Jehovah's Witness and Bloodless Cadiac Surgery

Multidisciplinary approach to blood conservation

Recombinant erythropoietin: This agent that has been used routinely in renal failure patients has found it use in bloodless cardiac surgery patients. High-dose erythropoietin (600-800 U/kg load, 500 U/kg every other day) before and after surgery has been shown to increase the hematocrit significantly after the surgery.

Aprotonin

Hypertonic saline-dextran (HSD) solutions: Oliviera et al compared clinical, hemodynamic, laboratory evolution, and fluid balance of 20 Jehovah's Witnesses over the first 72 h following CPB. Ten patients received hypertonic saline-dextran (HSD) immediately prior to CPB. All patients survived and were maintained in stable hemodynamic and metabolic condition throughout the study period. HSD induced high cardiac output, low vascular resistance immediately after administration. Vascular resistance remained low until the end of CPB. HSD patients ran a slightly negative fluid balance, while control patients ran a large positive fluid balance. Currently they use HSD pretreatment routinely for Jehovah's Witnesses undergoing CPB.

Intraoperative autologous blood donation

Intraoperative cell salvage

Continuous shed blood reinfusion

Drawing as few blood specimens as possible

Hypotensive anesthesia: It has been employed in may cases successfully to reduce the introperative bleeding.

Iron supplements: In acute situations these patients can be treated with IV iron (Imferon). The required dosage can be calculated based on the current hemoglobin level and the desired hemoglobin level you would like to achieve. First, half a milliliter of iron should be given as a test dose to look for any reaction. If the patient doesn't get a reaction then the entire dose can be given as a single infusion diluted in 100 ml of D5W. In addition these patients must be treated with oral iron pills give 2-3 times a day.

Beta Blockers: Beta blockers reduce the heart rate and myocardial oxygen demand.

Hence, if e A study reported in 1991, discussed using heparin-coated cardiopulmonary bypass equipment during perfusion with low systemic heparinization in three Jehovah's witnesses who underwent successful revascularization. During perfusion, they maintained activated clotting time (ACT) above 180 seconds. Prebypass haematocrit was 38 +/- 3% and dropped to 22 +/- 1% after seven days. Another study used plateletpheresis and plasmapheresis, to conserve and minimize blood loss in four patients who successfully underwent scoliosis surgery.

Study Year Patients/Mortality % Redo/Mortality Hct-Pre Hct-Post

Cooley 1991 663/7%

Spence 1992 59/5.1%

Grebenik 1995 6/0

Chikada 1996 25/4% 6/0 22.7% 27%

Rosengrat 1997 50/4% 30%

Factors contributing to increased mortality are repeat cardiac operations, severe left ventricular dysfunction (defined as an LVEF less than 0.35), and a hemoglobin level lower than 80 g/L (8 g/dL) on postoperative day 1(cooley).

References:

Laparoscopic splenectomy in a Jehovah's Witness with profound anemia. Ferzli GS, Hurwitz JB, Fiorillo MA, Hayek NE, Dysarz FA, Kiel T. Surg Endosc 1997 Aug;11(8):850-1

Jehovah's Witnesses and surgery Jehovah's witness Jovanovic S, Hansbro SD, Munsch CM, Cross MH. Redo cardiac surgery in a Jehovah's Witness, the importance of a multidisciplinary approach to blood conservation. Perfusion 2000 Jun;15(3):251-5

Open-heart surgery in Jehovah's Witness patients Chikada M, Furuse A, Kotsuka Y, Yagyu K. Cardiovasc Surg 1996 Jun;4(3):311-4

Effects of hypertonic saline dextran on the postoperative evolution of Jehovah's Witness patients submitted to cardiac surgery with cardiopulmonary bypass Oliviera et al. Shock 1995 Jun;3(6):391-4

Open heart operations without transfusion using a multimodality blood conservation strategy in 50 Jehovah's Witness patients: implications for a "bloodless" surgical technique. Rosen gart TK, Helm RE, DeBois WJ, Garcia N, Krieger KH, Isom OW J Am Coll Surg 1997 Jun;184(6):618-29

Dougherty JE, Gallagher RC, Hirst JA, Rinaldi MJ, Biskup JM, Chamberlain RD, Waters D Coronary stent placement as a bridge to coronary artery bypass surgery in an unstable, anemic Jehovah's Witness patient: a case report and review of bloodless surgery techniques. Conn Med 1997 Apr;61(4):195-9

Transfusion guidelines for cardiovascular surgery: lessons learned from operations in Jehovah's Witnesses. Spence RK, Alexander JB, DelRossi AJ, Cernaianu AD, Cilley J Jr, Pello MJ, Atabek U, Camishion RC, Vertrees RA. J Vasc Surg 1992 Dec;16(6):825-9; discussion 829-31

Podesta A, Carmagnini E. Erythropoietin in Jehova's witness heart surgery. Minerva Cardioangiol 1999 Jul-Aug;47(7-8):261-7 Genova.

Lewis CT, Murphy MC, Cooley DA Risk factors for cardiac operations in adult Jehovah's Witnesses. Ann Thorac Surg 1991 Mar;51(3):448-50

Anesthetic management of the patient who refuses blood transfusions. Dupuis JF, Nguyen DT. Int Anesthesiol Clin 1998 Summer;36(3):117-31

Clinical application of heparin-coated perfusion equipment with special emphasis on patients refusing homologous transfusions. von Segesser LK, Weiss BM, Garcia E, Turina MI. Perfusion 1991;6(3):227-33

Management of Jehovah's Witness patients for scoliosis surgery: the use of platelet and plasmapheresis. Safwat AM, Reitan JA, Benson D. J Clin Anesth 1997 Sep;9(6):510-3

High risk cardiac surgery in Jehovah's Witnesses. Grebenik CR, Sinclair ME, Westaby S. J Cardiovasc Surg (Torino) 1996 Oct;37(5):511-5