Anesthesia Considerations 

Jehovah's Witness Patients 

 

 

Background

 

• Traditionally, orthodox Jehovah’s Witnesses won’t accept homologous or autologous whole blood, pRBCs, plasma, platelets & WBCs, even when necessary to prevent morbidity/mortality

• Refusal is based on religious beliefs deriving from strict literal interpretation of passages in the Bible forbidding the “eating” of blood

• Belief that eternal life may be forfeited if they do not exactly follow biblical commands

• Usually refused

  • Whole blood

  • RBCs

  • Platelets

  • FFP

  • Cryoprecipitated antihemophilic factor

  • Granulocytes

  • Fibrin glue/sealant

  • Predeposited autologous blood/components

• Usually accepted

  • Normovolemic hemodilution*

  • Intraoperative RBC salvage*

  • Erythropoietin (albumin-free)

  • Hemodialysis**

  • Heart-lung equipment**

*Usually accepted if patient remains in continuous contact with blood

**If non-blood prime used

• Individual Decision (according to the individual’s preference)

  • Albumin

  • Immune globulins

  • Factor concentrates

  • Organ & tissue transplants

 

 

Considerations

 

• Need for preoperative hemoglobin optimization & perioperative blood conservation 

• Legal issues

  • A patient's legal right to refuse or consent to treatment is based on common law & is therefore is constantly evolving as new cases are decided

  • Clinicians should not administer emergency treatment without consent if they have reason to believe that the patient would refuse such treatment if he or she were capable

  • In certain pediatric cases, the child may be made a ward of the court in order to administer clinically necessary blood transfusions

• Informed consent

  • Must outline risks & benefits of receiving or refusing transfusions to the individual patient in their clinical situation

  • Discuss alternatives to transfusion (may include transferring patient to another facility with more experience)

  • Determine specifically which blood products/procedures the patient will accept & refuse

  • If necessary, follow appropriate procedures to obtain court intervention (ex pediatric patients, patients with dementia, comatose, etc)

 

 

Conflicts 

 

• Conflict between beneficence & autonomy, where autonomy is generally given precedence over beneficence

• Physicians are ordinarily taught to preserve life, yet they must also respect a competent adult patient's right to refuse treatment

 

 

Management

 

• Optimize preop hemoglobin 

  • Enhance RBC production

    • Iron supplementation if deficient

      • Oral in divided doses

      • IV if short time before surgery, intolerance to po Fe, or GI absorption problems

    • Folate and/or vitamin B12 supplementation if deficient

    • Erythropoietin

      • If anemia of renal/chronic disease

• Minimize iatrogenic blood loss

  • Avoid unnecessary testing

  • Minimize test sample volume (ex pediatric tubes)

• Minimize intraop blood loss

  • Meticulous surgical technique

  • Regional anesthesia

  • Maintain normothermia, physiologic pH

  • Intraoperative cell salvage

  • Normovolemic hemodilution

• Ensure hemostasis 

  • Antifibrinolytic agents (tranexamic acid, aprotinin, etc)

  • Fibrinogen concentrate (if acceptable to patient)

  • Desmopressin

  • Prothrombin complex concentrates (where appropriate)

  • Recombinant Factor VIIa (controversial)

• Maintain circulating blood volume

  • Crystalloid

  • Synthetic colloid

 

 

In Pregnancy

 

• Epidural blood patch may be acceptable if blood remains in constant connection to patient (i.e. injecting syringe is connected to vein via tube)