Many techniques have been used in the management of the anemic Jehovah’s Witness patient (1,2). We report the use of intraoperative autologous cell-saver transfusion to increase the hematocrit from <5.0% to 10.2% in a Jehovah’s Witness after uneventful vaginal hysterectomy and bilateral salpingo-oophorectomy (VHBSO) complicated by a postoperative retroperitoneal hemorrhage. Allogenic fresh frozen plasma (FFP) was also given, with previous consent, during the hemorrhage. Recent blood policy reform within the Jehovah’s Witness community is discussed in association with this severe anemia.
The patient was a 48-yr-old (163-cm, 56-kg) woman who presented with uterine prolapse and stress incontinence. Her history was unremarkable for cardiac or pulmonary disease; however, she did have an occasional bloody stool secondary to bleeding hemorrhoids. Her vital signs included a blood pressure of 84/60 mm Hg and a heart rate of 68 bpm. She was scheduled for a VHBSO and anterior repair. Surgery was postponed until her hematocrit had increased from 30.4% to 38.0% after treatment with oral ferrous sulfate. She was a Jehovah’s Witness and had specific instructions concerning the transfusion of blood products. She refused predonated autologous and allogenic red blood cell (RBC) transfusions. However, she would accept intraoperative autologous cell-saver transfusion, as well as allogenic FFP, platelets, albumin, and hydroxyethyl starch. This was documented in her chart.
A VHBSO and anterior repair were performed uneventfully by using general anesthesia. Blood loss of 200 mL was replaced with 1600 mL of lactated Ringer’s solution. Postoperative vital signs included a blood pressure of 109/51 mm Hg, heart rate of 66 bpm, temperature of 35.4°C, and oxygen saturation of 100%. Supplemental oxygen via a face mask was provided.
Approximately 1 h postoperatively, the patient’s arterial blood pressure decreased to 80/40 mm Hg with a heart rate of 76 bpm. The patient denied abdominal pain, abdominal tenderness, and showed no external bleeding. Urine output was 112 mL/h. She had a history of relatively low blood pressures, and the decision was made to keep her in the recovery room for observation. Blood was drawn for determination of a hematocrit.
Systolic blood pressure remained in the 80-mm Hg range with a heart rate of 100 bpm. Two 500-mL boluses of lactated Ringer’s solution were administered along with 10 mg of ephedrine. A right radial arterial line was inserted, an electrocardiogram was ordered, and hematology results showed a hematocrit of 24.3%.
Blood was sent for additional studies. The electrocardiogram showed sinus tachycardia with no acute changes. Systolic blood pressure continued in the 80-mm Hg range. Hydroxyethyl starch (500 mL) was infused, and the surgeon again discussed blood transfusion options with the patient. The patient reaffirmed her objection to allogenic RBC transfusion and again agreed to autologous cell-saver, allogenic FFP, and platelet transfusion as needed. This was documented again in her chart.
A consulting internist recommended repeating the hematocrit and obtaining an abdominal computerized tomography scan. However, her arterial blood pressure decreased to 56/20 mm Hg, albumin 25% (50 mL) was infused, and the decision was made to return to the operating room (OR) for emergency exploratory laparotomy. She was placed on a nonrebreather face mask and arterial blood was sent for analysis. The patient’s mental status deteriorated as OR and cell-saver personnel were being mobilized. Urine output decreased to 5 mL/h. The OR nurses retrieved the emergency cell-saver collection unit and prepared it for use. Arterial blood gas results were pH 7.43, PaCO2 37 mm Hg, PaO2 433 mm Hg, and bicarbonate 23.8 mEq/L.
Preinduction arterial blood pressure and heart rate were 78/45 mm Hg and 104 bpm, respectively. Anesthesia was induced with 3 mg d-tubocurarine, 200 mg ketamine, and 100 mg succinylcholine IV. With a fraction of inspired oxygen of 1.0, anesthesia was maintained with 6 mg vecuronium, 4 mg midazolam, 100 μg fentanyl, and 300 μg phenylephrine, all in divided doses, for the 75-min duration of the case. Vascular access consisted of two large bore catheters and a right radial arterial line. Fluid warmers were used. The previous hematocrit was 11.9%, platelets were 126 × 109/L, fibrinogen was 102 mg/dL, prothrombin time was 15.6 s, and an activated partial thromboplastin time was 33.2 s. With continuing significant blood loss and abnormal coagulation results, 600 mL of FFP was started along with crystalloid and hydroxyethyl starch. Dilute blood (3000 mL) had been collected from the field suction into a BRAT® (COBE Cardiovascular, Inc., Arvada, CO) autologous blood collection reservoir, and a second 3000-mL reservoir was set up. Arterial blood pressure continued to decrease to a nadir of 55/36 mm Hg, and her heart rate increased to 118 bpm. No ST depression was observed on leads V5 or II. Blood was sent to the laboratory for numerous studies, and a hematocrit of 5.0% was determined by using a Hemata Stat-II™ (Separation Technology, Inc., Altamonte Springs, FL).
The salvaged blood was processed manually by a Haemonetics® Cell Saver 5 (Haemonetics Corp., Braintree, MA). In approximately 6 mins, autologous RBCs were being transfused IV. Shortly thereafter, hemostasis was achieved from a right ovarian pedicle hemorrhage, and arterial blood pressure began increasing. A total of 6000 mL of dilute blood was scavenged by field suction and returned to the patient as 675 mL of autologous packed RBCs with a hematocrit of approximately 60%. Three cycles were used to concentrate the scavenged blood. She was taken to the recovery room with her trachea intubated.
Initial vital signs in the recovery room revealed an arterial blood pressure of 100/40 mm Hg, heart rate of 100 bpm, temperature of 35.9°C, and an oxygen saturation of 100%. Total perioperative fluid intake included approximately 6000 mL crystalloid, 1000 mL hydroxyethyl starch, 675 mL cell-saver RBCs, 600 mL FFP, and 100 mL of albumin 25%. Urine output for the second operation was 70 mL. Repeat prothrombin time and activated partial thromboplastin time were 14.5 and 32.5 s, respectively, while the hematocrit had increased to 10.2%. The patient was placed in the intensive care unit and was tracheally extubated early on postoperative Day 2. Her hematocrit remained approximately 10% for the first 5 days. A discussion on Day 7 found her to be in excellent spirits and very thankful for the outcome of her second operation. She was discharged home with a hematocrit of 19.8% on postoperative Day 11 without any known cardiac or neurologic injury.
Traditionally, religious doctrine developed by the Watchtower Bible and Tract Society (WTS), the controlling faction of Jehovah’s Witnesses, has eschewed the medical transfusion of blood and most blood components among its members. This practice stems from their literal interpretation of numerous biblical passages, which espouse “none of you may eat blood” (Leviticus 17:12) and “abstain… from blood” (Acts 15:29) (3). Current policy of the WTS prohibits treatment with whole blood, stored autologous and allogenic RBCs, FFP, platelets, and hemoglobin solutions. However, acceptable blood components include albumin, fibrin, and certain autologous blood, bone marrow, and stem cell transfusion (4). As medical treatments have become increasingly complex, so have the blood policy rules of the WTS.
Recently, an anonymous group of Jehovah’s Witnesses, unhappy with the complicated and sometimes contradictory blood policy rules, formed the Associated Jehovah’s Witnesses for Reform on Blood group. Two web sites, New Light on Blood and Hourglass2 Outpost (http://www.hourglass2.org/), have served as forums for anonymous dialogue that question the blood policy as set forth by the WTS elders. In addition to this reform movement, the WTS doctrine was revised at the 1998 European Commission of Human Rights to allow Bulgarian Jehovah’s Witnesses “free choice” to receive blood transfusions “without any control or sanction on the part of the association” (4,6). Currently, to knowingly accept a blood transfusion or to publicly criticize the WTS blood policy may result in disfellowship.
While it was not known if our patient was an Associated Jehovah’s Witnesses for Reform on Blood member, there appears to be a growing number of Jehovah’s Witnesses questioning the traditional blood policy of the WTS. Our patient agreed to cell-saver, albumin, and hydroxyethyl starch transfusion, which are all acceptable by WTS policy. She also agreed to FFP and platelet transfusion, which are prohibited by WTS policy. (Despite a postoperative platelet nadir of 37 × 109/L, platelets were not transfused as microvascular bleeding was absent.) While her transfusion preferences were unusual, reports of Jehovah’s Witnesses acceptance of FFP and preoperative autologous RBC donation have been documented (7,8). This increasing diversity within the organization brings to the forefront the importance of obtaining confidential, individualized, informed consent pertaining to specific blood products.
It is advisable to document the patient’s decision concerning the acceptance or refusal of specific blood products for transfusion in the hospital chart (9). However, this documentation is not a substitute for informed consent, which should include information on common and uncommon risks and benefits of transfusion, alternatives to transfusion, and the consequences of not receiving transfusion. This discussion should be far enough in advance as to allow for alternative treatments if so desired by the patient. Also, the patient must be competent and should be allowed to ask questions and make an uncoerced choice concerning transfusion (10). Once transfusion refusal has been documented, failure to respect the patient’s request, even when presented with life threatening anemia, places the physician at risk for “consent to battery” liability, as numerous legal cases have upheld a competent adult patient’s right to refuse blood transfusion (11,12).
Numerous case reports describing severe anemias have been published in the medical literature over the past 30 years. Many involve Jehovah’s Witnesses who refused blood component transfusion, including cell-saver autotransfusion, because of their religious beliefs. Numerous Jehovah’s Witnesses have died as a result. This is the lowest intraoperative hematocrit (5.0%) reported in the English literature that had a successful outcome secondary to cell-saver autotransfusion (13). Kunz and Mahr (14) and Atabek et al. (15) described the survival of two Jehovah’s Witnesses with postoperative nadir hematocrits of 7.0% and 9.3%, respectively. Both patients received intraoperative cell-saver autotransfusion. Lichtenstein et al. (16) reported the survival of a Jehovah’s Witness who was transfused allogenic blood postoperatively via court order for a hematocrit of 4.0%. Three patients with severe anemias (hemoglobin 1.4–2.1 g/dL) survived without RBC transfusion (17–19). However, these patients received various treatment modalities, such as perfluorochemicals, hypothermia, pentobarbital coma, ionotropic drugs, prolonged neuromuscular blockade and increased fraction of inspired oxygen. Finally, the lowest recorded intraoperative hemoglobin concentration in a surviving patient was 1.1 g/dL (20). The patient had a metastatic renal cell carcinoma excised and received 22 U of allogenic RBCs.
In our case, the use of cell-saver autotransfusion was probably important in preventing morbidity and mortality. The preoperative hematocrit of 38.0% decreased to 11.9% in approximately six hours. Next, the hematocrit decreased to 5.0%, over an 80-minute period. The intraoperative hematocrit nadir is unknown, as blood loss continued for a short time after the 5.0% sample was drawn. Analysis of data presented by Viele and Weiskopf (13) showed a mortality rate of 63% (five of eight) secondary to untransfused anemias less than a hematocrit of 6.0%. However, the true mortality rate at such low hematocrit levels is unknown as data were collected from case reports and are probably incomplete.
Fontana et al. (21) studied oxygen consumption and cardiovascular function in healthy young patients during profound intraoperative normovolemic hemodilution to an average hemoglobin concentration of 3.0 g/dL. At this extreme level of hemodilution, the “critical level” of global oxygen delivery was not reached. This critical level, as described by Shibutani et al. (22), is the threshold at which oxygen consumption decreases linearly secondary to decreasing oxygen delivery. No adverse outcomes were noted in the eight patients enrolled in their study. Conversely, van Woerkens et al. (23) found the critical level of hemodilution in an anesthetized patient, who preoperatively refused all forms of blood transfusion, to be at a hemoglobin concentration of 4.0 g/dL. At this level, oxygen consumption started to decrease secondary to insufficient oxygen delivery. Twelve sets of data points were analyzed via invasive monitoring in this nonemergent case. The patient exsanguinated 12 hours postoperatively with a hemoglobin concentration of 1.6 g/dL. Whereas van Woerkens et al.’s (23) case was unique in illustrating the physiologic end point of oxygenation in one patient, our efforts concentrated on maintaining adequate cellular oxygenation until definitive treatment with cell-saver autotransfusion could be provided.
In summary, the preoperative discussion and acceptance of specific blood components by this Jehovah’s Witness patient allowed for the rapid intraoperative collection and transfusion of autologous RBCs for a hematocrit of <5.0%, which were probably important in preventing morbidity and mortality.
1. Testa LD, Tobias JD. Techniques of blood conservation. Am J Anesthesiol 1996; 23:63–72.
2. Mann MC, Votto J, Kambe J, McNamee MJ. Management of the severely anemic patient who refuses transfusion: lessons learned during the care of a Jehovah’s Witness. Ann Intern Med 1992; 117:1042–8.
3. Malak J. Jehovah’s Witnesses and medicine: an overview of beliefs and issues in their care. J Med Assoc Ga 1998; 87:322–7.
4. Muramoto O. Recent developments in medical care of Jehovah’s Witnesses. West J Med 1999; 170:297–301.
6. Muramoto O. Bioethics of the refusal of blood by Jehovah’s Witnesses. Part 2. A novel approach based on rational non-interventional paternalism. J Med Ethics 1998; 24:295–301.
7. Findley LJ, Redstone PM. Blood transfusion in adult Jehovah’s Witnesses. Arch Intern Med 1982; 142:606–7.
8. Vanelli P, Castelli P, Condemi AM, Santoli C. Blood saving in Jehovah’s Witnesses. Ann Thorac Surg 1991; 52:899–900.
9. Sazama K. Practical issues in informed consent for transfusion. Am J Clin Pathol 1997; 107(4 Suppl 1):S72–4.
10. Goldman EB. Legal considerations for allogeneic blood transfusion. Am J Surg 1995; 170(6A Suppl):27S–31S.
11. Blumenreich GA. Informed consent. AANA 1998; 66:221–4.
12. Hartman KM, Liang BA. Exceptions to informed consent in emergency medicine. Hosp Physician 1999; 35:53–60.
13. Viele MK, Weiskopf RB. What can we learn about the need for transfusion from patients who refuse blood? The experience with Jehovah’s Witnesses. Transfusion 1994; 34:396–401.
14. Kunz J, Mahr R. Management of severe blood loss after tumor resection in a Jehovah’s Witness. Gynakol Geburtshilfliche Rundsch 1995; 35:34–7.
15. Atabek U, Spence RK, Pello M, et al. Pancreaticoduodenectomy without homologous blood transfusion in an anemic Jehovah’s Witness. Arch Surg 1992; 127:349–51.
16. Lichtenstein A, Eckhart WF, Swanson KJ, et al. Unplanned intraoperative and postoperative hemodilution: oxygen transport and consumption during severe anemia. Anesthesiology 1988; 69:119–22.
17. Brimacombe J, Skippen P, Talbutt P. Acute anaemia to a haemoglobin of 14 g.l−1
with survival. Anaesth Intensive Care 1991;19:581–3.
18. Karn KE, Ogburn PL, Julian T, et al. Use of a whole blood substitute, Fluosol-DA 20%, after massive postpartum hemorrhage. Obstet Gynecol 1985; 65:127–30.
19. Akingbola OA, Custer JR, Bunchman TE, Sedman AB. Management of severe anemia without transfusion in a pediatric Jehovah’s Witness patient. Crit Care Med 1994; 22:524–8.
20. Zollinger A, Hager P, Singer T, et al. Extreme hemodilution due to massive blood loss in tumor surgery. Anesthesiology 1997; 87:985–7.
21. Fontana JL, Welborn L, Mongan PD, et al. Oxygen consumption and cardiovascular function in children during profound intraoperative normovolemic hemodilution. Anesth Analg 1995; 80:219–25.
22. Shibutani K, Komatsu T, Kubal K, et al. Critical level of oxygen delivery in anesthetized man. Crit Care Med 1983; 11:640–3.
23. van Woerkens ECSM, Trouwborst A, van Lanschot JJB. Profound hemodilution: what is the critical level of hemodilution at which oxygen delivery-dependent oxygen consumption starts in an anesthetized human? Anesth Analg 1992; 75:818–21.