Management of Severe Anemia in a Jehovah's Witness Patient With Lung Abscess Secondary to Malpositioned Laparoscopic Adjustable Gastric Band: A Case Report.

Jehovah's Witnesses is a Christian denomination widely recognized for their steadfast refusal of blood transfusions, even when facing severe anemia. We describe a unique case of a 42-year-old Jehovah's Witness woman with severe iron deficiency anemia. She necessitated surgical correction of a malpositioned gastric band within the context of a complex necrotizing aspiration pneumonia secondary to esophageal obstruction. Medical management of this severe anemia has been a challenge as traditional approaches, like a blood transfusion, are not possible. Instead, a multifaceted approach has been described with intravenous iron infusions, recombinant human erythropoietin, vitamin B12, folate, and vitamin C administration. We emphasize the lack of consensus on guideline protocols regarding management of severe anemia for Jehovah's Witness patients and the subsequent need for more investigation into that matter. It also underscores the significance of respecting patient autonomy through close collaboration between patients and their health care providers to ensure effective patient-centered care.

Obstetric outcomes in Jehovah's Witnesses: case series over nine years in a London teaching hospital.

OBJECTIVES: The aim of the study is to assess obstetric and fetal outcomes of Jehovah's Witnesses (JWs) mothers in an inner city teaching hospital, as well as to examine the acceptance rates of various blood fractions and blood transfusion alternatives. METHODS: Case series to evaluate the maternal and fetal outcomes of JWs over a nine period between 2013 and 2021. RESULTS: There were 146 pregnancies extracted from our database, of which 10 were early pregnancy losses. Data from 136 deliveries > 24 weeks' gestation were assessed, with a mean maternal age and gestational age of 30.26 (± 5.4) years and 38.7 (± 5.3) weeks, respectively. 57% had normal vaginal deliveries, 8% had instrumental births and 35% had caesarean births. Mean estimated blood loss at caesarean was 575 (± 305.6) mls, while the overall mean estimated loss was 427.8 (± 299.8) mls. Cell salvage was performed in all caesarean sections but autologous transfusion was only necessary for 26%. Consultant presence was documented in 62% of caesarean births. The mean birthweight and 5-min Apgar scores were 3.31 (± 0.05) kg and 9.1 (± 0.09), respectively. There were no maternal deaths or admissions to the adult intensive care unit and the most serious complication was a uterine rupture following a trial of scar, after which the baby required cooling for hypoxic ischaemic encephalopathy. CONCLUSIONS: Pregnant JWs received obstetric care led by senior clinicians, with optimisation of haematinics, minimizing of blood loss at delivery and access to technology such as cell salvage.

Ethical issues in solid organ transplantation: transfusion-free transplantation in Jehovah's witness patients.

PURPOSE OF REVIEW: Jehovah's Witnesses do not accept transfusion of major allogeneic blood fractions. Successful solid organ transplantation is challenging for Jehovah's Witnesses when anemia, coagulation disturbances, and difficult technical aspects co-exist, and key blood bank resources cannot be utilized. Organ availability for transplantation is limited and demand exceeds supply for all organ types. Historically, the likelihood of poor outcomes in Jehovah's Witnesses patients placed ethical limitations on transplant candidacy for this population violating the precept of maximal utilization of a limited resource. The review's purpose is to describe advancements and strategies that make Jehovah's Witnesses transplant outcomes comparable to transfusion-eligible patients and allay the ethical concerns of their candidacy. RECENT FINDINGS: Immunomodulation from allogeneic transfusion is a cause of significant postop morbidity. Blood conservation strategies have led to improved outcomes across different medical and surgical cohorts and set the stage for expanded utility in Jehovah's Witnesses with organ insufficiency.Published single-center series with descriptions of specific peri-operative strategies describe the path to major blood product avoidance. SUMMARY: Comparable outcomes in solid organ transplantation for Jehovah's Witnesses without allogeneic transfusion are possible when inclusion-exclusion criteria are respected, and blood conservation strategies employed.

A secure blood-saving protocol for Jehovah's Witnesses in primary total hip replacement.

OBJECTIVES: The study aimed to analyze the efficacy of the blood management protocol developed by our team for patients who are Jehovah's Witnesses (JW) presenting for primary total hip replacement (THR). PATIENTS AND METHODS: Thirty JW patients (6 males, 24 females; mean age: 70.1±9.8 years; range, 65 to 81 years) and 30 age- and sex-matched controls (6 males, 24 females; mean age: 68.7±9.1 years; range, 62 to 79 years) who underwent primary THR at our institution between January 2018 and June 2020 were retrospectively evaluated. While the surgical technique of THR was not different among the groups, blood loss management differed between the groups. Patients in the control group were given 1 g of intravenous tranexamic acid (TXA) 15 min before the surgical incision. In addition to the same TXA protocol, intraoperative cell salvage with a continuous autologous transfusion system was used for JW patients. The estimated blood loss (EBL) was determined using Meunier's formula. Hemoglobin (Hgb) decline, EBL on the first and third postoperative days, allogenic blood transfusion (ABT) requirement, and complications were analyzed between groups. RESULTS: There were no significant differences between groups regarding demographic and clinical characteristics (p>0.05), ABT requirement (p>0.999), and Hgb decline in the first and third postoperative days (p=0.540 and p=0.836, respectively). Furthermore, both groups did not significantly differ between EBL in the first and third postoperative days (p=0.396 and p=0.616, respectively) and the length of hospital stay (p=0.547). Similar complication rates were noted for both groups. Hemoglobin level assessments revealed that values on the first and third postoperative days were significantly lower than the baseline Hgb value in both cohorts (p<0.001). CONCLUSION: A combination of intravenous administration of 1 g of TXA, meticulous hemostasis, and intraoperative use of cell saver constitutes a reasonable strategy for achieving the goal of transfusion-free primary THR with predictable levels of blood loss that are similar to non-JW patients.

Optimizing Safety and Success: The Advantages of Bloodless Cardiac Surgery. A Systematic Review and Meta-Analysis of Outcomes in Jehovah's Witnesses.

Transfusions are extremely frequent after cardiac surgery, and they have a considerable economic burden and impact on outcomes. Optimal patient blood management could play a fundamental role in reducing the rate of transfusion and Jehovah's Witnesses (JW) represent the ideal surrogate study population. This meta-analysis compares outcomes of JWs and non-JWs' patients undergoing cardiac surgery, assessing the safety of a bloodless cardiac surgery. A scoping review was conducted using a search strategy for studies assessing outcomes of JW undergoing cardiac surgery. The primary outcome was perioperative mortality, and a random-effects meta-analysis was performed. Ten studies were included in our meta-analysis, involving 780 JW patients refusing any type of transfusion ("JW") and 1182 patients accepting transfusion if needed ("non-JW"). 86% of non-JW patients received at least 1 transfusion. There was no significant difference in terms of perioperative mortality (OR 0.91; 95% CI 0.55-1.52; p = 0.72). The volume blood loss was significantly less in the JW (p = 0.001), while the rate of reoperation for bleeding was also lower, but not statistically significative, in the JW (p = 0.16). Both preoperative and postoperative hemoglobin and hematocrit were significantly higher in the JW. Therefore, we concluded that bloodless cardiac surgery is safe and early outcomes are similar between JW and non-JW patients: optimal patient blood management is fundamental in guarantying these results. Further studies are needed to assess if a limitation of transfusion could have a positive long-term impact on outcomes.

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.

Between Autonomy and Paternalism: Attitudes of Nursing Personnel Towards Jehovah's Witnesses' Refusal of Blood Transfusion.

Objectives: The study describes the attitudes of Polish nursing personnel towards Jehovah's Witnesses' (JWs') refusal to receive blood and blood products. Methods: We developed an online survey assessing nurses' knowledge and attitudes towards JWs' refusal of blood transfusion in a life-threatening condition. It also examined nurses' attitudes towards ethical and legal issues associated with JWs' refusal of blood transfusions. These questions were explored using a sample of 202 Polish nurses. Results: Nurses' knowledge of JWs' stance towards blood transfusions is inadequate and they tended to be ill-disposed towards JWs' refusal of blood transfusions. Although most nurses respected adult JW patients' autonomy and supported their right to refuse blood, in the case of JW children they are guided by paternalism. Nurses' attitudes were affected by whether they had children, whether they declared themselves religious, their level of education and prior experience with patients who had refused a blood transfusion. Conclusion: Since most nurses felt unprepared to care for JW patients, this study reveals an urgent need to train nurses in transcultural nursing and increase nurses' cultural competencies, and that this should be incorporated into medical curricula .

Is Head and Neck Free Flap Reconstruction Feasible in Jehovah's Witness Patients?

BACKGROUND: Jehovah's Witnesses (JW) population are members of a religious group that refuses blood transfusion. This presents a dilemma for surgical teams when performing major surgical procedures on these patients. PURPOSE: This study aimed to assess the safety and feasibility of undergoing microvascular free flaps for maxillofacial reconstruction in JW patients and whether the type of underlying pathology impacts outcomes. STUDY DESIGN, SETTING, AND SAMPLE: This was a multi-institutional retrospective cohort study. The sample consisted of all JW patients who have undergone microvascular free tissue transfer for maxillofacial pathology between January 2016 and January 2021. PREDICTOR VARIABLE: The primary predictor variable was the underlying pathology for which patients underwent head and neck free flap reconstruction; this was benign versus malignant disease. MAIN OUTCOME VARIABLES: The primary outcome variables were safety, defined as discharge from the hospital with no mortality, and feasibility defined as successful free flap reconstruction. COVARIATES: Other variables included age, race, sex, length of surgery, length of hospital stay, and intraoperative use of vasopressors. ANALYSIS: Data analysis was performed utilizing t-tests for means and χ2 for proportions. Alpha was set at < 0.05. RESULTS: A total of 12 participants from 7 participating sites met the inclusion criteria. There were 9 males and 3 females with a mean age of 58.3 ± 8.3 years. There were no deaths in this cohort and all patients were discharged from the hospital. All 12 free flap reconstructions were successful with no incidents of free flap loss; none of the patients received any blood transfusions or any other blood products. Subgroup analysis showed that patients treated for malignant disease versus benign disease had longer operations (11.2 ± 2.9 vs 6.3 ± 0.2 hours, P < .01) and a longer hospital length of stay (11.8 ± 4.9 vs 5.3 ± 0.5 days, P = .04). CONCLUSION AND RELEVANCE: Our series supports the safety and feasibility of maxillofacial free flap reconstruction in this challenging subset of patients. Microvascular reconstructive surgeries for malignant diseases often result in longer operative times and hospital stays.

Comprehensive management of Jehovah's Witness in pregnancy.

Jehovah's Witness (JW) is a denomination of Christianity which has many-fold higher morbidity and mortality compared to the general population as they refuse blood transfusion. Information is scanty regarding guidelines on the optimal approach to pregnant ladies of JW faith. In this review we have attempted to analyse the ways and techniques available which can be used to reduce the morbidity and mortality of these women. In antenatal care, haematological status can be optimised to reduce modifiable risk factors, namely anaemia by parenteral iron therapy from the second trimester onwards especially in patients who do not respond to oral iron therapy. In severe cases, erythropoietin serves as an effective alternative to blood transfusion. During the intrapartum period, using antifibrinolytics, cell salvage, bloodless surgical techniques, and uterine cooling for patients undergoing caesarean delivery have been proven effective. To conclude, complications of pregnant JW patients may be reduced if they comply with the preventives and targeted monitoring during the various phases of pregnancy. Further studies are warranted as this population exists as a minor group but is growing worldwide.

Cardiac Surgery in Jehovah's Witnesses: 329 Consecutive Cases.

OBJECTIVES: This study aimed to describe the outcome of Jehovah's Witnesses (JWs) undergoing cardiac surgery at the authors' center. DESIGN: A single-center retrospective cohort study. SETTING: At a cardiovascular center with a tertiary intensive care unit (ICU) and specific experience with cardiac surgery in JWs. The institutional protocol describing all perioperative care in JWs has been applied for 21 years. PARTICIPANTS: All JWs undergoing cardiac surgery in the Amphia Hospital from January 1, 2001 to January 31, 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The study cohort comprised 329 JWs undergoing cardiac surgery. Twenty-three patients (6.8%) were treated preoperatively for anemia. The mean European System for Cardiac Operative Risk Evaluation score was 5.1 (range 0-18). Coronary artery bypass grafting (53.2%) was performed most frequently, followed by aortic valve replacement (13.4%). Mean preoperative hemoglobin levels were 14.5 g/dL (range 9.8-18.5 g/dL), dropping to 11.6 g/dL (range 6.6-15.6 g/dL) at hospital discharge. Mean blood loss was 439 ± 349 mL in the first 12 hours postsurgery. Maximum mean postoperative troponin levels were 431 ± 424 ng/L. Resternotomy and postoperative myocardial infarction occurred in 3.6% and 4.2% of patients, respectively. On average, patients had an ICU stay of 1.4 ± 1.8 days and a hospital stay of 6.8 ± 4.2 days. Hospital mortality was 0.6% and was related to cardiac failure. CONCLUSIONS: This study demonstrated that cardiac surgery in JWs is safe when adhering to a strict perioperative patient blood management protocol.

Cardiac Surgery in Jehovah's Witnesses Patients and Association With Peri-Operative Outcomes: A Systematic Review and Meta-Analysis.

BACKGROUND: Strategies for blood conservation, coupled with a careful preoperative assessment, may be applied to Jehovah's Witnesses (JW) patients who are candidates for cardiac surgery interventions. There is a need to assess clinical outcomes and safety of bloodless surgery in JW patients undergoing cardiac surgery. METHODS: We performed a systematic review and meta-analysis of studies comparing JW patients with controls undergoing cardiac surgery. The primary endpoint was short-term mortality (in-hospital or 30-day mortality). Peri-procedural myocardial infarction, re-exploration for bleeding, pre-and postoperative Hb levels and cardiopulmonary bypass (CPB) time were also analyzed. RESULTS: A total of 10 studies including 2,302 patients were included. The pooled analysis showed no substantial differences in terms of short-term mortality among the two groups (OR 1.13, 95% CI 0.74-1.73, I2=0%). There were no differences in peri-operative outcomes among JW patients and controls (OR 0.97, 95% CI 0.39-2.41, I2=18% for myocardial infarction; OR 0.80, 95% CI 0.51-1.25, I2=0% for re-exploration for bleeding). JW patients had a higher level of preoperative Hb (Standardized Mean Difference [SMD] 0.32, 95% CI 0.06-0.57) and a trend toward a higher level of postoperative Hb (SMD 0.44, 95% CI -0.01-0.90). A slightly lower CPB time emerged in JWs compared with controls (SMD -0.11, 95% CI -0.30-0.07). CONCLUSIONS: JW patients undergoing cardiac surgery, with avoidance of blood transfusions, did not have substantially different peri-operative outcomes compared with controls, with specific reference to mortality, myocardial infarction, and re-exploration for bleeding. Our results support the safety and feasibility of bloodless cardiac surgery, applying patient blood management strategies.

Managing Sickle Cell Disease in Patients for Whom Blood Transfusion Is Not an Option.

Sickle Cell Disease (SCD) is a hereditary blood disorder affecting beta hemoglobin. This disorder causes sickle-shaped red blood cells with decreased oxygen-carrying capacity resulting in vaso-occlusive crises. These crises are often treated with analgesics, antibiotics, IV fluids, supplementary oxygen, and allogeneic blood transfusion. This treatment regimen becomes complicated when caring for SCD patients for whom blood transfusion is not an option. Blood transfusion may not be an option due to the patient's religious, personal, or medical concerns and in scenarios where blood is not available for transfusion. Some examples include the patient being a Jehovah's Witness, blood-borne pathogens concerns, or prior history of multiple alloantibodies and severe transfusion reactions. The number of patients in these categories is growing. The patients and their autonomy should be respected during treatment. This review focuses on the currently available modalities to best manage this subgroup of SCD patients without blood transfusion, including new professional guidelines and new therapies to reduce the severity of SCD as approved by the Food and Drug Administration since 2017.

Hematopoietic Stimulation During Impella 5.5 Support to Avoid Transfusions in a Jehovah's Witness.

The population presenting with cardiogenic shock is heterogenous. Anemia is common in advanced heart failure and associated with poor outcomes. Microaxial flow pumps may cause ongoing blood trauma and worsen anemia. Treatment with recombinant erythropoietin, iron, vitamin B, and folate is recommended before cardiac surgery to reduce perioperative transfusion requirements but no data exist on the feasibility and safety during support with microaxial flow pumps. This novel strategy was born out of necessity to support a Jehovah's Witness who opposes blood transfusion but required mechanical circulatory support. We present its efficacy over the duration of 19 days of Impella 5.5 support where hemoglobin level remained stable, and platelet count significantly improved despite a brief episode of gastrointestinal bleeding. No thromboembolic complications occurred. We anticipate this strategy could help not only Jehovah's Witnesses, but also patients awaiting cardiac transplantation since transfusions stimulate development of antibodies which may preclude or postpone finding a suitable donor organ. Furthermore, it may minimize or prevent perioperative needs for transfusions for patients being bridged to durable left ventricular assist devices.

Damage control surgery of the critical Jehovah's Witness patient - a narrative review.

SUMMARY: South Africa has a high burden of trauma related injuries with haemorrhage remaining a leading treatable complication of trauma. Expedient management of haemorrhage serves to reduce patient morbidity and mortality. Damage control surgery aims to minimise haemorrhage, contain contamination, and allow restoration of physiology in an intensive care unit (ICU) before proceeding to definitive surgery. Over time, damage control surgery has found favour in non-traumarelated surgeries in unstable patients. The Jehovah's Witness (JW) religion believes that blood is sacred and strictly do not consent to blood or blood product transfusions, including in emergency settings. Thus, the management of a bleeding or bled-out JW patient proves to be a unique challenge in modern medicine. For the JW patient who is undergoing damage control surgery, the primary goal is to win time for recovery of the haemoglobin level by maintaining adequate oxygen delivery to tissues. We review the multiple methods available to optimise haemodynamic stability in a bleeding JW patient. These include techniques aimed at (i) minimising blood loss, (ii) optimising oxygen delivery (DO2), (iii) optimising oxygen consumption (VO2), and (iv) correction of coagulopathy. The management of haemorrhage in the JW patient remains challenging. It is imperative for healthcare professionals to be aware of all options available when treating these patients in order to provide optimal treatment whilst maintaining respect for their beliefs.