Outcomes in cardiac surgery in 500 consecutive Jehovah's Witness patients: 21 year Experience

Abstract

BackgroundRefusal of heterogenic blood products can be for religious reasons as in Jehovah's Witnesses or otherwise or as requested by an increasing number of patients. Furthermore blood reserves are under continuous demand with increasing costs. Therefore, transfusion avoidance strategies are desirable. We describe a historic comparison and current results of blood saving protocols in Jehovah's Witnesses patients.MethodsData on 250 Jehovah's Witness patients operated upon between 1991 and 2003 (group A) were reviewed and compared with a second population of 250 patients treated from 2003 to 2012 (group B).ResultsIn group A, mean age was 51 years of age compared to 68 years in group B. An iterative procedure was performed in 13% of patients in group B. Thirty days mortality was 3% in group A and 1% in group B despite greater operative risk factors, with more redo, and lower ejection fraction in group B. Several factors contributed to the low morbidity-mortality in group B, namely: preoperative erythropoietin to attain a minimal hemoglobin value of 14 g/dl, warm blood cardioplegia, the implementation of the Cornell University protocol and fast track extubation.ConclusionsCardiac surgery without transfusion in high-risk patients such as Jehovah Witnesses can be carried out with results equivalent to those of low risk patients. Recent advances in surgical techniques and blood conservation protocols are main contributing factors.

Bloodless medicine: what to do when you can't transfuse

“…Although there are previous reports of management and outcomes for patients who do not accept ABT, [4][5][6][7][8][9][10][11][12][13][14][15][16][17] most are series of cases of surgical patients with simple outcome measures, such as length of stay and mortality, without matched control groups for comparison. [5][6][7][8][9][10][11][12][13][14][15][16][17] A study from 2002 showed that the risk of death in surgical patients with a postoperative hemoglobin level of 7.1-8.0 was low, although a morbid event (defined as a myocardial infarction, arrhythmia, congestive heart failure, or infection) occurred in 9.4% of patients.…”

“…[1][2][3] In fact, several academic health centers are establishing "Bloodless Medicine & Surgery Programs" that specialize in treating patients who do not accept allogeneic blood transfusions (ABTs). [4][5][6][7][8][9][10][11][12][13][14][15][16] A multidisciplinary approach is frequently required to optimize clinical outcomes for these patients, particularly in the setting of multiple comorbidities or high-risk surgical procedures.…”

“…[4][5][6][7][8][9][10][11][12][13][14][15][16] Based on religious beliefs, these individuals do not accept blood products considered to be "primary components," which includes RBCs, WBCs, platelets, or plasma. 4 In addition, JW patients do not typically accept autologous blood donated preoperatively, although most will accept autologous blood that is considered to be physically contiguous with one's body.…”

“…[4][5][6][7][8][9][10][11][12][13][14][15][16][17] Moreover, there are no standard, established guidelines to manage cytopenias in these patients, nor are there many studies to inform optimal treatment approaches. Here, we outline prior studies on bloodless management and discuss the approaches used at our institution to care for patients who refuse transfusions (hereafter referred to as "bloodless patients").…”

“…We close with suggestions for further studies to guide management of bloodless patients. Because recent evidence suggests that bloodless patients do as well, if not better than other patients, [4][5][6][7][8][9][10][11][12][13][14][15][16] advances in bloodless medicine are likely to benefit all patients with anemia. Given the significant expense associated with transfusion therapy,…”