Bloodless management of significantly elevated transcranial Doppler velocity value in a Jehovah's witness child with sickle cell disease: A tertiary centre experience-A case report.

BACKGROUND: Effective management of complications in sickle cell disease (SCD), such as stroke prevention, often necessitates the use of blood transfusions. However, individuals who adhere to the religious tenets of Jehovah's Witnesses strictly abstain from accepting blood transfusions, thereby presenting a formidable challenge in clinical decision-making. CASE REPORT: This is a case of a 3 year old child Jehovah's Witness who was found to have significantly elevated transcranial Doppler (TCD) velocity values between 193 and 203 cm/s, following routine screening. This was an otherwise clinically stable child, whose mother was diligently ensuring he had adequate medical care. Ideally, a prophylactic exchange blood transfusion program would have been commenced immediately but was not done due to due to the lack of consent from the caregiver. Patient was initially on hydroxyurea at 15 mg/kg and self medicating on omega 3 supplements and astymin syrup. Further elevation of TCD velocity upto 242 cm/s after a repeat testing, necessitated graduated increase of the dosage of hydroxyurea to 35 mg/kg to optimize its therapeutic effect, and discontinuation of omega 3 fatty acids and replacement of astymin with folic acid, vitamin C and B complex. Following these adjustments, the TCD dropped to below 190 cm/s reducing the risk of stroke in the child. CONCLUSION: This case report demonstrates the successful implementation of a bloodless management strategy for stroke prevention in a Jehovah's Witness child with SCD. This study contributes to the existing literature by providing valuable insights and practical guidance for healthcare providers facing similar ethical and medical dilemmas.

Successfully Managing Severe Anemia in a Trauma Patient Who Refused Blood Transfusion: A Case Report.

BACKGROUND Surgical management in patients who undergo traumatic blood loss but who refuse blood transfusion can be challenging, but physicians and surgeons must comply with the wishes and beliefs of their patients. This report describes the management of severe anemia, with hemoglobin level of 2.5 g/dL, in a 71-year-old male Korean trauma patient who declined blood transfusion. CASE REPORT A 71-year-old man was admitted to hospital with severe blood loss following trauma. He declined blood transfusion due to his religious belief as a Jehovah's Witness. On day 4, the patient's hemoglobin level dropped from 7.7 to 3.9 g/dL. Despite the need for blood transfusion, the patient refused. Hence, therapeutic strategies, including crystalloid fluid resuscitation, bleeding control, vasopressor support, erythropoietin administration, supplementation with iron, folic acid, and vitamin B12, coagulopathy correction, oxygen consumption reduction, and mechanical ventilation were implemented. Following 16 days of supportive management, the hemoglobin reached 7.4 g/dL. However, it suddenly decreased on day 41 (2.5 g/dL) due to episodes of melena secondary to an actively bleeding gastric ulcer, which was successfully managed with endoscopic hemostasis. Despite increased vasopressor dosage and addition of vasopressin and hydrocortisone, the patient became unresponsive with persistent hypotension. Methylene blue was used as the final therapeutic agent. The patient responded well and subsequently recovered without blood transfusion. CONCLUSIONS This report has presented the clinical challenges of managing the case of a patient who requires but declines blood transfusion and has highlighted the approach to clinical care while respecting the wishes of the patient.

Jehovah's witness head and neck free flap reconstruction patient outcomes.

BACKGROUND: Jehovah's Witnesses are members of a Christian religious denomination that rejects the transfusion of whole blood and component blood products. Given new transfusion-free strategies, Jehovah's Witness patients are undergoing free flap reconstructions with increased regularity. However, outcome data remains limited. With this study, we sought to examine post-operative outcomes in Jehovah's Witness patients undergoing free flap reconstruction of the head and neck, compare their outcomes to non-Jehovah's Witness patients, and enumerate strategies to enhance the safety of transfusion-free surgery. METHODS: A retrospective chart review was carried out on 10 patients who identified as Jehovah's Witness and 63 patients who did not. Demographic information, pre-operative laboratory values, peri-operative resuscitative interventions, and peri-operative outcome measures were compiled. Descriptive data analysis, Mann-Whitney, Chi-square tests, and multivariate analysis were used. RESULTS: Jehovah's Witness patients were significantly older than non-Jehovah's Witness patients (p = 0.03) and had significantly higher ASA scores (p = 0.009). Head and neck cancer was the primary surgical indication in both groups (p = 0.71). Jehovah's witness patients have significantly less intraoperative blood loss (p = 0.011) and lower post-operative hemoglobin (p = 0.002) compared to non-Jehovah's Witness patients. While Jehovah's Witness patients had significantly higher rates of severe anemia (p = 0.014), there was no significant difference between the two groups in other post-operative complications and readmission rates even in a multivariate analysis accounting for age and ASA score. CONCLUSIONS: Free flap microvascular reconstruction can be reliably performed on Jehovah's Witness head and neck patients without an increased risk of complication. Policies such as the use of non-blood volume expanders, albumin, Epogen, perioperative iron supplementation, cell saver and acute normovolemic hemodilution are key to ensuring good outcomes.

When blood is not an option: Optimal bloodless management of severe anemia in pregnancy.

Standard treatment for severe anemia in pregnancy is allogeneic blood transfusion, but this is not acceptable to all patients. Options for alternative anemia treatment are available. In this case report, a 32-year-old G2P1 woman who was a Jehovah's Witness presented at 27 weeks gestation with dyspnea, palpitations, and severe anemia (hemoglobin 2.8 g/dL) related to chronic rectal bleeding. She declined blood transfusion. An anemia management protocol (high-dose erythropoietin-stimulating agent, iron, vitamin D, vitamin C, folate, vitamin B12) rapidly increased endogenous erythropoiesis. After 12 days, hemoglobin increased to 8 g/dL. A bovine hemoglobin-based oxygen carrier was available for acute bleeding but was not used. This case highlights that early initiation of multimodal therapy can adequately increase endogenous erythropoiesis to treat life-threatening anemia in antepartum patients who do not accept blood transfusion.

Patient blood management when blood is not an option: a report of two cases.

There are many patients who refuse to receive blood transfusions for religious or other reasons. Bloodless medicine and surgery are no longer new concept, but patients who refuse blood transfusion are still transferred to the bloodless center, regardless of patients' intention, for treatment. Here, we discuss the need for patient blood management when blood is not an option to treat them. Two patients of advanced age were transferred to our bloodless center due to refusal of transfusion. They are Jehovah's Witnesses and refused to receive blood transfusion despite life-threatening anemia and severe underlying diseases. Patient blood management protocols including iron supplementation, subcutaneous erythropoietin, folic acid and vitamin B were implemented to improve hematopoiesis, and supportive care was also performed to treat underlying diseases. Levels of Hemoglobin/Hematocrit and their symptom gradually improved about a week after treatment, and their condition had gradually stabilized. They were discharged safely. We treated patients of advanced age with severe underlying diseases and life-threatening anemia using patient blood management due to refusal of a blood transfusion. The patient blood management may be a useful alternative strategy, which meet the needs of patients who refuse blood transfusions as well as the need to reduce the use of blood products due to limited supply.

Operating on Jehovah's Witnesses: A Challenging Surgical Issue.

Blood transfusion is often utilized in surgery. Greece is the second-highest consumer of blood components in Europe. It has been shown that at least half of all transfusions are unnecessary and could be avoided. Jehovah's Witnesses (JWs) are a Christian religion that do not accept transfusion of whole blood or the four primary components of blood-namely, red blood cells, white blood cells, platelets, and plasma. This a retrospective study from September of 2015 to January of 2018, analyzing all JWs who underwent an elective operation at the Second Department of Propaedeutic Surgery in Laiko University Hospital. Twenty-nine (Rogers et al. in NCCN Guidelines Version 2.2014 Cancer- and Chemotherapy-Induced Anemia. NCCN Clinical Practice Guidelines in Oncology. National Comprehensive Cancer Network, Fort Washington, 2013) JW patients, 23 females (74.1%) and eight males, were operated on during the aforementioned period. The median ASA score was 1 (range 1-3), and only two of the patients needed postoperative monitoring in the ICU. Almost half of the patients (45.1%) needed iron infusion and EPO injection preoperatively. Two patients presented with postoperative complications, with no postoperative deaths. In conclusion, we found that surgery, in our small group of JW patients, was safe and successful despite the lack of blood transfusion. Techniques developed to treat JW patients should be more widely used to improve clinical outcomes and reduce costs to the healthcare system.

Use of hyperbaric oxygenation as an adjunctive treatment for severe pernicious anaemia in a bloodless medicine patient.

Severe anaemia in patients who cannot receive blood transfusion is an indication for the use of hyperbaric oxygen therapy (HBO). Most reports of the use of HBO for anaemia involve patients with acute blood loss. This report details a case of HBO used for a patient with severe pernicious anaemia. A 35-year-old Jehovah's Witnesses believer presented to a hospital with fatigue, dyspnoea and haemoglobin of 26 g/L. She was diagnosed with pernicious anaemia. As she could not receive blood transfusion due to her religious beliefs, vitamin B12 supplementation and HBO were administered and resulted in significant improvement in her condition. The mechanisms of action of HBO, including increased systemic plasma oxygenation, can alleviate signs and symptoms of anaemia regardless of its aetiology. HBO administration can greatly enhance the plasma arterial oxygen content, leading to clinical improvement in patients with anaemia who cannot receive blood transfusion.

Strategies for 'bloodless' surgery: the experience of cytoreductive surgery for peritoneal carcinomatosis in Jehovah's Witnesses.

BACKGROUND: Cytoreductive surgery (CRS) for the management of peritoneal carcinomatosis (PC) can involve significant blood loss which necessitates the transfusion of blood products. This poses a particular challenge in the Jehovah's Witnesses population whose beliefs do not permit the transfusion of blood products or blood-related derivatives. This report describes the experience of one institution performing CRS with hyperthermic intraperitoneal chemotherapy (HIPEC) for PC in Jehovah's Witnesses and perioperative management strategies employed to avoid blood transfusion. METHODS: A review of literature and prospectively collated data of Jehovah's Witnesses patients who underwent extensive CRS for PC and HIPEC for PC. RESULTS: Four patients had CRS and HIPEC for PC. The median PC index score was 11 and complete cytoreduction was achieved in all cases. Primary tumours were ovarian (n = 1), colorectal (n = 2) and neuroendocrine tumour of gastrointestinal origin (n = 1). The median difference between preoperative and postoperative haemoglobin was 38 g/L (23-43 g/L). Strategies included acute normovolumaeic haemodilution and autotransfusion within a closed circuit, autotransfusion from cell salvage and provisions for possible use of a haemoglobin based oxygen carrier. Ancillary measures identified and implemented to minimize transfusion dependence included, but were not limited to, preoperative iron infusion, perioperative acute haemodilution and cell salvage, administration of tranexamic acid, prothrombinex and use of paediatric tubes for venepuncture. CONCLUSION: The review suggests CRS and HIPEC for extensive PC can be done safely in circumstances where transfusion of allogenic blood products is not permitted.

Total Knee Arthroplasty Is Safe in Jehovah's Witness Patients-A 12-Year Perspective.

Despite the evolution of blood management protocols, total knee arthroplasty (TKA) occasionally requires allogeneic blood transfusion. This poses a particular challenge for Jehovah's Witnesses (JW) who believe that the Bible strictly prohibits the use of blood products. The aim of this study was to compare JW and a matched-control cohort of non-JW candidates undergoing TKA to assess the safety using modern blood management protocols. Fifty-five JW patients (63 knees) who underwent TKA at our institution between 2005 and 2017 were matched to 63 non-JW patients (63 knees). Patient demographics, intraoperative details, and postoperative complications including in-hospital complications, revisions, and 90-day readmissions were collected and compared between the groups. Additionally, subgroup analysis was performed comparing JW patients who were administered tranexamic acid (TXA) between the two groups. Baseline demographics did not vary significantly between the study cohorts. The mean follow-up was 3.1 years in both the JW and non-JW cohorts. Postoperative complications, including in-hospital complications (7.9 vs. 4.8%; p = 0.47), revision TKA (1.6 vs. 1.6%; p = 1.00), and 90-day readmission (1.6 vs. 4.8%; p = 0.31) were not significantly different between the JW and non-JW groups. Subgroup analysis demonstrated JW patients who received TXA had a significantly lower decline in postoperative hemoglobin (Hgb) (8.6 vs. 14.0%; p < 0.01). At a follow-up of up to 12 years, JW patients who underwent TKA have outcomes equivalent to non-JW patients without the need for transfusion. Our findings support that surgeons are more likely to optimize JW patients preoperatively with iron and folate supplementation. Despite these variations in preoperative optimization efforts, no significant difference with regard to Hgb or hematocrit levels was demonstrated. Level of evidence is III, retrospective observational study.

Early Experiences With PEGylated Carboxyhemoglobin Bovine in Anemic Jehovah's Witnesses: A Case Series and Review of the Literature.

Jehovah's Witnesses (JW) represent a complex patient population due to their refusal to accept blood transfusions on religious grounds. Pharmacologic management of anemic JW patients is limited to stimulation of hematopoiesis by iron and erythropoietin supplementation and reduction of blood loss by prothrombin complex concentrates (PCCs). Hemoglobin-based oxygen carriers (HBOCs) represent the only pharmacologic modality for JW patients capable of acutely increasing a patient's oxygen carrying capacity in the setting of organ failure, yet clinical safety and efficacy data are lacking in this population. We report 3 cases in which the HBOC, PEGylated carboxyhemoglobin bovine (Sanguinate®), was requested under emergent circumstances for severely anemic (hemoglobin <5 g/dL) JW patients who refused blood transfusions. Two patients received PEGylated carboxyhemoglobin infusions for severe anemia, while the third patient died prior to receiving the medication. One patient who received Sanguinate died after 5 units of medication. The other patient's hemoglobin recovered and she was discharged in stable condition. This series demonstrates the complex nature of the critically anemic JW population and highlights the clinical considerations of using HBOCs in clinical practice and the critical need for further research before they can be broadly recommended.

[Mitral Valve Repair in a Jehovah's Witnesses Patient with Post Myocardial Infarction Papillary Muscle Rupture;Report of a Case].

A 70-years old man was referred to our department for acute heart failure due to post myocardial infarction papillary muscle rupture. We planned emergent surgery, but he refused blood transfusion because of religious reason( Jehovah's Witness). Therefore, we chose medical therapy using intra-aortic balloon pumping and catecholamine. He was also treated with subcutaneous erythropoietin and intravenous iron supplement to increase preoperative hemoglobin. One month later, we decided to undergo mitral valve repair because he was stabilized with medical treatment. The patient underwent mitral valve repair with artificial chordae through median sternotomy. The mitral valve A3 prolapse was caused by posterior papillary muscle rupture. No blood transfusion was given and postoperative course was uneventful. We experienced successful mitral repair for post infarction papillary muscle rupture in a Jehova's Witnessess patient.

Transfusion support and alternatives for Jehovah's Witness patients.

PURPOSE OF REVIEW: Jehovah's Witness patients with critical anemia or undergoing major surgery are challenging for healthcare providers to manage, as most will decline transfusion of whole blood and its main components. Recent advances in our understanding of hemostatic agents, alternative hemoglobin-based oxygen carriers, and patient blood management have culminated in a complex array of options to manage critical anemia and bleeding in this patient population. RECENT FINDINGS: Refusal of blood products in the setting of critical anemia is associated with significant risk of morbidity and mortality. With implementation of patient blood management measures, targeted treatment of anemia and coagulopathy has reduced the need for transfusions. Likewise, increased clinical experience with hemoglobin-based oxygen carriers in Jehovah's Witnesses with critical anemia has provided new insights into their potential benefits and pitfalls. SUMMARY: Options and alternatives to manage the Jehovah's Witness patient in the perioperative setting or in the setting of critical anemia will be reviewed.

[Mortality after high-risk surgery in Jehovah's Witness patients]. / Letalität nach operativen Risikoeingriffen bei Zeugen Jehovas.

BACKGROUND: Jehovah's Witness (JW) patients strictly refuse allogeneic blood transfusion for religious reasons. Nevertheless, JW also wish to benefit from modern therapeutic concepts including major surgical procedures without facing an excessive risk of death. The Northwest Hospital in Frankfurt am Main Germany is a confidential clinic of JW and performs approximately 100 surgical interventions per year on this patient group. MATERIAL AND METHODS: A retrospective analysis of closed medical cases performed in the years 2008-2018 at the Northwest Hospital aimed to clarify (1) the frequency of surgical procedures in JW patients associated with a statistical allogeneic transfusion risk (presence of preoperative anemia and/or in-house transfusion probability >10%) during this time period, (2) the degree of acceptance of strategies avoiding blood transfusion by JW and (3) the anemia-related postoperative mortality rate in JW patients. RESULTS: In the 11- year observation period 123 surgical procedures with a relevant allogeneic transfusion risk were performed in 105 JW patients. Anemia according to World Health Organization (WHO) criteria was present in 44% of cases on the day of surgery. Synthetic and recombinant drugs (tranexamic acid, desmopressin, erythropoetin, rFVIIa) were generally accepted, acute normovolemic hemodilution (ANH) in 92% and cell salvage in 96%. Coagulation factor concentrates extracted from human plasma and therefore generally refused by JW so far, were accepted by 83% of patients following detailed elucidation. Out of 105 JW patients 7 (6.6%) died during the postoperative hospital stay. In 4 of the 7 fatal cases the cause of death could be traced back to severe postoperative anemia. CONCLUSION: Given optimal management JW patients can undergo major surgery without an excessive risk of death. The 6.6% in-hospital mortality observed in this institution was in the range of the 4% generally observed after surgery in Europe. The majority of JW patients accepted a variety of blood conservation strategies following appropriate elucidation. This also included coagulation factor concentrates extracted from human plasma enabling an effective treatment of even severe bleeding complications. In this analysis postoperative hemoglobin concentrations below 6 g/dl in older JW patients were associated with a high mortality risk due to anemia.

Long-term survival and quality of life in Jehovah's witnesses after cardiac surgery: a case control study.

BACKGROUND: We previously analyzed morbidity and mortality in Jehovah's Witnesses patients after cardiac surgery compared to control population patients. Patients who were Jehovah's Witnesses were operated in accordance with their philosophical convictions and in respect of their refusal of transfusions. We propose to assess long-term survival and quality of life in the patients of this preliminary study. METHODS: We contacted 31 adult Jehovah's Witnesses patients who underwent heart surgery at the Brugmann hospital between 1991 and 2012 and compared them to a control population of 62 patients that had no transfusion restriction, and matched them for sex, age at the time of intervention and the type of surgery performed. We compared long-term quality of life in both populations through the MacNew software, a validated instrument to assess quality of life of patients with cardiovascular disease. The long-term survival of patients was analyzed by Kaplan Meier curves. RESULTS: Long-term quality of life and survival do not appear different between the two groups. Patient evaluation by MacNew software shows comparable physical (p = 0.54), emotional (p = 0.12), social (p = 0.21) and global (p = 0.25) scores between the two populations. The analysis of the actuarial survival curves shows no differences in terms of long-term survival of these patients (p = 0.37). CONCLUSIONS: Cardiac surgery in Jehovah's Witnesses can be performed with identical long-term quality of life and survival compared to surgery without blood transfusion restriction, if one follows rigorous blood conserving strategies. TRIAL REGISTRATION: NCT03348072 . Retrospectively registered 16 November 2017.

[Off-pump Coronary Artery Bypass Grafting in Jehovah's Witness Patient on Hemodialysis;Report of a Case].

Cardiac surgery in Jehovah's witnesses is challenging due to their refusal of blood transfusion. Furthermore, dialysis patients often suffer from anemia and are also prone to bleeding. We performed offpump coronary artery bypass grafting (CABG) [OPCAB] on a Jehovah's witness male patient on hemodialysis. His preoperative hemoglobin level was around 10.0 g/dl. We used cell saver-collected blood as much as possible during operation. His postoperative course was uneventful with the lowest hemoglobin level of 7.2 g/dl using iron supplements and erythropoietin. This case indicates that intraoperative blood salvage and perioperative management of anemia make OPCAB without blood transfusion possible even in Jehovah's witness hemodialysis patients, when their preoperative hemoglobin levels are maintained greater than 10.0 g/dl.

[Cell salvage : Scientific evidence, clinical practice and legal framework]. / Maschinelle Autotransfusion : Wissenschaftliche Evidenz, klinische Praxis und rechtliche Rahmenbedingungen.

Cell salvage is an efficient method to reduce the transfusion of homologous banked blood, as documented by several meta-analyses detected in a systematic literature search. Cell salvage is widely used in orthopedics, trauma surgery, cardiovascular and abdominal transplantation surgery. The retransfusion of unwashed shed blood from wounds or drainage is not permitted according to German regulations. Following irradiation of wound blood, salvaged blood can also be used in tumor surgery. Cell salvage makes a valuable contribution to providing sufficient compatible blood for transfusions in cases of massive blood loss. Certain surgical procedures for Jehovah's Witnesses are only possible with the use of cell salvage. Another possible use is the washing of homologous banked blood, e. g. to prevent potassium-induced arrhythmia or sequestration of autologous platelets. Other advantages besides a good compatibility are the high vitality and functionality of the unstored autologous red blood cells. These have been declared a pharmaceutical product by the German transfusion task force in 2014, so that the autologous red blood cells are now under the control of the Pharmaceutical Products Act (AMG). The new hemotherapy guidelines, however, tolerate cell salvage only under strict rules, whereby the production of autologous blood during or after surgery is still possible without additional special permits. The new guidelines now require the introduction of a quality management system for cell salvage and regular quality controls. These quality controls include a control of the product hematocrit for every application, monthly controls of the protein and albumin elimination rates and the erythrocyte recovery rate for each cell salvage device. Testing for infection markers is not required. The application of cell salvage has to be reported to the appropriate authorities.

Strategies to Avoid Neonatal Blood Transfusions for Families of the Jehovah's Witness Faith.

Beliefs and restrictions regarding acceptance of blood products by members of the Jehovah's Witness faith often provoke discussion among health care professionals regarding alternative interventions. Establishing and maintaining an open dialog with women and families of the Jehovah's Witness faith regarding their beliefs on the use of blood and blood products are vital in creating a therapeutic relationship between families and the health care team. Such rapport facilitates the discussion of strategies to avoid blood transfusions for newborns and provides women and families multiple opportunities to develop of a holistic birth plan congruent with their beliefs.

Obstetric outcomes and acceptance of alternative therapies to blood transfusion by Jehovah's Witnesses in Japan: a single-center study.

We sought to investigate obstetric outcomes and acceptance rates for blood products or types of autotransfusion by Jehovah's Witnesses (JWs) at a single institution in Japan. We retrospectively reviewed cases of 84 pregnant JW patients and 95 deliveries from April 2001 to August 2017. We examined the acceptance rates of blood transfusions, blood products, and autotransfusion types in patients who experienced postpartum hemorrhage (PPH), and investigated estimated hemorrhage volume at delivery and PPH treatments. Of the 84 JW patients, none accepted blood transfusion; however, 75 patients (89.3%) accepted blood products, 57 (67.9%) accepted autotransfusion using intraoperative cell salvage, and four (4.8%) refused all alternatives to blood transfusion. Furthermore, PPH > 1000 mL occurred in 18 of the 95 (18.9%) deliveries. Of these 18 patients, four (22.2%) required blood products and three (16.7%) required supracervical hysterectomy to control PPH. No maternal deaths occurred. Approximately 95% of the patients observed accepted all or some alternatives to blood transfusion. To treat JW patients in a safer manner, understanding their individual acceptance of alternatives to blood transfusion is important for the strategic use of such alternatives.