TRANSFUSION MEDICINE
| CARE OF THE JEHOVAH’S WITNESS PATIENT FOR ELECTIVE SURGERY —D. John Doyle, MD, PhD, Staff Anesthesiologist, Department of General Anesthesiology, Cleveland Clinic, Cleveland |
| Jehovah’s Witnesses: ≈6 million members worldwide, with ≈1 million in United States; traditionally, orthodox members do not accept homologous or autologous whole blood, packed red blood cells (RBCs), plasma, platelets, or white blood cells (WBCs), even when clinically necessary; can result in challenging dilemma for physicians because routine, safe, and potentially life-saving medical intervention unacceptable to this population |
| Beliefs: Christian religion whose followers believe Bible to be true and literal word of God; faith began in late 1870s as Bible study group led by Charles T. Russell; his teachings subsequently spread throughout world through official doctrinal journal (Watchtower), that began in 1879; in 1881, Watchtower Bible and Tract Society formed as central organization for Jehovah’s Witness faith; view Jehovah as ultimate moral authority and do not salute flags, join service organizations, enlist in military, vote in public elections, or take interest in civil government; in contrast to most other Christian religions, they do not believe in concept of trinity or usual Christian concept of heaven and hell; base religious beliefs on strict literal interpretation of Bible and hold that eternal life may be forfeited if they do not exactly follow biblical commands; believe that Jesus did not die on cross, but on upright pole; do not stand for national anthem or own flag; cannot buy Girl Scout cookies; cannot be cheerleaders, do not celebrate holidays; cannot own or wear cross; cannot accept Christmas gifts; cannot speak to former members who are shunned |
| Blood transfusions: Jehovah’s Witnesses believe biblical injunctions about blood include animal and human blood, and that transfusion of blood equal to “eating blood”; even use of autologous blood, predonated in preparation for surgery, prohibited, as is transfusion of any of primary blood components, regardless of source; determination that blood transfusions violation of God’s law made in 1945 and primarily based on 3 biblical passages (Genesis 9:3-4, Leviticus 17:10-16, and Acts 15:28-29); quote from 1961 published in Watchtower takes aggressive stance, “the blood in any person is in reality the person himself poisons due to personal living, eating, and drinking habits the poisons that produce the impulse to commit suicide, murder, or steal are in the blood”; another quote from same year states that “moral insanity, sexual perversions, repression, inferiority complexes, petty crimes often follow in the wake of blood transfusions” (current stance on blood not as aggressive); some in Jehovah’s Witness community have not agreed with these issues; Associated Jehovah’s Witnesses for Reform on Blood have Web site (www.ajwrb.org) outlining their position on why blood should be allowed under reasonable circumstances; despite refusal to accept transfusions, contemporary Jehovah’s Witnesses not against modern medical care; for most part, informed health care consumers; seek out competent health care providers who will zealously respect their wishes; may carry card that makes clear they do not want blood |
| Hospital liaison committees: established by Jehovah’s Witnesses in most major cities; consist of specially trained members who provide educational programs and work with physicians on individual cases; goal to assist in providing care to brethren within strict limitations of religious beliefs; can provide vast array of useful information on alternatives to blood transfusion therapy and maintain comprehensive file of up-to-date clinical articles gathered from peer-reviewed medical literature |
| Legal issues: often center on patient consent; in United States, patient’s legal right to refuse or consent to treatment based on common law, and therefore, in state of continuous evolution as new cases decided; first article of Bill of Rights provides that “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof ”; interpreted to protect all religious beliefs from discriminatory government interference; much of law based on Jehovah’s Witness cases; in United States, case that established competent adult’s right to refuse treatment occurred in 1914 |
| Refusal of blood transfusion: all hospitals should have protocol to deal with refusal of blood transfusion; protocols should provide for informed consent about benefits and risks of receiving or refusing transfusions; outline alternatives to transfusion, including possibility of transferring patient or using artificial blood; explain role of local hospital liaison committee if patient Jehovah’s Witness, especially if patient not fully apprised of rules about primary and secondary blood components; identify actions to be taken if determined that court intervention necessary |
| Usually refused: whole blood; erythrocytes; platelets; fresh-frozen plasma; granulocytes; cryoprecipitate; predonated autologous blood |
| Usually accepted: normovolemic hemodilution; intraoperative RBC salvage (in continuity); erythropoietin; hemodialysis, cardiopulmonary bypass, and veno-veno bypass (provided nonblood prime used) |
| Individual decision (conscience items): albumin; immune globulins; factor concentrates; tissue transplants; artificial blood |
| Clinical management to minimize need for blood transfusion: minimize iatrogenic blood loss by eliminating unnecessary tests and reduction of blood sample volume; minimize intraoperative RBC loss by using normovolemic hemodilution and other “bloodless” surgery techniques; enhance RBC production with erythropoietin, iron, and folate |
| Blood management policies: accept limitation that allogeneic blood cannot be used; use alternatives to allogeneic blood whenever possible and appropriate; discuss consequences with patient, including potential for life-threatening hemorrhage and death if not transfused; if unable or unwilling to treat Jehovah’s Witness patient, stabilize and transfer patient to sympathetic institution; contact local liaison committee for information and help; in emergency or if patient unconscious, look for advance directive; seek legal assistance when dealing with unconscious or incompetent adults (and especially with children) |
| Complex conditions: whole blood unacceptable if taken as blood transfusion, but may be acceptable if taken as contained in bone marrow transplant; plasma proteins unacceptable if taken together as plasma, but acceptable if taken as individual blood components; stem cells unacceptable if taken from umbilical cord blood, but acceptable if taken from peripheral blood or bone marrow |
| New information on blood: quote from Watchtower states, “ when it comes to fractions of any of the primary components, each Christian, after careful and prayerful meditation, must conscientiously decide for himself”; letter sent to hospital liaison committee members seems to indicate less emphasis being placed on concept of being “disfellowshipped” |
| TRANSFUSION UPDATE —Terri G. Monk, MD, Professor of Anesthesiology, Duke University School of Medicine, Durham, North Carolina |
| Introduction: need for blood transfusion once considered good outcome; but because of onset of AIDS in 1980s, blood transfusion now considered by some to be bad outcome; much media attention placed on negative effects of blood; in 1983, risk of getting HIV from blood transfusion ≈1 in 100 |
| Red Cross organization: individuals donating blood received detailed questionnaire asking about sexual practices; questionnaire could be marked indicating blood should be discarded after withdrawal; by 1990s, dramatic improvement in risk of acquiring infectious disease from blood; currently, risk of acquiring AIDS from blood transfusion ≈1 in >2 million units of blood; risk for hepatitis C also ≈1 in 2 million; Canada did not institute questionnaire; collected much infected blood; many hemophiliac children in Canada developed AIDS; problem became so severe that government filed criminal charges; decision found Canadian Red Cross negligent, and organization disbanded in 1990s |
| Risks: yearly risk of dying from driving on major highways ≈1 in 10,000; some concerns that Creutzfeldt-Jakob or West Nile virus may enter blood supply and limit amount of blood donation; no longer accepting donors in United States who have lived in Europe or England for >6 mo; also do not receive blood from European countries; patients still not completely convinced about safety of blood |
| Demographics: of blood cell needs follow demographics of Social Security; most procedures requiring blood (eg, open heart surgery, orthopaedic joint surgery) performed on elderly; as “baby boom” generation ages, can no longer donate, but will require blood; shortfall of 4 million units of blood projected in United States by 2030; Canada cancelling elective surgery often because of lack of blood |
| Eliminating transfusion trigger: guidelines from American Society of Anesthesiologists (ASA) vague; state that RBC transfusion rarely indicated if hemoglobin (Hb) >10 g/dL and usually indicated if Hb ≤6 g/dL; also states that use of intermediate Hb level for transfusion should be based on risk for complications of inadequate oxygenation; use of single transfusion trigger not recommended; study indicates that in healthy young patients without comorbidity, “it’s probably safe to take them down to a hemoglobin of 6 g/dL” |
| Evidence-based transfusion therapy: Transfusion Requirement in Clinical Care (TRICC) trial enrolled 838 patients with euvolemia in intensive care unit (ICU); to be included in protocol, Hb level must have been <9 g/dL within 72 hr after ICU admission; patients randomized to “restrictive” (transfused when hemoglobin dropped to <7 g/dL) or “liberal” (transfused when hemoglobin dropped to <10 g/dL) transfusion strategy; primary outcome was rate of deaths from all causes in first 30 days after admission; mean Hb in restrictive group ≈8 g/dL, in liberal group, mean Hb 10.5 g/dL; found no difference in number of infections between groups, no difference in neurologic complications, and no difference in overall complications; more cardiac events in patients with liberal transfusion strategy (possibly related to fluid overload); primary outcome and length of hospital stay no different between groups; patients maintained at Hb of 10 g/ dL had higher death rate within hospital; concluded that Hb concentration should be maintained at 7-9 g/dL in critically ill patient, but those with acute myocardial infarction (MI) and unstable angina may be exceptions; restrictive transfusion practice decreased number of RBC units transfused by 54%; another study looked at RBC transfusion in elderly patients with acute MI; found that 43% of elderly individuals anemic (hematocrit <39%) when admitted to hospital; those who received RBC transfusion had lower 30-day mortality rate if hematocrit ≤30% on hospital admission; those with hematocrit ≥36% on hospital admission had higher mortality rate, possibly due to fluid overload; transfusion recommended in acute MI with hematocrit <30% and Hb <10 g/dL |
| Designated RBC transfusion: blood donor known to potential recipient; accepted in pediatrics; controversial in adults; more viral markers in blood from designated donors than from repeat volunteers at Red Cross; asking someone to donate blood for another person coercive practice; designated donation not recommended, except for spouse; may have potentially deleterious effect on national blood inventory (reduces volunteer donor pool) |
| Preoperative autologous blood donation (PAD): began in 1982 with scare about AIDS from blood transfusion; in beginning, studies showed PAD effective; but good evidence now showing PAD “not a very good blood saving modality”; in 2003, down to ≈3% of blood supply; study from Kaiser Permanente looked at PAD before elective hysterectomy; 18% transfusion rate in patients who predonated blood, compared to <1% in patients who did not; even though autologous blood donated, risks for infection developing during storage period, erroneous transfusion, or mislabeling present; also found that patients who predonated blood more anemic on arrival at hospital; concluded that PAD causes preoperative anemia and associated with more liberal transfusion policy; suggested eliminating PAD for hysterectomy; studies also suggest PAD unnecessary before radical prostatectomy; not cost effective (only 45 min estimated life savings for every unit of blood predonated); wasteful (50%-60% of all units of predonated blood thrown away; not placed into general donor pool) |
| Acute normovolemic hemodilution (ANH): involves removal of blood from patient shortly before surgical blood loss; blood reinfused at end of surgery; always connected to patient at end of surgery; eliminates problems with erroneous transfusion; blood remains at room temperature, so infection avoided; technician, not anesthesia provider, should perform ANH; fresh whole autologous blood available for transfusion; contraindications include anemia, ASA Class 4, significant coronary artery disease, congestive heart failure, and recent acute MI; blood withdrawn from antecubital or arterial catheter, not from central artery catheter; formula for amount of blood to withdraw starts with blood volume multiplied by initial hematocrit, minus final hematocrit desired; monitor heart rate and ST segment; if tachycardia develops, correct hypovolemia; if it continues, abandon hemodilution and replace blood |
| Preoperative erythropoietin therapy: epoetin alfa (Procrit) approved for presurgical use in anemic patient; stimulates bone marrow to increase RBC mass in preoperative period |
| Conclusion: PAD results in chronic hemodilution; contributes little to blood conservation; ANH saves same amount of blood, less expensive, safer, and more convenient; if autologous strategy necessary, hemodilution “is the way to go”; to avoid transfusion, combine pharmacologic strategies (eg, erythropoietin) with autologous blood collection technique (either PAD or hemodilution); augmented acute normovolemic hemodilution (AANH) will occur when O2 -carrying blood substitutes become available |
Educational Objectives
| The goal of this activity is to educate the listener about care of the Jehovah’s Witness patient for elective surgery and other specific issues in transfusion medicine. After hearing and assimilating this program, the participant will be better able to: |
 | 1. Review the basic religious beliefs of the Jehovah’s Witness faith, more specifically, the beliefs concerning blood transfusions. |
| 2. Summarize the clinical management of the Jehovah’s Witness patient to minimize the need for blood. |
| 3. Explain the current blood management policies for the Jehovah’s Witness patient. |
| 4. Evaluate the advantages and disadvantages of preoperative autologous blood donation vs acute normovolemic hemodilution. |
| 5. Describe the use of preoperative erythropoietin therapy in blood transfusion. |
Discussed on This Program
Epoetin alfa (erythropoietin; EPO) [Epogen, Procrit]
Suggested Reading
Bailey R et al: The view of Jehovah's Witnesses on blood substitutes. Artif Cells Blood Substit Immobil Biotechnol 26:571, 1998; Benson K: Management of the Jehovah's Witness Oncology Patient: Perspective of the Transfusion Service. Cancer Control 2:552, 1995; Dodd RY et al: Current prevalence and incidence of infectious disease markers and estimated window-period risk in the American Red Cross blood donor population. Transfusion 42:975, 2002; Goodnough LM et al: Efficacy and cost-effectiveness of autologous blood predeposit in patients undergoing radical prostatectomy procedures. Urology 44:226, 1994; Goodnough LT et al: A randomized trial comparing acute normovolemic hemodilution and preoperative autologous blood donation in total hip arthroplasty. Transfusion 40:1054, 2000; Goodnough LT et al: A randomized trial of acute normovolemic hemodilution compared to preoperative autologous blood donation in total knee arthroplasty. Vox Sang 77:11, 1999; Goodnough LT et al: Acute preoperative hemodilution in patients undergoing radical prostatectomy: a case study analysis of efficacy. Anesth Analg 78:932, 1994; Goodnough LT et al: Erythropoietin therapy in the perioperative setting. Clin Orthop Relat Res 12:82, 1998; Goodnough LT et al: The impact of preoperative autologous blood donation on orthopaedic surgical practice. Vox Sang 59:65, 1990; Goodnough LT: Autologous blood donation. Anesthesiol Clin North America 23:263, 2005; Goodnough LT: Risks of blood transfusion. Anesthesiol Clin North America 23:241, 2005; Grafstein E et al: Guidelines for red blood cell and plasma transfusion for adults and children: an emergency physician's overview of the 1997 Canadian Blood Plasma transfusion and infectious risk. Can Med Assoc J 156:S1, 1997; Hebert PC et al: A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 340:409, 1999; Kanter MH et al: Preoperative autologous blood donations before elective hysterectomy. JAMA 276:798, 1996; Monk TG et al: A prospective randomized comparison of three blood conservation strategies for radical prostatectomy. Anesthesiology 91:24, 1999; Monk TG et al: Issues in transfusion medicine. Anesthesiol Clin North America 23:xiii, 2005; Muramoto O: Recent developments in medical care of Jehovah's Witnesses. West J Med 170:297, 1999; Nuttall GA et al: Current transfusion practices of members of the American Society of Anesthesiologists: a survey. Anesthesiology 99:1433, 2003; Orton SL et al: Validation of selected donor-screening questions: structure, content, and comprehension. Transfusion 40:1407, 2000; Practice Guidelines for blood component therapy: A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy. Anesthesiology 84:732, 1996; Roback JD et al: Longitudinal monitoring of WBC subsets in packed RBC units after filtration: implications for transfusion transmission of infections. Transfusion 40:500, 2000; Spence RK: Management of severe anemia in a pediatric Jehovah's Witness patient. Crit Care Med 23:416, 1995; Spence RK: Surgical red blood cell transfusion practice policies. Blood Management Practice Guidelines Conference. Am J Surg 170:3S, 1995; Trevitt CR et al: Variant Creutzfeldt-Jakob disease: pathology, epidemiology, and public health implications. Am J Clin Nutr 78:651S, 2003; Wang B et al: Prevalence of transfusion-transmissible viral infections in first-time US blood donors by donation site. Transfusion 43:705, 2003; Wu WC et al: Blood transfusion in elderly patients with acute myocardial infarction. N Engl J Med 345:1230, 2001; Zou S et al: Patterns of age- and sex-specific prevalence of major blood-borne infections in United States blood donors, 1995 to 2002: American Red Cross blood donor study. Transfusion 44:1640, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed: Dr. Monk has received research support from Aspect Medical Systems, R.W. Johnson Pharmaceutical Research Institute, and Ortho Biotech.
Dr. Doyle spoke in Naples, Florida at Survey of Current Issues in Surgical Anesthesia, held November 14-17, 2004, and sponsored by The Cleveland Clinic Foundation; Dr. Monk, in Chicago at Challenges for Clinicians in the New Millennium , held December 3-5, 2004, and sponsored by The University of Chicago Pritzker School of Medicine. The Audio- Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
|
