Reoperation, emergency and urgent open cardiac surgery in Jehovah's Witnesses

Short-term outcome of cardiac surgery under cardiopulmonary bypass in patients who refuse transfusion: a controlled study

BACKGROUND

Although bloodless cardiac surgery has been successfully performed for many years, studies with controls permitting transfusion are few and their results inconclusive. This study compares the outcome of cardiac surgery on Jehovah's Witnesses (JW) refusing transfusion, with that of controls permitting transfusion if required.

METHODS

Data from 172 operations in 162 JW were compared with 172 matched controls. Risk factors, preoperative, operative, 48 hour postoperative variables, outcome data and transfusions were recorded.

RESULTS

Preoperative and operative variables were similar in both groups except for more previous cardiac operations, and more frequent use of cell saver and aprotinin in JW, who bled less and had higher hemoglobin concentrations at all periods. Thirty-day mortality was higher in JW (9.9% vs. 3.5%; P=0.03) (Risk difference 6.4%; CI95%: 2.7-10.1). Nevertheless operative mortality was similar in both groups (9.9% vs. 7.6%; P=0.44). Mortality in low-risk subjects was higher in JW (8.9% vs. 1.0%; P=0.02) (Risk difference 7.9%; CI95%: 2.7-13.2). Moreover, death associated with hemorrhage and anemia tended to be more frequent in JW. Mortality of transfused controls (14.1%) and their matched JW (13.0%) was similar. In contrast, mortality of non-transfused controls was zero versus 6.3% in their matched JW (P=0.059).

CONCLUSIONS

Low-risk JW had significantly higher mortality than controls. Bleeding related deaths tended to be more frequent in JW. Blood-sparing maneuvers should be intensively implemented in both JW and patients permitting transfusion in order to reduce bleeding and the need for transfusion with its harmful effects.

Patient blood management - a new paradigm for transfusion medicine?

The saving of many lives in history has been duly credited to blood transfusions. What is frequently overlooked is the fact that, in light of a wealth of evidence as well as other management options, a therapy deemed suitable yesterday may no longer be the first choice today. Use of blood has not been based upon scientific evaluation of benefits, but mostly on anecdotal experience and a variety of factors are challenging current practice. Blood is a precious resource with an ever limiting supply due to the aging population. Costs have also continually increased due to advances (and complexities) in collection, testing, processing and administration of transfusion, which could make up 5% of the total health service budget. Risks of transfusions remain a major concern, with advances in blood screening and processing shifting the profile from infectious to non‐infectious risks. Most worrying though, is the accumulating literature demonstrating a strong (often dose‐dependent) association between transfusion and adverse outcomes. These include increased length of stay, postoperative infection, morbidity and mortality. To this end, a recent international consensus conference on transfusion outcomes (ICCTO) concluded that there was little evidence to corroborate that blood would improve patients’ outcomes in the vast majority of clinical scenarios in which transfusions are currently routinely considered; more appropriate clinical management options should be adopted and transfusion avoided wherever possible. On the other hand, there are patients for whom the perceived benefits of transfusion are likely to outweigh the potential risks. Consensus guidelines for blood component therapy have been developed to assist clinicians in identifying these patients and most of these guidelines have long advocated more conservative ‘triggers’ for transfusion. However, significant variation in practice and inappropriate transfusions are still prevalent. The ‘blood must always be good philosophy’ continues to permeate clinical practice. An alternative approach, however, is being adopted in an increasing number of centres. Experience in managing Jehovah’s Witness patients has shown that complex care without transfusion is possible and results are comparable with, if not better than those of transfused patients. These experiences and rising awareness of downsides of transfusion helped create what has become known as ‘patient blood management’. Principles of this approach include optimizing erythropoiesis, reducing surgical blood loss and harnessing the patient’s physiological tolerance of anaemia. Treatment is tailored to the individual patient, using a multidisciplinary team approach and employing a combination of modalities. Results have demonstrated reduction of transfusion, improved patient outcomes and patient satisfaction. Significant healthcare cost savings have also followed. Despite the success of patient blood management programmes and calls for practice change, the potential and actual harm to patients caused through inappropriate transfusion is still not sufficiently tangible for the public and many clinicians. This has to change. The medical, ethical, legal and economic evidence cannot be ignored. Patient blood management needs to be implemented as the standard of care for all patients.

Meeting the clinical challenge of care for Jehovah’s Witnesses1 1Editor’s Note: This article represents the current position of the Watch Tower Society on the use of blood components and fractions in the care of patients who are Jehovah’s Witnesses

Quality patient care entails more than simply biomedical interventions. Respect for the wishes, values, and preferences of patients are important elements of quality care. Unique aspects of the beliefs of Jehovah's Witnesses may present physicians with ethical and clinical conflicts. Witnesses believe that allogeneic blood transfusion (ie, whole blood, red blood cells, white cells, platelets, and plasma) and preoperative autologous blood deposit (PAD) are prohibited by several Biblical passages. This article reviews the Witness position on medical care, blood components, and fractions, placing these and related interventions into categories that may help physicians to individualize clinical management plans and meet the challenge of caring for patients who are Jehovah's Witnesses. It includes an overview of cost, safety, efficacy, and medicolegal issues related to patient care using transfusion-alternative strategies.

[Treatment of post-traumatic acute anemia by recombinant human erythropoietin in Jehovah's Witnesses]

A 20-year-old Jehovah's witness patient experienced a femur fracture, with a section of the femoral artery and vein. On admission, haemoglobin concentration was 5.6 g.dL-1 and haematocrit 17%. Because of aponevrotomy, blood losses persisted. As the patient refused blood transfusion, recombinant human erythropoietin and parenteral iron were administered, associated with mild hypothermia, sedation and mechanical ventilation. After 21 days, the haemoglobin concentration increased to 10.9 g.dL-1 and haematocrit to 33% Recombinant human erythropoietin and parenteral iron may provide an alternative safe and effective therapy in life-threatening anaemia when blood transfusions are not accepted by the patient.

[Blood transfusion in surgery: can it still be reduced by human recombinant erythropoietin?]

New agents such as recombinant human erythropoietin (rHu EPO) modify conventional transfusionnal strategies. For accurate indications, such as, anaemia associated with chronic renal failure, cancer or cardiac disease, the preoperative prescription of rHu EPO may reduce transfusion requirements. rHu EPO may also be associated with pre-deposit transfusion in patients with anaemia before blood donation, when the transfusion needs are high, or the period for blood pre-deposit donation shortened. Postoperatively rHu EPO is only efficient if it is administered for a prolonged period; this condition limits its indications and value because of its high cost.

Cardiac surgery in special populations, Part 2: Women, pregnant patients, and Jehovah's Witnesses

This is the second in a series of articles that discusses cardiac surgery in patients who belong to special populations. Women are often the victims of sex bias regarding their referral to cardiac testing, and are consequently sicker when they present for heart surgery. Pregnant women undergoing cardiac surgery require vigilant care while undergoing surgery, with anticoagulant administration and valve selection to achieve positive maternal and fetal outcomes. Progressive improvements in technology, perioperative care, and pharmaceutical development has made cardiac surgery in Jehovah's Witnesses safer than in the past.

Successful reoperation for ascending aorta and arch aneurysm in a Jehovah's Witness

A young woman of the Jehovah's Witness faith presented with a rupturing aneurysm of the ascending aorta and transverse aortic arch. She had Marfan syndrome and previous aortic valve replacement. Despite reoperation conditions, successful operation via median sternotomy was carried out using deep hypothermia and circulatory arrest.