Case 1—1993 The role of erythropoietin in Jehovah's Witnesses requiring cardiac surgery

Case 1 * A 46-year-old female Jehovah’s Witness presented for cardiac surgery. She had a history of rheumatic heart disease, which consisted of moderate-to-severe aortic regurgitation and mild aortic stenosis, moderate-to-severe mitral regurgitation, severe tricuspid regurgitation, and pulmonary hypertension. The patient was also in chronic atria1 fibrillation. Her preoperative medical regimen consisted of digoxin, furosemide, verapamil, captopril, and coumadin. Preoperative laboratory studies were significant for a hemoglobin of 12.2 g/dL and hematocrit of 35.9%. In view of the relatively low hematocrit and the patient’s refusal to accept any blood products, the surgery was postponed and she was treated with oral iron and 10,000 units of r-erythropoietin by subcutaneous daily injection. She was rescheduled to undergo aortic valve replacement, mitral valve replacement, and tricuspid valvuloplasty 3 weeks later. At that time, the hemoglobin had risen to 14.7 g/dL, and the hematocrit to 42.6%. Coumadin had been discontinued 4 days prior to surgery. The PT was 13.6111.9 set, and the patient received 20 mg of vitamin K, intramuscularly (IM), on the day prior to surgery. The patient was premeditated with morphine, 5 mg, and scopolamine, 0.3 mg IM, and was transferred to the operating room while receiving O2 via nasal cannula. Her initial vital signs were a blood pressure (BP) 105/50 mmHg and heart rate (HR) of 85 beatsimin, in atria1 fibrillation. Peripheral venous, radial artery, and pulmonary artery (PA) catheters were placed. The patient’s baseline mean PA pressure (PAP) was 42 mmHg, central venous pressure (CVP) 23 mmHg, and cardiac output (CO) by thermodilution was 3.1 L/min. Following a smooth induction and maintenance of anesthesia with fentanyl, metocurine, and oxygen, her mean PAP was 16 mmHg. A transesophageal echocardiogram (TEE) probe was placed after induction. The patient was on total cardiopulmonary bypass (CPB) for 3 hours 52 minutes, during which time she underwent aortic and mitral valve replacements with St. Jude prostheses and DeVega tricuspid annuloplasty. Cardiotomy suction was used to return blood to the