Revisiones bibliográficas. Documentación científica en Ortopedia y Traumatología, medicina deportiva, artroscopia, artroplastia y de todas las patologías del sistema Músculo-Esquelético
El tratamiento con dosis bajas de eritropoyetina no está asociado con los beneficios clínicos en los Testigos de Jehová gravemente anémicos: una súplica para un cambio.
Low-dose erythropoietin treatment is not associated with clinical benefits in severely anaemic Jehovah's Witnesses: a plea for a change.
Blood Transfus. 2016 Nov 15:1-10. doi: 10.2450/2016.0085-16. [Epub ahead of print]
Abstract
BACKGROUND: Jehovah's Witnesses who refuse blood transfusion have high mortality. Erythropoietin (EPO) has been used as an alternative to blood transfusion. The optimal dosing of EPO in anaemic Jehovah's Witnesses is unknown. The aim of our study was to evaluate the clinical benefits of treatment with a low dose (<600 IU/kg/week) of epoietin beta (EPO-β). MATERIALS AND METHODS: This was an observational study, retrospectively considering a 10-year period during which 3,529 adult Jehovah's Witnesses with a total of 10,786 hospital admissions were identified from databases of four major public hospitals in New Zealand. Patients with severe symptomatic anaemia (haemoglobin <80 g/L) who were unable to tolerate physical activity were included in the study. Patients treated without EPO were assigned to the conventional therapy group and those treated with EPO to the EPO treatment group. RESULTS: Ninety-one Jehovah's Witnesses met the eligibility criteria. Propensity score matching yielded a total of 57 patients. Patients treated with conventional therapy and those treated with EPO had similar durations of severe anaemia (average difference 6.25 days, 95% confidence interval [CI]: -3.77-16.27 days; p=0.221). The mortality rate among Jehovah's Witnesses treated with conventional therapy was 4.68 per year (95% CI: 2.23-9.82), while that in those treated with EPO was 2.77 per year (95% CI: 0.89-8.60). Treatment with EPO was associated with a mortality ratio of 0.59 (95% CI: 0.1-2.6; p=0.236). Both groups of patients had similar in-hospital survival (p=0.703). DISCUSSION: Treatment with low-dose EPO-β was not associated with either shorter duration of severe anaemia or a reduction in mortality.
There are many patient groups who may refuse blood products; the most well known amongst them is the Jehovah's Witness faith. Treatment of anaemia and bleeding in such patients presents a challenge to medical, anaesthetic, and surgical teams. This review examines the perioperative issues and management of Jehovah's Witnesses. The history and beliefs of Jehovah's Witnesses are outlined together with their impact on ethics and the law, and different management options throughout the perioperative period are discussed.
BACKGROUND AND OBJECTIVES: Jehovah's Witnesses patients refuse blood transfusions for religious reasons. Anesthesiologists must master specific legal knowledge to provide care to these patients. Understanding how the Law and the Federal Council of Medicine treat this issue is critical to know how to act in this context. The aim of this paper was to establish a treatment protocol for the Jehovah's Witness patient with emphasis on ethical and legal duty of the anesthesiologist. CONTENT: The article analyzes the Constitution, Criminal Code, resolutions of the Federal Council of Medicine, opinions, and jurisprudence to understand the limits of the conflict between the autonomy of will of Jehovah's Witnesses to refuse transfusion and the physician's duty to provide the transfusion. Based on this evidence, a care protocol is suggested. CONCLUSIONS: The Federal Council of Medicine resolution 1021/1980, the penal code Article 135, which classifies denial of care as a crime and the Supreme Court decision on the HC 268,459/SP process imposes on the physician the obligation of blood transfusion when life is threatened. The patient's or guardian's consent is not necessary, as the autonomy of will manifestation of the Jehovah's Witness patient refusing blood transfusion for himself and relatives, even in emergencies, is no not forbidden.
Int J Surg Case Rep. 2016;23:116-9. doi: 10.1016/j.ijscr.2016.04.024. Epub 2016 Apr 19.
Abstract
INTRODUCTION: A bloodless surgery can be desirable also for non Jehovah's witnesses patients, but requires a team approach from the very first assessment to ensure adequate planning. PRESENTATION OF THE CASE: Our patient, a Jehovah's witnesses, was scheduled for right lower lobectomy due to pulmonary adenocarcinoma. Her firm denies to receive any kind of transfusions, forced clinicians to a bloodless management of the case. DISCUSSION: Before surgery a meticulous coagulopathy research and hemodynamic optimization are useful to prepare patient to operation. During surgery, controlled hypotension can help to obtain effective hemostasis. After surgery, clinicians monitored any possible active bleeding, using continuous noninvasive hemoglobin monitoring, limiting the blood loss due to serial in vitro testing. The optimization of cardiac index and delivery of oxygen were continued to grant a fast recovery. CONCLUSION: Bloodless surgery is likely to gain popularity, and become standard practice for all patients. The need for transfusion should be targeted on individual case, avoiding strictly fixed limit often leading to unnecessary transfusion.
KEYWORDS: Bleeding monitoring; Bloodless surgery; Case report; Jehovah's witness surgery; Thoracic surgery
¿La cápsula de cadera permanece cerrada después de la artroscopia de cadera con cierre capsular de rutina para el choque femoroacetabular? Un análisis de imágenes por resonancia magnética en pacientes postoperatorios sintomáticos
Does the Hip Capsule Remain Closed After Hip Arthroscopy With Routine Capsular Closure for Femoroacetabular Impingement? A Magnetic Resonance Imaging Analysis in Symptomatic Postoperative Patients
Fuente Este artículo es originalmente publicado en:
The purpose of this study was to examine the hip capsule in a subset of symptomatic patients who underwent capsular closure during hip arthroscopy.
CONCLUSIONS:
In a subset of symptomatic patients after hip arthroscopy for FAI, the majority (92.5%) of the repaired hip capsules remained closed at greater than 1 year of follow-up. The hip capsule adjacent to the capsulotomy and subsequent repair is thickened compared with the same location on the contralateral, nonoperative hip. Aside from gender, patient-related and FAI(femoroacetabular impingement)-related factors do not correlate with capsular thickness nor do they seem to correlate with the propensity to develop a capsular defect.
Resumen
PROPÓSITO: El propósito de este estudio fue examinar la cápsula de cadera en un subconjunto de pacientes sintomáticos sometidos a cierre capsular durante la artroscopia de cadera.
CONCLUSIONES: En un subgrupo de pacientes sintomáticos después de artroscopia de cadera por FAI (pinzamiento femoroacetabular), la mayoría (92,5%) de las cápsulas de cadera reparadas permanecieron cerradas en más de 1 año de seguimiento. La cápsula de cadera adyacente a la capsulotomía y la reparación posterior se espesa en comparación con la misma localización en la cadera contralateral no operatoria. Aparte del sexo, los factores relacionados con el paciente y FAI no se correlacionan con el espesor capsular ni parecen correlacionarse con la propensión a desarrollar un defecto capsular.
Dr. Carlos R. Zaidenberg, Dr. Gabriel A. Clembosky, Dr. Christian J. Perrotto, Dr. Alvaro J. Muratore
Todos los derechos reservados para:
ASOCIACIÓN ARGENTINA DE ARTROSCOPÍA
RESUMEN:
Entre Noviembre de 1997 y Junio de 2002 se realizó la resección artroscópica de gangliones palmares a diecinueve pacientes, doce mujeres y siete varones, con un seguimiento promedio de once meses.
El diagnostico fue clínico, identificando una tumoración de tamaño moderado o mínimo en borde radial de muñeca. La resonancia nuclear magnética fue usada en trece pacientes mientras que a los seis restantes se les realizó artrografía, en todos los casos se localizó el origen de la lesión.
La artroscopia permitió identificar el pedículo del ganglión en la articulación radio carpiana entre los ligamentos radio-hueso grande y radio-escafoideo en cinco pacientes, en el borde radial del ligamento radio-hueso grande en tres pacientes y en un caso en la articulación escafo-lunar. Siete gangliones provenían de la articulación medio carpiana (trapecio- escafoidea) y en tres casos artroscópicamente no observamos el origen del ganglión.
La resección artroscópica consistió en una pequeña sinovectomía del área involucrada. La artroscopía se presenta como una herramienta confiable en el tratamiento de los gangliones palmares del borde radial de la muñeca que provienen de la articulación radio y medio carpiana.
ABSTRACT:
Between November 1997 and June 2002 we performed arthroscopic resections of 19 palmar ganglions, twelve in women and 7 in men. The average follow-up was 11 months.
We used magnetic resonance in 13 patients and arthrography in the remaining six, identifying the origin of the ganglia in all of them.
Arthroscopy allowed us to identify the stalk in the radiocarpal joint between the radio-capitate and radio- scaphoid ligaments in 5 patients, on the radial border of the radio-capitate ligament in three patients, and in one case we found it in the scapho-lunate joint. The remaining seven came from the midcarpal joint (trapecio-scaphoid), and we were unable to identify the stalk in three cases.
In the arthroscopic procedure, we performed a small synovectomy on the stalk area. The arthroscopy has shown to be a reliable tool in the treatment of palmar ganglions of the radial border of the wrist coming from the radio carpal and midcarpal joint.
Anaesthesia. 2016 Dec 20. doi: 10.1111/anae.13773. [Epub ahead of print]
Abstract
Despite current recommendations on the management of pre-operative anaemia, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in surgical patients. A number of experienced researchers and clinicians took part in an expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the peri-operative period. These statements include: a diagnostic approach for anaemia and iron deficiency in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up. We urge anaesthetists and peri-operative physicians to embrace these recommendations, and hospital administrators to enable implementation of these concepts by allocating adequate resources.
Allogeneic blood remains a scarce and expensive resource, even as the risks of disease transmission and other complications associated with blood transfusion are well known. Blood conservation, however, is a quality-of-care concept that transcends these and other known and unknown complications of transfusion, to involve a gamut of strategies meant to prevent exposure of patients to allogeneic blood. In urging a halt to incessant allogeneic blood transfusion, we report three cases to highlight the benefits of multimodal multidisciplinary collaboration in blood conservation. The three patients were chosen on account of either religious objection to any blood transfusion or the likelihood of exposure to several units of allogeneic blood. The blood conservation plan proposed for each patient was discussed with the respective surgeon and patient. Multimodal multidisciplinary approach to blood conservation utilising combination of strategies best suited for each individual patient will remarkably reduce the exposure of patients to allogeneic blood thereby ensuring better use of the scarce resource, and and preventing potential clinical complications and spiritual trespass of Jehovah's Witnesses.
BACKGROUND: Cell salvage is commonly used as part of a blood conservation strategy. However concerns among clinicians exist about the efficacy of transfusion of washed cell salvage. CONCLUSIONS: Washed cell salvage is efficacious in reducing the need for allogeneic RBC transfusion and risk of infection in surgery.
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