Recombinant human erythropoietin in severe anaemia: issues of dosing and duration

The majority of Jehovah's Witnesses refuse blood product transfusion, even when it can be lifesaving. Treatment with recombinant human erythropoietin (RHuEPO) is a valuable adjunct in Jehovah's Witness patients undergoing surgery. A number of additional strategies, including acute normovolaemic haemodilution, intra-operative blood salvage and reinfusion, iron and folate supplementation are also utilized to avoid blood transfusion. Critically ill patients have blunted erythropoietin production and decreased endogenous iron availability. This case report reviews the treatment of anaemia in critically ill Jehovah's Witness patients after surgery and discusses the potential need for higher RHuEPO dosing strategies and longer duration of therapy.     

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.     

Erythropoietin in a patient following multiple trauma

We report on a Jehovah's Witness who had severe blood loss following major trauma. The problems of her management without blood transfusion, and with the use of recombinant human erythropoietin therapy for severe anaemia, are described.     

Hyperbaric oxygen therapy in the management of severe acute anaemia in a Jehovah's Witness

A case is described in which a Jehovah's Witness patient who refused blood transfusion suffered massive antepartum haemorrhage, her haemoglobin falling as low as 2.0 g.dl(-1). She was treated on an intensive care unit with intermittent positive pressure ventilation and general supportive measures, pulsed hyperbaric oxygen therapy and recombinant human erythropoietin.     

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.     

Perioperativer Einsatz von rhEPO bei Angehörigen der Glaubensgemeinschaft „Zeugen Jehovas“

Erythropoietin, the hematopoietic growth factor, is synthesised in the kidneys and liver and regulates red blood cell production. Within the last few years, recombinant DNA technology has produced synthetic erythropoietin (rhEPO). Some patients, especially Jehova's Witnesses, will not accept blood transfusion. The perioperative administration of rhEPO increases the patients' hematocrit (HCt) to a higher than physiological level. Methods and results. We report a case of a 66-year-old female Jehova's Witness who refused blood transfusions and responded favourably to rhEPO treatment. A total hip arthroplasty was planned. A pre-treatment hemoglobin level (Hb) of 13.7 g/dl and HCt of 43% were documented. After preoperative subcutaneous application of 5000 I.E. rhEPO three times per week and daily oral substitution of 300 mg ferrous sulfate over a period of 3 weeks, the Hb increased to 15.5 g/dl and the HCt to 49%. The operation was carried out after the ninth application of rhEPO. Postoperatively, the Hb concentration was 11.8 g/dl and the HCt 35%. Therefore, postoperative administration of rhEPO was not considered indicated. No side effects of rhEPO application were noted. The patient left hospital on the 10th postoperative day. Conclusions. The case report describes perioperative management using human rhEPO in Jehova's Witnesses. Treatment with rhEPO increases preoperative Hb levels to a point making it possible to compensate for operative blood loss. RhEPO combined with daily iron substitution may be useful in patients who refuse transfusion based on religious convictions.     

Totally endoscopic coronary artery bypass on the beating heart in Jehovah's Witness and HIV patients: case report

Minimally invasive direct coronary artery bypass has been widely employed as an approach for revascularization of the left anterior descending coronary artery. Recent advances in minimally invasive cardiac surgery enhanced with technological assistance have meant that these operations are now being performed through smaller incisions. We present 2 cases, both of which emphasize the beneficial role of the DaVinci robotic system in performing bloodless coronary surgery without blood transfusion and in reducing blood contact in instances in which there is a high risk for infection. In the first case, a Jehovah's Witness patient, blood transfusion was not an option; in the second case, a human immunodeficiency virus (HIV)-positive patient, blood contact would have put the staff at risk for HIV infection.     

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.     

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.     

The use of recombinant human erythropoietin in a Jehovah's Witness requiring major reconstructive surgery.

We report on a new approach to the anemic Jehovah's Witness patient requiring a major operation using preoperative and perioperative erythropoietin. The use of recombinant human erythropoietin in this and other clinical situations is discussed.     

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.     

Pancreaticoduodenectomy without homologous blood transfusion in an anemic Jehovah's Witness.

Whipple pancreaticoduodenectomy is an accepted procedure for management of periampullary and pancreatic carcinomas and has modern mortality rates of less than 10%. The procedure is associated with significant operative blood loss. Therefore, blood transfusion is an important supportive measure. We report the case of a bleeding ampullary carcinoma in a Jehovah's Witness who refused transfusion of all homologous blood products. Despite a preoperative hemoglobin level of 51 g/L, curative pancreaticoduodenectomy was successfully performed. The success of the procedure can be primarily attributed to careful surgical technique, intraoperative autotransfusion, avoidance of postoperative complications, minimization of perioperative phlebotomies, use of human recombinant erythropoietin, and, possibly, the use of the perfluorocarbon emulsion Fluosol DA-20%. The case illustrates several important principles for the surgical treatment of patients with severe anemia who refuse transfusion of homologous blood products.     

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.      

The Ross operation in a Jehovah's Witness: a paradigm for heart surgery in children without transfusion

A 3-year-old 18 kg male child of the Jehovah's Witness faith presented with severe aortic regurgitation. A successful Ross procedure was performed using a pulmonary autograft, without the use of blood or blood product transfusion. Blood conservation strategy included: (1) preoperative treatment with recombinant human erythropoietin; (2) intraoperative strategies, including technical modifications to the Ross procedure, and the prophylactic use of fibrin glue; (3) utilization of a heparin-bonded cardiopulmonary bypass circuit and assisted venous drainage; and 4) the use of prebypass phlebotomy, cell-saving device and autotransfusion. The patient was discharged home on postoperative day 7 with a hemoglobin level of 11.9.     

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.     

Successful repair of a giant abdominal aortoiliac aneurysm in a Jehovah's Witness

We report the case of a 76-year-old man of the Jehovah's Witness faith who had a giant abdominal aortoiliac aneurysm that was successfully operated on using an aortoiliac Y-graft bypass technique, without the use of stored allogenic blood. Cell saver technique and recombinant human erythropoietin (epoetin beta) were used during the perioperative period. The patient had good postoperative care with a multidisciplinary approach.     

Bloodless surgery of acute type A aortic dissection in a Jehovah's Witness patient

We report successful surgery for acute type A aortic dissection in a Jehovah's Witness patient without the use of any transfusion of allogeneic blood or blood products. We combined the normothermic cross-clamping technique with a blood conservation strategy.     

Traitement d'une anémie aiguë post-traumatique par érythropoïétine humaine recombinante chez un témoin de Jéhovah

A 20-year-old Jehovah's witness patient experienced a femur fracture, with a section of the femoral artery and vein. On admission, haemoglobin concentration was 5.8 g·dL⁻¹ and haematocrit 17%. Because of aponevrotomy, blood losses persisted. As the patient refused blood transfusion, recombinant human erythropoietin and parenteral iron were administered, associated with mild hypothermia, sedation and mechanical ventilation. After 21 days, the haemoglobin concentration increased to 10.9 g·dL⁻¹ and haematocrit to 33%. Recombinant human erythropoietin and parenteral iron may provide an alternative safe and effective therapy in life-threatening anaemia when blood transfusions are not accepted by the patient.     

Live donor liver transplantation without blood products: strategies developed for Jehovah's Witnesses offer broad application

OBJECTIVE: Developing strategies for transfusion-free live donor liver transplantation in Jehovah's Witness patients. SUMMARY BACKGROUND DATA: Liver transplantation is the standard of care for patients with end-stage liver disease. A disproportionate increase in transplant candidates and an allocation policy restructuring, favoring patients with advanced disease, have led to longer waiting time and increased medical acuity for transplant recipients. Consequently, Jehovah's Witness patients, who refuse blood product transfusion, are usually excluded from liver transplantation. We combined blood augmentation and conservation practices with live donor liver transplantation (LDLT) to accomplish successful LDLT in Jehovah's Witness patients without blood products. Our algorithm provides broad possibilities for blood conservation for all surgical patients. METHODS: From September 1998 until June 2001, 38 LDLTs were performed at Keck USC School of Medicine: 8 in Jehovah's Witness patients (transfusion-free group) and 30 in non-Jehovah's Witness patients (transfusion-eligible group). All transfusion-free patients underwent preoperative blood augmentation with erythropoietin, intraoperative cell salvage, and acute normovolemic hemodilution. These techniques were used in only 7%, 80%, and 10%, respectively, in transfusion-eligible patients. Perioperative clinical data and outcomes were retrospectively reviewed. Data from both groups were statistically analyzed. RESULTS: Preoperative liver disease severity was similar in both groups; however, transfusion-free patients had significantly higher hematocrit levels following erythropoietin augmentation. Operative time, blood loss, and postoperative hematocrits were similar in both groups. No blood products were used in transfusion-free patients while 80% of transfusion-eligible patients received a median of 4.5+/- 3.5 units of packed red cell. ICU and total hospital stay were similar in both groups. The survival rate was 100% in transfusion-free patients and 90% in transfusion-eligible patients. CONCLUSIONS: Timely LDLT can be done successfully without blood product transfusion in selected patients. Preoperative preparation, intraoperative cell salvage, and acute normovolemic hemodilution are essential. These techniques may be widely applied to all patients for several surgical procedures. Chronic blood product shortages, as well as the known and unknown risk of blood products, should serve as the driving force for development of transfusion-free technology.     

Off-pump myocardial revascularizaton in a Jehovah's Witness patient with pheochromocytoma

We present a female Jehovah's Witness patient with concomitant severe left main and left anterior descending coronary artery disease and pheochromocytoma who underwent successful off-pump myocardial revascularization. Perioperative management of this patient included alpha-blockade with Doxazosin followed by beta-blockade with Metoprolol. A short-acting Phentolamine was used for alpha-blockade before surgery. Because she refused transfusion of blood and blood products, erythropoietin and iron was used to increase her hemoglobin in both the preoperative and postoperative periods. Intraoperative strategy included off-pump myocardial revascularization, the use of a pulmonary catheter to monitor hemodynamics, the use of norepinephrine and epinephrine to increase blood pressure, the employment of the cell saver, and transesophageal echocardiography.