Author(s)
Matthew Lin, BS
Liyang Tang, MD
Rick Selby, MD
Niels Kokot, MD
Affiliation(s)
Keck School of Medicine; Department of Otolaryngology – Head and Neck Surgery, Keck School of Medicine of USC; Department of Surgery, Keck School of Medicine of USC;
Abstract:
Introduction: Jehovah’s Witnesses (JW) will not accept transfusion of major blood fractions. They form the ideal cohort to test feasibility of transfusion avoidance during the performance of complex head and neck surgery. We describe outcomes following free and pedicled flap reconstructions in JW patients.
Methods: Retrospective chart review was performed on 13 adult JW who presented between January 2003 to December 2019. All underwent free and/or pedicled flaps to the head and neck region without transfusion of RBC, platelets, or plasma. Demographics, pre-operative CCI Score, blood augmentation data, peri-operative hematologic data, and outcomes were compiled.
Results: Thirteen patients (9F, 4M) underwent free flap (Nf9), pedicled flap (Nf3), or free and pedicled flap (Nf1) reconstruction primarily for head and neck cancer (85%). Pre-operative blood augmentation with iron, erythropoietin, and folate was used for 11 patients to reduce anemia risk. Mean pre-op hemoglobin (Hb) was 11.5 (range 7.3-16). No patients had abnormal pre-op platelet counts or international normalized ratio (INR) values. Cell salvage (Nf2) and acute normovolemic hemodilution (Nf3) were used. Mean estimated blood loss was 487 mL (range 20-2000 mL). Mean post-operative Hb was 8.6 (range 4.0-11.2). Mean post-op platelet count was 209×109/L (range 103-343×109/L). Mean post-op INR was 1.2 (range 0.9-1.6). Complications included post-op infection (Nf3), bleeding with return to OR (Nf2) and fatal carotid artery rupture (Nf1). Aside from sole mortality, all flaps survived (Nf12).
Conclusions: Complex microvascular flap reconstructions for head and neck pathology can be safely accomplished without major product transfusion. This proof of concept leads to a broader acceptance of blood conservation and transfusion avoidance for mainstream patients.