Blood-sparing removal technique of extracorporeal membrane oxygenation circuit in a Jehovah Witness patient

Abstract

Rationale: Percutaneous cardiopulmonary support (PCPS) using extracorporeal membrane oxygenation (ECMO) is widely used in the critical patients with cardiopulmonary collapse. It is a representative blood-consuming procedure. In limited situations in which the option of blood transfusion is unavailable, there is no general agreement as to whether ECMO is contraindicated. Patient concerns: A 61-year-old male Jehovah Witness with acute respiratory collapse and loss of consciousness was rushed to our emergency room. Throughout his hospital course, the patient's family refused any type of blood transfusion even at the risk of death. Diagnosis: The clinical situations were secondary to a massive pulmonary thromboembolism Interventions: The patient underwent veno-venous ECMO via both femoral veins. The patient was recovered by intensive medical care although the level of hemoglobin (Hb) and hematocrit (Hct) was gradually decreased from 15.8 g/dl and 46.8% to 11.7 g/dl and 36.5%, respectively. Outcomes: On hospital day 3, ECMO was successfully removed using a blood-sparing ECMO removal technique involving the recycling of blood within the circuit by continuous saline infusion. There was no significant change in level of Hb/Hct and hemodynamic profile. At 2 days after ECMO removal, the level of Hb/Hct was elevated up to 9.2 g/dl and 30.0%, respectively without any transfusion. Lessons: Our blood-sparing removal technique of ECMO appears to be feasible and led to no significant adverse impact on hemodynamic status. The technique might be helpful for critical patients who cannot receive blood transfusion due to any cause.

Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature

“…Therefore, the refusal for blood transfusions, most often encountered in patients of Jehovah’s Witness faith, could be counted as a contraindication for the use of ECMO. In recent years, case reports of Jehovah’s Witnesses safely treated without blood transfusion while on ECMO have been published [ 152 , 153 , 154 , 155 ]. Managing patients without blood transfusions while on an extracorporeal circuit is very rare; however, it is an important option for these patients and advocates even more for a center specialized and very experienced in ECMO treatment.…”

Extracorporeal membrane oxygenation in Jehovah’s Witness patients: Case report, literature review, and summary of recommendations

“…Two articles were ruled out due to ethical concerns regarding the administration of ECMO to children of JW parents. The other four case reports [2][3][4][5] are summarized in Table 2. Three cases were respiratory ECMO patients with VV ECMO, one of whom required conversion to VA due to right ventricular failure.…”

“…A surgical cell-saver was used in three cases to auto-transfuse blood from the circuit. Park et al 5 described the return of blood by introducing saline into the circuit after clamping the drainage cannula with a connector and using the drive of the centrifugal ECMO pump, without complications. Despite all these and other measures, in all cases a constant fall in hemoglobin levels was found.…”

“…The use of a cell-saver is feasible and safe; in comparison with other blood-sparing techniques, it reduces the risk of air embolism, and clot mobilization. 5…”