Management of anemia in patients who decline blood transfusion

Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper

Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient's values and target the best outcome possible given the patient's desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes.

Management of peri-surgical anemia in elective surgery. Conclusions and recommendations according to Delphi-UCLA methodology

INTRODUCTION

Preoperative anemia affects approximately one third of surgical patients. It increases the risk of blood transfusion and influences short- and medium-term functional outcomes, increases comorbidities, complications and costs. The "Patient Blood Management" (PBM) programs, for integrated and multidisciplinary management of patients, are considered as paradigms of quality care and have as one of the fundamental objectives to correct perioperative anemia. PBM has been incorporated into the schemes for intensified recovery of surgical patients: the recent Enhanced Recovery After Surgery 2021 pathway (in Spanish RICA 2021) includes almost 30 indirect recommendations for PBM.

OBJECTIVE

To make a consensus document with RAND/UCLA Delphi methodology to increase the penetration and priority of the RICA 2021 recommendations on PBM in daily clinical practice.

MATERIAL AND METHODS

A coordinating group composed of 6 specialists from Hematology-Hemotherapy, Anesthesiology and Internal Medicine with expertise in anemia and PBM was formed. A survey was elaborated using Delphi RAND/UCLA methodology to reach a consensus on the key areas and priority professional actions to be developed at the present time to improve the management of perioperative anemia. The survey questions were extracted from the PBM recommendations contained in the RICA 2021 pathway. The development of the electronic survey (Google Platform) and the management of the responses was the responsibility of an expert in quality of care and clinical safety. Participants were selected by invitation from speakers at AWGE-GIEMSA scientific meetings and national representatives of PBM-related working groups (Seville Document, SEDAR HTF section and RICA 2021 pathway participants). In the first round of the survey, the anonymized online questionnaire had 28 questions: 20 of them were about PBM concepts included in ERAS guidelines (2 about general PBM organization, 10 on diagnosis and treatment of preoperative anemia, 3 on management of postoperative anemia, 5 on transfusion criteria) and 8 on pending aspects of research. Responses were organized according to a 10-point Likter scale (0: strongly disagree to 10: strongly agree). Any additional contributions that the participants considered appropriate were allowed. They were considered consensual because all the questions obtained an average score of more than 9 points, except one (question 14). The second round of the survey consisted of 37 questions, resulting from the reformulation of the questions of the first round and the incorporation of the participants' comments. It consisted of 2 questions about general organization of PBM programme, 15 questions on the diagnosis and treatment of preoperative anemia; 3 on the management of postoperative anemia, 6 on transfusional criteria and finally 11 questions on aspects pending od future investigations. Statistical treatment: tabulation of mean, median and interquartiles 25-75 of the value of each survey question (Tables 1, 2 and 3).

RESULTS

Except for one, all the recommendations were accepted. Except for three, all above 8, and most with an average score of 9 or higher. They are grouped into: 1.- "It is important and necessary to detect and etiologically diagnose any preoperative anemia state in ALL patients who are candidates for surgical procedures with potential bleeding risk, including pregnant patients". 2.- "The preoperative treatment of anemia should be initiated sufficiently in advance and with all the necessary hematinic contributions to correct this condition". 3.- "There is NO justification for transfusing any unit of packed red blood cells preoperatively in stable patients with moderate anemia Hb 8-10g/dL who are candidates for potentially bleeding surgery that cannot be delayed." 4.- "It is recommended to universalize restrictive criteria for red blood cell transfusion in surgical and obstetric patients." 5.- "Postoperative anemia should be treated to improve postoperative results and accelerate postoperative recovery in the short and medium term".

CONCLUSIONS

There was a large consensus, with maximum acceptance,strong level of evidence and high recommendation in most of the questions asked. Our work helps to identify initiatives and performances who can be suitables for the implementation of PBM programs at each hospital and for all patients.

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.

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.

Recommendations From the International Consensus Conference on Anemia Management in Surgical Patients (ICCAMS)

BACKGROUND

Perioperative anemia has been associated with increased risk of red blood cell transfusion and increased morbidity and mortality after surgery. The optimal approach to the diagnosis and management of perioperative anemia is not fully established.

OBJECTIVE

To develop consensus recommendations for anemia management in surgical patients.

METHODS

An international expert panel reviewed the current evidence and developed recommendations using modified RAND Delphi methodology.

RESULTS

The panel recommends that all patients except those undergoing minor procedures be screened for anemia before surgery. Appropriate therapy for anemia should be guided by an accurate diagnosis of the etiology. The need to proceed with surgery in some patients with anemia is expected to persist. However, early identification and effective treatment of anemia has the potential to reduce the risks associated with surgery and improve clinical outcomes. As with preoperative anemia, postoperative anemia should be treated in the perioperative period.

CONCLUSIONS

Early identification and effective treatment of anemia has the potential to improve clinical outcomes in surgical patients.

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.

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.

Preoperative Correction of Anemia to Allow a 3000 ml Blood Loss Without Transfusion in a Jehovah's Witness Presenting for Explantation of an Infected Hip Joint Prosthesis: A Case Report

A 70-year-old Jehovah's Witness was treated with iron carboxymaltose intravenously, recombinant human erythropoietin alpha subcutaneously, and vitamin B12 and folate orally for 9 weeks to raise hemoglobin (Hb) from 10.8 to 17.0 g/dL before explantation of an infected hip joint prosthesis. The target Hb was calculated from the following formula: Hbtarget = Hbfinal/(1 - ABL/EBV), where Hbtarget= Hb to achieve before surgery, Hbfinal = lowest Hb patient could tolerate taking into consideration his comorbidities (7 g/dL), ABL = volume of blood the surgeon estimated the patient would lose intra- and postoperatively (3000 mL), and EBV = estimated blood volume (75 mL/kg for an adult man). Spinal anesthesia was provided with a single shot hyperbaric bupivacaine and fentanyl. Acute hypervolemic hemodilution was achieved with lactated Ringer's solution and hydroxyethyl starch. To further minimize blood loss, controlled hypotension to a mean blood pressure of 55 mm Hg was achieved with a propofol infusion and tranexamic acid was administered. Surgical blood loss was estimated to be 2500 mL. Hb at the end of surgery was 13.3 g/dL; on postoperative day 5, 11.7 g/L. No blood products were utilized.

Blood transfusion and alternatives in Jehovah's Witness patients

PURPOSE OF REVIEW

More than 8.5 million people in the world observe the Jehovah's Witness faith, and require unique consideration for perioperative blood management as they generally refuse transfusion of blood and blood products. This review addresses a collaborative approach to each patient throughout the perioperative arena. The principles of this approach include optimization of hemoglobin levels preoperatively, attention to blood-salvaging methods intraoperatively, and minimization of blood draws postoperatively. In addition, we review the technologies currently in development as transfusion alternatives, including hemoglobin-based oxygen carriers.

RECENT FINDINGS

Progress has been made recently in the field of synthetic blood alternatives and hemoglobin-based oxygen carriers, which may lead to improved outcomes in this patient population.

SUMMARY

Utilization of multiple prevention and mitigation strategies to optimize oxygen supply and decrease oxygen demand will lead to decreased incidence of critical anemia and subsequent improved mortality in Jehovah's Witness patients.

Acute Blood Loss Anemia in the Setting of Abdominal Aortic Aneurysm Rupture in a Jehovah's Witness

Acute blood loss anemia occurs due to many variants. The standard of care in managing acute blood loss anemia is challenged in this case. Jehovah's Witnesses's (JW) management of blood loss anemia continues to remain a controversy in medicine since they do not allow the use of blood products. This case highlights the management of acute blood loss anemia, utilizing a multidisciplinary bloodless approach in a JW who underwent an endovascular aneurysmal repair (EVAR) of an impending rupture of abdominal aortic aneurysm (AAA). The severity of anemia with hemoglobin of 2.7 g/dL and survival outcome is unique; however, the minimal hemoglobin level required to sustain life is still unclear.

Management of pregnancy in case of multiple and giant uterine fibroids

Uterine fibroids are common among women of reproductive age. During the pregnancy, the potential complications of fibroids, although rare, are of frequent clinical concern. Available studies describing management and obstetrical outcomes in pregnant women with giant fibroids are limited. We present the case of a 39-year-old pregnant woman with multiple and large uterine fibroids. During the pregnancy, there was adequate fetal development, without major maternal complications. Given the characteristics of the fibroids and breech position of the fetus, an elective caesarean section was decided, and postpartum hysterectomy planned. This challenging obstetrical case required a multidisciplinary approach.We considered crucial discussing five main issues: preconceptional counselling, tailored pregnancy surveillance, decision of time and route of delivery, decision to perform a peripartum hysterectomy and management of decreasing blood loss perioperatively. Given the limitation of the published reports, we believe that sharing our experience, along with a literature review, is beneficial for other clinicians.