Total spinal anaesthesia for a Jehovah's Witness with primary aldosteronism

Resection of Large Urological Tumors With or Without Inferior Vena Cava Extension in Jehova's Witnesses

Background: Renal and adrenal tumors with/without tumor thrombus in the inferior vena cava (IVC) pose a challenge to the surgeon due to the potential for massive hemorrhage and tumor thromboemboli. The situation would be more critical for Jehovah's Witness (JW) patients which refuse blood transfusion. A transplant-based (TB) approach to these tumors in JWs would result a safe surgical method, providing limited blood loss and perioperative complications. We report our experience using a TB surgical approach in JW harboring large adrenal/renal tumors with/without tumor thrombus trying to determine its usefulness in this setting.

Patients and Methods: From 2003 to 2011, 7 patients underwent resection of renal/adrenal tumors with/without tumor thrombus in the IVC by means of a TB approach. Thrombus level was renal (n = 2), retrohepatic (n = 1), and suprahepatic (n = 1). The remaining 3 patients did not present thrombus. No pre-operative optimization or cell-saver were used. Estimated blood loss, perioperative complications (Clavien-Dindo and cause), hemoglobin/hematocrit loss, and length of stay were considered main outcomes.

Results: The intervention was successfully completed without transfusion in all cases. Operative time and blood loss were 2.5 h (range: 1.83–5.75) and 150 cc (range: 100–750), respectively. No major post-operative complications were registered. However, minor complications were detected in 57% of the patients included. Median hemoglobin loss was 1.13 mg/dL, which translated a median hematocrit loss of 2.3%. Patients were discharged in a median of 7 days (range 5–20).

Conclusions: A TB-surgical approach provides enhanced retroperitoneal exposure and optimal vascular control, thus limiting operative blood loss or major complication development, thus resulting useful in JWs.

Combined spinal-epidural-general anesthesia

Each one of the three kinds of anesthesia (spinal, epidural, general) has its advantages and disadvantages. A new concept of combined spinal-epidural-general anesthesia (CSEGA) is illustrated with the objective of producing a new kind of anesthesia. The aim is to draw out the good from each compartment. CSEGA can be based on muscle relaxation and anesthesia on its spinal part with the epidural augmentation. The endotracheal intubation can be kept in place with a very small dose of an inhalational anesthetic. There is no need for muscle relaxant drugs, i.v. opioids or benzodiazepines, for postoperative analgesia serves the epidural catheter. Very small doses of local anesthetic drugs injected into the spinal or epidural compartments, could be all that is needed for operations on any part of the body, including thorax and head. CSEGA is a new concept in anesthesia. The mixing of regional anesthesia with general anesthesia affords the anesthesiologist the opportunity to lower the local anesthetic doses, avoid using many kinds of intravenous drugs (muscle relaxants, opioids, benzodiazepines, etc.) and to approach a kind of anesthesia that is closer to the ideal.