Jehovah's Witness Needing Critical Care: A Narrative Review on the Expanding Arsenal

Present day Jehovah's Witness (JW) religion accounts for 8.5 million followers. A tenant feature of the JW faith is religious objection to transfusions of blood and blood products. Interpatient variability, as it pertains to blood and blood products may occur; hence, a confidential interview will determine which products individual may consent to (Marsh and Bevan, 2002). This belief and practice place great restrictions on treating medical professionals in scenarios of life-threatening anaemia and active haemorrhage. The review to follow explores the physiological and pathophysiological consequences of severe anaemia. Non-blood transfusion practices are explored, many of which are potentially lifesaving. Particular attention is drawn to the evolving science involving artificial oxygen carriers and their use in emergency situations. A greater safety profile ensures its future use amongst religious objectors to be greatly beneficial. Intravenous iron supplementation has enjoyed a lively debate within the critical care community. A review of recent systematic and meta-analysis supports its use in the ICU; however, more investigation is needed into the complementary use of hepcidin.

Major abdominal surgery for Jehovah's Witnesses: Challenge while practicing bloodless medicine in a middle income country

We present a 59-year-old female Jehovah's Witness patient transferred from another facility to our tertiary center as an emergency case owing to anemia due to gastrointestinal bleeding. A computed tomography scan and gastroscopy confirmed an invasion of the duodenum by a malignant process. The patient underwent a Whipple procedure and a right hemicolectomy refusing blood transfusion. On the 17th postoperative day, the patient was discharged following a successful surgery. This article's objectives are to first highlight the moral and ethical quandary and then share our surgical experiences with this particular patient population. In conclusion, Jehovah's Witnesses' management of major abdominal surgery poses considerable clinical, moral, and legal difficulties. Despite them, doctors must put the patients' needs first while also honoring their religious convictions. However, urgent situations continue to arise, forcing medical professionals to weigh their religious convictions against the need to save a patient's life.

Everyday Cardiac Surgery in Jehovah's Witnesses of Typically Advanced Age: Clinical Outcome and Matched Comparison

BACKGROUND AND OBJECTIVES

Jehovah's Witnesses (JW) reject the transfusion of blood components based on their religious beliefs, even if they are in danger of harm or death. In cardiac surgery, this significantly reduces the margin of safety and leads to ethical conflicts. Informed consent should be carefully documented and the patient's family should be involved. This study aims to compare the postoperative course of JW who underwent major cardiac surgery with a similar population of non-Witnesses (NW).

PATIENTS AND METHODS

Demographic, procedural, and postoperative data of all consecutive JW who underwent cardiac surgery at our institution were obtained from the records. They were compared with a propensity-score-matched group of NW. Anemic JW were treated with erythropoietin and/or iron as needed. Cardiac surgery was performed by experienced surgeons using median sternotomy and cardiopulmonary bypass. Common blood-sparing techniques were routinely used. Periprocedural morbidity and mortality were statistically evaluated for both groups.

RESULTS

A total of 32 JW and 64 NW were part of the matched dataset, showing no demographic or procedural differences. EPO was used preoperatively in 34.4% and postoperatively in 15.6% of JW but not in NW. Preoperative hemoglobin levels were similar (JW, 8.09 ± 0.99 mmol/L; NW, 8.18 ± 1.06; p = 0.683). JW did not receive any transfusions except for one who revoked, while NW transfusion rates were 2.5 ± 3.1 units for red cells (p < 0.001) and 0.3 ± 0.8 for platelets (p = 0.018). Postoperative levels differed significantly for hemoglobin (JW, 6.05 ± 1.00 mmol/L; NW, 6.88 ± 0.87; p < 0.001), and hematocrit (JW, 0.29 ± 0.04; NW, 0.33 ± 0.04; p < 0.001) but not for creatinine. Early mortality was similar (JW, 6.3%; NW, 4.7%; p = 0.745). There were more pacemakers and pneumonias in JW, while all other postoperative conditions were not different.

CONCLUSIONS

Real-world data indicate that Jehovah's Witnesses can safely undergo cardiac surgery provided that patients are preconditioned and treated by experienced surgeons who use blood-saving strategies. Postoperative anemia is observed but does not translate into a worse clinical outcome. This is consistent with other studies. Finally, the results of this study suggest that all patients should benefit from optimal pretreatment and blood-sparing strategies in cardiac surgery, not just Jehovah's Witnesses.

Challenges in the care of Ewing’s sarcoma in a Jehovah’s Witness patient

Ewing’s sarcoma is a bone and soft tissue neoplasm, whose management is related to hematological toxicity. This aspect represents a medical and ethical challenge in Jehovah’s Witnesses patients, who, due to their religious beliefs, reject the blood component transfusion, with the risk of discontinuing chemotherapy or using suboptimal doses. We present the case of a 34-year-old Colombian woman, Jehovah’s Witness, diagnosed with Ewing’s sarcoma with clinical stage IIB (T1N0M0) in the left maxillary and mandibular regions, treated with chemotherapy, who presented a hemoglobin nadir of up to 4.5 g/dL, and surgical indication as part of the treatment. In these patients, the transfusion decision has ethical implications that require therapeutic alternatives and a multidisciplinary approach.

The Need to Adjust the Informed Consent for Jewish Patients for Treatments Involving Porcine Medical Constituents

In order to obtain full informed consent for medical treatments, it is imperative to provide patients of diverse ethnic backgrounds with all relevant information. Since the pig is considered an impure animal in Judaism, Jewish patients may wish to be informed of porcine-derived substances used in treating. The present study is the first to explore the level of knowledge of Jewish participants as to whether the medical use of pig is permitted by their religion, and the extent to which they believe it should be permitted. 714 Jewish participants completed a study questionnaire that included 15 medical uses of pigs. Findings indicated that the knowledge of Jewish law regarding these uses is a significant mediator in predicting the attitude toward the permissibility of these uses. I conclude with practical recommendations as to how to enhance cultural competence and improve the informed consent process when treating Jewish patients with porcine-derived constituents.

Pediatric Perioperative Clinical Pharmacy Practice: Clinical Considerations and Management: An Opinion of the Pediatrics and Perioperative Care Practice and Research Networks of the American College of Clinical Pharmacy

Pediatric perioperative clinical pharmacists are uniquely positioned to provide therapeutic and medication management expertise at a particularly vulnerable transition of care from the preoperative space, through surgery, and postoperative setting. There are many direct-patient care activities that are included in the role of the pediatric perioperative pharmacist, as well as many opportunities to develop effective, optimized, and safe medication use processes. This article outlines many of the areas in which a pediatric perioperative clinical pharmacist may intervene.

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 n-butyl-2-cyanoacrylate for microvascular decompression in a Jehovah's witness patient

OBJECTIVE

We report the application of n-butyl-2-cyanoacrylate (n-BCA) in microvascular decompression (MVD) surgery for a Jehovah's Witness patient. To our best knowledge, this is the first case wherein n-BCA has been employed as an adhesive to the offending artery.

CASE PRESENTATION

A 55-year-old female Jehovah's Witness patient was suffering from serious right hemifacial spasm. Although MVD surgery was needed, the patient resisted any curative medical treatment involving the application of whole blood products, including fibrin glue. Thus, we proposed several choices using artificial materials, including n-BCA as an adhesive, and received informed consent from the patient.

RESULT

MVD was performed on the dolichoectatic right vertebral artery and right posterior inferior cerebellar artery. The abnormal vessel response disappeared during the procedure and transposition using n-BCA of the concerned vessels was successful. The patient experienced a favorable postoperative clinical course and has been free from the spasm for a year. No abnormal findings were detected in the radiological examination during the follow-up period.

CONCLUSION

Although careful follow-up is mandatory, n-BCA is a possible alternative option in MVD surgery.

Posterior spine fusion in a Jehovah's Witness patient with severe rigid idiopathic scoliosis – A case report

Introduction

Early onset scoliosis (EOS) represent a challenge for spine surgeons. The selection of the best treatment is complex. Some patients, such as Jehovah's Witnesses who refuse blood transfusions, are at high risk of complication when surgical treatment is required because blood loss is a major cause of morbidity and postoperative transfusion rates.

Research question

Describe blood-saving techniques that allowed an extensive and invasive surgical procedure in a Jehovah's Witness patient.

Material and method

17-year-old Jehovah's Witness girl with severe 120° Cobb Lenke 1A idiopathic scoliosis started as EOS was prepared with 4 cycles of recombinant human erythropoietin, iron and folic acid supplementation that brought her hemoglobin level from 13.6 g/dl to 16.2 g/dl. In the first surgical time, a temporary rod was implanted. Spine dissection using bipolar sealer and a special electrocautery that operates at lower temperatures than traditional ones was performed. Facetectomies and multilevel Ponte osteotomies was performed using an ultrasonic bone scalpel. The second surgical time, the definitive rods were placed, and the correction of the deformity was achieved using the rod link reducer technique.

Results

A good correction of the main curve in the coronal plane is achieve. The Hb nadir was 7.2 g/dl four days after the second operation. The postoperative course was uneventful.

Discussion and conclusion

The integration of modern and traditional preoperative, intraoperative, and postoperative blood sparing techniques allowed us to perform an extensive and invasive surgical procedure in a Jehovah's Witness girl with a severe idiopathic scoliosis.

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The management of spine deformities in JW patients represent a challenges for spine surgeons.

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In pediatric scoliosis fusion surgery, blood loss is a major cause of morbidity.

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Preoperative, intraoperative, postoperative blood sparing techniques are essential for a good result.

Interventions involving spiritual and religious themes in pharmacy student patient encounters during advanced practice rotations

INTRODUCTION

Patient spiritual and religious beliefs can impact their health care choices and outcomes. Pharmacists and other health care providers need to be prepared when these beliefs present changes from usual medical care. The objective of this research brief was to describe interventions related to spirituality and/or religion that are encountered by students during advanced pharmacy practice experience (APPE) patient care activities.

METHODS

Fourth-year pharmacy students were asked to complete a web-based questionnaire defining the frequency and setting of patient care activities that incorporated spiritual beliefs during APPEs. Data analysis utilized descriptive statistics.

RESULTS

Sixty-three students completed the questionnaire. The most common theme encountered was that of patient refusal of specific therapy based on patient's spiritual or religious beliefs. This result remained consistent across multiple practice settings, except in the community practice setting, where product substitution due to a religious forbidden ingredient was the most common theme encountered.

CONCLUSIONS

Training for future and current pharmacists should provide them with the tools needed to navigate spiritual and religious-focused barriers, such as patient refusal of care and substitutes for religiously forbidden ingredients.

Perioperative management including dual cell salvage in a Jehovah's Witness patient undergoing major urological surgery

Complex surgery associated with major hemorrhage presents particular risks for Jehovah's Witnesses who do not accept transfusion of blood products. Intraoperative use of two cell saver machines simultaneously can maximize the yield of salvaged blood from both the operative field and from washed surgical swabs and can potentially be life-saving.

A single-center experience with head-to-toe microsurgical reconstruction in bloodless medicine patients

Patients who decline blood transfusions, including members of the Jehovah's Witness faith, often face challenges when they require or desire prolonged operations such as free tissue transfer (FTT). This study aims to outline our institution's experience with treating bloodless medicine patients and offers the first anatomically comprehensive evaluation of FTT in this population. All patients undergoing FTT from 2017 to 2020 at a single institution were retrospectively reviewed. Patients who declined blood products were selected. Outcomes of interest include flap success, operative complications, and changes to hemoglobin measurements. Ten patients undergoing 11 FTT procedures were identified. Average age was 62.4 years (SD 7.6). Most patients were female (n = 9) and Black (n = 8). Average body mass index was 31.3 (SD 5.6), American Society of Anesthesiologists Physical Status was 2.9 (SD 0.5), and Charlson Comorbidity Index was 3.8 (SD 1.1). Sites of FTT reconstruction were breast (6), lower extremity (3), and scalp (2). Average operative time was 390 min (SD 85.1), with an average estimated blood loss of 170 mL (SD 100.4). The difference between preoperative hemoglobin to first postoperative hemoglobin measurement averaged 2.2 g/dL (SD 1.4). Average patient follow-up was 12 months (SD 7.8). Flap success occurred in 10 cases. One patient with flap failure was successfully reconstructed with a second procedure. Despite a small, heterogeneous cohort, our success rate in this highly comorbid population indicates that FTT can be performed effectively for patients who cannot use blood products. Bloodless medicine protocols are beneficial to providers serving patients with transfusion restrictions and systems that strive to limit transfusion volume and risk.

Perioperative blood conservation strategies for pediatric scoliosis surgery

PURPOSE

Many pediatric patients with severe scoliosis requiring surgery have baseline anemia. Pediatric scoliosis fusion surgery is associated with perioperative blood loss requiring transfusion. As such, many patients in this surgical population could benefit from a perioperative blood conservation program.

METHODS

Here we present a narrative review of perioperative blood conservation strategies for pediatric scoliosis surgery involving nurses, transfusion medicine physicians, anesthesiologists, surgeons, dieticians, perfusionists and neurophysiologists spanning the pre-, intra- and postoperative phases of care.

RESULTS

The review highlights how perioperative blood conservation strategies, have the potential to minimize exposures to exogenous blood products. Further, we describe a relevant example of blood conservation related to the care of a Jehovah's Witness patient undergoing staged scoliosis repair. Lastly, we outline areas which would benefit from clinical studies to further elucidate perioperative blood conservation interventions and their outcomes relevant to pediatric scoliosis surgery patients.

CONCLUSION

Interdisciplinary communication and meticulous blood conservation strategies are proving to be a means of reducing if not eliminating the need for allogeneic blood products for surgical correction of pediatric scoliosis.

Vena Cava Tumor Thrombus Associated With Renal Angiomyolipoma in a Jehovah's Witness Patient

We present a case of a young premenopausal female patient who was found to have a left-sided renal mass consistent with angiomyolipoma (AML) with Mayo Level IIIa vena caval tumor thrombus. The patient is of Jehovah's witness faith and would not accept blood transfusion. The following case report discusses workup and treatment for AML with tumor thrombus extension, as well as pre-operative optimization and intra-operative techniques during nephrectomy and thrombectomy to minimize blood loss in a patient unaccepting of blood transfusion.

Preoperative Management of a Jehovah's Witness Patient Undergoing Head and Neck Surgery With High Risk of Bleeding

ABSTRACT

Surgery in head and neck district is often associated with bleeding as major complication and need of blood transfusions. Homologous blood transfusions may be unacceptable to some patient groups such as the Jehovah's Witness (JW) patients. Refusal of potentially life-saving treatment creates ethical dilemmas for treating clinicians.This is the first report in literature which examines the management and treatment of a female JW patient who underwent major surgical procedure for squamous cell carcinoma of the jaw with a high risk of hemorrage which rejected any possibility of blood and hemocomponent transfusion by virtue of her religious principles.

Is There Sufficient Evidence Justifying Limited Access of Jehovah's Witness Patients to Kidney Transplantation?

BACKGROUND

Jehovah's Witnesses (JWs) refuse blood transfusions due to religious issues. This situation may impact kidney transplantation (KT) outcomes in case of hemorrhagic complications. We evaluated demographic characteristics of this population, hematologic safety, and graft outcomes.

METHODS

This was a retrospective, single-center study comparing KT outcomes in JW patients versus a non-JW control group. Hematologic endpoints included clinical indication for blood transfusion (hemoglobin <7 g/dL), decrease of hemoglobin >2 g/dL or hematocrit >5% in the first week after KT, hemorrhagic complications requiring surgery, and de novo prescription of erythropoiesis-stimulating agents. Secondary endpoints included delayed graft function, treated biopsy-proven acute rejection, renal function, mortality, and graft survival at 12 months.

RESULTS

From January 1989 to September 2018, we identified 143 JW (10 pediatric) and selected 142 matched control (non-JW) patients. There were no differences in the incidence of clinical indication for transfusion (13.3% versus 11.3%, P = 0.640), but a higher proportion of non-JW patients received transfusions (2.1% versus 9.2%, P = 0.010). There were no differences in the proportion of patients with decreased hemoglobin concentration, in reinterventions due to hemorrhagic complications, in the use of erythropoiesis-stimulating agents at hospital discharge, in the incidence of acute rejection, in renal function, and in mortality or graft survival rate at 12 months.

CONCLUSIONS

In summary, this matched control cohort study suggests that, when clinically indicated, blood transfusions can be safely avoided in the majority of JW kidney transplant, who achieve and maintain comparable hemoglobin concentrations during the first year after transplantation compared with non-JW patients.

Cardiopulmonary bypass management and acute kidney injury in 118 Jehovah's Witness patients: a retrospective propensity-matched multicentre cohort from 30,942 patients

INTRODUCTION

Patients refusing blood products in cardiac surgery present challenges for cardiopulmonary bypass. Accurate detail of the modifiable factors of cardiopulmonary bypass relating to acute kidney injury is previously unreported in this patient population.

METHODS

A total of 118 adult Jehovah's Witness patients refusing transfusion were propensity matched to 118 adult patients accepting transfusion from the 30,942 patients in the Australian and New Zealand Collaborative Perfusion Registry. The primary endpoint was acute kidney injury. Intraoperative and bypass management characteristics were also compared between early (2007-2012) and late (2013-2018) cohorts along with the acceptance or refusal of transfusion.

RESULTS

In patients accepting transfusion, 49% received a blood product. In patients refusing transfusion, acute kidney injury was lower (8% vs. 22%; p = 0.003) cell salvage use was higher (70% vs. 22%; p < 0.001), as was use of haemofiltration (8% vs. 4%; p = 0.03) and tranexamic acid in the early period (87% vs. 62%, p = 0.004) but not late (100% vs. 97%; p = 0.15). There was no difference in modifiable cardiopulmonary bypass factors (mean arterial pressure, minimum oxygen delivery (DO2i), retrograde autologous prime, circuit prime volume) between the two groups; however, prime volume decreased and DO2i increased over time for both. Patients refusing transfusion had lower postoperative blood loss (p = 0.02) and shorter postoperative length of stay (p < 0.001) with no difference in morbidity (p = 0.46) or mortality (p = 0.68).

CONCLUSION

Refusal of transfusion in patients undergoing cardiopulmonary bypass was associated with reduced acute kidney injury, hospital stay and postoperative blood loss, while not impacting mortality.

Pancreatic resections in patients who refuse blood transfusions. The application of a perioperative protocol for a true bloodless surgery

BACKGROUND

The refusal of blood transfusions compels surgeons to face ethical and clinical issues. A single-institution experience with a dedicated perioperative blood management protocol was reviewed to assess feasibility and short-term outcomes of true bloodless pancreatic surgery.

METHODS

The institutional database was reviewed to identify patients who refused transfusion and were scheduled for elective pancreatic surgery from 2010 through 2018. A protocol to optimize the hemoglobin values by administration of drugs stimulating erythropoiesis was systematically used.

RESULTS

Perioperative outcomes of 32 Jehovah's Witnesses patients were included. Median age was 67 years (range, 31-77). Nineteen (59.4%) patients were treated with preoperative erythropoietin. Twenty-four (75%) patients underwent pylorus-preserving pancreaticoduodenectomy, 4 (12.5%) distal pancreatectomy (DP) with splenectomy, 3 (9.4%) spleen-preserving DP, and 1 (3.1%) total pancreatectomy. Median estimated blood loss and surgical duration were 400 mL (range, 100-1000) and 470 min (range, 290-595), respectively. Median preoperative hemoglobin was 13.9 g/dL (range, 11.7-15.8) while median postoperative nadir hemoglobin was 10.5 g/dL (range, 7.1-14.1). The most common histological diagnosis (n = 15, 46.9%) was pancreatic ductal adenocarcinoma. Clavien-Dindo grade I-II complications occurred in fourteen (43.8%) patients while one (3.1%) patient had a Clavien-Dindo grade IIIa complication wich was an abdominal collection that required percutaneous drainage. Six (18.8%) patients presented biochemical leak or postoperative pancreatic fistula grade B. Median hospital stay was 16 days (range, 8-54) with no patient requiring transfusion or re-operation and no 90-day mortality.

CONCLUSIONS

A multidisciplinary approach and specific perioperative management allowed performing pancreatic resections in patients who refused transfusion with good short-term outcomes.

Substernal goiter excision in a Jehovah's Witness

Jehovah's Witnesses present a unique challenge in oral and head and neck surgery. We report a case of a substernal goiter excised on a Jehovah's Witness without the use of blood transfusion, in accordance with the patient's beliefs. Additionally, we review the literature on the care of this patient population, focusing on preoperative optimization, perioperative management, and postoperative care.

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.

Emergency Surgical Resection of Primary Pulmonary Artery Sarcoma Without Blood Transfusion

A primary pulmonary artery sarcoma is an extremely rare type of malignant tumor. We report the case of a 59-year-old woman, a member of the Jehovah's Witnesses church, with extensive primary pulmonary artery sarcoma who had life-threatening hemoptysis and underwent emergency surgery. Although the resected margin at the right pulmonary artery was positive, we performed reconstruction of that artery and a left pneumonectomy as life-saving procedures using intraoperative autologous blood transfusion and cell salvage in a continuous circuit to avoid blood transfusion. Surgical indications and procedures in this case of surgery without transfusion are also presented.

Pulmonary Valve Replacement in an Adult Jehovah's Witness with Tetralogy of Fallot

The refusal of Jehovah's Witnesses to use blood products can limit access to cardiac surgery, as patients may not be offered surgery for complex disease, especially revision surgery. We report a successful, complex adult congenital heart disease (ACHD) surgery with intraoperative and perioperative optimization. We have tried to highlight through this case that complex ACHD surgeries can be performed in Jehovah's Witness patients with skilled perioperative and intraoperative management. The role of bovine hemoglobin in this population is being defined and was found helpful in this case.

Liver transplantation in Jehovah's witnesses: 13 consecutive cases at a single institution

Background

Jehovah’s Witnesses represent a tremendous clinical challenge when indicated to liver transplantation because they refuse blood transfusion on religious grounds and the procedure is historically associated with potential massive peri-operative blood loss. We herein describe a peri-operative management pathway with strategies toward a transfusion-free environment with the aim not only of offering liver transplant to selected Jehovah’s Witnesses patients but also, ultimately, of translating this practice to all general surgical procedures.

Methods

This is a retrospective review of prospective medical records of JW patients who underwent LT at our Institution. The peri-operative multimodal strategy to liver transplantation in Jehovah’s Witnesses includes a pre-operative red cell mass optimization package and the intra-operative use of normovolemic haemodilution, veno-venous bypass and low central venous pressure.

Results

In a 9-year period, 13 Jehovah’s Witness patients received liver transplantation at our centre representing the largest liver transplant program from deceased donors in Jehovah’s Witnesses patients reported so far. No patient received blood bank products but 3 had fibrinogen concentrate and one tranexamic acid to correct ongoing hyper-fibrinolysis. There were 4 cases of acute kidney injury (one required extracorporeal renal replacement treatment) and one patient needed vasoactive medications to support blood pressure for the first 2 postoperative days. Two patients underwent re-laparotomy. Finally, of the 13 recipients, 12 were alive at the 1 year follow-up interview and 1 died due to septic complications.

Conclusions

Our experience confirms that liver transplantation in selected Jehovah’s Witnesses patients can be feasible and safe provided that it is carried out at a very experienced centre and according to a multidisciplinary approach.

Severe anemia may not be a contraindication to debridement in a Jehovah's witness patient with necrotizng fasciitis of the lower extremity - A case report

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Necrotizing fasciitis should be recognized early and transferred to an tertiary surgical center for management.

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Surgical approach should be focused on the principal of “less is more” in regards to surgical debridement technique.

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Patient values were upheld, being a Jehovah’s Witness.

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A multidisciplinary approach is critical for best prognosis.

Introduction

Necrotizing fasciitis is a severe soft tissue infection characterized by rapidly progressing necrosis involving the fascia and subcutaneous tissue. Necrotizing fasciitis of the lower extremity in a Jehovah’s Witness patient in the setting of severe anemia and systemic sepsis is uncommon.

Case presentation

A 62-year-old man of Jehovah’s Witness faith with a history of alcohol use disorder and uncontrolled diabetes mellitus initially presented with a non-healing diabetic foot ulcer, subsequently developed sepsis and necrotizing fasciitis. He underwent an above the knee amputation and was transferred to our institution’s Surgical Intensive Care Unit for further management. The patient presented in critical condition with a hemoglobin of 4.7 g/dL and progression of necrotizing fasciitis of the lower extremity stump. He underwent revision amputation and numerous excisional debridements along with IV antibiotics, epoetin alfa, and iron sucrose. He successfully recovered with minimal blood loss and was discharged with a hemoglobin of 8 g/dL.

Discussion

This case highlights some of the challenges involved in managing necrotizing fasciitis. The conversation with the Jehovah’s Witness patient in a life-threatening condition must be held with the upmost respect. Surgical decision making and operative technique is critical in determining the boundary of excisional debridement to perform in the absence of the ability to transfuse blood. The medical management was focused on resuscitation for sepsis, severe anemia, hyperglycemia, and wound management.

Conclusion

Severely anemic patients in critical condition can survive necrotizing fasciitis with a well-planned interdisciplinary approach without compromising patient autonomy.

Transfusion-related Acute Lung Injury in the Perioperative Patient

Transfusion-related acute lung injury is a leading cause of death associated with the use of blood products. Transfusion-related acute lung injury is a diagnosis of exclusion which can be difficult to identify during surgery amid the various physiologic and pathophysiologic changes associated with the perioperative period. As anesthesiologists supervise delivery of a large portion of inpatient prescribed blood products, and since the incidence of transfusion-related acute lung injury in the perioperative patient is higher than in nonsurgical patients, anesthesiologists need to consider transfusion-related acute lung injury in the perioperative setting, identify at-risk patients, recognize early signs of transfusion-related acute lung injury, and have established strategies for its prevention and treatment.

Jehovah's Witness Patients: Interventions for Successful Stem Cell Transplantation Without Blood Product Transfusions for Hematologic Malignancies

BACKGROUND

Jehovah's Witnesses are members of a religion that prohibits them from accepting blood product transfusions. This refusal makes them a particularly compelling population in the context of hematologic malignancies and stem cell transplantation, because blood product transfusions are a mainstay of supportive treatment.

OBJECTIVES

This article presents preventive and supportive measures allowing Jehovah's Witness patients the opportunity to receive a stem cell transplantation without blood product transfusions.

METHODS

A literature review was done that included evidence focusing on optimizing hematopoiesis, blood loss prevention, alterations in chemotherapy regimens, and implications for nursing practice.

FINDINGS

With proper preventive and supportive care measures, Jehovah's Witness patients can receive stem cell transplantations for hematologic malignancies without blood product transfusions.

Major liver surgery in a Jehovah’s Witness patient: challenges for safe surgery

Jehovah’s Witnesses presenting for major surgery run the risk of major bleeding, which is complicated by the refusal to accept blood transfusion. We present a case of a 63-year-old woman, a Jehovah’s Witness, who was diagnosed with hepatocellular carcinoma and advised for curative laparoscopic liver segmentectomy. Due to the risk of significant intraoperative haemorrhage, her perioperative care was coordinated in a multidisciplinary manner. Informed consent requires the physician to advise on the material risks of undertaking major surgery without blood transfusion and the possible alternatives. Conflicting ethical issues of patient autonomy and beneficence related to refusal of blood products also arise. Perioperative strategies to minimise blood loss, maximise haematopoiesis and tolerance of anaemia to facilitate safe surgery in such patients are also presented. Written patient consent obtained.

Thrombolytic therapy for critical limb ischemia in a Jehovah's Witness with severe anemia

A patient's refusal to receive blood products can pose both clinical and ethical challenges to the surgeon. In this report, we review the case of a Jehovah's Witness presenting with critical lower limb ischemia and severe anemia for whom the decision of whether to perform thrombolytic therapy was complicated by his refusal to accept blood products. The case demonstrates that thrombolytic therapy can produce favorable results in severely anemic patients even when transfusion is not an option. We conclude that offering thrombolytic therapy in this context is a reasonable therapeutic option from both a clinical and ethical perspective.

Antineoplastic chemotherapy in Jehovah's Witness patients with acute myelogenous leukemia refusing blood products - a matched pair analysis

BACKGROUND

Acute myelogenous leukemia (AML) may be cured in a substantial number of patients using intensive chemotherapeutic regimens leading to temporary severe myelosuppression. Patients belonging to the denomination of Jehovah's Witnesses (JW), however, are bound by their religious convictions not to accept blood products and are therefore at higher risk for life-threatening events. Reports how to handle this challenge are mainly anecdotal.

MATERIAL AND METHODS

We here report in much more detail about our experience with nine patients belonging to the denomination of JW who were treated for AML in our department from 1998 to 2007 and who explicitly wished to receive chemotherapy without blood transfusions.

RESULTS

Reduced dose induction chemotherapy administered by several treatment cycles to prevent sustained myelosuppression still led to complete remissions in three out of nine of JW patients but was associated with a high rate of relapse. No durable remission was achieved. The overall hazard ratio for death was 12.1 compared to a matched control group treated with full transfusion support. The predominant cause of non-AML mortality was severe anemia (four out of five early deaths) and uncontrollable bleeding (n = 1).

CONCLUSION

Reduced dose chemotherapy without transfusion support in JW suffering from AML is associated with a lower rate of remission, high mortality by severe anemia and very low chances for long-term remissions. Less hematotoxic treatment options including hypomethylating agents or molecular targeted therapies with intensive consolidation after improvement of bone marrow function are promising for these patients but need further investigation.

Treatment of individuals who cannot receive blood products for religious or other reasons

By virtue of their religious principles, Jehovah's Witnesses (JWs) generally object to receiving blood products, raising numerous ethical, legal, and medical challenges for providers who care for these patients, especially in the emergent setting. In this review, we discuss several areas relevant to the care of JWs, including the current literature on "bloodless" medical care in the setting of perioperative and intraoperative management, acute blood loss, trauma, pregnancy, and malignancy. We have found that medical and administrative efforts in the form of bloodless medicine and surgery programs can be instrumental in helping to reduce risks of morbidity and mortality in these patients. Planning prior to an anticipated event associated with blood loss or anemia (such as elective surgery, pregnancy, and chemotherapy) is critical. Specifically, bloodless medicine programs should prioritize vigilant early screening and management of anemias, early establishment of patient wishes regarding transfusion, and the incorporation of those wishes into multidisciplinary medical and surgical care. Although there are now a variety of human-based and nonhuman-based products available as transfusion alternatives, the degree and quality of evidence to support their use varies significantly between products and is also largely dependent on the clinical setting.

Major abdominal surgery in Jehovah's Witnesses

Introduction Patients who are Jehovah's Witnesses pose difficult ethical and moral dilemmas for surgeons because of their refusal to receive blood and blood products. This article outlines the personal experiences of six Jehovah's Witnesses who underwent major abdominal surgery at a single institution and also summarises the literature on the perioperative care of these patients. Methods The patients recorded their thoughts and the dilemmas they faced during their surgical journey. We also reviewed the recent literature on the ethical principles involved in treating such patients and strategies recommended to make surgery safer. Results All patients were supported in their decision making by the clinical team and the Hospital Liaison Committee for Jehovah's Witnesses. The patients recognised the ethical and moral difficulties experienced by clinicians in this setting. However, they described taking strength from their belief in Jehovah. A multitude of techniques are available to minimise the risk associated with major surgery in Jehovah's Witness patients, many of which have been adopted to minimise unnecessary use of blood products in general. Nevertheless, the risks of catastrophic haemorrhage and consequent mortality remain an unresolved issue for the treating team. Conclusions Respect for a patient's autonomy in this setting is the overriding ethical principle, with detailed discussion forming an important part of the preparation of a Jehovah's Witness for major abdominal surgery. Clinicians must be diligent in the documentation of the patient's wishes to ensure all members of the team can abide by these.

Medical and Surgical Management of Postpartum Hemorrhage in a Woman with Factor XIII Deficiency

Factor XIII deficiency is a rare inherited coagulopathy. Factor XIII is the last clotting factor in the coagulation cascade to insure strength and stability to fibrin clots. Without this enzyme, the fibrous clot is unstable and nonresistant to fibrinolysis. Gravid women with this congenital disease are especially at risk for complications including miscarriages and hemorrhage without appropriate interventions. We present a case of a woman in her 20s with Factor XIII deficiency who was treated with cryoprecipitate and had a successful normal spontaneous vaginal delivery; subsequently, patient suffered from postpartum hemorrhage and consumptive coagulopathy due to consumption of Factor XIII, requiring emergency surgical intervention. Intraoperative management was challenged by an ethical dilemma involving the patient's religious beliefs about not receiving blood. This paper will discuss the mechanism of Factor XIII and the medical and surgical management involved with this patient.

Transfusion Ethics in a Pediatric Jehovah's Witness Trauma Patient: Simulation Case

INTRODUCTION

Current ethical practice allows for adult patients with decision-making capacity to refuse blood transfusion, even at the cost of high morbidity or mortality. However, for an adult patient who is of the Jehovah's Witness faith, an unwanted blood transfusion confers a psychospiritual cost to the patient and a financial cost to health care entities. The ethical boundaries are increasingly ambiguous with minors who are members of the Jehovah's Witness faith. This simulation experience intends to identify and address knowledge gaps in the care of minors in an emergent setting using a biomedical ethics framework.

METHODS

This scenario provides an immersive simulation experience involving a 12-year-old Jehovah's Witness patient requiring emergent laparotomy for splenic hemorrhage. Patient interview (via simulation manikin with instructor voice) and care handoff take place in an operating room setting. The learner ascertains the patient's and family's refusal of blood products. Induction of general anesthesia results in profound patient hypotension secondary to acute blood-loss anemia. Pulseless electrical activity results if packed red blood cells are not administered. Ethical principles require the learner to impose an unwanted lifesaving therapy on a minor patient over the objections of family members. Secondly, the anesthesia provider must advocate for transfusion on these ethical grounds against a well-meaning but ultimately misguided surgeon who opposes transfusion. An included learner evaluation form based on ACGME core competencies facilitates postsimulation debriefing.

RESULTS

Participants were primarily anesthesia residents and fellows. Anecdotally, the residents said that it "felt good to be an attending" and that the simulation helped them appreciate how important conflict resolution skills are in the OR setting. Additionally, faculty appreciated the ability to assess the development of crucial assertiveness skills, with the option of remediating incorrect behavior during the debriefing.

DISCUSSION

This simulation experience provides experience in the emergent medical management of a pediatric trauma patient while also incorporating specific ethical consent issues unique to pediatric and trauma patient populations. Furthermore, this experience develops professionalism skills and practice in assertive patient advocacy.

Long-lasting extreme anemia during the therapy of acute lymphoblastic leukemia in a Jehovah's Witness patient

BACKGROUND

The treatment of patients with acute leukemia, who due to their religious beliefs refuse to accept blood transfusion, is a great challenge for hematologists.

CASE REPORT

We present a case of acute pre-T-lymphoblastic leukemia in a Jehovah's Witness who did not accept blood transfusion during chemotherapy. Standard induction and consolidation chemotherapy was used (according to the PALG ALL-6 regiment).

RESULTS

During consolidation cycles, darbepoietin alfa, intravenous iron, and total parenteral nutrition was administered. Extreme (Hb < 5 g/dL), long-lasting (41 days) anemia was observed with the lowest Hb concentration amounting to 1.3 g/dL (lasting 7 days).

CONCLUSION

We believe this to be the lowest Hb value observed, particularly one that persisted for such a long period of time and resulted in the patient surviving without consequences. The patient remains in complete remission for more than 2 years after diagnosis.