Anaesthesia for bilateral mastectomy in a Jehovah's Witness patient with epilepsy and review of alternatives to homologous blood transfusion

The anaesthetic management of a Jehovah's Witness patient for bilateral mastectomy for carcinoma of the breast is described. The patient is also a known epileptic patient who developed fits the night before surgery. Surgery was re-scheduled for one week later to allow control of the epilepsy. Surgery was carried out under general anaesthesia. The patient refused blood transfusion. Modified normovolaemic haemodilution was the alternative to homologous blood transfusion used in the patient. This was safe except for the post-operative morbidity due to severe anaemia in the patient. The surgical outcome was good. The safety of not transfusing blood in Jehovah's Witness patient for surgical procedures for which blood transfusion is needed is well illustrated by this case. A review of alternatives to homologous blood transfusion is done.     

Right trisectionectomy of the liver for intrahepatic cholangiocarcinoma with bile duct invasion in a Jehovah's Witness

Intrahepatic cholangiocarcinoma (ICC) is well known to have a very poor prognosis. Aggressive surgical strategies in the treatment of ICC, including major hepatectomy, have been reported to afford patients the best chance for significant survival. Recent advancements in surgical techniques concerning live donor liver transplantation have dramatically improved the results of major hepatectomy. However, surgical treatment of biliary malignancy is complex and is known to increase the likelihood of blood transfusion. We describe a Jehovah's Witness patient with ICC and concomitant bile duct invasion who had a successful right trisectionectomy with bile duct resection, lymph node dissection, and Rouxen-Y hepatico-jejunostomy without blood transfusion. A multidisciplinary preparation was crucial in obtaining this positive outcome. Importantly, bloodless liver transection techniques with inflow clamping, meticulous dissection, and hemostasis should be utilized for major hepatectomy in a Jehovah's Witness. The success of this case may alert clinicians to consider a hepatectomy as a possible option in the treatment of ICC in a Jehovah's Witness.     

Temporary partial intra-iliac balloon occlusion for the treatment of acetabulum fracture in a Jehovah's Witness: a case report

Blunt trauma patients with acetabular fractures can lose as much as 2 L of blood after injury, and approximately 40% of these patients require blood transfusions. Fractures involving the anterior and posterior columns may require more than 1 surgery for adequate fracture fixation, increasing the potential for greater blood loss. Although blood transfusions may be medically necessary in these cases, Jehovah's Witnesses often refuse transfusion as a matter of religious conviction. The religious tenets of this faith preclude the use of blood transfusions and certain other blood products, based on an interpretation of Acts 15:29. To treat patients with these beliefs, various techniques have been developed to minimize blood loss as an alternative to transfusion. Temporary arterial balloon occlusion, also known as an "internal tourniquet," was first reported in 1954 for use in severe penetrating abdominal trauma. It was later used to control basilar artery bleeding and to limit blood loss in Jehovah's Witness patients undergoing revision total hip or knee arthroplasty. This case report documents the successful use of temporary balloon occlusion to minimize blood loss during an open reduction internal fixation of a both-column acetabulum fracture in a Jehovah's Witness patient. The method used for achieving this intra-iliac balloon occlusion is described in detail so that others also may implement this technique.     

Pulmonary Embolus after Retrieval of a Temporary Inferior Vena Caval Filter in a Jehovah's Witness Undergoing Gastric Bypass Surgery

We present the case of pulmonary embolus after retrieval of a temporary inferior vena caval (IVC) filter in a Jehovah's Witness patient who underwent uneventful laparoscopic gastric bypass surgery. The 40-year-old female was admitted to the hospital 2 days after retrieval of the filter with bilateral pulmonary emboli for which she received anticoagulation therapy and consequently developed thoracic bleeding. We present this complicated case to highlight the risk of pulmonary emboli after IVC filter removal without anticoagulation, and to demonstrate the additional risk in managing a Jehovah's Witness patient.     

Bloodless intensive care: a case series and review of Jehovah's Witnesses in ICU

The objective of this study was to assess the outcome of Jehovah's Witness (JW) patients admitted to a major Australasian ICU and to review the literature regarding the management of critically ill Jehovah's Witness patients. All Jehovah's Witness patients admitted to the ICU between January 1999 and September 2003 were identified from a prospective database. Their ICU mortality, APACHE II scores, APACHE II risk of death and ICU length of stay were compared to the general ICU population. Twenty-one (0.24%) out of 8869 patients (excluding re-admissions) admitted to the ICU over this period were Jehovah's Witness patients. Their mean APACHE II score was 14.1 (+/- 7.0), the mean APACHE II risk of death was 21.2% (+/- 16.6), and the mean nadir haemoglobin (Hb) was 80.2 g/l (+/- 36.4). Four out of 21 Jehovah's Witness patients died in ICU compared to 782 out of 8848 non- Jehovah's Witness patients (19.0% vs 8.8%, P = 0.10, chi square). The median ICU length of stay in both groups was two days (P = 0.64, Wilcoxon rank sum). The lowest Hb recorded in a survivor was 23 g/l. Jehovah's Witness patients appear to be an uncommon patient population in a major Australasian ICU but are not over-represented when compared with their prevalence in the community. Despite similar severity of illness scores and predicted mortality to those in the general ICU population, there was a trend towards higher mortality in Jehovah's Witness patients.     

Resection of a large atrial hemangioma using a bloodless surgical technique: a case report

We present a biatrial hemangioma in a Jehovah's Witness patient. Hemangioma is extremely rare, accounting for 1% to 2% of benign cardiac tumors. Complete resection of a large hemangioma is mandatory due to its potentially life-threatening risk. In Jehovah's Witness patients, it is necessary to employ bloodless surgery protocols to maximize the patient's outcome. Our patient had undergone 6 weeks of monitoring and erythropoietin therapy prior to surgery, raising her hemoglobin level from 11.6 g/dL to 16.8 g/dL. Intraoperative bloodless surgical protocols as well as a continuous blood circuit were utilized. The patient's hemoglobin level on postoperative day one was 14.5 g/dL; one year postsurgery, the patient was symptom free.     

Anesthesia management of a Jehovah's Witness patient with pheochromocytoma undergoing off pump coronary artery bypass graft surgery--acase report

Concomitant coronary artery disease (CAD) and pheochromocytoma are rare. Patients with advanced CAD requiring coronary artery bypass graft (CABG) surgery and clinically active pheochromocytoma present a challenge to anesthesiologists. The risk is much higher if the patient is an anemic Jehovah's Witness because these patients refuse to receive blood or blood products, even when faced with a life-threatening hemorrhage. To our knowledge, this is the first case to describe the anesthetic management of an anemic Jehovah's Witness patient with pheochromocytoma presenting for off-pump CABG surgery.     

Pancreaticoduodenectomy after neoadjuvant therapy in a Jehovah's witness with locally advanced pancreatic cancer: case report and approach to avoid transfusion

Although the morbidity and mortality rates associated with pancreaticoduodenectomy (PD) have been improving over the past several decades, perioperative transfusions are often needed. Here, we review the preoperative planning and overall management of a Jehovah's Witness patient with locally advanced pancreatic cancer who would not accept blood transfusion. Management of this case is reviewed, along with the relevant literature regarding major surgery in the Jehovah's Witness population. The use of neoadjuvant chemoradiation was used successfully in locally advanced disease, allowing surgical resection. In addition, we outline a cogent strategy using pre-, intra-, and postoperative techniques to minimize blood loss and maintain hemoglobin at acceptable levels thereby preventing the need for transfusion. These strategies, once in place, may be able to reduce transfusions in all patients having major resections for malignancy.     

Care of the injured Jehovah's Witness patient: case report and review of the literature

Care for the Jehovah's Witness patient can be a challenge and often a dilemma to clinicians because of the patient's religious beliefs and teachings against receiving blood and blood products, especially in emergency or trauma settings. We present a case of a severely injured elderly Jehovah's Witness patient who survived. We also review the literature and offer an organized approach to care for such patients.     

Rapid sequence quadruple joint replacement in a rheumatoid Jehovah's Witness

We report the case of a wheelchair-bound rheumatoid Jehovah's Witness who underwent rapid sequence, staged, simultaneous ipsilateral hip and knee replacements. Using perioperative erythropoietin and postoperative blood salvage, all four joints were reconstructed without homologous blood transfusion. One year following surgery, the patient has achieved an independent functional status, and all four replaced joints remain painless.     

Recombinant human erythropoietin use in a critically ill Jehovah's witness after cardiac surgery

Complex cardiac surgery often requires blood transfusion. Some patients refuse transfusion, even when it is potentially life-threatening to do so. Although recombinant human erythropoietin (rhEPO) has been used to reduce the need for blood transfusion, it has been considered ineffective in critically ill patients. The time course of hematological responses in a Jehovah's Witness patient with acute renal failure and severe cardiac disease suggests that a trial of rhEPO should be considered for salvage therapy in critically ill patients. IMPLICATIONS: The authors describe successful treatment of life-threatening anemia using recombinant human erythropoietin in a critically ill Jehovah's Witness patient after cardiac surgery.     

Primary and revision total hip replacement in patients who are Jehovah's Witnesses

The Jehovah's Witnesses do not accept allogeneic blood transfusion or certain types of autologous blood transfusion and, therefore, present the orthopaedic surgeon with a challenge in the management of perioperative blood loss. Accepting a patient who is a Jehovah's Witness as a surgical candidate requires the surgeon to be prepared medically to use known techniques to limit red blood cell loss or increase red blood cell mass, to resort to extraordinary means when necessary, and to be prepared philosophically to deal with catastrophic blood loss in a patient who may refuse even potentially life-saving transfusion. Issues pertinent to the management of intraoperative blood loss in the patient who is a Jehovah's Witness require careful delineation and specific treatment guidelines. The authors herein review their past and current experiences in the perioperative blood management of this patient population in an attempt to address this need.     

Malignant fibrous histiocytoma of the heart complicated by factor XI deficiency in a Jehovah's Witness patient

We describe a 16-year-old girl with malignant fibrous histiocytoma (MFH) of the heart complicated by factor XI deficiency. The preoperative diagnosis was left atrial myxoma. We decided to perform the operation owing to a normal bleeding time. Operative findings suggested a malignant tumor. The patient was a Jehovah's Witness, and extensive excision was not performed because blood transfusion was not allowed. We resected as much of the tumor and left atrial appendage as possible. The pathologic diagnosis was MFH. Excessive bleeding was not observed during the operation. Bleeding time helps to determine whether a surgical procedure is indicated in patients with factor XI deficiency.     

Multidisciplinary management of a Jehovah’s Witness patient for the removal of a renal cell carcinoma extending into the right atrium

PURPOSE: To highlight the management of a Jehovah's witness surgical patient presenting for cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest. CLINICAL FEATURES: A 47-yr-old male, Jehovah's Witness, with renal cell carcinoma was admitted for left radical nephrectomy and excision of tumour thrombus extending into the junction of the inferior vena cava (IVC) and right atrium (RA). The preoperative goals were to maximize red blood cell mass, delineate the extent of tumour extension and develop a surgical plan incorporating blood conservation strategies to minimize blood loss. A midline abdominal incision was made to optimize removal of the non-caval portion of the tumour from the intra-abdominal region. CPB and deep hypothermic circulatory arrest were instituted to aid in removing the tumour from the IVC and RA. Intraoperative blood conservation strategies included the use of acute normovolemic hemodilution, antifibrinolytics, cell salvage, point-of-care monitoring of heparin and protamine blood concentrations, leukocyte-depleting filter, and meticulous surgical techniques. The patient was successfully weaned from CPB and was transported to the cardiothoracic intensive care unit without complication. The patient was discharged home one week after the operation with a hemoglobin of 10.2 g x dL(-1) and a hematocrit of 31.2%. CONCLUSION: Multiple blood conservation techniques were employed to manage this Jehovah's Witness patient through complex cardiac surgery, which was previously denied to him at other institutions. The successful outcome of this patient, while respecting the right to refuse allogeneic blood products, is a result of a multidisciplinary collaboration as well as the application of established blood conservation techniques.     

Anesthesia for laparoscopic adrenalectomy (pheochromocytoma) in an anemic adult Jehovah’s Witness

PURPOSE: To report the anesthetic management of an anemic Jehovah's Witness patient presenting for laparoscopic adrenalectomy for pheochromocytoma. CLINICAL FEATURES: A 49-yr-old woman presented with hemodynamic instability progressing to cardiogenic shock and subsequent acute renal failure. Her course was complicated by anemia. An adrenal pheochromocytoma was diagnosed. Preoperatively, alpha- and beta-adrenergic blockade was instituted with phenoxybenzamine and metoprolol therapy and her anemia was treated with erythropoietin. She underwent laparoscopic resection of the adrenal tumour. A cell saver device was employed and attached to the laparoscopic suction-irrigation apparatus to provide salvage capability in the event of a major hemorrhage. The surgical intervention was uneventful and well tolerated. The patient was discharged home and well on follow-up. CONCLUSIONS: Cell salvage is the only mechanism currently acceptable to Jehovah's Witnesses which will allow for perioperative salvage and replacement of blood loss. Its use is encouraged in all situations in which surgical hemorrhage is anticipated.     

Perfusing the Jehovah's Witness patient with heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is an uncommon, yet dangerous side-effect of heparin therapy. The problems associated with the HIT patient while undergoing cardiopulmonary bypass increase dramatically when the patient is also of Jehovah's Witness faith. This case report depicts the techniques utilized and the decisions made over the course of a simple surgical procedure for an extremely high-risk patient.     

Beriplex P/N: an alternative to fresh frozen plasma in severe haemorrhage

The management of Jehovah's Witnesses suffering from severe haemorrhage can be very difficult. Those patients who are taking oral anticoagulant therapy pose an additional risk and the difficulty may be compounded by the development of coagulopathy. Several alternatives to blood products have been reported to be useful in this situation. We report the successful management of an emergency postsurgical wound bleeding in a Jehovah's Witness using Beriplex (a concentrate of factors II, VII, IX and X). The patient, who was taking warfarin, presented 10 days after an elective laminectomy with significant bleeding from the surgical wound and coagulopathy. Despite early surgical measures, there was continuing haemorrhage. This was arrested by giving Beriplex intra-operatively. To our knowledge this is the first reported case of the use of Beriplex in a Jehovah's Witness for control of emergency haemorrhage and coagulopathy.     

Multiple Choice Questions

27. A blood transfusion may lawfully be administered to:

1. Anadult Jehovah's Witness undergoing elective surgery if theanaesthetistfeels it would be in the patient's best interests.
2. An adultpatient in an emergency whose Jehovah's Witness statusis uncertain.
3. An unconscious adult patient who is carrying an advance directiveindicating his Jehovah's Witness status and refusing transfusionof blood products.
4. A child of Jehovah's Witness parents forwhom a specific issueorder has been obtained.
5. A child ofJehovah's Witness parents in an emergency.

28. The followingmay reduce intraoperative blood transfusionrequirements:

1. Highstarting packed cell volume.
2. High percentageof hypochromaticred cells.
3.      

Aortocoronary bypass in Jehovah's Witnesses: review of 46 patients.

The hemodilution technique for cardiopulmonary bypass using blood substitutes for priming has permitted open heart operations in Jehovah's Witnesses who refuse to accept blood, and has reduced the need for massive blood transfusion in certain procedures including aortocoronary bypass. A series of 46 Jehovah's Witness patients underwent aortocoronary bypass procedures. Of these, two patients died, representing a mortality of 4.3 per cent. Neither patient's death was related to lack of blood transfusions. The hospital stay and recovery time of all the other patients was not affected by failure to transfuse blood. The excellent short- and long-term results of this particular group paralleled those observed in our larger series of over 2700 other patients who have undergone coronary bypass surgery since 1969. Among these patients not of the Jehovah's Witness religion, blood transfusion was not necessary in about 30 per cent, while the remainder averaged less than two units per patient. Our results with Jehovah's Witness patients encourage our policy of avoiding blood transfusions whenever possible in all operations. Further justification for our conservative attitude is provided by the current shortage of blood in relation to a projected continuous increase of aortocoronary bypass procedures in the future.     

Use of the Hemobag for modified ultrafiltration in a Jehovah's Witness patient undergoing cardiac surgery

Modified ultrafiltration is an important technique to concentrate the patient's circulating blood volume and the residual whole blood in the extracorporeal circuit post-cardiopulmonary bypass. The Hemobag system is a device cleared by the US Food and Drug Administration and represents a novel and safe modification of traditional modified ultrafiltration systems. It is quick and easy to operate by the perfusionist during the hemoconcentration process. Hemoconcentration is accomplished by having the Hemobag "recovery loop" circuit separate from the extracorporeal circuit. This allows the surgeons to continue with surgery, decannulate, and administer protamine simultaneously while the Hemobag is in use. The successful use of the Hemobag in a Jehovah's Witness patient has not been previously described in the literature. This case report describes how to set up and operate the Hemobag in a Jehovah's Witness patient undergoing cardiac surgery that requires an extracorporeal circuit.