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.      

Transfusion-free cardiopulmonary bypass in Jehovah's Witness patients weighing less than 5 kg

Performing cardiac surgery on pediatric Jehovah's Witness patients is a great challenge for the surgical team and especially for the perfusionist. Jehovah's Witnesses reject blood transfusions on the grounds of their literal interpretation of passages of the Bible. In accordance with this belief, Jehovah's Witnesses feel that it is also forbidden to retransfuse autologous blood that has been separated from their own circulatory system. We report the use of cardiopulmonary bypass (CPB) during open-heart surgery in three infants with a body weight of 4.5 kg, 3.5 kg, and 3.1 kg, respectively, without transfusion of blood components. A small-volume CPB circuit with a priming volume of 200 mL, including the arterial line filter, was designed to decrease the degree of hemodilution. A dedicated pediatric heart lung machine console with remote pump heads and intensive blood conservation efforts allowed the operation without the use of donor blood. The CPB circuits were primed with crystalloid solution only. The procedures were performed in normothermia or in moderate hypothermia. Pre-CPB hemoglobin levels were 10.8 g/dL, 10.6 g/dL, and 8.5 g/dL. The hemoglobin concentrations measured during CPB ranged from 5.9 to 6.5 g/dL, 6.4 to 6.8 g/dL, and 5.5 to 5.9 g/dL, respectively. The patients did not receive any blood or blood products during their entire hospital stay.     

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.     

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.     

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.     

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.     

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.     

Elective plastic surgery in a Jehovah's Witness: a case series and review of the literature

"Bloodless" plastic surgery in the Jehovah's Witness patient is an area that has received little attention in the surgical literature. Given the unique and firmly held beliefs of this group of patients, caring for them can be particularly challenging for the plastic surgeon. The authors report a case of bilateral breast reconstruction with saline-filled implants complicated by a postoperative hematoma and one involving a staged approach to massive breast reduction, both in Jehovah's Witness patients. A third patient involving a staged panniculectomy for a complicated wound infection is also described. The historical background, philosophical views, ethical issues, legal aspects, surgical outcomes, and management techniques relevant to caring for this unique patient population are also reviewed in detail.     

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.     

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.     

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.     

Transfusion-free complex cardiac surgery with cardiopulmonary bypass in a 3.55-kg Jehovah's Witness neonate

Complex cardiac surgery using cardiopulmonary bypass normally requires the transfusion of autologous blood components, particularly in neonates. This is predominately caused by the relatively high priming volume of the circuit with subsequent extreme hemodilution and the often extended and complex perfusions leading to progressive consumption of platelets and coagulation factors. We report on a strategy to minimize the cardiopulmonary bypass circuit and adjust the perfusion technique that resulted in transfusion-free correction of tetralogy of Fallot with an absent pulmonary valve and an aneurysm of the left pulmonary artery in a 3.55 kg Jehovah's Witness neonate boy.     

Rupture of chronic type B aortic dissection in a Jehovah's Witness: successful surgical repair without blood transfusion

The patient, a 55-year-old female Jehovah's Witness who had suffered type B aortic dissection since the age of 53 years, presented with enlargement of the false lumen in the distal aortic arch and was subsequently admitted to our hospital. While hospitalized, her enlarged false lumen ruptured and she underwent replacement of the distal aortic arch and descending thoracic aorta without blood transfusion. Blood conservation strategies for this patient included the following: 1) meticulous hemostasis when incising muscle or soft tissue, 2) minimal use of gauze and discard suckers, 3) exclusive use of a cell salvage device "from skin to skin," 4) low-prime cardiopulmonary bypass, 5) minimal laboratory blood sampling, and 6) preoperative and postoperative erythropoietin treatment. Hemoglobin (Hb) values were 12.5, 15.5, 10.0, and 9.7 g/dL on admission, before rupture, after rupture, and just after the operation, respectively. The patient had an uneventful postoperative course, except for prolonged rehabilitation. The postoperative lowest Hb value was 5.2 g/dL on postoperative day 5, and the Hb value at hospital discharge (postoperative day 55) was 11.0 g/dL. Our experience with blood conservation surgery on this Jehovah's Witness patient suggests that ruptured chronic type B aortic dissection can be safely repaired on bypass through a left thoracotomy with no blood transfusion if the preoperative Hb value is >10.0 g/dL.     

Bloodless extracorporeal membrane oxygenation in the Jehovah's Witness patient

The successful use of prolonged extracorporeal life support with a heart-lung machine was first performed in 1972, as described by Hill et al., on a young man with post-traumatic respiratory failure. The first successful use of extracorporeal membrane oxygenation (ECMO) was 1976 by Bartlett et al. Since this time, the use of ECMO for neonatal and pediatric pulmonary support has become a standard of care in many children's hospitals. The use of ECMO, being a very invasive procedure, is not without risk. In our experience, most patients require multiple transfusions of the different blood components (packed red blood cells, plasma, platelets, and cryoprecipitate). Exposure to one or more blood products often occurs with connection to the ECMO circuit, as the circuit is generally primed with blood products or whole blood. Jehovah's Witnesses (JWs) are known best in the medical community for their refusal of blood products, even at the risk of death, which presents challenges for health care providers. This belief stems from the biblical passages that have been quoted as forbidding transfusion: Genesis 9:3-4, Leviticus 17:13-14, and Acts 15:19-21. This refusal of blood poses even greater challenges when treating the pediatric JW population. When a blood product is deemed medically necessary for the JW patient, the healthcare provider must either seek legal intervention, or support the patient's/family's wishes and associated outcome. This ethical dilemma may be further complicated in the setting of therapies, which may pose additional risks and potentially less clear benefit such as with ECMO. Bloodless cardiac surgery with cardiopulmonary bypass has been reported in the JW population in adults and pediatrics, including neonates. After a thorough search of the literature, no published report of a JW patient being supported on ECMO without blood or blood component utilization was identified. This case report will present our experience with multiple day, bloodless ECMO support of a 17-year-old male patient of the JW faith.     

Cardiac surgery in extreme haemodilution without donor blood, blood products or artificial macromolecules.

A triple aorto-coronary vein bypass was performed in a 56-year-old Jehovah's Witness. Neither donor blood, albumin nor artificial macromolecules were used. Ten litres of non-haemic fluid were given during surgery and an additional 4 litres during the first 18 postoperative hours. During perfusion the haematocrit fell to 19 vol% and total protein in serum to 29 g/l. Eighteen hours after surgery, the patient was extubated without any signs of oedema and with a positive water balance of only 2.2 l. Diuretics were not given. Acid-base and electrolyte values were within normal limits both during and after operation. This and similar cases reported in the literature show that during extracorporeal circulation it is possible to reduce the concentrations of red cells and plasma proteins to below 40% of pre-operative values without serious complications.     

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.     

Autologous priming technique to reduce blood transfusion in pediatric cardiopulmonary bypass

Excessive hemodilution during cardiopulmonary bypass is associated with decreased oxygen carrying capacity, edema, and organ dysfunction. The use of blood products is often necessary to prime the extracorporeal circuit for pediatric cardiac surgical patients. However, the use of blood products carries serious risks both in the acute and long-term aspects of patient care. Autologous priming of the extracorporeal circuit used in conjunction with ultrafiltration, pharmacologic manipulation, and cell salvage may decrease the need for blood transfusion in the pediatric cardiac surgical population. We have developed a technique that enables us to perform transfusionless complex congenital heart repair targeting patients as small as 5 kg.     

Anaesthesia and critical care of Jehovah's Witnesses

The Jehovah's Witness religion is a Christian movement, foundedin the US in the 1870s, with 6 million members worldwide (150,000in the UK). Members of this faith have strong beliefs basedupon passages from the Bible that are interpreted as prohibitingthe ‘consumption’ of blood. Their beliefs preventthem from accepting transfusion of whole blood or its primarycomponents. They also believe that blood that has been removedfrom the body is ‘unclean’ and should be disposedof. The use of procedures that involve the removal and storageof their own blood are often unacceptable (Table 1). View this table: [in this window] [in a new window]   Table 1 Acceptability of blood products and transfusion-related procedures in Jehovah's Witnesses   Blood-free major surgery in the Jehovah's Witness patient presentsa challenge to the anaesthetic and surgical team. The problemsassociated with their management highlights a growing health-careissue – the supply, safety and appropriate use of bloodproducts. Techniques learnt from treating them may prove beneficialto all patients undergoing major surgery.