-face."

In addition to sending the details of the surgical protocol to RaeLynn's parents, several phone calls were made between Dr. Said, Summar and Frank Gehrke, RaeLynn's father. This step further strengthened RaeLynn's parents' trust in Mayo Clinic physicians.

Redefining Open Heart Surgery

Months before the date of the surgery, the plan was started. He started with RaeLynn taking iron supplements and the drug improving erythropoietin hemoglobin. These measures helped the baby's bone marrow produce high levels of red blood cells, which meant that she had more blood than typical patients entering the surgery.

Perfusionist Caitlin Blau, who was responsible for the operation of the heart-lung machine during surgery, used a formula that determines the fall of hemoglobin from RaeLynn if no blood was used, then calculated the value had to be to support life.

"We found that to do the procedure, we needed a hemoglobin between 15 and 16 years old," says Blau.

On the day of surgery, RaeLynn's hemoglobin was in this range at 16 grams / deciliter (g / dL). But his hemoglobin level was not the only obstacle that the team had to handle.

"For newborns and infants, it is the norm to start the machine with the blood of someone else, which makes this case particularly difficult" Blau explains.

Instead of blood, a crystalloid solution was used to fill the tubing and reservoir of the machine. The heart-lung machine itself was also modified with smaller tubes and was positioned near RaeLynn to make the tube as short as possible. These changes minimized the volume of blood coming out of RaeLynn, into the machine, and back into his body.

"For newborns and infants, it is the norm to start the machine with the blood of someone else, which has made this particularly difficult case. " – Caitlin Blau

"Another critical discussion revolved around the blood we normally collect for some labs throughout the case. We decided as a team the minimum amount we could do, the better," says Blau. "I drew less than I would normally, while safely monitoring RaeLynn's lab values."

Once the procedure was completed and the intervention successfully completed, RaeLynn's hemoglobin level was 12 g / dL – higher than the 10 g / dL that she had before receive iron and erythropoietin supplements before the operation.

Considering a better level of care

Even with all the preparations, RaeLynn's parents were ready to face complications.

"We were ready for something to go wrong, so when everything was going so well, we were so relieved and so happy," says Summar.

Just two days after opening her chest and correcting her deformities, the baby was happy and smiling. During the two-week post-operative visit to RaeLynn, his doctors said that "his TTY was working fine," says Summar.

"We are very grateful for the care provided by the entire team: her doctors and all her nurses took good care of our little girl and stayed so respectful of our beliefs," says Summar. "They had excellent communication with us from the beginning until the end of the whole process."

Franks says that since his surgery, RaeLynn has grown enormously. She has become stronger, has more energy and her personality has blossomed.

"We are very grateful for the care provided by the whole team: her doctors and all her nurses took good care of our little girl and remained so respectful of our beliefs." – Summary of Gehrke

The experience has not only allowed the development of RaeLynn, but she has also advanced the knowledge of her doctors on this type of single surgery.

"Transfusions can save lives, but transfusions are not without risk," says Dr. Stensrud. "It was a learning experience because we can adapt everything we have done here."

Indeed, the future of neonatal and infant heart surgery might look like the example of RaeLynn surgery, Blau adds.

"This case really highlights the fact that we can do it," she says.


Tags: Cardiology and Cardiac Surgery Cardiology and Cardiac Surgery Dr. Grace Arteaga Dr. Paul Stensrud ] Dr. Sameh Said Children's Center of the Mayo Clinic Tetralogy of Fallot


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