Mon, 2006-10-23 05:49
By Janaka Perera - Asian Tribune
{*filter*} conservation and transfusion alternatives have become
increasingly important in health care worldwide. Concerns about {*filter*}
safety, periodic {*filter*} shortages, liability issues and consumer demand
for are drawing attention to transfusion alternatives and {*filter*}less
surgery, according to the International Society of Hematology.
After the worldwide AIDS epidemic cast the spotlight on {*filter*} in the
1980s, efforts to eliminate its unseen threats intensified. The refusal
of {*filter*} products by patients has led to greater awareness of {*filter*}
conservation strategies. Increased awareness of the risks of
transfusion including communicable diseases such as HIV has resulted in
greater numbers of patients not accepting {*filter*} for non-religious
reasons, while Jehovah's witnesses refuse {*filter*} transfusions on
religious grounds.
We know the case of a leading Sri Lankan doctor who died of after a
contaminated {*filter*} transfusion following injuries she received in a
motor accident. Similar cases were having been reported from other
countries too.
Peter Carolan, Senior Officer of the International Federation of Red
Cross and Red Crescent Societies say: "Absolute guarantees on {*filter*}
supplies can never be given." He adds, "There will always be new
infections for which at the moment there is no test."
Collecting {*filter*} samples from the wrong patient, mislabeling samples
and requesting {*filter*} for the wrong patient cost the lives of at least
440 people in the USA between 1995 and 2001, according to the Awake
magazine August 2006.
{*filter*} brings oxygen, nutrients and defensive help to our body cells and
carries away junk such as toxic carbon dioxide, the contents of damaged
and dying cells and other waste. And non one can guarantee that all of
the junk in {*filter*} has been identified and removed before it given to
someone else.
Says Dr. Prasad Krishnan of Apollo Hospital, Colombo, one of the few
Cardiac Surgeons who have performed {*filter*}less surgery in Sri Lanka:
"Giving someone else's {*filter*} has a certain risk for transmission of
diseases although we have tests to check so many of the known diseases
- there is still a small chance that something can be transmitted.
There are also allergic reactions that can happen because our body
always considers anything that is not our own as foreign and fights
with it - that is nature's way."
While {*filter*}less heart surgery eliminates the risks of {*filter*}
transfusion; it does make cardiac surgery, especially in children
complicated and difficult, due to the obligatory hemodilution of
cardiopulmonary bypass.
As The Royal College of Surgeons of England notes, {*filter*}less surgery
requires a co-coordinated multidisciplinary approach. Senior surgical,
unaesthetic and theatre staff is expected to discuss cases in advance,
and the skill mix and number of support staff need to be modified to
facilitate {*filter*} conservation strategies.
Dr. Krishnan stresses the need for the doctor to be confident in
performing and the patient to be aware of the risks {*filter*}less heart
surgery. If properly done, the results are most gratifying.
"Basically when you have to operate inside the heart you have to stop
it. When you have to stop the heart {*filter*} has to be kept continuously
flowing to ensure that the rest of the body is alive."
"In other words the surgeon must take over the heart's functions to
keep the {*filter*} flowing. Normally the right side of the heart gets {*filter*}
without oxygen, which it pumps to the lungs, the {*filter*} takes up oxygen
from the lungs and comes to the left side of the heart which than pumps
the {*filter*} to the body. The surgeon has to take this {*filter*} before it
comes to the heart, add oxygen to the {*filter*} outside the body and pump
it back to the body."
"All forming a fluid filled closed loop circuit; so the body continues
to get oxygen. At that point the doctor has to stop the heart and cut
it open to do the operation, inside the heart (e.g. like closing a
hole). When you have to connect a patient to a heart lung machine for
the operation the tubing and everything in the machine has to be filled
with fluid - not with air- because when {*filter*} comes you cannot have
air bubbles in the system. When the {*filter*} mixes with this fluid it gets
diluted. In {*filter*} you get hemoglobin, which carries oxygen. That is why
{*filter*} is red. We need a certain level of hemoglobin to carry oxygen.
You cannot dilute {*filter*} as much as you want and expect the patient to
stay alive. So we have to be able to minimize the dilution. We are
talking about operating inside the heart NOT on the coronary arteries,
which are on the surface of the heart. The latter can sometimes be done
without stopping the heart.
He emphasizes:
"These are the requirements for the operation, which is a very
difficult in little children who have a smaller {*filter*} volume in their
body resulting in a higher dilution, after connecting to the heart-lung
machine. It leaves very little margin for error. Consequences can be
very grave since this is a matter of life and death. In the case of
other organs you can live without them functioning - without an eye
or without a limb or with one kidney. But without a heart you have no
chance of living at all."
Dr. Krishnan further says: "When the patient is put on a heart lung
machine you have to insert pipes (cannulae) into the major {*filter*}
vessels in the body. Even if you make a needle hole {*filter*} will flow
profusely - because there is a large volume of {*filter*} flowing in these
pipes sometimes at high pressure. So putting these cannulae and every
little step has to be done meticulously - perfectly - leaving no
room for errors. The quickness in which you do the surgery is vital -
because the longer you do surgery the leakage of {*filter*} from within the
{*filter*} vessels into the body. In the event of leakage you need more and
more volume of {*filter*}, which means you, has to keep on adding fluid,
which is will result in more dilution of {*filter*}. So it is important to
do the surgery correctly and quickly. Very stringent conditions have to
be met if {*filter*}less heart surgery is to be successful, especially in
children. You have no margin for error."
According to him, side effects of not giving {*filter*} occur if the patient
ends up losing too much of {*filter*} or the {*filter*} ends up getting diluted
too much. So surgeons make sure that the problem is avoided.
In the case of hole in the heart he notes: "When you have a hole in the
heart you have too much {*filter*} flowing in your lungs. The pressure of
the lung starts to go up and progressively keep increasing with age.
And it reaches a certain point where you need that hole to be alive. If
you close the hole you die because the pressure of the lung are is so
high that the heart cannot pump all the {*filter*} through the lungs. If you
are beyond that stage you die early. And closer you are to that stage
the greater the risk in closing the hole."
At Apollo Hospital Colombo, {*filter*}less surgery was performed
successfully on two children - five years and 13 years- suffering
from this disease.
The 5 year old had a tumor inside the heart that was obstructing the
flow of {*filter*} and had to be removed. The 13 year old had a large hole
in the heart, that had produced a very severe increase in the lung
{*filter*} pressure, and she was told to be inoperable. After detailed tests
at Apollo Hospital , we found she may still have a chance and after
explaining the higher risk involved to the parents, she underwent
closure of the hole successfully. Both the operations were performed
without any {*filter*} transfusion whatsoever.
There is an increasing international recognition that one of the aims
of good clinical care is to avoid {*filter*} transfusion wherever possible.
- Asian Tribune -
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