[HSF] aortic root replacement ,svere hyperbilirubinemia

[Claudia Teles]

Dear Surgeons,

The most frequent causes for an acute hemolytic  reaction after heart
surgery are  immune hemolytic reactions, cold hemagglutinins or  mechanic
hemolysis (this is more common because of mechanical prosthesis
malpositioning, but it can happen in other circumstances too),but surprises
also exist. Occasionally, you can get a Paroxistic Nocturnal Hemoglobinuria
 patient who undergoes surgery without previous diagnosis. Has this patient
ever received blood transfusions before the surgery?
I would recommend a direct Coombs test and a complete immune hemolysis
diagnostic panel in an immune hematology lab facillity first, to screen for
irregular antibodies and a test for cold hemagglutinins. It's interesting to
keep in mind that mononucleosis, quinidine, pennicillin, warm hemagglutinin
syndromes seen in Lupus (Evans Syndrome) - all of them can cause immune
hemolytic anemia, that can be exacerbated by a major surgical procedure.
Post transfusional purpura is a delayed reaction that occurs commonly after
one week from the index transfusion. Acute thrombocytopenia might be because
of consumption, or Rapid Onset HIT, or because of decompensation of a
previous alloimmunized state (Lupus, PNH, etc).
Hope this helps.

Claudia
 Aortic valve replacement and coronary revascularization in paroxysmal
nocturnal hemoglobinuria. *Knobloch
K*<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Knobloch%20K%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus>,
*Lichtenberg A*<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Lichtenberg%20A%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus>,
*Leyh RG*<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Leyh%20RG%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus>,
*Schubert J*<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Schubert%20J%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus>
.

Department of Cardiothoracic and Vascular Surgery, Hannover Medical School,
Carl-Neuberg-Strasse 1, 30625 Hannover, Germany. knobloch at thg.mh-hannover.de

Cardiac surgery in patients with paroxysmal nocturnal hemoglobinuria (PNH),
which is an acquired hemolytic anemia associated with thrombocytopenia and
an abnormal susceptibility to venous thromboses, requires special
perioperative measures. PNH is based on a clonal defect of hematopoietic
stem cells characterized by deficiency in
glycosyl-phosphatidylinositol-anchored surface proteins. The major mechanism
of hemolysis consists of unregulated complement activation. In cardiac
surgery, PNH-induced granulocytopenia increases the risk of postoperative
infection. PNH-induced complement activation is further exaggerated by
extracorporeal circulation in cardiac surgery leading to putative hemolytic
crisis. Here, we report on a patient who developed PNH after severe aplastic
anemia undergoing aortic valve replacement and coronary revascularization
using extracorporeal circulation and discuss the special perioperative
management and the relevant literature on this issue. Special emphasis
should be given to optimal preoperative patient preparation including G-CSF
administration and red blood pack transfusions, perioperative platelet
substitution, fluid management, and antibiotic prophylaxis



2007/8/4, Hgrmd at aol.com <Hgrmd at aol.com>:
>
> Erdinc,
> Your're right.  That wasn't much blood loss considering the  type and
> magnitude of your procedure.  I guess I'd have to agree with  Prasanna
> that this is
> probably some type of hemolytic problem.  Was it a  transfusion reaction?
> This is not an area in which I have unusual  expertise.  If she's reading
> this,
> perhaps Claudia, our Brazilian  hematologic guru, should weigh in.
> Still, Erdinc, you really have to get the problem solved of  operating
> with
> no available platelet transfusions.  What do you do if the  platelet count
> is
> low or if the patient has been on platelet inhibitors?
>
> Hal
>
>
>
> ************************************** Get a sneak peek of the all-new AOL
> at
> http://discover.aol.com/memed/aolcom30tour
> _______________________________________________
> OpenHeart-L mailing list
>
> Send postings to:
> OpenHeart-L at lists.hsforum.com
>
> To UNSUBSCRIBE, to CHANGE email address, or to view archives:
> http://mmp.cjp.com/mailman/listinfo/openheart-l
>
> All messages transmitted by the OpenHeart-L are subject to the policies
> and
> disclaimers posted at:
> http://www.hsforum.com/listdisclaim
> -----------------------------------------
>



-- 
Claudia Teles
Hemostasis Section - INCARDIO