October 11, 2011

USA: 68-Year-Old Woman Contemplating Autologous Blood Donation Before Elective Surgery

CHICAGO, Illinois / Journal of American Medical Association / October 11, 2011

Clinical Crossroads

READERS RESPOND

A 68-Year-Old Woman Contemplating Autologous
Blood Donation Before Elective Surgery

By Anjala Tess, MD

Dr Tess is Hospitalist and Associate Program Director for the Internal Medicine Training Program, Beth Israel Deaconess Medical Center, and Assistant Professor in Medicine, Harvard Medical School, Boston, Massachusetts.


The patient described and interviewed below faces a crossroads in her medical care. Consider her medical history and perspective, expressed in her own words, and review the questions posed. How would you approach this crossroads?

Using evidence from the literature as well as your own experience, respond by selecting Submit a Response. Responses will be selected for posting online based on their timeliness and quality, including use of the available evidence, weighing the issues, and addressing the patient's concerns.

The discussion of this Clinical Crossroads case, authored by Lynne Uhl, MD, will be published in the November 2, 2011, issue of JAMA; responses must be received by October 30, 2011, to be considered for online posting.

CASE PRESENTATION
Ms C is a 68-year-old woman who presented with progressive right knee pain and swelling. She first developed pain and swelling in her right knee in 2003 and was diagnosed as having osteoarthritis. She underwent arthroscopy and bursectomy in 2006, but in the last few years, she has experienced worsening of her pain as well as significant physical limitations. Joint injections with steroids have resulted in little improvement, and now she is planning to undergo knee replacement surgery in 8 weeks.

Ms C's medical history includes osteoarthritis, hypertension, hyperthyroidism, hypercholesterolemia, and uterine fibroids in addition to the arthroscopy in 2006. Her medications include hydrochlorothiazide, levothyroxine, simvastatin, and aspirin. She has no known drug allergies.

On examination, Ms C is a healthy-appearing woman with normal vital signs. Her physical examination results were normal except for pain on palpation of medial right knee, an antalgic gait, and difficulty with toe and heel walking due to pain. A routine complete blood cell count revealed a white blood cell count of 7900/μL, hemoglobin of 15.1 g/dL, mean corpuscular volume of 92 fL, red blood cell distribution width of 13.4%, and platelet count of 290 × 103/μL.

MS C: HER VIEW
Personally, I do not want anyone else's blood. I believe I should give my own blood for safety reasons. I read the paper a lot and watch the news, and you hear so much about infectious diseases. That's my concern; I have never had an infectious disease in my life and at this age, I don't think I want to get one.

I was thinking about donating my own blood for after my surgery so I wouldn't have any worries at all about infection. Did I get hepatitis? Did I get some other kind of disease? I think a doctor should always counsel their patients about the do's and the don’ts of transfusion and explain the risks and options to them

If I am not able to donate my own blood for my surgery, I would first discuss it with my family and see if they would donate some blood for me. If my family is not able to, then I would have to make the decision about whether to take the blood from the hospital. I would like Dr Uhl to answer the question, “What is my risk if I do not donate my own blood and I have to take the blood from the hospital?”

AT THE CROSSROADS: QUESTIONS FOR READERS

What strategies can be used to minimize the need of blood transfusion for patients facing elective surgery? What options are available for preoperative patient blood management? When should a patient consider preoperative autologous donation? What intraoperative and postoperative measures are available to reduce need for allogeneic transfusion? How should clinicians counsel patients about the risks of transfusion and perioperative blood management?

What is your advice for Ms C?

AUTHOR INFORMATION
Dr Anjala Tess is Hospitalist and Associate Program Director for the Internal Medicine Training Program, Beth Israel Deaconess Medical Center, and Assistant Professor in Medicine, Harvard Medical School, Boston, Massachusetts.

© 2011 American Medical Association.
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