title: Use of hyperbaric oxygen therapy and PEGylated carboxyhemoglobin bovine in a Jehovah's Witness with life-threatening anemia following postpartum hemorrhage.
abstract: We present a case of a Jehovah's Witness patient who refused blood products, with the exception of albumin and clotting factors, and underwent cesarean section under spinal anesthesia complicated by postpartum hemorrhage. She was fluid resuscitated and treated with multiple uterotonics and internal iliac artery embolization. Because of agitation she required emergency tracheal intubation. Her hemoglobin concentration dropped from a preoperative value of 12mg/dL to 3mg/dL on postoperative day one. She was acidotic, requiring vasopressors for hemodynamic stability and remained ventilated and sedated. She was treated with daily erythropoietin, iron therapy and cyanocobalamin. Because of ongoing hemorrhage, continued acidemia and vasopressor requirements she was co-treated with PEGylated carboxyhemoglobin bovine and hyperbaric oxygen therapy to reverse her oxygen debt. On postoperative day eight her hemoglobin concentration was 7mg/dL, she was hemodynamically stable and vasopressors were discontinued. She was extubated and discharged from the intensive care unit on postoperative day eight. This report highlights the multiple modalities used in treating a severely anemic patient who refused blood, the use of an investigational new drug, the process of obtaining this drug via the United States Food and Drug Administration emergency expanded access regulation for single patient clinical treatment, and ethical dilemmas faced during treatment.
authors.affiliation: Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA, USA. Electronic address: Kokila-thenuwara@uiowa.edu.
authors.forename: K
authors.initials: K
authors.lastname: Thenuwara
authors.affiliation: Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
authors.forename: J
authors.initials: J
authors.lastname: Thomas
authors.affiliation: Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
authors.forename: M
authors.initials: M
authors.lastname: Ibsen
authors.affiliation: Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
authors.forename: U
authors.initials: U
authors.lastname: Ituk
authors.affiliation: Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
authors.forename: K
authors.initials: K
authors.lastname: Choi
authors.affiliation: Departments of Pharmaceutical Care & Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
authors.forename: E
authors.initials: E
authors.lastname: Nickel
authors.affiliation: Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
authors.forename: M J
authors.initials: MJ
authors.lastname: Goodheart
mesh_terms: D000328:Adult; D000740:Anemia / Q000628:therapy*; D002263:Carboxyhemoglobin / Q000627:therapeutic use*; D002585:Cesarean Section; D005260:Female; D006801:Humans; D006931:Hyperbaric Oxygenation / Q000379:methods*; D033221:Jehovah's Witnesses; D006473:Postpartum Hemorrhage / Q000628:therapy*
chemical_list: D002263:Carboxyhemoglobin
keywords: Hyperbaric oxygen therapy; Jehovah’s Witness; PEGylated carboxyhemoglobin bovine