Jehovah’s Witness patients are at increased risk for morbidity and mortality associated with blood loss due to their refusal, on religious grounds, of both homologous blood transfusion and autologous blood that has been removed from continuity with the body. They believe that it is wrong to accept or receive any type of blood product.
Even though it is commonly accepted that the Jehovah’s Witnesses will not receive any blood products, this does quite often vary from patient to patient. Therefore, it is recommended that each individual patient be presented with all possible options, including Albumin, in an effort to better assess the individuals personal convictions in relation to transfusion.
II. EXCLUSION PATIENTS:
A. Patients with significant coagulopathies
B. Patients with an expanding hematoma
C. Patients on thrombolytic therapy
D. Patients that are anemic for a known or unknown reason
E. Patients with a hemoglobinopathy
III. POTENTIAL PERFUSION TECHNIQUES:
A. Semi-Continuous Flow Centrifugation – Autotransfusion.
B. The use of perfluorocarbons
C. Hemoconcentration (this would include Modified Ultrafiltration)
IV. REGIMEN FOR JEHOVAH’S WITNESS PATIENTS IN OPEN-HEART SURGERY:
A. Fluids: Crystalloid fluid only, colloid administration should be Hespan or Dextran.
(Caution should be used with Dextran due to its theoretical effect on platelet function)
B. If possible, patients should be placed on Erythropoietin as far in advance of surgery as possible. Hematocrit should be > 36% prior to surgery and Erythropoietin continued until patient discharge for a hematocrit less than 30%.
C. If the patient will allow autologous blood donation in the O.R. suite, this procedure should be maximized to sequester as much blood as possible, only to be reinfused after the protamine.
D. Any and all excess tubing should be removed from the CPB circuit and the pump pushed as close to the table as possible. The smallest diameter tubing allowed by individual flow requirements should be substituted for the standard perfusion circuit.
E. Priming volume should be kept to a minimum. Consider Retrograde Autologous Prime (RAP).
F. Diuretics and hemoconcentration should be aggressively used during CPB. Mannitol may be used: 12.5 Gm in prime, 12.5 Gm when beginning to rewarm, 12.5 Gm just prior to coming off CPB.
G. Exclusive use of intraoperative cell saver. All blood salvaged and continuously reinfused through the cell saver in a closed circuit. Minimize use of laps, sponges and discard suckers. The entire bypass circuit should also be processed.
H. Modified Ultrafiltration (MUF) has proven to be quite effective in the Jehovah’s Witnesses population. It is not uncommon to raise the patient’s hematocrit 3-7% with MUF in a 20 minute time period. (Eg. Raised from Hct 23% to 28% in 20 minutes.)
I. All chest tube drainage should be reinfused if chest drainage is > 50 ml/hr. for the first 8 hours post-op.
J. If the patient has well preserved ventricular function, SVR should be maintained at > 1000 in an attempt to decrease the circulating vascular volume.
K. Great attention should be given to anticoagulation and heparin reversal to prevent heparin rebound post operation.