Ethics, Legal Issues, and Pediatric Physiology
What blood product remains unacceptable following the recent changes to Jehovah’s Witness guidelines?
Allogeneic whole blood
What is the most common cause of anemia in children?
Iron deficiency anemia
What antifibrinolytic is commonly used to reduce surgical blood loss in pediatric patients in Canada?
Tranexamic acid
What can be given if bleeding persists after surgery?
Anti-fibrinolytics (infusion or bolus) along with iron and erythropoiesis stimulating agents if patient is anemic
During a preoperative conversation, the parents of the 12-year-old patient state they will not permit any transfusion even if life-threatening bleeding occurs during the surgery. Their child expresses fear and uncertainty towards this statement and asks if they could make their own decision. What next step is the most appropriate?
Because there is no universal age of consent, the best step is to further explore the capacity and wishes of both the child and parents and involve the HLC and hospital ethics department as needed for support. It is important to ensure the decision is made in the best interest of the child.
List 3 groups that can help support difficult ethical conversations with pediatric JW patients and their families.
How long can it take to replete iron reserves when using oral iron supplements?
At least six weeks. However, complete iron store repletion can take up to 3 months.
Explain the impact that patient positioning and mechanical ventilation may have on intraoperative bleeding.
Increased abdominal and airway pressures can impede venous returning and increase venous pressures, potentially increasing bleeding.
Why is excessive crystalloid administration counterproductive in a patient with post-operative anemia?
This can worsen anemia through dilution, lead to coagulopathies, and cause tissue edema
A pediatric patient presents following a motor vehicle accident and required an emergency trauma laparotomy due to their clinical instability. The parents
clarify they are Jehovah’s Witnesses and will not accept blood transfusions for their child. What is the most appropriate approach?
The clinician in this scenario is permitted to act rapidly in the best
interests of the patient as this is an emergency, which may include giving blood components or products while wishes are being clarified with the parents, HLC, and ethics as needed.
Describe the elements of informed consent.
What is the best way to prevent iatrogenic blood loss and hospital acquired anemia in the perioperative period?
Minimizing unnecessary phlebotomy, and using pediatric collection tubes or point-of-care testing if possible.
Describe 3 surgical techniques that can reduce intraoperative blood loss.
Topical hemostasis, minimally invasive approaches, multiple surgeons, staged opening of incision, tourniquets, tamponade, local infiltration with epinephrine or TXA
What is a technique that can reduce blood loss through phlebotomy and provide real-time insights on clot formation?
Viscoelastic testing (TEG and ROTEM). However, normal ranges are currently based off adult values, which differ from young pediatric patients.
During a family meeting debriefing an emergency open pelvic fracture fixation in a 10-year-old JW that fell from a height, you disclose to the family that 2 units of blood were transfused as the patient was extremely unstable at initial presentation. The parents are distressed and ask if they will be removed from the JW faith. What will you tell them?
In urgent scenarios, any emergent
transfusions in children do not result in their immediate removal from JW
congregations. If allogeneic whole blood is given counselling should be offered to patients and families including the HLC for JWs and hospital ethicists to help them understand what has happened and to support them moving forwards.
Explain why in young patients, despite having a higher circulating blood volume in mL/kg, they are more vulnerable during intraoperative bleeding?
Their smaller absolute body weights result in a very low total blood volume. Losing a small volume of blood would make up a large percent of their total volume, a value that would otherwise be inconsequential for an adult.
Besides iron supplementation, name 2 other adjuncts that can be used to optimize red blood cell mass.
Erythropoietin stimulating agents, folate, vitamin C
Describe 3 anesthetic techniques that can reduce intraoperative blood loss.
Neuraxial and regional techniques, judicious fluid administration, maintaining homeostasis (avoiding acidosis and hypothermia), care with positioning, antifibrinolytic agents
What common emergence side effect should be prevented in the post-anesthetic care unit, especially in anemic patients?
Shivering and hypothermia. This will drastically increase oxygen demand.
A 3 year old JW patient is being booked for a highly vascular choroid plexus tumour resection. What can be done pre-operatively to reduce the risk of bleeding during the surgery?
Consider an embolization procedure, neoadjuvant chemotherapy, or radiation to shrink and devascularize the tumour.
Describe 3 differences in the hemostatic and coagulation system in young pediatric patients compared to adults.
- Lower vit K related factors
- Lower thrombin
- Lower protein C and S
- Increased vWF
- Impaired platelet function
- Abnormal fibrin networks
Provide 2 reasons why IV iron may be preferred over oral iron.
Bypasses post-inflammatory surges in hepcidin which limits oral iron absorption
With the recent policy change surrounding preoperative autologous donations, name 2 drawbacks of this strategy in pediatric patients.
All other risks not unique to autologous blood: bacterial contamination, transfusion reactions, mislabeled units
A pediatric patient with severe anemia is being considered for hyperbaric oxygen therapy. What is a major limitation that must be considered?
Availability and of an appropriate in proximity to the hospital, and feasibility of transporting the patient there (especially if critically ill or ventilated)
You are the on-call anesthesiologist when you learn about an urgent case to be done later in the day. The patient is a 4-year-old pediatric JW, and you learn they are anemic with a Hb at 84g/L. What are two things you should do to help optimize the patient preoperatively?
Start IV iron + ESA
Discuss with patient and family on what products are accepted