Maintenance of normal hematocrit in high-risk thyroid surgery without allogeneic blood transfusion: a case report NATHANIEL I. USORO*, MBBCH, FWACS, FICS , SAMUEL INWANG † , MBBCH, Dip. Anaesth. & INIABASI U. ILORI † , MBBCH, DA, FWACS *Surgery Department and † Anesthesiology Department, University of Calabar Teaching Hospital, Calabar, Nigeria Correspondence to: Dr Nathaniel I. Usoro, Surgery Department, University of Calabar Teaching Hospital, Moore Road, Calabar 540001, Nigeria E-mail: natusoro@yahoo.com Publication data Received: 17 July 2009 Revision received: 23 August 2009 Second revision received: 21 November 2009 Accepted: 18 December 2009 Keywords • Acute normovolemic hemodilution • Blood conservation • Blood management • Bloodless surgery • Hematocrit • Iron therapy • Thyroidectomy ABSTRACT Bloodless surgery was introduced initially for the care of patients who refused blood transfusion. Recently however, adverse outcome with blood transfusion has been reported in virtually all subspecialties of surgery and conversely, improved outcome with non-transfusion surgery. Thus blood conservation is the standard of care because it is evidence-based. Thyroid surgery is historically associated with blood loss, and a lower hemato- crit would be expected postoperatively. We report a case of subtotal thyroidectomy for a large simple multinodular goiter using planned blood-conservation techniques tailored to the patient that resulted in maintenance of a normal hematocrit throughout the perioperative period. The patient received oral hematinics preoperatively, while acute normo- volemic hemodilution and other techniques were used to minimize intraoperative blood loss. The outcome was an optimized hematocrit preoperatively, minimal blood loss intraoperatively, and hematocrit which remained optimal on the third postoperative day and 3 weeks postoperatively. No allogeneic blood was used at any stage. This suggests that maintenance of normal hematocrit can be regarded as an achievable goal in high-risk surgery through blood-conservation techniques. Avoid- ing allogeneic blood transfusion is possible in a resource-poor setting, where HIV prevalence is high and screening of blood may be suboptimal, and it is the ideal clinical approach as demonstrated in this case report. CASE REPORT A 44-year-old woman presented at the Surgical Outpa- tient Department with anterior neck swelling of 4-year duration measuring 9 cm (vertical) ¥ 13 cm (transverse). The swelling was bigger to the right of midline than to the left and her trachea was deviated to the left. However, she had neither pressure symptoms nor any other symptoms. Clinical diagnosis of simple multi- nodular goiter was made and thyroid function tests done showed normal parameters. Her hematocrit was 34%. She was offered subtotal thyroidectomy using blood- conservation techniques and she consented. A blood- conservation plan was drawn up and anesthesiologist’s review sought. From the first outpatient visit the patient was placed on oral ferrous gluconate 900 mg (105 mg elemental iron) daily along with adjuncts (Vitamin C, Vitamin B Complex, and Multivitamins). Six weeks later Transfusion Alternatives in Transfusion Medicine TATM © 2010 The Authors Journal Compilation © 2010 Medical Education Global Solutions • Transfusion Alternatives in Transfusion Medicine doi: 10.1111/j.1778-428X.2010.01125.x 43