Blood Conservation Techniques and Perioperative Planning ...The topic was only continued if the patient signalled a clear wish for this. Half the patients had a close relative present

Helping Hands for Blood Conservation Techniques and Perioperative Planning Part 8 May 2001

What has been managed with Blood Conservation Techniques at present ?? Let�s see experiences with:

PERIOPERATIVE BLOOD CONSERVATION

AND SURGICAL MANAGEMENT OF JEHOVAH'S WITNESSES and of

others without the use of allogenic blood

K.R Part 8 of Helping Hands of Blood Conservation Techniques, May 2001 Page 2

Table of Content

WHAT HAS BEEN MANAGED WITH BLOOD CONSERVATION TECHNIQUES AT PRESENT ?? ............................................................................................................. 1

PERIOPERATIVE BLOOD CONSERVATION AND SURGICAL MANAGEMENT OF JEHOVAH'S WITNESSES AND OF OTHERS WITHOUT THE USE OF ALLOGENIC BLOOD................................................................................................. 1

I. ETHICS, BLOOD TRANSFUSION AND JEHOVAH�S WITNESSES ................................................. 6 A. Adults Ethics and Refusal of Blood .......................................................................................................... 6

1. General Aspects and Ethics................................................................................................................... 6 2. Respecting Patients Rights .................................................................................................................... 9 3. Interventional Paternalism................................................................................................................... 11 4. Costs of Refusing Treatments ............................................................................................................. 12 5. Refusal of Blood Transfusion Therapy ............................................................................................... 12 6. Ethics of Intrauterine Transfusions ..................................................................................................... 15 7. Law and Ethics Minors and Mentally disabled Adult ......................................................................... 16 8. Obstetric Haemorrhage in Women who Refuse Blood Transfusion ................................................... 17 9. Informed Consent................................................................................................................................ 17

B. Severe Anemia Postoperative Management ............................................................................................ 18 1. Acute Anemia and Management ......................................................................................................... 18

a) Acute Anemia treatment General Aspects................................................................................. 18 b) Acute Anemia and EPO ............................................................................................................ 20

2. Postoperative Management of Severe Anemia.................................................................................... 21 C. Children................................................................................................................................................... 22 D. Adolescent�s and Transfusion Ethics ...................................................................................................... 24 E. Management of the "No" Allogenicblood Request"................................................................................ 24 F. Perioperative Management ...................................................................................................................... 26

1. Surgery and Anemia............................................................................................................................ 26 2. Aggressive Non-Blood Management .................................................................................................. 27 3. Heparin induced Thrombocytopenia ................................................................................................... 29

G. Blood Transfusion................................................................................................................................... 29 II. PREMATURE INFANTS......................................................................................................................... 33

A. Anemia of Prematurity and EPO............................................................................................................ 33 III. ANESTHESIA.......................................................................................................................................... 34

A. General Aspects ...................................................................................................................................... 34 B. Hypotensive Anesthesia .......................................................................................................................... 37 C. Hypothermic Anesthesia ......................................................................................................................... 39 D. Spinal Anesthesia .................................................................................................................................... 41 E. Acute Hemodilution ................................................................................................................................ 41 F. Hyper Baric Oxygen Therapy (HBO)...................................................................................................... 45

1. HBO General Aspects of Anemia Treatments .................................................................................... 45 2. HBO for massive Antepartum Haemorrhage ...................................................................................... 46

G. Cell salvage-Autotransfusion .................................................................................................................. 46 1. AUTO General Aspects ...................................................................................................................... 46 2. AUTO Trans and EPO ........................................................................................................................ 48 3. AUTO and Heparin Coated Circuits ................................................................................................... 49

H. Perfluorocarbons (PFCs)......................................................................................................................... 49 A. PFC First Generation Experiences ..................................................................................................... 49 B. Second Generation of PFC ................................................................................................................. 53

I.Epidural Blood Patch for Cerebrospinalfluid leakage ............................................................................... 55 J. Iatrogenic Anemia .................................................................................................................................... 55

1. Minimizing Iatrogenic Phlebotomy induced Anemia ......................................................................... 55 K. Anesthesia for Laparoscopic Surgery ..................................................................................................... 56

1. Anesthesia for Laparoscopic Adrenalectomy ............................................................................ 56 IV. PERISURGICAL ERYTHROPOIETIN ............................................................................................... 56

1. EPO for those Refusing Blood Transfusions ...................................................................................... 56


2. EPO in Orthopedic surgery ................................................................................................................. 58 3. EPO in Hemipelvectomy for Cancer................................................................................................... 60 4. EPO in Postsurgical Anemia ............................................................................................................... 60 5. EPO in Neurosurgery .......................................................................................................................... 62 6. EPO in Gastrointestinal Surgery ......................................................................................................... 62 7. EPO in Gynecologic and Obstetric Surgery........................................................................................ 63 8. EPO in Cardio-Vascular Surgery ........................................................................................................ 63 9. EPO in Trauma.................................................................................................................................... 66 10. EPO for Urologic Surgery................................................................................................................. 67

V. NEUROSURGERY ................................................................................................................................... 67 1. EPO in Skull Surgery .......................................................................................................................... 67 2. Neurosurgery monitoring for Cerebral Trauma .................................................................................. 68

VI. HEAD AND NECK .................................................................................................................................. 69 1. Epistaxis................................................................................................................................................... 69 2. Floor of Mouth and Mandibular surgery.................................................................................................. 69 3. Maxillofacial Surgery .............................................................................................................................. 70 4. Tonsillar Surgery ..................................................................................................................................... 70 5. ORL Surgery in Children......................................................................................................................... 71

VII. CARDIAC SURGERY IN ADULTS ................................................................................................... 72 1. Blood ConservationTechnique for Adults ............................................................................................... 72

1. General Aspects .................................................................................................................................. 72 2. Aortic Surgery..................................................................................................................................... 73 3. Open Heart Surgery............................................................................................................................. 73 4. Coronary Surgery and Stenting ........................................................................................................... 76

2.Valve Replacements.................................................................................................................................. 79 1. General Aspects of Complicated Operations ...................................................................................... 79 2. Aortic Valve ........................................................................................................................................ 80 3. Mitral valve Replascement.................................................................................................................. 81 4. Double Valves Replacement ............................................................................................................... 81 5. Triple Valve Replacement................................................................................................................... 81

3. Coronary Artery Surgery: ........................................................................................................................ 82 4. Coronary stent Placement ........................................................................................................................ 83 5. Heparin-Bonded Circuits ......................................................................................................................... 83 6. Aprotinin in Cardiac Surgery:.................................................................................................................. 84 7. Desmopressin in Cardiac Surgery:.......................................................................................................... 85 8. Erythropoietin in Cardiac Surgery ........................................................................................................... 86 9. Ventricular Assist Device ........................................................................................................................ 87 10. "REDO" Reoperation Surgery ............................................................................................................... 88 11. Cardiac Surgery in Pregnancy................................................................................................................ 90

VIII. CARDIAC SURGERY IN CHILDREN.............................................................................................. 91 1. General Aspects ....................................................................................................................................... 91 2. Infective Endocarditis Surgery................................................................................................................. 94 3. Aortic Homograft..................................................................................................................................... 95 4. Congenital Heart Defects ......................................................................................................................... 95

1. Cardiac Surgery in JW General Aspects ............................................................................................. 95 2. Cardiac Surgery in JW Children "Ross Operation"............................................................................. 97

IX. Vascular Surgery...................................................................................................................................... 98 1. Aneurysm Repair General Aspects ..................................................................................................... 98 2. Ascending Aorta Aneurysm................................................................................................................ 98 3. Descending Aorta Aneurysm .............................................................................................................. 99 4. Abdominal Aneurysm Surgery.......................................................................................................... 100

X. Lung Surgery ........................................................................................................................................... 101 XI. OBSTETRICS AND GYNECOLOGY................................................................................................. 101

A. General Aspects .................................................................................................................................... 101 B. Special Situation.................................................................................................................................... 102

1. Postpartum Anemia........................................................................................................................... 102 2. Surgical Strategies for Blood Conservation in Gynecology............................................................. 102 3. Severe Anemia in Gynecologic ond Obstetric Emergencies............................................................. 104 4. Cervical Cancer Surgery and Pregnancy........................................................................................... 105 5. EPO in Obstetrics and Gynecology................................................................................................... 105


6. Autotransfusion in Gynecology and Obstetrics................................................................................. 106 7. Anesthetic and Intensive Care Techniques in Gynecology and Obstretics ....................................... 108

XII. UROLOGIC .......................................................................................................................................... 109 XIII. ABDOMINAL ..................................................................................................................................... 110

1. Liver, Gallbladder ............................................................................................................................. 110 2. Haemodilution Anaesthesia in Abdominal Surgery .......................................................................... 111

a) Adults Abdominal Surgery...................................................................................................... 111 b) Children Abdominal Surgery .................................................................................................. 112

3. Major Abdominal Surgery ................................................................................................................ 112 4. Splenic injury and Treatment ............................................................................................................ 113

a) Surgical Splenectomy.............................................................................................................. 113 b) Non operative Management of Splenic tear ............................................................................ 113

5. Laparoscopic Surgery........................................................................................................................ 114 a) Laparoscopic Trauma Surgery................................................................................................. 114

1) Laparoscopic Adrenalectomy ............................................................................................. 114 2) Laparoscopic Spleenctomy................................................................................................. 114

XIV. TRANSPLANTATION....................................................................................................................... 115 1. Liver Transplantation............................................................................................................................. 115 2. Renal Transplantation ............................................................................................................................ 116 3. Heart Transplantation............................................................................................................................. 118 4. Lung Transplantation ............................................................................................................................. 118 5. Bone Marrow Transaplantation ............................................................................................................. 119

XV. ORTHOPEDIC ..................................................................................................................................... 119 1. Orthopedics General Aspects................................................................................................................ 119 2. Spinal Surgery........................................................................................................................................ 120 3. Hip Surgery............................................................................................................................................ 124

XVI. TRAUMA AND EMERGENCY ........................................................................................................ 126 1. Trauma and Emergency treatments................................................................................................... 126

a) General Aspects............................................................................................................................ 126 b) Monitoring of Trauma Patients ................................................................................................... 127 c) Phlebotomy induced Iatrogenic Anemia ..................................................................................... 127 d) Myocardial Ischemia During the Perioperative Period ................................................................ 128

2. Cranial Trauma Management............................................................................................................ 128 3. Cervical Spinal Fracture treatment.................................................................................................... 128 4. Thermal Trauma Management .......................................................................................................... 129

A. Non Blood Management in Burns ............................................................................................... 129 a) Adult Thermal Victims............................................................................................................ 129 b) Burns in Children .................................................................................................................... 130

B. EPO in Thermal Injury ................................................................................................................ 131 5. Trauma and Acute Anemia Treatment .............................................................................................. 131

A. Autotransfusion..................................................................................................................................... 133 1. Autotransfusion General aspects ....................................................................................................... 133 2. AT from Laparoscopically Salvaged Blood...................................................................................... 134

B. Aneurysm Surgery................................................................................................................................. 134 1. General aspects of Aortic Aneurysm Repair ..................................................................................... 134 2. Ascending Aorta Aneurysm Surgery ................................................................................................ 134 3. Thoracic Aorta Aneurysm Surgery ................................................................................................... 135 4. Abdominal Aorta Aneurysm Surgery................................................................................................ 135

C. Hyperbaric Oxygen Therapy ................................................................................................................. 136 D. Gastrointestinal Emergencies and Surgery............................................................................................ 137 E. Transcathetral embolization and Chemoembolization........................................................................... 138

1. TAE Chemo for Metastatic Paraganglioma ...................................................................................... 138 2. TAE and Chemoembolization of Hepatocellular Cancer .................................................................. 138

XVII. BLOOD DISEASES........................................................................................................................... 139 A. Hematologic Disease and Anemias....................................................................................................... 139

1. Anemia of Chronic Disease............................................................................................................... 139 a. ACD and EPO .............................................................................................................................. 139 b. Anemia and Fluorocarbons........................................................................................................... 139

2. Hemophilia and Factor treatment ...................................................................................................... 140 a) Splenic Tear Management with Factor VIII................................................................................. 140


b) Use of Recombinant Factor VII treatment ................................................................................... 140 c) Percutaneous Nephrolithotripsy in Hemophilia A patient supported by Factor VIII ................... 141 d) Therapy of Intracranial Hemorrhage in a Hemophilia A patient with Inhibitors ........................ 141

3. Sickle Cell Anemia ........................................................................................................................... 141 4. Kawasaki Syndrome.......................................................................................................................... 142 5. Thrombocytopenic Purpura (TTP) .................................................................................................... 142 6. Thrombocytopenia (ITP) and HIT .................................................................................................... 142 7. Acquired von Willebrand Syndrome................................................................................................. 142

a) Coagulopathy induced by Plasma expanders ............................................................................... 142 8. Kasabach-Merritt Syndrome in JW infant......................................................................................... 143 9. ABO Hemolytic Disease ................................................................................................................... 143 10. Other Coagulopathies...................................................................................................................... 143

B. Leukemia and related Diseases ............................................................................................................. 143 1. Acute Lymphoblastic Leukemia ....................................................................................................... 143 2. Acute Myeloblastic Leukemia .......................................................................................................... 145 3. Acute Promyelosytic Leukemia ........................................................................................................ 146 4. Acute Hairy Cell Leukemia............................................................................................................... 146 5. Acute Monocytic Leukemia .............................................................................................................. 147 6. Myelodysplastic syndrome................................................................................................................ 147 7. Lymphoma Maligna .......................................................................................................................... 147

1. Hodgkins Disease .................................................................................................................... 147 2. Non Hodkin Lymphoma .......................................................................................................... 147

8. Peripheral Stem-Cell Transplant ....................................................................................................... 148 C. Thrombosis and Treatments of Thromboembolism .............................................................................. 148

1. Treatment of Pulmonary Embolism .................................................................................................. 148 XVIII. CANCER THERAPY ...................................................................................................................... 148

1. Cancer Chemotherapy....................................................................................................................... 148 2. Childhood Cancer Therapy ............................................................................................................... 149 3. Childhood Tumor Surgery and Blood Conservation......................................................................... 149

A. Tumor Resections ................................................................................................................................. 152 A. General Aspects of Tumor Surgery.................................................................................................. 152 B. Lung and/or ThoracicTumor ............................................................................................................ 152

1. Lung Cancer ............................................................................................................................ 152 2. Mediastinal Tumor .................................................................................................................. 152

C. Renal Tumors ................................................................................................................................... 152 D. Gastrointestinal Tumors ................................................................................................................... 153

1. Gastric Surgery ........................................................................................................................ 153 a) Statistics of Gastric and Colorectal Cancer in far East ....................................................... 153

2. Esophagus Surgery .................................................................................................................. 153 3. Duodenal Surgery .................................................................................................................... 153 4. Abdominal Desmoid Tumor Resection ................................................................................... 154 5. Colon cancer Surgery .............................................................................................................. 154 6. Rectal Carcinoma Resection.................................................................................................... 154

E. Gynecologic Tumors ........................................................................................................................ 155 F. Spinal Tumors................................................................................................................................... 156 G. Pelvic Tumors .................................................................................................................................. 157 H. Head and Neck Tumors.................................................................................................................... 157 I. Oral and Maxillo Facial Tumors........................................................................................................ 158

B. Cancer ................................................................................................................................................... 158 1. The Use of EPO in Solid Tumors...................................................................................................... 158 2. Hemodilution Anesthesia in Cancer Surgery .................................................................................... 159

XIX SPECIAL BLOOD CONSERVATION PROGRAMS...................................................................... 159 1. Bloodless Surgery (BS) General Aspects.......................................................................................... 159 2. BS Treatment of Anemia................................................................................................................... 161 3. BS Clinics for Heart Surgery ............................................................................................................ 162 4. BS treatment for Gynecologic disease .............................................................................................. 162


I. ETHICS, BLOOD TRANSFUSION AND JEHOVAH�S WITNESSES

A. Adults Ethics and Refusal of Blood 1. General Aspects and Ethics

(1) Norum J, Risberg T, Solberg E FAITH AMONG PATIENTS WITH ADVANCED CANCER. A PILOT STUDY ON PATIENTS OFFERED "NO MORE THAN" PALLIATION. Support Care Cancer 2000 Mar;8(2):110-114.

Department of Oncology, University Hospital of Tromso, Norway. [email protected] Spiritual wellbeing is an important topic in cancer care. Being religious is reported by patients facing dilemmas concerning the quality and meaning of life to be potentially helpful. However, the fear of death may be close to the surface and easily stimulated. The aim of this study was to clarify patients' attitudes to faith. Between February 1998 and February 1999, 20 patients aged 37-74 years and suffering from ten different incurable cancers were enrolled in the study. An interview technique focusing on the topic by way of an open question about faith was employed. The topic was only continued if the patient signalled a clear wish for this. Half the patients had a close relative present during the conversation, and an oncology nurse was present in all cases. Most patients (18, or 90%) intimated that the topic was of interest: 85% responded by saying they believed in God, and 75% reported that they prayed. A quarter (25%) mentioned that they had visited their local Lutheran pastor before their admission to hospital. One patient reported being a Jehovah's Witness and one, a member of the Norwegian Humanistically Ethical Association (HEA). Following the conversation, 4 patients requested a visit from the hospital chaplain, 1 asked for contact with the Salvation Army to be arranged, and 1 wanted to talk to the local leader of HEA. Following the conversation all patients were observed by a nurse, and no raised level of anxiety was reported. Sixteen of the patients died within a median of 18 (1-180) days after the conversation. In conclusion, most patients responded positively to a question about faith. The topic should be addressed in the treatment of patients with advanced disease. However, care must be taken to avoid frightening the patients. Patients' attitudes with regard to what death brings deserve respect

(2) Ridley DT JEHOVAH'S WITNESSES' REFUSAL OF BLOOD: OBEDIENCE TO SCRIPTURE AND RELIGIOUS CONSCIENCE. J Med Ethics 1999 Dec;25(6):469-472.

[email protected] Jehovah's Witnesses are students of the Bible. They refuse transfusions out of obedience to the scriptural directive to abstain and keep from blood. Dr Muramoto disagrees with the Witnesses' religious beliefs in this regard. Despite this basic disagreement over the meaning of Biblical texts, Muramoto flouts the religious basis for the Witnesses' position. His proposed policy change about accepting transfusions in private not only conflicts with the Witnesses' fundamental beliefs but it promotes hypocrisy. In addition, Muramoto's arguments about pressure to conform and coerced disclosure of private information misrepresent the beliefs and practices of Jehovah's Witnesses and ignore the element of individual conscience. In short, Muramoto resorts to distortion and uncorroborated assertions in his effort to portray a matter of religious faith as a matter of medical ethical debate. Comment in: J Med Ethics 1999 Dec;25(6):463-8


(3) Muramoto O BIOETHICS OF THE REFUSAL OF BLOOD BY JEHOVAH'S WITNESSES: PART 3. A PROPOSAL FOR A DON'T-ASK-DON'T-TELL POLICY. J Med Ethics 1999 Dec;25(6):463-468.

Kaiser Permanente Northwest Division, Oregon, USA. Of growing concern over Jehovah's Witnesses' (JWs) refusal of blood is the intrusion of the religious organisation into its members' personal decision making about medical care. The organisation currently may apply severe religious sanctions to JWs who opt for certain forms of blood-based treatment. While the doctrine may be maintained as the unchangeable "law of God", the autonomy of individual JW patients could still be protected by the organisation modifying its current policy so that it strictly adheres to the right of privacy regarding personal medical information. The author proposes that the controlling religious organisation adopt a "don't-ask-don't-tell" policy, which assures JWs that they would neither be asked nor compelled to reveal personal medical information, either to one another or to the church organisation. This would relieve patients of the fear of breach of medical confidentiality and ensure a truly autonomous decision on blood-based treatments without fear of organisational control or sanction. Comment in: J Med Ethics 1999 Dec;25(6):469-72

(4) Schonholz DH BLOOD TRANSFUSION AND THE PREGNANT JEHOVAH'S WITNESS PATIENT: AVOIDING A DILEMMA. Mt Sinai J Med 1999 Sep;66(4):277-9

Department of Obstetrics, Gynecology and Reproductive Medicine, The Mount Sinai School of Medicine, New York, NY 10029, USA. The pregnant Jehovah's Witness patient's refusal of lifesaving transfusion creates a conflict for the physician. While legal steps may be initiated to address the problem, a medical approach stressing prophylaxis which anticipates and avoids the ethical dilemma of managing a hemorrhaging pregnant Jehovah's Witness is preferable.

(5) Malyon D TRANSFUSION-FREE TREATMENT OF JEHOVAH'S WITNESSES: RESPECTING THE AUTONOMOUS PATIENT'S MOTIVES. J Med Ethics 1998 Dec;24(6):376-81

Hospital Liaison Committee for Jehovah's Witnesses, Luton. What makes Jehovah's Witnesses tick? What motivates practitioners of medicine? How is benevolent human behaviour to be interpreted? The explanation that fear of censure, mind-control techniques or enlightened self-interest are the real motivators of human conduct is questioned. Those who believe that man was created in "God's image", hold that humanity has the potential to rise above selfishly driven attitudes and actions, and reflect the qualities of love, kindness and justice that separate us from the beasts. A comparison of general medical ethics and disciplines, and those of the Jehovah's Witness community, is made in this context. The easy charge that frequent deaths result from refusal of blood transfusions is examined. The central source of antipathy towards Jehovah's Witnesses, namely the alleged imposition of extreme and even harmful refusal of blood therapy on our children is addressed. Of course, "...few dilemmas are likely to be resolved wisely or satisfactorily by a blinkered adherence to abstract principles alone. Solutions to most cases will be dictated by a combination of factors. The support of medical ethics by Jehovah's Witnesses, and their willingness to share in reasoned and ethical debate, while at the same time holding firm to their religious and conscientious principles are emphasised

(6) Malak J JEHOVAH'S WITNESSES AND MEDICINE: AN OVERVIEW OF BELIEFS AND ISSUES IN THEIR CARE. J Med AssocGa 1998 Nov;87(4):322-327.


Permanente Medical Group of the Hudson Valley, PC, USA.

(7) Bailey R, Ariga T THE VIEW OF JEHOVAH'S WITNESSES ON BLOOD SUBSTITUTES. Artif Cells Blood Substit Immobil Biotechnol 1998 Nov;26(5-6):571-576.

Hospital Information Services, Watch Tower Bible and Tract Society, Kanagawa, Japan.

(8) Rhodes R ETHICAL CONSIDERATIONS FOR RESIDENTS. Acad Med 1998 Aug;73(8):854-64

Department of Medical Education, Mount Sinai School of Medicine of the City University of New York 10029, USA. [email protected] To help residents understand the moral obligations they have undertaken by becoming doctors, the author presents an overview of the ethical landscape of medical practice. She begins by stating that doctors' primary obligation is to use the knowledge of science in working together with others for the good of their patients. This involves (1) relying on the scientific method (and thus eschewing nonscientific alternatives) and supporting or conducting scientific research; (2) embracing the cooperative model (i.e., when appropriate, working cooperatively with other physicians and other health care providers); and (3) working for the good of the patient to preserve life, cure disease, restore or preserve function, educate, and alleviate suffering. In order to fulfill this complex obligation physicians must be professionally competent, they must respect their colleagues and patients, and they must genuinely care about their patients' well-being. The author then discusses the moral complexity of common encounters in medical practice. She explains the ethical conflicts that underlie issues of paternalism, justice, the use of patients for teaching, and end-of-life care. Since new moral problems are introduced with new technology and since medicine is confronting an increasing demand for services in the face of shrinking resources, she maintains that, more than ever, physicians must be aware of the ethical dimensions of their work and be able to organize their understanding of the issues. To meet the complex and demanding commitments of medical practice and to successfully navigate the ethical challenges that they will encounter, physicians must mold themselves not only to be knowledge and skilled professionals but also to be respectful and compassionate human beings.

(9) Vuk T, Putarek K, Jukic I, Rojnic N, Balija M, Grgicevic D [WHAT WE CAN LEARN FROM REFUSAL OF TRANSFUSION THERAPY FROM EXPERIENCE WITH JEHOVAH'S WITNESSES]. [ARTICLE IN SERBO-CROATIAN (ROMAN)] Lijec Vjesn 1997 Aug; 119 (8-9): 243-245

Hrvatski zavod za transfuzijsku medicinu, Zagreb. Patients who refuse blood transfusion for personal or religious reasons present complex medical, legal and moral problems. Blood transfusion has been doctrinally forbidden for Jehovah�s Witnesses since 1945. Their refusal is based on the strict interpretation of several Biblical passages. A clear understanding of the philosophy of the Jehovah's Witnesses regarding blood transfusion and of the medicolegal and ethical aspects of their care is essential to clinicians who care for such patients. Various ethical principles, including the patient�s autonomy, the interest of society in preserving life and the dignity of medical profession can be confronted. There are no clear guidelines which physicians can follow in deciding to treat or not treat in the presence of a patient�s refusal. However, most authors agree that a competent adult has an absolute right to decline medical treatment, and that it is not morally or ethically correct to force patient to an unwanted treatment. We wished to present the experiences with the use of alternative methods in the treatment of Jehovah's Witnesses and to discuss ethical and legal aspects of treatment decisions in the presence of blood transfusion refusal.

(10) Jayasekara G JEHOVAH'S WITNESSES. Ann R Coll Surg Engl 1997 Mar; 79(2 Suppl): 93-94


(11) Carroll PA WHEN A JEHOVAH�S WITNESS REFUSES A TRANSFUSION. Nursing 1995 Aug; 25(8): 60-61 Comment in: Nursing 1996 Jan; 26(1): 6

(12) Ulsenheimer K [REFUSAL OF BLOOD TRANSFUSION FOR RELIGIOUS REASONS]. [ARTICLE IN GERMAN] Geburtshilfe Frauenheilkd 1994 Jun; 54(6): M83-M86

2. Respecting Patients Rights

(1) Malyon D TRANSFUSION-FREE TREATMENT OF JEHOVAH'S WITNESSES: RESPECTING THE AUTONOMOUS PATIENT'S RIGHTS. J Med Ethics 1998 Oct;24(5):302-7

Jehovah's Witnesses Hospital Liaison Committee, Luton, Bedfordshire. Do six million Jehovah's Witnesses mean what they say? Muramoto's not-so-subtle proposition is that they don't, because of a system of control akin to the Orwellian "thought police". My response is that the fast developing cooperative relationship between our worldwide community and the medical profession as a whole, and the proven record of that community's steadfast integrity in relation to their Christian principles is the evidence that we do! I seek to highlight the inaccuracy of information, which Muramoto admits came largely from dis-enchanted ex-members, by quoting "established" medical ethical opinion that refusal of blood transfusions must be respected as evidence of patient autonomy. Personal experience of my work on hospital liaison committees for Jehovah's Witnesses is reviewed and I endeavour to prove that our view of blood, and its association with life, goes to the very core of the human psyche. Lastly I suggest that faith transcends rationality. Human beings are more than just minds! Our deep moral sense and consciousness that our dignity is diminished by living our lives solely on the "self interest" principle, lies at the heart of true personal autonomy. Maybe it's a case of "two men looking through the same bars: one seeing mud, the other stars". Comment on: J Med Ethics 1998 Oct;24(5):295-301

(2) Ridley DT HONORING JEHOVAH'S WITNESSES' ADVANCE DIRECTIVES IN EMERGENCIES: A RESPONSE TO DRS. MIGDEN AND BRAEN. Acad Emerg Med 1998 Aug;5(8):824-35

Watchtower Bible and Tract Society of New York, Inc., Patterson, USA. [email protected] Jehovah's Witnesses refuse blood transfusions out of obedience to the Bible's command to all Christians to abstain from blood. The Witnesses take this scriptural injunction seriously and, of their own initiative, execute advance medical directive cards to communicate their refusal to medical personnel in the event of their incapacity. In portraying the Witnesses' refusal of blood as the uninformed result of their subjugation by the Watchtower Society, Migden and Braen distort the facts about Jehovah's Witnesses, the basis for their refusal of blood, and their use of the blood refusal card. Further, not only does Migden and Braen's analysis subordinate patient values to professional preference in all cases, but the heightened scrutiny protocol they propose is useless because it cannot possibly be implemented in the hypothetical they posit. Finally, their legal analysis is not well founded and practitioners who choose to follow it will do so at their peril. Comment on: Acad Emerg Med 1998 Aug;5(8):815-24

(3) Migden DR, Braen GR THE JEHOVAH'S WITNESS BLOOD REFUSAL CARD: ETHICAL AND MEDICOLEGAL CONSIDERATIONS FOR EMERGENCY PHYSICIANS. Acad Emerg Med 1998 Aug;5(8):815-24


Emergency Department, Group Health Cooperative of Puget Sound/Virginia Mason Medical Center, Seattle, WA 98111, USA. [email protected] Jehovah's Witnesses are members of a Christian group that does not allow blood transfusion. It is a general practice for adult Witnesses to carry on their person a wallet-sized advance directive card refusing blood. The blood refusal card directs that no blood is to be given to the owner under any circumstance, even if physicians believe transfusion will be lifesaving. Although the card claims to refuse blood on a religious basis, it also states that there are various dangers associated with blood. The possibility that in an emergency the dangers of blood may be relatively small, as compared with the likelihood of death due to exsanguination without blood, is not noted on the card. Emergency physicians should look for evidence of an informed refusal when evaluating these documents. Advance directives regarding life and death decisions should be subject to scrutiny and not be automatically accepted at face value. A goodfaith decision to transfuse the unconscious adult Jehovah's Witness, in emergent need of blood, is justified if the patient does not have a blood refusal advance directive that is informed and otherwise survives a high level of scrutiny. The ethical and medicolegal considerations upon which this thesis is based are discussed. Comment in: Acad Emerg Med 1998 Aug;5(8):753-5 Comment in: Acad Emerg Med 1998 Aug;5(8):755-7 Comment in: Acad Emerg Med 1998 Aug;5(8):824-35 Comment in: Acad Emerg Med 1999 Feb;6(2):159-60

(4) Adams J RESPECTING THE RIGHT TO BE WRONG. Acad Emerg Med 1998 Aug;5(8):753-755. Comment on: Acad Emerg Med 1998 Aug;5(8):768-72 Comment on: Acad Emerg Med 1998 Aug;5(8):796-801 Comment on: Acad Emerg Med 1998 Aug;5(8):815-24

(5) Kahle R, Dietrich R [ARGUMENTS OF JEHOVAH'S WITNESSES FOR REFUSING BLOOD TRANSFUSIONS]. [ARTICLE IN GERMAN] Anasthesiol Intensivmed Notfallmed Schmerzther 1996 Oct; 31(8): 490-491

Krankenhausinformationsdienst fur Zeugen Jehovas, Deutschland.

(6) Gouezec H, Ballay JL, Le Couls H, Malledant Y [TRANSFUSION AND JEHOVAH'S WITNESSES. A REVIEW OF MEDICOSURGICAL ATTITUDES IN A UNIVERSITY HOSPITAL IN 1995]. [ARTICLE IN FRENCH] Ann Fr Anesth Reanim 1996;15(7):1121-3

Unite de securite transfusionnelle, CHU, hopital Pontchaillou, Rennes, France. The aim of this study was to evaluate the attitudes of physicians (anaesthetists + other doctors + surgeons) towards Jehovah's witness patients refusing blood transfusion. Such a situation is not uncommon: 79% of respondents uncountered it. For scheduled surgery in adults, 75% of these physicians (54% of anaesthetists) would accept to lake care of these patients. In case of emergency or unforeseen indication for transfusion, 54% of these physicians (72% of anaesthetists) would administer blood, despite a written transfusion refusal. These figures would be 95 and 97% respectively in children.

(7) Ferdinand R JEHOVAH'S WITNESSES AND ADVANCE DIRECTIVES. Am J Nurs 1996 Mar;96(3):64

University of Medicine and Dentistry of New Jersey, Newark, USA.


(8) Fontanarosa PB, Giorgio GT THE ROLE OF THE EMERGENCY PHYSICIAN IN THE MANAGEMENT OF JEHOVAH'S WITNESSES. Ann Emerg Med 1989 Oct;18(10):1089-1095

Northeastern Ohio University College of Medicine, Department of Emergency Medicine, Akron City Hospital 44309. Patients presenting to the emergency department who refuse recommended treatment present substantial management and medicolegal problems for the emergency physician. Members of the Jehovah's Witness religion, who number approximately 700,000 in the United States, create specific medical, ethical, and legal challenges when they require but refuse necessary blood component therapy. Appropriate management involves timely medical intervention, an awareness of the religious rights and beliefs of Jehovah's Witnesses and a sound understanding of the ramifications of their emergency care. A protocol is presented for responding to opposition to transfusions by Jehovah's Witnesses. The protocol should increase the likelihood of an effective medical and ethical response by emergency physicians and should help to protect against potential legal actions

3. Interventional Paternalism

(1) Muramoto O BIOETHICS OF THE REFUSAL OF BLOOD BY JEHOVAH'S WITNESSES: PART 2. A NOVEL APPROACH BASED ON RATIONAL NON-INTERVENTIONAL PATERNALISM. J Med Ethics 1998 Oct;24(5):295-301

Kaiser Permanente Northwest Division, Oregon, USA. [email protected] Most physicians dealing with Jehovah's Witnesses (JWs) who refuse blood-based treatment are uncertain as to any obligation to educate patients where it concerns the JW blood doctrine itself. They often feel they must unquestioningly comply when demands are framed as religiously based. Recent discussion by dissidents and reformers of morally questionable policies by the JW organisation raise ethical dilemmas about "passive" support of this doctrine by some concerned physicians. In this paper, Part 2, I propose that physicians discuss the misinformation and irrationality behind the blood doctrine with the JW patient by raising questions that provide new perspectives. A meeting should be held non-coercively and in strict confidence, and the patient's decision after the meeting should be fully honoured (non-interventional). A rational deliberation based on new information and a new perspective would enable a certain segment of JW patients to make truly informed, autonomous and rational decisions. Comment in: J Med Ethics 1998 Oct;24(5):302-7

(2) Muramoto O BIOETHICS OF THE REFUSAL OF BLOOD BY JEHOVAH'S WITNESSES: PART 1. SHOULD BIOETHICAL DELIBERATION CONSIDER DISSIDENTS' VIEWS? J Med Ethics 1998 Aug;24(4):223-30

Kaiser Permanente, Portland, OR, USA. [email protected] Jehovah's Witnesses' (JWs) refusal of blood transfusions has recently gained support in the medical community because of the growing popularity of "no-blood" treatment. Many physicians, particularly so-called "sympathetic doctors", are establishing a close relationship with this religious organization. On the other hand, it is little known that this blood doctrine is being strongly criticized by reform-minded current and former JWs who have expressed conscientious dissent from the organization. Their arguments reveal religious practices that conflict with many physicians' moral standards. They also suggest that a certain segment of "regular" or orthodox JWs may have different attitudes towards the blood doctrine. The author considers these viewpoints and argues that there are ethical flaws in the blood doctrine, and that the medical community should reconsider its supportive position. The usual physician assumption that JWs are acting autonomously and uniformly in refusing blood is seriously questioned.


(3) Oian P [JEHOVAH'S WITNESSES--BLOOD TRANSFUSION OR NOT? ARE PHYSICIANS ALL-TIME LOSERS]? [ARTICLE IN NORWEGIAN] Tidsskr Nor Laegeforen 1996 Feb 20;116(5):646-647

Kvinneklinikken, Regionsykehuset i Tromso.

(4) Sacks DA, Koppes RH. BLOOD TRANSFUSION AND JEHOVAH�S WITNESSES: MEDICAL AND LEGAL ISSUES IN OBSTETRICS AND GYNECOLOGY. Am J Obstet Gynecol 1986 March; 154(3): 483-86 Jehovah�s Witnesses are members of a religious denomination whose beliefs prohibit the use of blood or blood products. Plasma volume expanders and extracorporeal hemodilution of the patient�s own blood are theologically acceptable. Acute massive hemorrhage in which only blood is lifesaving may be encountered in obstetrics and gynecology. Either witholding or administering blood in such circumstances may have legal consequences for the physician and hospital. Factors to be considered include fetal viability, the presence of dependent children, and rules of informed consent. Whenever possible, the potential for transfusion should be anticipated and clearly discussed with the patient. When appropriate, the physician and hospital should move rapidly to obtain jucicial resolution.

4. Costs of Refusing Treatments

(1) Savulescu J THE COST OF REFUSING TREATMENT AND EQUALITY OF OUTCOME. J Med Ethics 1998 Aug;24(4):231-6

Monash University, Clayton, Victoria, Australia. Patients have a right to refuse medical treatment. But what should happen after a patient has refused recommended treatment? In many cases, patients receive alternative forms of treatment. These forms of care may be less cost-effective. Does respect for autonomy extend to providing these alternatives? How for does justice constrain autonomy? I begin by providing three arguments that such alternatives should not be offered to those who refuse treatment. I argue that the best argument which refusers can appeal to is based on the egalitarian principle of equality of outcome. However, this principle does not ultimately support a right to less cost-effective alternatives. I focus on Jehovah's Witnesses refusing blood and requesting alternative treatments. However, the point applies to many patients who refuse cost-effective medical care.

(2) Muramoto O MEDICAL ETHICS IN THE TREATMENT OF JEHOVAH'S WITNESSES. Arch Intern Med 1998 May 25;158(10):1155-1156

(3) Smith ML ETHICAL PERSPECTIVES ON JEHOVAH'S WITNESSES' REFUSAL OF BLOOD. Cleve Clin J Med 1997 Oct; 64 (9): 475-481

Ethics Committee, Cleveland Clinic, Foundation, OH 44195, USA. smithm(comat)cesmtp.ccf org When Jehovah�s Witnesses refuse blood, they regularly ask their physicians to explore and provide all other medically and scientifically based alternatives, even when these alternatives may not be as effective and may carry risk of failure that could lead to physical disabilities or death. An awareness of the values at stake and of other cases from personal experience and the literature can help physicians, patients, and their families to move toward ethically responsible decisions and actions.

5. Refusal of Blood Transfusion Therapy


(1) Pertek JP, Vagner JC, Pertek J [JEHOVAH'S WITNESSES, INDISPENSABLE BLOOD TRANSFUSION AND JUSTICE]. [ARTICLE IN FRENCH] Ann Fr Anesth Reanim 1999 Mar;18(3):385-386.

(2) Wilcox P JEHOVAH'S WITNESSES AND BLOOD TRANSFUSION. Lancet 1999 Feb 27;353(9154):757-758. Comment on: Lancet 1998 Sep 5;352(9130):824

(3) Walters BL JEHOVAH'S WITNESSES AND BLOOD TRANSFUSIONS. Acad Emerg Med 1999 Feb;6(2):159-160. Comment on: Acad Emerg Med 1998 Aug;5(8):755-7 Comment on: Acad Emerg Med 1998 Aug;5(8):815-24 Comment on: Acad Emerg Med 1998 Aug;5(8):824-35

(4) Salipante DM REFUSAL OF BLOOD BY A CRITICALLY ILL PATIENT: A HEALTHCARE CHALLENGE. Crit Care Nurse 1998 Apr;18(2):68-76.

Strong Memorial Hospital, University of Rochester Medical Center, NY, USA.

(5) Doyle DJ JEHOVAH'S WITNESSES AND BLOOD TRANSFUSIONS. CMAJ 1998 Mar 24;158(6):717-718.

(6) Letsoalo JL LAW, BLOOD TRANSFUSIONS AND JEHOVAH'S WITNESSES. Med Law 1998;17(4):633-8

University of the North, South Africa. Jehovah's Witnesses respect divine law. Where secular law is in conflict with divine law, they prefer God's law to man's law. They accept all medical treatment except where blood is involved. Doctors worldwide have come to respect their conscientious stand on blood and many doctors have successfully invented and applied techniques of bloodless surgery.

(7) Smith ML ETHICAL PERSPECTIVES ON JEHOVAH'S WITNESSES' REFUSAL OF BLOOD. Cleve Clin J Med 1997 Oct;64(9):475-81

Ethics Committee, Cleveland Clinic, Foundation, OH 44195, USA. smithm(comat)cesmtp.ccf.org When Jehovah's Witnesses refuse blood, they regularly ask their physicians to explore and provide all other medically and scientifically based alternatives, even when these alternatives may not be as effective and may carry risk of failure that could lead to physical disabilities or death. An awareness of the values at stake and of other cases from personal experience and the literature can help physicians, patients, and their families to move toward ethically responsible decisions and actions.

(8) Biscoping J [COMMENT ON THE MINI-SYMPOSIUM, "EXTREME ANEMIA IN TRANSFUSION REFUSAL"].[ARTICLE IN GERMAN] Anasthesiol Intensivmed Notfallmed Schmerzther 1997 Jul;32(7):470, 472-3


Comment on: Anasthesiol Intensivmed Notfallmed Schmerzther 1996 Oct;31(8):488-90

(9) Bennett DR, Shulman IA PRACTICAL ISSUES WHEN CONFRONTING THE PATIENT WHO REFUSES BLOOD TRANSFUSION THERAPY. Am J Clin Pathol 1997 Apr; 107(4 Suppl 1): S23-S27

Los Angeles County + University of Southern California Medical Center 90033, USA. Caring for the Jehovah's Witness patient poses unique challenges to the medical community. Understanding the patient's viewpoint regarding the refusal of blood and blood products is an essential component in treating these patients effectively. There are currently numerous alternatives to allogeneic blood products that can be used in a variety of settings. The intent of this article is to present the beliefs of Jehovah's Witnesses regarding blood transfusion and to review the use of crystalloids, colloids, hemostatic drugs, erythropoietin, hemodilution, blood salvaging, intraoperative blood-conserving strategies, and artificial blood solutions as alternative treatments for these patients.

(10) Shimasaki H, Yamamoto H, Magaribuchi T, Urabe N, Shimasaki A [ARE WE LEGALLY ALLOWED TO ADMINISTER BLOOD FOR LIFESAVING TO A PATIENT WHO REFUSES IT]? [ARTICLE IN JAPANESE] Masui 1997 Apr;46(4):556-559.

Department of Anesthesiology, Kitano Hospital, Osaka. We surveyed the literatures and discussed the legal issues whether we should administer blood for lifesaving to a patient who refuses it. The valid refusal of the transfusion requires the distinct intention of a competent patient. Minors below fifteen years of age are incompetent and their parents make a substituted judgement. Anyone must not give priority to the parents' belief and blood ought to be transfused if necessary for the children's benefits. We could evade liability for withholding blood only when we manage an operation arranged to succeed without blood transfusion, undergoing the sufficient treatments to avoid the risks, as well as on the basis of the valid refusal of a patient. The release deed and the intervention of hospital directors, ethics committees and courts are invalid for the immunity from liability. Anesthesiologists have to take the responsibility on themselves of administering blood or not. A statute law should be established to define what is a patient's valid intention and who is responsible.

(11) Kahle R, Dietrich R [ARGUMENTS OF JEHOVAH'S WITNESSES FOR REFUSING BLOOD TRANSFUSIONS]. [ARTICLE IN GERMAN] Anasthesiol Intensivmed Notfallmed Schmerzther 1996 Oct;31(8):490-1


(12) Cooper R, Quiney N ELECTIVE SURGERY IN AN ANAEMIC JEHOVAH'S WITNESS. Br J Hosp Med 1996 Jul 10;56(2-3):107-108

Musgrove Park Hospital, Taunton, England.

(13) Finfer S, Howell S, Miller J, Willett K, Wilson-MacDonald J. MANAGING PATIENTS WHO REFUSE BLOOD TRANSFUSIONS: AN ETHICAL DILEMMA. MAJOR TRAUMA IN TWO PATIENTS REFUSING BLOOD TRANSFUSION. BMJ 1994 May 28; 308: 1423-26 Patients who refuse blood transfusions after severe blood loss have a poor prognosis but survival is possible. Below Simon Finfer and colleagues describe how they managed two patients who presented after a car crash. We asked an ethical expert, a former pathologist who is a Jehovah�s Witness, and a lawyer to comment on the issues that these cases raised.


(14) Ulsenheimer K [REFUSAL OF BLOOD TRANSFUSION FOR RELIGIOUS REASONS]. [ARTICLE IN GERMAN] Geburtshilfe Frauenheilkd 1994 Jun;54(6):M83-6

(15) Viele MK, Weiskopf RB WHAT CAN WE LEARN ABOUT THE NEED FOR TRANSFUSION FROM PATIENTS WHO REFUSE BLOOD? THE EXPERIENCE WITH JEHOVAH'S WITNESSES. Transfusion 1994 May; 34(5): 396-401

Department of Laboratory Medicine, University of California, San Francisco. BACKGROUND: A transfusion threshold of 7 g per dL (70 g/L) of hemoglobin has been proposed for patients, although scant human data are available to support this recommendation. STUDY DESIGN AND METHODS: The medical community's experience with Jehovah�s Witnesses was examined, in order to assess the lowest tolerable hemoglobin concentration and the lower transfusion threshold of 7 g per dL (70 g/L) of hemoglobin. A MEDLINE search was conducted to capture medical and surgical reports involving Jehovah�s Witnesses from 1970 through early 1993. RESULTS: Sixty-one reports of untransfused Jehovah�s Witnesses with hemoglobin concentrations < or = 8 g per dL (80 g/L) or hematocrits < or = 24 percent (0.24) were identified. Of 50 reported deaths, 23, as stated in the original reports, were primarily due to anemia. Except for three patients who died after cardiac surgery, all patients whose deaths were attributed to anemia died with hemoglobin concentrations < or = 5 g per dL (50 g/L). Twenty-five survivors were reported with hemoglobin < or = 5 g per dL (50 g/L). CONCLUSION: These data have significant limitations but suggest that survival, without transfusion, is possible at low hemoglobin concentrations, while mortality with an unknown incidence is encountered at hemoglobin concentrations below 5 g per dL (50 g/L).

(16) Mann MC, Votto J, Kambe J, McNamee MJ MANAGEMENT OF THE SEVERELY ANEMIC PATIENT WHO REFUSES TRANSFUSION: LESSONS LEARNED DURING THE CARE OF A JEHOVAH'S WITNESS. Ann Intern Med 1992 Dec 15; 117(12): 1042-1048

University of Connecticut Health Center, Farmington. OBJECTIVE: To present the case of a Jehovah�s Witness with severe anemia and to review the religious philosophy of such patients, the ethical and medicolegal aspects of their care, and the therapeutic options available to clinicians. DATA SOURCES: A MEDLINE literature search (1980 to 1992) identified most studies. Other studies were selected from the bibliographies of identified articles. STUDY SELECTION: Selection of articles was limited to the history, philosophy, medicolegal and ethical issues, and clinical management of anemic Jehovah�s Witnesses; a recent article on recommendations for red cell transfusion was also reviewed. CONCLUSIONS: A clear understanding of the philosophy of the Jehovah's Witnesses regarding blood transfusion and of the medicolegal and ethical aspects of their care is essential to clinicians who care for such patients. One must also be aware of the many alternative therapeutic options that can maximize oxygen delivery and minimize oxygen consumption. The insights gained from this review are applicable to any severely anemic patient who refuses blood transfusion.

(17) Riegler R [PROBLEMS IN THE REFUSAL OF BLOOD TRANSFUSION]. [ARTICIE IN GERMAN] Anaesthesist 1985 Feb; 34(2): 55-58 Three examples of refusal of blood transfusion by patients (Jehovah�s witnesses) are presented to discuss the medicolegal and ethical problems anaesthetists may be faced with in daily clinical routine. For many cases deliberate hypotension is recommended. The primary aim has to be to comply with the patient's wish, but in case of acute and extraordinary bloodless, there might develop a conflict from an ethical as well as a legal view between the patient�s desire and the medical opinion.

6. Ethics of Intrauterine Transfusions


(1) Filkins JA A PREGNANT MOTHER'S RIGHT TO REFUSE TREATMENT BENEFICIAL TO HER FETUS: REFUSING BLOOD TRANSFUSIONS. Spec Law Dig Health Care Law 1999 Nov;(248):9-31.

Office of the Medical Examiner, County of Cook, Chicago, IL, USA.

(2) Williams L RELIGIOUS RESTRICTIONS AND THE TRAUMA PATIENT. CRNA 1997 Feb;8(1):40-44

Colombia Presbyterian/St Luke's Medical Center, USA. This article discusses some of the dilemmas the Certified Registered Nurse Anesthetist (CRNA) faces when the patient refuses potential life-saving blood products or a blood transfusion. Even if the CRNA disagrees with the patient's decision, the patient's right to refuse is taken very seriously in the legal arena. Without a court order, the patient cannot be forced to receive blood or blood products. It would be easier if there were clear guidelines; unfortunately, these do not exist. In the past, courts were more likely to agree with the anesthesia provider and order the transfusion, even if the patient were competent. Today, courts are less likely to do so in these cases. However, there are circumstances in which obtaining a court order for the transfusion is more predictable, such as if the patient is a child in a true emergency situation, or if the patient is pregnant and the fetus is viable

(3) Boyd ME. THE OBSTETRICIAN AND GYNAECOLOGIST AND THE JEHOVAH�S WITNESS. Journal SOGC 1992 July/August; 12: 7-9 In summary, my experience with Jehovah�s Witnesses has been entirely positive. The vast majority of patients undergo uncomplicated deliveries and operations. In the most unusual circumstances, when emergencies arise, it then becomes most important that expedient decisions are made. The patients do not �wish to die�; they are interested in good medical care but they will not accept blood transfusion. They and their families are willing to accept the consequences of that decision. I have never been reproached for respecting their wishes.

(4) Ganiats TG, Norcross WA, Schneiderman LJ, Alexander M, Hundertmark P, Baughan DM INTRAUTERINE TRANSFUSION: ETHICAL ISSUES INVOLVING A JEHOVAH'S WITNESS MOTHER. J Fam Pract 1987 May;24(5):467-472 Published erratum appears in J Fam Pract 1987 Aug;25(2):112

(5) Drew NC THE PREGNANT JEHOVAH'S WITNESS. J Med Ethics 1981 Sep; 7(3): 137-139 The prospect of dealing with a rapidly and inexorably bleeding patient fills most medical practitioners with alarm. When that patient is a Jehovah's Witness, the knowledge that a blood transfusion is likely to be refused turns that alarm into a state of acute anxiety and conflict. This state is further heightened when the patient is young and otherwise healthy � a situation found particularly in obstetric practice with the occurrence of ante- and post-partum haemorrhage, and ectopic pregnancy. In the last 25 years in England, Wales, Scotland and Northern Ireland, there has been one maternal death in which the refusal to accept a blood transfusion has been considered to be an avoidable factor. In this article I have attempted to identify the magnitude of the problem in obstetric practice and have sought to clarify the moral and legal aspects.

7. Law and Ethics Minors and Mentally disabled Adult


(1) Webb SL, Marshall MF, Boettcher F, Perlmutter M REFUSAL OF TREATMENT BY AN ADOLESCENT: THE DELIVERANCES OF DIFFERENT CONSCIENCES. HEC Forum 1998 Mar;10(1):9-23.

(2) Spike J, Greenlaw J CASE CONSULTATION: WHEN TO INVOKE STATE AGENCIES TO TREAT: THE CASES OF A MINOR AND A MENTALLY DISABLED ADULT. J Law Med Ethics 1996 Spring;24(1):65-9

(3) Alegre Amor A, Castro Izaguirre E, Molero Labarta T, Mataix Corbi R [EMERGENCY TRANSFUSION IN AN UNDER AGE PATIENT IN A JEHOVAH'S WITNESSES FAMILY. WHAT DOES THE CURRENT LAW INDICATE]? [ARTICLE IN SPANISH] Med Clin (Barc) 1988 Sep 10;91(7):275

8. Obstetric Haemorrhage in Women who Refuse Blood Transfusion

(1) Thomas JM THE TREATMENT OF OBSTETRIC HAEMORRHAGE IN WOMEN WHO REFUSE BLOOD TRANSFUSION. Br J Obstret Gynecol 1998 Jan;105(1):127-128.

9. Informed Consent

(1) Shander A INFORMED CONSENT AND "REFORM" JEHOVAH'S WITNESS PATIENTS. Anesthesiology 1999 Jun;90(6):1787 Comment on: Anesthesiology 1998 Aug;89(2):537

(2) Nishimoto M, Tachibana S, Kawakami M, Orino T, Nakao K, Tokitsu K, Morita T, Hashimoto T, Sasaki S [INFORMED CONSENT AND SURGICAL TREATMENT IN A 38-YEAR-OLD FEMALE, JEHOVAH'S WITNESS WITH LUNG CANCER]. [ARTICLE IN JAPANESE] Kyobu Geka 1998 Jul;51(7):558-60

Department of Thoracic and Cardiovascular Surgery, Osaka Medical School, Japan. A 38-year-old female was found to have abnormal lesion in the left lower lung by chest X-ray examination which was done for her periodical health examination in March, 1997. She was referred to our Institution for operation of the pulmonary lesion by her family physician. The pathology was reported to be adenocarcinoma by the preoperative bronchofiberscopy. As she was Jehovah's witness, she refused to receive either homologous or autologous blood transfusion on the ground of her faith. Prior to the operation, the consultation was held together with the patient, family and doctors in reference to the informed consent. In June, 1997, she had left lower lobectomy without blood transfusion. Postoperative course was uneventful. The problems of surgical treatment in Jehovah's witness rejected blood transfusion are discussed.

(3) Savulescu J, Momeyer RW SHOULD INFORMED CONSENT BE BASED ON RATIONAL BELIEFS? J Med Ethics 1997 Oct; 23(5): 282-288

Green College, Oxford, Ohio, USA. Our aim is to expand the regulative ideal governing consent. We argue that consent should not only be informed but also based on rational beliefs. We argue that holding true beliefs promotes autonomy. Information is important insofar as it helps a person to hold the relevant true beliefs. But in order to hold


the relevant true beliefs, competent people must also think rationally. Insofar as information is important, rational deliberation is important. Just as physicians should aim to provide relevant information regarding the medical procedures prior to patients consenting to have those procedures, they should also assist patients to think more rationally. We distinguish between rational choice/action and rational belief. While autonomous choice need not necessarily be rational, it should be based on rational belief. The implication for the doctrine of informed consent and the practice of medicine is that, if physicians are to respect patient autonomy and help patients to choose and act more rationally, not only must they provide information, but they should care more about the theoretical rationality of their patients. They should not abandon their patients to irrationality. They should help their patients to deliberate more effectively and to care more about thinking rationally. We illustrate these arguments in the context of Jehovah�s Witnesses refusing life-saving blood transfusions. Insofar as Jehovah's Witnesses should be informed of the consequences of their actions, they should also deliberate rationally about these consequences.

(4) Ferdinand R JEHOVAH'S WITNESSES AND ADVANCE DIRECTIVES. Am J Nurs 1996 Mar; 96(3): 64

University of Medicine and Dentistry of New Jersey, Newark, USA.

(5) Briggs CA INFORMED REFUSAL AND PATIENT AUTONOMY: USING REFLECTION TO EXAMINE HOW NURSING KNOWLEDGE AND THEORY AFFECT ATTITUDES. Intensive Crit Care Nurs 1995 Dec; 11(6): 314-3I7 Reflection is a medium increasingly being used in nursing to explore critical incidents, promote learning and integrate theory and practice. In this paper reflection is used to explore the influences of different types of nursing knowledge and theory upon reactions to informed refusal of treatment and the concept of patient autonomy. The paper contains consideration of the care of a Jehovah's Witness and her family who refused a badly-needed blood transfusion. Comment in: Intensive Crit Care Nurs 1996 Jun; 12(3): 189

(6) Hönig JF, Lilie H, Merten HA, Braun U. THE LEGAL AND MEDICAL ASPECTS OF REFUSAL TO CONSENT TO A BLOOD TRANSFUSION. Anaesthesist 1992; 41: 396-98 (Article in German) The limited understanding of a patient, such as a Jehovah�s Witness, who has consented to an operation but refuses a blood transfusion for personal or religious reasons, placed the physician in a moral dilemma. According to Article 2 II of the German Constitution, the fact that the patient has withheld or expressly refused his consent, i.e., in writing, mandates that the legal right of physical integrity be upheld with final legal effect, even in the case of an emergency. If this right to self-determination is abused, the person giving treatment is guilty of bodily harm in the sense of § 223 of the German Penal Code. Intraoperative haemodilution, the cell-saver procedure, and colloidal and crystalloid volume replacement represent alternative methods of blood transfusion for Jehovah�s Witnesses.

B. Severe Anemia Postoperative Management 1. Acute Anemia and Management

a) Acute Anemia treatment General Aspects

(1) Otteni JC [JEHOVAH'S WITNESS: A CASE OF A TRAFFIC ACCIDENT WITH A FATAL OUTCOME]. [ARTICLE IN FRENCH] Ann Fr Anesth Reanim 1998;17(5):432.


(2) Biscoping J [COMMENT ON THE MINI-SYMPOSIUM, "EXTREME ANEMIA IN TRANSFUSION REFUSAL"]. [ARTICLE IN GERMAN] Anaesthesiol Intensivmed Notfallmed Schmerzther 1997 Jul;32(7):470,472-473. Comment on: Anasthesiol Intensivmed Notfallmed Schmerzther 1996 Oct;31(8):488-90

(3) Schweitzer M, Osswald PM [FATAL HEMORRHAGIC SHOCK IN A JEHOVAH'S WITNESS]. [ARTIDE IN GERMAN] Anasthesiol Intensivmed Notfallmed Schmerzther 1996 Oct; 31(8): 504-506

Klinik fur Anasthesiologie und operative Intensivmedizin, Stadtkrankenhaus Hanau.

(4) Tessmann R, von Lupke U [SURVIVAL OF VERY SEVERE HEMORRHAGE-INDUCED ANEMIA IN A JEHOVAH'S WITNESS]. [ARTICLE IN GERMAN] Anasthesiol Intensivmed Notfallmed Schmerzther 1996 Oct; 31(8): 50l-504

Abteilung fur Anasthesie und Intensivmedizin, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main.

(5) Busse J, Wesseling C [TOLERATING EXTREME INTRAOPERATIVE BLOOD LOSS BY A JEHOVAH'S WITNESS PATIENT]. [ARTICLE IN GERMAN] Anasthesiol Intensivmed Notfallmed Schmerzther 1996 Oct; 31(8): 498-501

Abteilung fur Anasthesie und operative Intensivmedizin, Stadtisches Krankenhaus Solingen.

(6) Zander R [OXYGEN SUPPLY AND ACID-BASE STATUS IN EXTREME ANEMIA]. [ARTICLE IN GERMAN] Anasthesiol Intensivmed Notfallmed Schmerzther 1996 Oct;31(8):492-494

Institut fur Physiologie und Pathophysiologie der Universitat, Mainz.

(7) Botero C, Smith CE, Morscher AH ANEMIA AND PERIOPERATIVE MYOCARDIAL ISCHEMIA IN A JEHOVAH'S WITNESS PATIENT. J Clin Anesth 1996 Aug;8(5):386-91

Department of Anesthesiology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH 44109, USA. We present a case in which an anemic patient with religious objections to blood transfusion experienced three episodes of severe myocardial ischemia during the perioperative period. The first episode of ischemia was successfully treated by discontinuing isoflurane and resolving the hypotension. The second and third episodes were successfully treated by heart rate control with esmolol and neostigmine.

(8) Freitag P MANAGEMENT OF A MULTIPLY INJURED JEHOVAH'S WITNESS WITH SEVERE ACUTE ANEMIA. Orthop Rev 1994 May;23(5):375


(9) Rupp RE, Ebraheim NA, Saddemi SR, Wido T MANAGEMENT OF A MULTIPLY INJURED JEHOVAH'S WITNESS WITH SEVERE ACUTE ANEMIA. Orthop Rev 1993 Jul;22(7):847-50

Department of Orthopaedic Surgery, Medical College of Ohio, Toledo. The refusal of blood products by Jehovah's Witnesses creates ethical and medicolegal dilemmas for the treating physician. Appropriate management involves some understanding of the beliefs of the Jehovah's Witnesses and knowledge of a variety of techniques to minimize blood loss. This case report describes the treatment of a Jehovah's Witness with severe anemia and multiple skeletal injuries. The need to keep blood loss to a minimum influenced the management of this patient.

(10) Kitchens CS ARE TRANSFUSIONS OVERRATED? SURGICAL OUTCOME OF JEHOVAH'S WITNESSES. Am J Med 1993 Feb;94(2):117-9 Physicians as well as their patients are quite familiar with the ever growing list of complications of transfusion. Blood is usually administered by physicians with the nearly unchallenged view that failure to transfuse would have dire consequences. Evidence supporting that view is very difficult to obtain. Although no controlled trial exists, data are collected from 16 reports of the surgical outcome of a series of patients of the Jehovah's Witness faith who were not given transfusion for operations during which transfusion is typically given. Analysis of these data supports the concept that approximately 0.5% to 1.5% of such operations are complicated by anemia resulting in death. This risk of not transfusing patients must be weighed against the cost, morbidity, and mortality that would be expected to accrue had these patients been transfused. These concepts should be employed whenever one is formulating a risk-benefit ratio for patients for whom transfusion is contemplated.

(11) Brimacombe J, Skippen P, Talbutt P ACUTE ANAEMIA TO A HAEMOGLOBIN OF 14 G.L-1 WITH SURVIVAL. Anaesth Intensive Care 1991 Nov;19(4):581-583

Department of Anaesthetics and Intensive Care, Cairns Base Hospital, Queensland, Australia.

(12) Howell PJ, Bamber PA SEVERE ACUTE ANAEMIA IN A JEHOVAH'S WITNESS. SURVIVAL WITHOUT BLOOD TRANSFUSION. Anaesthesia 1987 Jan;42(1):44-48 A case is described in which a Jehovah's Witness underwent emergency surgery following which her haemoglobin fell to 1.8 g/d litre. She was successfully treated in an intensive care unit with intermittent positive pressure ventilation of the lungs, high inspired oxygen concentrations and transfusions of large volumes of gelatin solution.

(13) Nearman HS, Eckhauser ML POSTOPERATIVE MANAGEMENT OF A SEVERELY ANEMIC JEHOVAH'S WITNESS. Crit Care Med 1983 Feb;11(2):142-143 Preoperative preparation and intraoperative techniques to minimize blood loss comprise standard therapy for the patient who refuses blood products on religious grounds. The severely anemic postoperative patient presents a particular problem in dealing with oxygen transport and consumption. The management of a Jehovah's Witness with a hematocrit of 6.6% is presented. Oxygen consumption (VO2) was decreased 30-50% by the use of body surface cooling, neuromuscular blocking agents, and narcotic-barbiturate administration.

b) Acute Anemia and EPO


(1) Boursas M, Benhassine L, Paris F, Kempf J, Vuillemin F [TREATMENT OF PERIOPERATIVE ACUTE ANEMIA BY HUMAN RECOMBINANT ERYTHROPOIETIN IN A JEHOVAH'S WITNESS]. [ARTICLE IN FRENCH] Ann Fr Anesth Reanim 1997;16(3):312-3

(2) Wolff M, Fandrey J, Hirner A, Jelkmann W PERIOPERATIVE USE OF RECOMBINANT HUMAN ERYTHROPOIETIN IN PATIENTS REFUSING BLOOD TRANSFUSIONS. PATHOPHYSIOLOGICAL CONSIDERATIONS BASED ON 5 CASES. Eur J Haematol 1997 Mar;58(3):154-9

Department of Surgery, University of Bonn, Germany. The efficacy of the administration of recombinant human erythropoietin (rHuEPO) in the treatment of anaemia in critically ill surgical patients refusing red cell transfusions requires further documentation. Herein, we report the outcome of 5 consecutive severely anaemic Jehovah's Witness patients (lowest haemoglobin concentration 27 g/1), who were discharged from the hospital in good condition after treatment. RHuEPO (50-280 U/kg body weight) was daily administered to 4 of the patients, who either exhibited preoperative anaemia or developed postoperative anaemia refractory to endogenous EPO probably due to inflammation. RHuEPO treatment was followed by a steep rise in reticulocytes and haemoglobin concentration. The fifth patient, who exhibited no signs of systemic inflammation following emergency hemicolectomy, was also treated with intravenous iron, but not with rHuEPO. His blood haemoglobin concentration rose from 27 g/l to 92 g/l in 3 wk. These observations indicate that the administration of rHuEPO is justified in the management of life-threatening anaemia, although only on a humanitarian basis, because there is no predictor for the possible spontaneous recovery.

(3) Streef C, Charpentier C, Audibert G, Laxenaire MC [TREATMENT OF POST-TRAUMATIC ACUTE ANEMIA BY RECOMBINANT HUMAN ERYTHROPOIETIN IN JEHOVAH'S WITNESSES]. [ARTICLE IN FRENCH] Ann Fr Anesth Reanim 1996;15(8):1199-202

Service d'anesthesie chirurgicale, hopitaux urbains, CHU, hopital central, Nancy, France. A 20-year-old Jehovah's witness patient experienced a femur fracture, with a section of the femoral artery and vein. On admission, haemoglobin concentration was 5.6 g.dL-1 and haematocrit 17%. Because of aponevrotomy, blood losses persisted. As the patient refused blood transfusion, recombinant human erythropoietin and parenteral iron were administered, associated with mild hypothermia, sedation and mechanical ventilation. After 21 days, the haemoglobin concentration increased to 10.9 g.dL-1 and haematocrit to 33% Recombinant human erythropoietin and parenteral iron may provide an alternative safe and effective therapy in life-threatening anaemia when blood transfusions are not accepted by the patient.

2. Postoperative Management of Severe Anemia

(1) Beyens T MANAGEMENT OF PROFOUND POSTOPERATIVE ANEMIA IN A JEHOVAH'S WITNESS. J Cardiothorac Vasc Anesth 1998 Feb; 12(1): 130

(2) Busuttil D, Copplestone A MANAGEMENT OF BLOOD LOSS IN JEHOVAH'S WITNESSES. BMJ 1995 Oct 28;311(7013):1115-6 Comment in: BMJ 1996 Feb 10;312(7027):380-1


(3) Green D MANAGEMENT OF THE SEVERELY ANEMIC JEHOVAH'S WITNESS. Ann Intern Med 1993 Jul 15; 119(2): 169

(4) Auerbach M, Ballard R MANAGEMENT OF THE SEVERELY ANEMIC JEHOVAH'S WITNESS. Ann Intern Med 1993 Jul 15; 119(2): 169

(5) Haq AU MANAGEMENT OF THE SEVERELY ANEMIC JEHOVAH'S WITNESS. Ann Intern Med 1993 Jul 15; 119(2): 170

(6) Youn BA, Burns JR MANAGEMENT OF THE SEVERELY ANEMIC JEHOVAH'S WITNESS. Ann Intern Med 1993 Jul 15; 119(2): 170 Comment on: Ann Intern Med 1992 Dec 15;117(12):1042-8

C. Children (1) McNeil SB

JOHNNY'S STORY: TRANSFUSING A JEHOVAH'S WITNESS. Pediatr Nurs 1997 May; 23(3): 287-288

Pediatric Oncology Concentration, University of South Florida, Tampa, USA. Jehovah�s Witnesses refuse blood transfusions for themselves and for their children. This action can be difficult for health professionals to understand and can lead to tensions between the staff and family. For one family, their refusal of blood for their child lead to a greater understanding of their religion and its beliefs for those who cared for them. Interspersed with their story are the medical reasons their son required blood, the reasons Jehovah�s Witnesses refuse blood transfusions, and what the acceptable alternatives are to Jehovah�s Witnesses. This article will share the thoughts and feelings of the family and the nursing staff who cared for the family during this crisis.

(2) Groudine SB THE CHILD JEHOVAH'S WITNESS PATIENT: A LEGAL AND ETHICAL DILEMMA. Surgery 1997 Mar; 121(3): 357-358

(3) Fontanilla L Jr THE DEATH OF AN INNOCENT. Hawaii Med J 1997 Mar; 56(3): 59-60

John A. Burns School of Medicine, USA.

(4) Morrison JE Jr, Lane G, Kelly S, Stool S THE JEHOVAH'S WITNESS FAMILY, TRANSFUSIONS, AND PEDIATRIC DAY SURGERY. Int J Pediatr Otorhinolaryngol 1997 Jan 3; 38(3): 197-205

Department of Anesthesiology, Children's Hospital, University of Colorado Health Science, Denver 80218, USA. [email protected] The pediatric otolaryngologist and anesthesiologist, when encountering a family of the Jehovah�s Witness (JW) faith, should be aware of the potential problems which may arise when deciding to proceed with surgery. Two case reports are presented which illustrate the difficult situations which can occur when unanticipated complications (i.e. profound bleeding) arise perioperatively. An overview of the history and


common tenets of the JW faith, previous legal perspectives, pertinent clinical information from the medical literature, and the protocol of The Children's Hospital, Denver, for dealing with this sensitive issue (drafted with the cooperation of the local JW Hospital Liaison Committee) are presented.

(5) Rosen P RELIGIOUS FREEDOM AND FORCED TRANSFUSION OF JEHOVAH'S WITNESS CHILDREN. J Emerg Med 1996 Mar; 14(2): 241-242 Comment on: J Emerg Med 1996 Mar-Apr;14(2):251-7

(6) Sheldon M ETHICAL ISSUES IN THE FORCED TRANSFUSION OF JEHOVAH'S WITNESS CHILDREN. J Emerg Med 1996 Mar; 14(2): 251-257

Department of Philosophy, Indiana University School of Medicine, Gary 46408, USA. This paper examines the views of Jehovah�s Witnesses in regards to their refusal of blood transfusions for themselves and their children. After setting out the legal framework society presently has in place for dealing with such refusals, the paper reviews the ethics literature that justifies the intervention by the State to force the transfusion of Jehovah's Witness children. It is claimed that the arguments such literature develops are seriously problematic. A different approach is suggested. Comment in: J Emerg Med 1996 Mar-Apr; 14(2): 241-2

(7) Morecroft JA, Wheeler RA, Drake DP, Wright VM MANAGEMENT OF BLOOD LOSS IN CHILDREN OF JEHOVAH'S WITNESSES. BMJ 1996 Feb 10; 312(7027): 380-381 Comment on: BMJ 1995 Oct 28;311(7013):1115-6

(8) Lynch RE MANAGEMENT OF SEVERE ANEMIA IN A PEDIATRIC JEHOVAH'S WITNESS PATIENT. Crit Care Med 1995 Mar; 23(3): 602-603

(9) Spence RK MANAGEMENT OF SEVERE ANEMIA IN A PEDIATRIC JEHOVAH'S WITNESS PATIENT. Crit Care Med 1995 Feb; 23(2): 416-417

(10) Akingbola OA, Custer JR, Bunchman TE, Sedman AB MANAGEMENT OF SEVERE ANEMIA WITHOUT TRANSFUSION IN A PEDIATRIC JEHOVAH'S WITNESS PATIENT. Crit Care Med 1994 Mar; 22(3): 524-528

Division of Critical Care, University of Michigan Medical Center, Ann Arbor 48109-0718. We report a case of a 12-year-old Jehovah�s Witness who refused blood transfusion for a severe anemia, which he developed after receiving a renal transplantation.The therapy adopted in this case is cumbersome, expensive, and potentially hazardous to the patient. However, we felt obliged to respect the religious views of our patient and his family. Our patient is a minor and, therefore, he qualifies for court-ordered transfusion, which would have been granted if child endangerment was pleaded in court. Such a step would have strained the relationship between the patient, his family, and the medical staff. Also, a case of child endangerment or negligence would have been difficult to justify in this situation, given the fact that both parents had each donated a kidney to their child at different times during his illness. Jonsen advocated a nonpaternalistic ethical view when dealing with Jehovah�s Witnesses.


(11) Odebiyi AI CULTURAL INFLUENCES AND PATIENT BEHAVIOUR: SOME EXPERIENCES IN THE PAEDIATRIC WARD OF A NIGERIAN HOSPITAL. Child Care Health Dev 1984 Jan; 10(1): 49-59 In this paper an attempt is made to analyse the incompatibilities between the professional and the layman�s ideology in terms of models of illness and their treatment. From an interview with paediatricians at the Ile-Ife Teaching Hospitals Complex in Nigeria, we found out that the conflicting encounters experienced could be divided into 2 groups: opposition as a result of religious ideology, held especially from the Jehovah�s Witnesses Sect; and opposition as a result of some child-rearing practices that were being strictly upheld by the mothers of the patients. From the cases cited, we noted that the adherence to some religious ideology was so strong that some patients were willing to withdraw from hospital treatment when it conflicted with a tenet of their religion. Of particular relevance here, was the fact that a religious leader of this sect agreed to a transfusion after he had been assured of secrecy. In this particular case, it was obvious that he feared �losing face� among his followers. We felt that a more flexible relationship between the doctor and patient would reduce the tension; hence a case was made for a transcultural perspective based on an adequate knowledge of behavioural sciences.

(12) Quintero C BLOOD ADMINISTRATION IN PEDIATRIC JEHOVAH�S WITNESSES. Nurs 1993 Jan; 19(1): 46-48 When children of Jehovah's Witnesses are in need of a blood transfusion, the rights of the parents and the responsibility of the State may be in conflict. Understanding the basis for the Jehovah�s Witnesses' beliefs and the precedents of court intervention may assist the nurse to balance the needs of the child and family with the sometimes conflicting interventions of the health care providers.

D. Adolescent�s and Transfusion Ethics (1) Lawry K, Slomka J, Goldfarb J

WHAT WENT WRONG: MULTIPLE PERSPECTIVES ON AN ADOLESCENT'S DECISION TO REFUSE BLOOD TRANSFUSIONS. Chn Pediatr (Phila) 1996 Jun; 35(6): 3l7-32l

Cleveland Clinic Foundation, Department of Pediatrics, OH 44195, USA. Persons with religious beliefs that conflict with mainstream medical practice create a tension for clinicians between honoring the different religious perspectives of the individual or carrying out what they believe to be their professional obligation. This is a patient presentation of an adolescent Jehovah�s Witness who refuses blood transfusions. The major issue in this patient is the conflict among three values (1) respect for religious beliefs, (2) respect for a competent persons right to refuse treatment, and (3) the ability of an adolescent to make good decisions for himself. Other dilemmas presented by this patient are the lack of a coordinated plan of care, the lack of communication with the patient and family, and the lack of attention to social factors that influence the patient�s situation and his resulting care. Comment in: Clin Pediatr (Phila) 1996 Jun; 35(6): 327-8

E. Management of the "No" Allogenicblood Request" (1) Malak J

JEHOVAH'S WITNESSES AND MEDICINE: AN OVERVIEW OF BELIEFS AND ISSUES IN THEIR CARE. J Med Assoc Ga 1998 Nov;87(4):322-7

Permanente Medical Group of the Hudson Valley, PC, USA.


(2) Robb N JEHOVAH'S WITNESSES LEADING EDUCATION DRIVE AS HOSPITALS ADJUST TO NO BLOOD REQUESTS. CMAJ 1996 Feb 15; 154(4): 557-560 Jehovah�s Witness representatives have visited more than 10 Canadian medical schools and 200 hospitals in an attempt to educate future and practising physicians about non-blood medicine. The trend is becoming more popular since the advent of MV, and there are now about 100 bloodless medicine and surgery centres around the world, including 52 in the US. However, a Jehovah�s Witness spokesman says Canada is "conspicuously absent" from the list of countries that offer bloodless-medicine programs. Comment in: Can Med Assoc J 1996 Aug 1; 155(3): 275-6

(3) Tsubokawa IK, Narita M, Mase E, Murakami I, Otagiri T, Kurokochi N, Mori K [ANESTHETIC MANAGEMENT OF TEN JEHOVAH'S WITNESS PATIENTS]. [ARTICLE IN JAPANESE] Masui 1996 Jan; 45(1): lll-ll4

Department of Anesthesiology and Resuscitology, Shinshu University, School of Medicine, Matsumoto. We experienced the anesthetic management of 10 Jehovah�s Witness patients. Some patients accepted either blood products, autologous blood transfusion with closed circuit, or Cell Saver. The patients' families expressed their wish that blood transfusion could be done in life threatening situations against the patients wish in some cases. It would be desirable to clear up an acceptable standard and write out it in each medical institution to avoid conflicts with the patient and families. Prior agreement is required among medical staffs on refusal of blood transfusion.

(4) Busuttil D, Copplestone A MANAGEMENT OF BLOOD LOSS IN JEHOVAH'S WITNESSES. BMJ 1995 Oct 28; 311(7013): 1115-1116 Some people suggest that Jehovah�s Witnesses should take financial responsibility for the excess expenses incurred by their choice not to have transfusions. However, other patients who require treatment for the effects of self harm � for example, from smoking � are not excluded from expensive treatments, and the treatment of anaemia in a Jehovah�s Witness should be seen in a similar context. Comment in: BMJ 1996 Feb 10; 312(7027): 380-1

(5) Bunte H [YOUR PATIENT IS A JEHOVAH'S WITNESS]. [ARTICLE IN GERMAN] Zentralbl Gynakol 1995; 117(2): 113

(6) Gombotz H, Kulier A [REDUCTION IN THE USE OF DONATED BLOOD IN SURGICAL MEDICINE]. [ARTICLE IN GERMAN] Anaesthesist 1995 Mar; 44(3): 191-218

Klinik fur Anasthesiologie, Universitat Graz, Osterreich. After rapid changes in transfusion practice over the past few years, blood conservation techniques have become standard in modern perioperative management. As a result, the amount of homologous blood products transfused has been markedly reduced in some types of surgical procedures. Provided that skilful surgical technique is applied and the use of blood products is restricted, autologous transfusion techniques (predonation of autologous blood, preoperative plasmapheresis, acute normovolaemic haemodilution, and intra- and postoperative blood salvage) can be performed with an acceptable risk for patients. In addition, stimulation of erythropoiesis with recombinant human erythropoietin, supplemental iron therapy, and improving haemostasis by aprotinin may further reduce homologous blood requirements. All patients undergoing elective surgery have to be informed about the side effects of transfusion of homologous blood products and the possibility of blood-saving methods. An individual


blood conservation plan, based on the patient's status and surgery, the equipment available, and personal experience should be worked out by the responsible anaesthesiologist, whereby a combination of different methods may be most effective. If storage is necessary, autologous blood products should be preparated like homologous products. The feasibility of predonation and retransfusion of autologous blood in patients with infectious diseases like hepatitis or acquired immune deficiency syndrome and the amount of laboratory testing are still under discussion. Although blood conservation programs are time-consuming and more expensive, they reduce the various risks of using homologous blood products.

(7) Mikami H [THE PATIENTS' RIGHT OF SELF-DECISION AND THE DISCRETION OF PHYSICIANS]. [ARTICLE IN JAPANESE] Hokkaido Igaku Zasshi 1994 Sep; 69(5): 1088-1095

Department of Legal Medicine, Hokkaido University School of Medicine, Sapporo, Japan. I attended the l0th liaison society of ethics committees in medical schools in Japan. Three topics on the problems of the terminal patients, Jehovah�s Witness needing blood transfusion and the patients suffering from AIDS were discussed by symposists consisted of 6 physicians, 2 nurses and a jurist. I picked up key phrases from the symposists' presentations with respect to professions. The physicians used the terms of terminal care, quality of life, informed consent, etc. The nurses emphasised a labor shortage, an ideal physician, cooperation of the patient�s family, etc. A jurist expressed euthanasia, death with dignity, right of living and dying, etc. The common issue relating with all terms would be "patients right of self-decision". Physicians should recognise this right and then exercise their discretion. All patients should be regarded as social beings under the medical care, which would be realised when physicians treat diseases with the relevant patients.

(8) Granger C MANAGING A JEHOVAH'S WITNESS WHO AGREES TO BLOOD TRANSFUSION. BMJ 1994 Sep 3; 309(6954): 612

(9) Robb N RULING ON JEHOVAH'S WITNESS TEEN IN NEW BRUNSWICK MAY HAVE "SETTLED THE LAW" FOR MDS. CMAJ 1994 Sep 1; 151(5): 625-628

(10) Spence RK THE JEHOVAH'S WITNESS PATIENT AND MEDICOLEGAL ASPECTS OF TRANSFUSION MEDICINE. Semin Vasc Surg 1994 Jun; 7(2): 121-126

Department of Surgery, Cooper Hospital, Camden, M.

F. Perioperative Management 1. Surgery and Anemia

(1) Cooper R, Quiney N ELECTIVE SURGERY IN AN ANAEMIC JEHOVAH'S WITNESS. Br J Hosp Med 1996 Jul 10; 56(2-3): 107-108

Musgrove Park Hospital, Taunton, England.

(2) Nussbaum W, deCastro N, Campbell M PERIOPERATIVE CHALLENGES IN THE CARE OF THE JEHOVAH'S WITNESS: A CASE REPORT. AANA J 1994 Apr; 62(2): 160-164


Same day admissions for surgery represent a growing portion of the operating room workload. Vigilance during preanesthetic evaluation and standards of preoperative preparation must be maintained for patients who are undergoing elective procedures. This case study reports the preanesthetic evaluation and perioperative management of a Jehovah�s Witness who bled to a hematocrit of 9.0% during a myomectomy. The discussion considers the need for preoperative preparation and conservation of circulating red blood cells. Perioperative management modalities to conserve red blood cells including deliberate, controlled hypotension; autotransfusion; and normovolemic and hypervolemic hemodilution, are presented.

(3) O�Malley RD. EMERGENCY SURGICAL PROCEDURES IN ADULT JEHOVAH�S WITNESSES. The Journal of Abdominal Surgery 1967 June; 9(6) 158-61 Operating without recourse to blood may, in many cases, be no more serious or even safer than operating in the face of diminished pulmonary or cardiac reserve, renal or liver failure, uncontrollable diabetes, or a number of other serious complications. Moreover, a transfusion itself is not without risks. We physicians, despite being absolute certain that some patients do die of hemorrhage, must in all fairness admit that the need for transfusion is at times overdramatized.

2. Aggressive Non-Blood Management

(1) Parker RI. AGGRESSIVE NON-BLOOD PRODUCT SUPPORT OF JEHOVAH�S WITNESSES. Critical Care Medicine 1994 Mar; 22(3): 381-2 Dr. Akingbola et al. describe their experience in caring for a critically ill child of Jehovah�s Witness parents. Out of concern for the family�s religious beliefs and the physicians� desire to maintain a good working relationship with this family, the authors elected to treat the patient, a 12-yr-old male, as an emancipation minor for medical decision-making purposes. This approach required the physicians to care for the patient without the benefit of blood or blood product support. A second major point of this article is the implicit statement that we as physicians owe our patients and their families the obligation to respect their wishes when possible. This obligation may require us to extend ourselves beyond our �medical comfort zones� and to do things differently for different patients. This fact aside, we still owe these families the courtesy of listening and objectively analyzing the risks of doing things their way. We must be aware that when dealing with life-threatening situations, our �patient� is often the entire family, and our therapy in some measure is directed toward them.

(2) Sacks DA, Koppes RH CARING FOR THE FEMALE JEHOVAH'S WITNESS: BALANCING MEDICINE, ETHICS, AND THE FIRST AMENDMENT. Am J Obstet Gynecol 1994 Feb; 170(2): 452-455

Department of Obstetrics and Gynecology, Kaiser Foundation Hospital, Bellflower, CA 90706. Blood transfusion has been doctrinally forbidden for Jehovah�s Witnesses since 1945. Despite serious theological consequences for its violation, this proscription may not be observed universally by members of the denomination. When a patient declines a lifesaving transfusion, a conflict is generated between the physician's autonomy-based and beneficence-based obligations to the patient. This conflict is intensified when the patient is a woman who had minor dependent children, either in utero or already born. A spectrum. of opinion exists regarding the resolution of this conflict. As one of society's repositories of moral and legal values, the court is the most appropriate forum in which religious, medical, and ethical viewpoints may receive a fair and impartial hearing.

(3) Cooper JR. PERIOPERATIVE CONSIDERATIONS IN JEHOVAH�S WITNESSES International Anesthesiology Clinics 1990 Fall; 28(4): 210-15 Over 1,000 patients of all ages have been treated to date and no legal actions have been filed for withholding transfusion from any JW patient. The vast majority of JW patients survived, and serve


as a kind of nontransfused �control� group. Clearly, major operations can be performed with acceptable results without transfusion.

(4) Wong DHW, Jenkins LC. SURGERY IN JEHOVAH�S WITNESSES Can J Anaesth 1989; 36(5): 578-85 This is a retrospective study of the outcome of surgical procedure in patients who were Jehovah�s Witnesses. Over a 75-month period, 58 Jehovah�s Witness patients had 78 surgical procedures at the Vancouver General Hospital. Three patients had preexisting anaemia of less than 100 g/L haemoglobin. Postoperative haemoglobin concentration decreased below 50 g/L in three paients. One patient had a postoperative haemoglobin of 34 g/L (haematocrit 10.1 per cent) and survived. One patient died from uncontrollable postoperative hemorrhage. Perioperative morbidity was not uncommon, including significant hypotension (eight cases), cardiac arrhythmias (six), myocardial ischemia (three), excessive bleeding (four), postoperative nausea or syncope (four), and wound or urinary tract infection (four).

(5) Smith EB. SURGERY IN JEHOVAH�S WITNESSES. Journal of the National Medical Association 1986; 78(7): 668-73 Surgical experience are described with 96 adult patients who professed and practised the Jehovah�s Witness faith and whose refusal of blood transfusions and blood-related products created problems in circulatory fluid volume, cardiorespiratory exchanges, cerebral, hepatic, and renal metabolic processes, and wound healing. The surgical mortality rate was representative and the surgical complication rate was excessive. The most frequent complications (93.5 percent) were wound-healing problems.

(6) Clarke JMF SURGERY IN JEHOVAH�S WITNESSES British Journal of Hospital Medicine 1982 May; 27(5): 497-500 The Jehovah�s Witnesses are represented in the UK in numbers great enough for problems connected with their refusal to accept blood transfusions to be quite frequent. The basis for their beliefs has been deeply researched and they have developed a sound moral and philosophical position which a doctor is unlikely to be able to erode. The decisions involved in dealing with a patient refusing a necessary blood transfusion have to be made by the individual doctor, guided by his conscience and bearing in mind the convictions of his patient.

(7) Lowell Dixon L, Smalley MG. JEHOVAH�S WITNESSES. THE SURGICAL/ETHICAL CHALLENGE. JAMA 1981 November; 246(21): 2471-72 Physicians face a special challenge in treating Jehovah�s Witnesses. Members of this faith have deep religious convictions against accepting homologous or autologous whole blood, packed RBCs, WBCs, or platelets. Many will allow the use of (non-blood-prime) heart-lung, dialysis, or similar equipment if the extracorporeal circulation is uninterrupted. Medical personnel need not be concerned about liability, for Witnesses will take adequate legal steps to relieve liability as to their informed refusal of blood. They accept nonblood replacement fluids. Using these and other meticulous techniques, physicians are performing major surgery of all types on adult and minor Witness patients. A standard of practice for such patients has thus developed that accords with the tenet of treating the �whole person�.

(8) Andrews IC, Roelofs R, Schwartz D. LEGAL, ETHICAL, AND MEDICAL GUIDELINES FOR JEHOVAH�S WITNESSES IN SURGERY. Weekly Anesthesiology Update 1979; 2: 2-8 One of their religious precepts, their refusal to accept transfusion of blood or its derivatives in medical treatment, is an important factor in the practice of anesthesiology. The Jehovah�s Witnesses� firm position on this issue is presented in their tract, Blood, Medicine and the Law of God, which refers to biblical passages and early medical literature which they feel clearly show that blood should not be taken by man in any form. This lesson will review the legal, ethical, and medical approaches that have


been established in some medical centers when a Jehovah�s Witness presents for elective surgery which usually requires transfusion of blood.

(9) Khine HH, Naidu R, Cowell H, MacEwen GD. A METHOD OF BLOOD CONSERVATION IN JEHOVAH�S WITNESSES: INCIRCULATION DIVERSION AND REFUSION. Anesth Analg 1973 April; 57: 279-80 Caring for Jehovah�s Witnesses undergoing major surgery where heavy blood loss may be anticipated poses a challenge to the surgical team. A few of these patients allow the withdrawal and storage of autologous blood prior to surgery, with intraoperative reinfusion as indicated; others agree to intraoperative withdrawal of their blood as long as its continuity with the body is not interrupted. However, the majority of patients who are Jehovah�s Witnesses believe that their blood should both remain in contact with the body and be in circulation. We have developed a technic to meet the special requirements of these patients.

(10) Minuck M, Lambie RS. ANESTHESIA AND SURGERY FOR JEHOVAH�S WITNESSES. Can Med A J 1961 May 27; 84; 1187-91 A Jehovah�s Witness presents no different problem than does the patient in whom ideal surgical treatment is impractical, on account of concomitant physical disease or extreme age. The medical management of the Jehovah�s Witnesses may be summarized thus: (1) tolerance of his religious beliefs; (2) careful preoperative assessment; (3) postponement of elective surgery if possible; (4) specialized anesthetic techniques; (5) autotransfusions and modified surgery.

3. Heparin induced Thrombocytopenia

(1) Brown DM PERFUSING THE JEHOVAH'S WITNESS PATIENT WITH HEPARIN-INDUCED THROMBOCYTOPENIA. J Extra Corpor Technol 1998 Dec;30(4):193-6

Heart Institute of Spokane, Washington 99203, USA. Heparin-induced thrombocytopenia (HIT) is an uncommon, yet dangerous side-effect of heparin therapy. The problems associated with the HIT patient while undergoing cardiopulmonary bypass increase dramatically when the patient is also of Jehovah's Witness faith. This case report depicts the techniques utilized and the decisions made over the course of a simple surgical procedure for an extremely high-risk patient.

G. Blood Transfusion (1) Doyle DJ

JEHOVAH'S WITNESSES AND BLOOD TRANSFUSIONS. CMAJ 1998 Mar 24;158(6):717-718

(2) Kahle R, Dietrich R [ARGUMENTS OF JEHOVAH'S WITNESSES FOR REFUSING BLOOD TRANSFUSIONS]. [ARTICLE IN GERMAN] Anasthesiol Intensivmed Notfallmed Schmerzther 1996 Oct;31(8):490-491


(3) Jacobsson L [JEHOVAH'S WITNESSES AND BLOOD TRANSFUSION]. [ARTICLE IN SWEDISH] Lakartidningen 1996 Sep 18; 93(38): 3227


Psykiatriska institutionen, Umea universitet. Comment in:Läkartidningen 1996 Dec 4;93(49):4523.

(4) Meidell Knutrud N, Kongsgaard U. BLOOD TRANSFUSION IN JEHOVAH�S WITNESS PATIENTS � A QUESTIONNAIRE TO NORWEGIAN ANAESTHESIOLOGISTS. [ARTICLE IN NORWEGIAN] Tidsskr Nor Lægeforen 1996; 116(23): 2795-98 Patients who are members of Jehovah�s Witnesses refuse blood transfusion, even when the indication for giving blood is vital. This is a matter of controversy both in the clinical situation and in the medical literature and the press. All 430 members of the Norwegian Association of Anaesthesiology were sent a questionnaire requesting the guidelines issued by their hospitals, and their personal, professional opinion when dealing with this group of patients in life-threatening conditions caused by loss of blood. 248 (58%) replied. 69 % of the answers indicated that the guidelines given by the National Board of Health were unclear. Under certain circumstances as many as 79% of the responding physicians would transfuse the patients against their will. 67% would refrain from giving anaesthesia to a member of Jehovah�s Witnesses who was scheduled for elective surgery where major blood loss was to be expected. Only seven hospitals stated that guidelines for dealing with this kind of situation were available.

(5) Gouezec H, Ballay JL, Le Couis H, Malledant Y [TRANSFUSION AND JEHOVAH'S WITNESSES. A REVIEW OF MEDICOSURGICAL ATTITUDES IN A UNIVERSITY HOSPITAL IN 1995]. [ARTICLE IN FRENCH] Ann Fr Anesth Reanim 1996; 15(7): 1121-1123

Unite de securite transfusionnelle, CHU, hopital Pontchaillou, Rennes, France. The aim of this study was to evaluate the attitudes of physicians (anaesthetists + other doctors + surgeons) towards Jehovah�s witness patients refusing blood transfusion. Such a situation is not uncommon: 79% of respondents encountered it. For scheduled surgery in adults, 75% of these physicians (54% of anaesthetists) would accept to lake care of these patients. In case of emergency or unforeseen indication for transfusion, 54% of these physicians (72% of anaesthetists) would administer blood, despite a written transfusion refusal. These figures would be 95 and 97% respectively in children.

(6) Aguilera P [BLOOD TRANSFUSIONS IN JEHOVAH'S WITNESSES]. [ARTICLE IN SPANISH] Rev Med Chil 1993 Apr; 121(4): 447-451

Facultad de Medicina, Universidad de los Andes, Santiago de Chile. Jehovah Witnesses cite religious motives to refuse transfusions of whole blood or its components for themselves and their children, even when life is endangered. An ethical analysis of decision making in health problems, is made, giving priority to the alternatives chosen by the patient. One of the elements that turns a therapeutic procedure into extraordinary is the moral impossibility of its use, originated in a subjective cause. The right to act with freedom in religious matters must also be considered. It is concluded that the denial of a Jehovah Witness to be transfused must be respected. However, in the case of children, the physicians should disregard the parents rejection.

(7) Kitchens CS ARE TRANSFUSIONS OVERRATED? SURGICAL OUTCOME OF JEHOVAH'S WITNESSES. Am J Med 1993 Feb; 94(2): 117-119 Physicians as well as their patients are quite familiar with the ever growing list of complications of transfusion. Blood is usually administered by physicians with the nearly unchallenged view that failure to transfuse would have dire consequences. Evidence supporting that view is very difficult to obtain. Although no controlled trial exists, data are collected from 16 reports of the surgical outcome of a series of patients of the Jehovah's Witness faith who were not given transfusion for operations during which transfusion is typically given. Analysis of these data supports the concept that approximately 0.5% to 1.5% of such operations are complicated by anemia resulting in death. This risk of not transfusing patients must be weighed against the cost, morbidity, and mortality that would be expected to accrue had,


these patients been transfused. These concepts should be employed whenever one is formulating a risk-benefit ratio for patients for whom transfusion is contemplated.

(8) Vincent JL TRANSFUSION IN THE EXSANGUINATING JEHOVAH'S WITNESS PATIENT � THE ATTITUDE OF INTENSIVE-CARE DOCTORS. Eur J Anaesthesiol 1991 Jul; 8(4): 297-300

Department of Intensive Care, Erasmus University, Free University of Brussels, Belgium. The attitude of a Jehovah�s Witness patient refusing a blood transfusion during an exsanguinating episode can raise important ethical problems. Various ethical principles, including the patient�s autonomy, the sanctity of life and the dignity of the medical profession can be confronted. A total of 242 doctors, members of the European Society of Intensive Care Medicine, answered a questionnaire indicating that 63% would transfuse in those circumstances. However, 26% would never inform the patient about this. Only 45% considered the blood transfusion as appropriate, of whom 25% were unable to define the best option. Doctors from France and Italy more commonly transfuse while those from The Netherlands, the United Kingdom and Scandinavia more commonly withhold transfusion. These data stress the need for a definition of the appropriate medical attitudes towards the patient refusing blood transfusion.

(9) Knudsen F, Guldager R [BLOOD TRANSFUSION AND JEHOVAH'S WITNESSES. ETHICAL AND MEDICOLEGAL ASPECTS]. [ARTICLE IN DANISH] Ugeskr Laeger 1991 Feb 25; 153(9): 632-636

Anaestesi-og intensivafdelingen, Kobenhavns Amts Sygehus i Herlev. Jehovah�s witnesses refuse transfusion of blood and blood products on the basis of religious convictions even when transfusion is considered necessary to save life. Medical treatment of these patients presents an ethical challenge for the physicians. The legal aspects of either administering blood to or withholding necessary blood transfusion from a Jehovah's witness are not clarified. Competent adult patients cannot be treated against their will. Children and unconscious patients must be treated according to �jus necessitatis�. Whether a competent advance directive from a patient before an operation in general anaesthesia can be or must be respected is legally obscure. Final clarification of the patients' rights and the physicians' legal status could be obtained by an amendment to the existing Practice of Medicine Acts as proposed in the report (1184) from the Danish Ministry of Justice. The ethical aspects of administering blood to or withholding blood from these patients are also complex. It is recommended to determine one's own attitude individually and to inform the patient about this before an operation.

(10) Singelenberg R THE BLOOD TRANSFUSION TABOO OF JEHOVAH'S WITNESSES: ORIGIN, DEVELOPMENT AND FUNCTION OF A CONTROVERSIAL DOCTRINE. Soc Sci Med 1990;31(4):515-523

Department of Cultural Anthropology, University of Utrecht, The Netherlands. Jehovah's Witnesses are not allowed to accept a blood transfusion. According to the Watch Tower Bible and Tract Society this therapy is a transgression of divine precepts. Additionally, in the judgement of the believers, secular proof is abundant these days; to them AIDS is a powerful justification to abstain from blood. Founded on the work of the anthropologist Mary Douglas, it is argued that the rejection of this medical therapy is based on perceptions of pollution and purity inherent in the Watch Tower Society's ideological concept of anti-worldliness. Rooted in the movement's pre-war opposition to vaccination the implementation of the taboo was triggered by the prevailing social-political climate surrounding the Society during the Second World War, resulting in this intriguing and controversial religious proscription. For the community of Jehovah's Witnesses the blood transfusion taboo still functions as a significant mechanism of sectarian boundary maintenance.


(11) Forman EN, Ladd RE. TELLING THE TRUTH IN THE FACE OF MEDICAL UNCERTAINTY AND DISAGREEMENT. The American Journal of Pediatric Hematology/Oncology 1989; 11(4): 463-66 There is still much uncertainty in treating childhood cancer: even with standard therapy, the outcome of treatment is not always predictable, and even among experienced and caring physicians, there can be differences of opinion about which therapy to recommend. Medical disagreements are of two kinds: those about facts, which can in principle be resolved, and those that have their source in attitudes and values, where appeal to professional expertise is not possible. If a professional makes a recommendation, this implies that there are facts and expertise to substantiate it. In the cases where there is no disagreement and little uncertainty, this implication is warranted. In cases where there is uncertainty and disagreement, however, making a recommendation without qualification constitutes an unethical imposition of the physician�s own values on his patients.

(12) Vercillo AP, Duprey SV. JEHOVAH�S WITNESSES AND THE TRANSFUSION OF BLOOD PRODUCTS. New York State Journal of Medicine 1988 September; 493-94 Does this refusal to accept blood constitute suicide? Jehovah�s Witnesses very much want to live, but not through the use of blood transfusions. In fact, they welcome all other conventional forms of medical therapy. According to Professor Robert M. Byrn, �Rejection of lifesaving therapy and attempted suicide are, and should be, as different in law as the proverbial apples and oranges.�

(13) Tierney WM, Weinberger M, Greene JY, Studdard PA JEHOVAH'S WITNESSES AND BLOOD TRANSFUSION: PHYSICIANS' ATTITUDES AND LEGAL PRECEDENTS. South Med J 1984 Apr; 77(4): 473-478 Patients with significant medical problems who refuse some aspects of their medical care present medicolegal and management problems for their physicians. The selective refusal of transfusion of blood products by Jehovah's Witnesses typifies such situations. To explore physicians' reactions to these constraints, we sent a questionnaire to medical students, residents, and faculty wherein we asked them to respond to case simulations involving Jehovah's Witnesses and refusal of transfusion. Fifty percent of all respondents, including 84% of the faculty, reported experience in dealing with Jehovah's Witnesses. Overall, respondents were more likely to give transfusion to an infant or an incompetent adult than to competent adults. Only educational level made a significant difference in response: faculty members most frequently mentioned obtaining a court order when giving transfusion against a patient's will. Case law, upon which legal grounds such decisions stand, is often conflicting and is evolving toward allowing patients a freer hand in their choices of therapy. We sketch the history and present status of these precedents and offer a framework for dealing with patients' refusal of care.

(14) Thomas JM MEETING THE SURGICAL AND ETHICAL CHALLENGE PRESENTED BY JEHOVAH�S WITNESSES. Can Med A J 1983 May 15; 128; 1153-54 Though firmly refusing blood transfusions, Witnesses will accept colloid or crystalloid replacement fluids and the use of heart-lung equipment primed with something other than blood. They accept electrocautery, hypotensive anesthesia and hypothermia, so surgeons are not limited in what they reasonably do.

(15) Linson MA CARING FOR JEHOVAH�S WITNESSES. Miami Medicine 1981 January, pp 25. Jehovah�s Witnesses are deeply religious people who strive at all costs to maintain their integrity to God. Physicians who have respected these beliefs have been able to perform many emergency and elective operations on Jehovah�s Witnesses. Doctors involved in this work consistently urge others to respect the wishes of Jehovah�s Witnesses and offer them the best care possible within the limitations imposed.


(16) Fatteh MM JEHOVAH'S WITNESSES, HOW CAN WE HELP THEM? J Med Assoc Ga 1980 Dec; 69(12): 977-979

II. PREMATURE INFANTS

A. Anemia of Prematurity and EPO (1) Soler M, Jeffries I.

THE VERY SMALL PREEMIE WHO IS THE CHILD OF A JEHOVAH�S WITNESS. Int Pediatr 1995; 10(3): 224-6 We present a case of a very small preemie, whose parents belonged to the Jehovah�s Witness faith, and refused a blood transfusion. Mortality statistics in infants weighing less than 750 g is a very strong predictor of death in this group of children. Decisions about whether a blood transfusion is warranted, the ethical dilemmas and medicolegal aspects concerning blood transfusion are discussed. General management principles and alternative therapeutic options are presented. The implications of blood transfusion in the very small preemie is complex. An understanding of the Jehovah�s Witness belief is essential for the proper management of these children. Finally, clinical guidelines were developed, including the role of erythropoietin therapy.

(2) Yu VYH, Bacsain MB. AVOIDANCE OF RED BLOOD CELL TRANSFUSION IN AN EXTREMELY PRETERM INFANT GIVEN RECOMBINANT HUMAN ERYTHROPOIETIN THERAPY. J Paediatr Child Health 1994 August; 30(4): 360-2 To avoid red blood cell (RBC) transfusions, recombinant human erythropoietin (rHuEPO) was given to an infant born at a gestation of 26 weeks and a birthweight of 830 g to parents who were Jehovah�s Witnesses. The infant had hyaline membrane disease and required 52 days of assisted ventilation and 19 days of oxygen therapy. He received theophylline therapy for 61 days for recurrent apnoea and bradycardia. He developed bilateral intraventricular haemorrhage (IHV) and left-sided periventricular leucomalacia (PVL). Intravenous rHuEPO was started on day 1 at 200 U/kg per day for 1 month followed by subcutaneous rHuEPO 400 U/kg three times a week for 6 more weeks, supplemented with Vitamin E, folic acid and iron. Blood sampling was kept to a minimum and non-invasive blood-gas monitoring was used consistently. Consequently, the estimated cumulative volume of blood loss from sampling was only 21 mL during his hospital stay. His haemoglobin (Hb) was 150 g/L at birth and this fell to below 100 g/L from day 25 onwards. His lowest leucocyte count was 3.6 x 109/L. He was discharged on day 83 with a Hb of 95 g/L, Hct of 29%, reticulocyte count of 2.8% and weight of 2400 g. At a postnatal age of 3 months, he had a Hb of 113 g/L. At 6 months, investigations showed: Hb 121 g/L, haematocrit 33%, reticulocyte 1% and a weight of 4.4 kg. He was readmitted to hospital once for an episode of vomiting and follow up to date showed developmental delay.

(3) Fernandes CJ, Hagan R, Freiberg A, Grauaug A, Kohan R. ERYTHROPOIETIN IN VERY PRETERM INFANTS. J Paediatr Child Health 1994 August; 30(4): 356-59 Three neonates (a male and two females of gestational ages 27, 27 and 29 weeks with birthweight 985, 660 and 1130 g), born to parents who are Jehovah�s Witnesses, were admitted to our neonatal intensive care unit over a 2 month period in 1992. Human recombinant erythropoietin (rHuEPO 200 u/kg sc. on alternate days for 6-8 weeks) was started early in conjunction with strict control of blood sampling in an attempt to avoid the need for blood transfusion. The lowest hemoglobin recorded was 95 g/L at 35 days of age in the first infant. The amount of blood withdrawn for sampling was 21.4 ml, 20.7 ml and 5.5 ml, respectively. All were discharged near their expected birthdate, never having received a blood transfusion in the Nursery. It is possible to manage sick, very preterm, very low birthweight neonates in a neonatal intensive care setting without the use of blood transfusions by the early use of rHuEPO in conjunction with strict control of blood sampling.


(4) Porter E, Ahn S, Cunningham P, Lazerson J. ANEMIA IN A PREMATURE INFANT OF A JEHOVAH�S WITNESS. Hosp Pract (Off Ed) 1994 May 15; 29(5): 99-100 A premature male infant became anemic because of iatrogenic blood loss. The infant weighed 1,600 gm, appropriate for the gestational age of 31 week. The endogenous course of anemia of prematurity include decreased red cell survival, hemodilution due to rapid increase in body size and blood volume, decreased serum erythropoietin, and marrow hyporesponsiveness. The anemia may be further exaggerated by iatrogenic blood loss from repeated laboratory blood samplings. Anemia in premature infants is almost universially treated with transfusion in neonatal intensive care units. However, when the parents� religious beliefs prohibit blood transfusions, an alternative must be sought. Treatment with erythropoietin with human recombinant erythropoietin was instituted on day 17, and the dose was increased from 200 IU/kg per week to 400 IU /kg on day 31, after which the anemia began to reverse and the infant discharged from the hospital.

(5) Velin P, Dupont D, Puig C, Golkar A [HUMAN RECOMBINANT ERYTHROPOIETIN AND ANEMIA IN PREMATURE INFANTS OF PARENTS WHO ARE JEHOVAH'S WITNESSES]. [ARTICLE IN FRENCH Arch Fr Pediatr 1993 Oct;50(8):721-2

(6) Davis P, Herbert M, Davies DP, Verrier Jones ER. CASE STUDY. ERYTHROPOIETIN FOR ANAEMIA IN A PRETERM JEHOVAH�S WITNESS BABY. Early Hum Dev 1992 March; 28(3): 279-83 An infant born at 24 weeks gestation to Jehovah�s Witness parents was made a Ward of Court and treated against their wishes with blood products. Erythropoietin was used without obvious benefit, but the child did well. The parents did not reject the child and maintained a good relationship with medical and nursing staff. We present this case in the light of current discussions on child welfare and recent reform of the law relating to child protection and highlight the many difficult dilemmas faced by the medical team.

III. ANESTHESIA

A. General Aspects (1) Chassot PG

[ANESTHESIA IN JEHOVAH'S WITNESSES]. [ARTICLE IN FRENCH] Rev Med Suisse Romande 1999 Mar;119(3):179-89

Service d'anesthesiologie, CHUV, Lausanne.

(2) Trovarelli T, Kahn B, Vernon S TRANSFUSION-FREE SURGERY IS A TREATMENT PLAN FOR ALL PATIENTS. AORN J 1998 Nov;68(5):773-8, 780-4

Ortho Biotech, Cliffside Park, NJ, USA. Due to the increased risks associated with allogenic blood transfusion, blood management in surgical procedures, especially in orthopedic settings, should include reduction of perioperative blood loss. Preoperative nursing assessment will help define patients at increased risk for transfusion. Both nonpharmacologic and pharmacologic techniques can help minimize allogenic transfusion by reducing blood loss. One such method of managing anemia and reducing patient exposure to allogenic transfusion is the perioperative use of recombinant human erythropoietin--erythropoietin


alfa--an innovative surgical blood management tool. Increased awareness by perioperative nurses of the use of erythropoietin alfa and patient implications can contribute to the overall blood conservation goal.

(3) Cromer MJ, Wolk DR A MINIMAL PRIMING TECHNIQUE THAT ALLOWS FOR A HIGHER CIRCULATING HEMOGLOBIN ON CARDIOPULMONARY BYPASS. Perfusion 1998 Sept;13(5):311-313.

St Joseph's Hospital of Atlanta, Georgia 30342, USA. Reduction in circuit prime during cardiopulmonary bypass has benefits for the patient with a low body surface area, anemia, patient refusal to receive blood products, and aids the practitioner's goal to minimize exposure to blood products. Described here is a simple, low-cost technique that has been shown to decrease priming volume in any bypass circuit and allow a significant increase in 'on bypass hemoglobin'.

(4) Ashley E. ANAESTHESIA FOR JEHOVAH�S WITNESSES. Br J Hosp Med 1997 October 4; 58(8): 375-80

Department of Anaesthesia and Pain Control, Hospital for Children NHS Trust, London.

(5) Pillgram-Larsen J. UNNGÅ BLODTRANSFUSJON VED ELEKTIV KIRURGI. [ARTICLE IN NORWEGIAN] Tidsskr Nor Lægeforen 1996; 116(23): 2795-98 Blodtransfusjoner kan unngås ved nøyaktig kirurgisk teknikk, ved retransfusjon av blod under og etter operasjonen, ved aksept av normovolemisk anemi, ved tapping av blod fra pasienten på forhånd, ved tapping ved start av anestesien, ved regionalanestesi eller anestesi med spontanventilasjon, ved god blodtrykkskontroll, ved stimulering av nydannelse av blod og ved å hemme patologisk blødningstendens. God preoperativ planlegging korter ned operasjonstiden og den tid pasienten ligger med åpent sår og siving. Gode kirurger arbeider bedre med god assistanse. Erfaring fra kirurgisk behandling av Jehovas vitner uten bruk av blod, viser at mortaliteten ikke er relatert til utgangsnivå for hemoglobin, men til peroperativt blodtap. Å unngå hypertensjon under operasjonen minsker blødningen. Elevasjon av operasjonsfeltet ved ekstremitetskirurgi minsker blødning. Blødning er relatert til koagulasjonsfaktorer, karets størrelse og blodtrykket, men ikke til minuttvolumet. Kraftig diatermi stopper blødninger og gir ikke dårlig vevstilheling. Regionalanestesi og spontanventilasjon gir mindre blødning, mens man ved overtrykksventilasjon ser økt venøst trykk og derved blødning.

(6) Selby IR, Lerman J. ANAESTHESIA FOR JEHOVAH�S WITNESSES. Anaesthesia 1996 January; 51(1): 95-96

(7) Tsubokawa K, Narita M, Mase E, Murakami I, Otagiri T, Kurokochi N, Mori K [ANESTHETIC MANAGEMENT OF TEN JEHOVAH'S WITNESS PATIENTS]. [ARTICLE IN JAPANESE] Masui 1996 Jan;45(1):111-114

Department of Anesthesiology and Resuscitology, Shinshu University, School of Medicine, Matsumoto. We experienced the anesthetic management of 10 Jehovah's Witness patients. Some patients accepted either blood products, autologous blood transfusion with closed circuit, or Cell Saver. The patients' families expressed their wish that blood transfusion could be done in life threatening situations against the patient's wish in some cases. It would be desirable to clear up an acceptable standard and write out it in each medical institution to avoid conflicts with the patient and families. Prior agreement is required among medical staffs on refusal of blood transfusion.


(8) Gombotz H, Kulier A [REDUCTION IN THE USE OF DONATED BLOOD IN SURGICAL MEDICINE]. [ARTICLE IN GERMAN] Anaesthesist 1995 Mar;44(3):191-218

Klinik fur Anasthesiologie, Universitat Graz, Osterreich. After rapid changes in transfusion practice over the past few years, blood conservation techniques have become standard in modern perioperative management. As a result, the amount of homologous blood products transfused has been markedly reduced in some types of surgical procedures. Provided that skillful surgical technique is applied and the use of blood products is restricted, autologous transfusion techniques (predonation of autologous blood, preoperative plasmapheresis, acute normovolaemic haemodilution, and intra- and postoperative blood salvage) can be performed with an acceptable risk for patients. In addition, stimulation of erythropoiesis with recombinant human erythropoietin, supplemental iron therapy, and improving haemostasis by aprotinin may further reduce homologous blood requirements. All patients undergoing elective surgery have to be informed about the side effects of transfusion of homologous blood products and the possibility of blood-saving methods. An individual blood conservation plan, based on the patient's status and surgery, the equipment available, and personal experience should be worked out by the responsible anaesthesiologist, whereby a combination of different methods may be most effective. If storage is necessary, autologous blood products should be preparated like homologous products. The feasibility of predonation and retransfusion of autologous blood in patients with infectious diseases like hepatitis or acquired immune deficiency syndrome and the amount of labaratomy testing are still under discussion. Although blood conservation programs are time-consuming and more expensive, they reduce the various risks of using homologous blood products.

(9) Spence RK, Costabile JP, Young GS, Norcross ED, Alexander JB, Pello MJ, Atabek UM, Camishion RC. IS HEMOGLOBIN LEVEL ALONE A RELIABLE PREDICTOR OF OUTCOME IN THE SEVERELY ANEMIC SURGICAL PATIENT? The American Surgeon 1992 February; 58(2): 92-95 The relationship between outcome and hemoglobin (Hbg), oxygen extraction ratio (ER), history of cardiac, renal, pulmonary, and/or hepatic disease, diabetes, malignancy, sepsis, hypertension, and active bleeding was analyzed in 47 patients with severe anemia (Hbg < 7.0 gm/dl, mean = 4.6 +/- .2 gm/dl) to evaluate the effect of Hbg on survival and to look for other predictors of outcome. All patients had refused blood transfusions on religious grounds and were participants in a randomized, controlled study of the blood substitute Fluosol-DA 20 per cent. Patients were analyzed as a group and after stratifying by Hbg into four levels: (Hbg < 3.0 gm/dl, N = 7; Hbg < 3.5 gm/dl, N = 12; Hbg < 4.0 gm/dl, N = 17; Hbg < 4.5 gm/dl, N = 23) and by ER into two levels of < 50 per cent and > 50 per cent. Only Hbg, ER, sepsis and active bleeding were predictors of outcome, with sepsis being the only significant, independent predictor of outcome at all levels (P < .01). Active bleeding was a predictor for levels of Hbg below 5.0 gm/dl. Hbg level alone was a significant predictor only at levels below 3 gm/dl (P < .05). Extraction ratio interacted with Hbg only below 3 gm/dl (P < .05). Multiple independent factors influence outcome in the severely anemic patient, the strongest being sepsis and active bleeding. Prevention of sepsis and early intervention to stop bleeding should improve survival in the patient who refuses transfusion.

(10) Kim WO. ANESTHETIC MANAGEMENT OF JEHOVAH�S WITNESS PATIENTS. J Korean Med Sci 1991 September; 6(3): 214-23 When a Jehovah�s Witness patient rejects transfusion because of his religious doctrine, the anesthesiologist is required to make an important decision. Each doctor must approach his patient respecting the patient�s wishes as much as possible, while still taking into account his own ethical criteria, moral judgement of the patient, and knowledge of medicine. This writer briefly examined the basis of the religious doctrine of a Jehovah�s Witness advocate and consulted a scholar of the criminal court about the legal interpretation of the doctor�s behaviour in our present situation where no detailed judicial precedent was available. I summarized medical solution here by referring to foreign records of medical studies and case reports in the hopes that it may aid in anesthetic management of Jehovah�s Witness patients.


(11) Benson KT. THE JEHOVAH�S WITNESS PATIENT: CONSIDERATIONS FOR THE ANESTHESIOLOGIST. Anesth Analg 1989 November; 69(5): 647-56 Jehovah�s Witnesses refuse blood or blood products on the basis of their religious beliefs. The decision involved in how or even whether to care for a patient refusing necessary blood transfusion have to be made by each individual physician. These decisions should be guided by their knowledge, their own moral and ethical beliefs, and with regard to the convictions of their patient. This study has provided a review of the religious background of the Jehovah�s Witnesses, the ethical issues and conflicts in caring for these patients, the significant past legal decisions rendered concerning this group, and how to proceed with anesthesia care when one elects to do so under the limits imposed by the patient�s religious beliefs.

(12) Garcia F, Juri H, Lapin R. ANEMIA AND ANESTHESIA. The Journal of Bloodless Medicine and Surgery 1986; 4(1): 15-18 We offer as data the treatment course of more than 10,000 patients who have undergone surgery and general anesthesia without the use of blood or blood products. The morbidity and mortality of these procedures compare very favorably with other series in which blood was used. Included in this group are two patients of the Jehovah�s Witness faith who underwent life-saving surgery with hemoglobin levels of less than 2 gm. Presently available techniques were used during these procedures. We use intravenous anesthesia, controlled hypotension, hypothermia, and the lates in inhalation agents in anesthesia. Furthermore, aggressively invasive monitoring to maximally hemodilute the patient is utilized. The transcutaneous oxygen monitor is used on all patients and has provided a means to continually minotor the capillary oxygen tension. Clinically, this has proven to be very useful.

B. Hypotensive Anesthesia (1) Van Hemelen G, Avery CM, Venn PJ, Curran JE, Brown AE, Lavery KM

MANAGEMENT OF JEHOVAH'S WITNESS PATIENTS UNDERGOING MAJOR HEAD AND NECK SURGERY. Head Neck 1999 Jan;21(1):80-4

Department of Maxillofacial Surgery, Queen Victoria Hospital, East Grinstead, West Sussex, UK. BACKGROUND: Several diverse strategies have been recommended to manage Jehovah's Witness patients undergoing surgery when significant blood loss is expected. However, many of the proposed management strategies cannot be used when the urgent nature of the disease precludes adequate preoperative preparation of the patient. We present our experience of the management of two Jehovah's Witnesses with oral carcinoma requiring extensive resection, neck dissection, and reconstruction with free tissue transfer. METHODS: Hypervolemic hemodilution, hypotensive anesthesia, meticulous surgical hemostasis, and antifibrinolytic therapy were used as an alternative to blood products or transfusion. RESULTS: Radical surgical ablation and state-of-the-art reconstruction were possible, as a single-stage procedure, even though blood transfusion or blood product replacement therapy was refused. CONCLUSION: Radical surgical ablation of oral carcinoma, with free tissue transfer reconstruction, is possible in this group of patients without the use of blood products or transfusion. There would have been no advantage in raising the red cell mass preoperatively, as the packed cell volume was ideal for free tissue transfer.

(2) Safwat AM, Reitan JA, Benson D. MANAGEMENT OF JEHOVAH'S WITNESS PATIENTS FOR SCOLIOSIS SURGERY: THE USE OF PLATELETS AND PLASMAPHERESIS. J Clin Anesth 1997 September; 9(6): 510-13 Four patients whose religious beliefs prohibited accepting blood during surgery for scoliosis were anesthetized and managed successfully using plateletpheresis and plasmapheresis. Blood losses were replaced with crystalloid and hetastarch solutions. In addition, a moderate hypotensive technique was used to minimize surgical blood loss. Postoperatively, the patients received iron therapy and/or


erythropoietin. Three of these patients had an uncomplicated postoperative course, however, the fourth patient had some postoperative bleeding with initial hemodynamic instability. We believe that patients who refuse to receive blood transfusion during surgery because of religious beliefs or health issues can be managed safely using other alternatives and techniques such as plateletpheresis and plasmapheresis, which conserve and minimize blood loss. Each case should be assessed on an individual basis.

(3) Victorino G, Wisner DH. JEHOVAH�S WITNESSES: UNIQUE PROBLEMS IN A UNIQUE TRAUMA POPULATION. J Am Coll Surg 1997 May; 184(5): 458-68 BACKGROUND: Jehovah�s Witnesses can create perplexing treatment problems by their refusal of blood transfusions. This dilemma is especially difficult for the trauma surgeon faced with critically low hemoglobin levels or life-threatening blood loss in an injured Jehovah�s Witness. STUDY DESIGN: Retrospectively review of the records of 58 Jehovah�s Witnesses admitted to a single trauma center between July 1992 and June 1995. RESULTS: There were 53 blunt and 5 penetrating injuries. Four patients (7 percent) received blood transfusions; one received banked blood and three received autotransfusions. Two patients were sedated and paralyzed to optimize oxygen utilization; one patient received erythropoietin. Eighteen patients had a general anesthetic and underwent an operative procedure; one underwent controlled hypotensive anesthesia with normovolemic hemodilution. The records of 21 patients (36 percent) included documentation of absolute refusal of blood or blood products; the exact status of consent for blood transfusion was not documented in the records of 33 patients (57 percent). One death and six complications occurred, none of which were attributed to acute blood loss or anemia. Treatment options and special techniques for the severely anemic patient refusing blood transfusions are discussed. CONCLUSIONS: Documentation of religious status and beliefs about blood transfusions, as well as knowledge of special treatment options available for anemic Jehovah�s Witnesses, is necessary to provide quality care to this unique population.

(4) Brodsky JW, Dickson JH, Erwin WD, Rossi CD. HYPOTENSIVE ANESTHESIA FOR SCOLIOSIS SURGERY IN JEHOVAH�S WITNESSES. Spine 1991 March; 16(3): 304-06 Hypotensive anesthesia has been advocated in spinal surgery for the purpose of diminishing operative blood loss. This study evaluated its effectiveness in 12 Jehovah�s Witnesses undergoing Harrington instrumentation and fusion who refused transfusion. Previous series from this institute did not use deliberate hypotension because of routinely low blood loss. Compared with matched controls operated on under normotensive anesthesia, the Jehovah�s Witness patients had lower absolute blood loss but also shorter operative time. Applied linear-regression analysis demonstrated that the diminished blood loss was associated with shorter operative time (P = 0.0002) rather than lower blood pressure. The majority of blood losses in spinal instrumentation with fusion occurs with decortication. This rapid bleeding occurs at venous pressures which are unaffected by arterial blood pressure manipulation. The authors conclude that spinal surgery is possible in Jehovah�s Witnesses without transfusion and that operative technique is the single most important determinant of blood loss.

(5) Rab GT, Gorin LJ, Eisele JH BILATERAL TOTAL HIP ARTHROPLASTY IN A JEHOVAH'S WITNESS WITH CHRONIC ANEMIA. Clin Orthop 1982 Mar;(163):134-6 A 15-year-old girl demonstrated the ability of a youthful person with systemic disease and chronic anemia to withstand major reconstructive surgery, despite religious beliefs prohibiting blood transfusion. With careful preoperative planning and meticulous hemostasis, as well as hypotensive anesthesia, such patients need not be denied the benefits of various reconstructive procedures, provided they and their families understand and appreciate the risks involved.


C. Hypothermic Anesthesia (1) St Rammos K, Bakas AJ, Panagopoulos FG

MITRAL VALVE REPLACEMENT IN A JEHOVAH'S WITNESS WITH DEXTROCARDIA AND SITUS SOLITUS. J Heart Valve Dis 1996 Nov;5(6):673-4

Aristotle University, Medical School, AHEPA, General Hospital, Thessaloniki, Greece. BACKGROUND AND AIMS OF THE STUDY: Dextrocardia with situs solitus and mitral valve insufficiency requiring surgical treatment is a rare presentation. Jehovah's Witnesses (JW), a specific religious group, deny any blood transfusion and for this reason the cardiac surgeon has to plan his operation well in advance, particularly in the case of adhesions from previous thoracic procedures. MATERIALS AND METHODS: A 50-year-old white female Jehovah's Witness with dextrocardia and situs solitus was referred for surgical treatment of massive mitral valve insufficiency of rheumatic etiology. Due to multiple adhesions from previous bilateral thoracotomies and the inverted position of the heart, cardiopulmonary bypass (CPB) was initiated with an aortic and a left common femoral vein cannulae. CPB was completed with an additional SVC cannula. The surgeon, having excellent exposure from the opposite side of the table, was able to perform a mitral valve replacement (MVR) with a 31 mm St. Jude Medical valve prosthesis, through a giant left atrium under moderate hypothermia and crystalloid cardioplegia. The operation was bloodless, with only two units of autotransfused blood being used with a postoperative hematocrit of 34%. RESULTS: The patient had an uneventful recovery and has been in NYHA class I for 24 months now. CONCLUSIONS: The case is presented for the safety of the approach, the excellent exposure from the left side in a dextrocardia case and the avoidance of blood transfusion in a Jehovah's patient.

(2) van Son JA, Hovaguimian H, Rao IM, He GW, Meiling GA, King DH, Starr A STRATEGIES FOR REPAIR OF CONGENITAL HEART DEFECTS IN INFANTS WITHOUT THE USE OF BLOOD. Ann Thorac Surg 1995 Feb;59(2):384-8

Albert Starr Academic Center for Cardiac Surgery, St. Vincent Hospital and Medical Center, Portland, Oregon. Eleven infants and children with a body weight of less than 10 kg (median weight, 6.8 kg) whose parents were Jehovah's Witnesses underwent repair (n = 10) or palliation (n = 1) of congenital heart defects without the use of blood products and with (n = 9) or without (n = 2) cardiopulmonary bypass (CPB). In 1 neonate (weight, 3.2 kg) with critical aortic stenosis, moderate hypothermia and a 3.5-minute period of inflow occlusion and circulatory arrest allowed an aortic valvotomy; in another patient (weight, 7.0 kg) with tricuspid and pulmonary atresia, transposition of the great arteries, and persistent left superior vena cava, a bilateral bidirectional cavopulmonary shunt procedure was performed without CPB. Use of heparin-bonded tubing allowed reduction of the initial dose of heparin sodium to 1 mg/kg. Tissue perfusion and oxygenation on bypass were adequate, as evidenced by a mean lowest pH of 7.38 +/- 0.09 and a mean lowest venous oxygen tension of 65.0 +/- 36.2 mm Hg. Although the mean postoperative hematocrit (Hct) was lower than the mean preoperative Hct (p < 0.05, analysis of variance and Scheffe's F test), the Hct within 2 hours after CPB was restored to a value (mean Hct, 27.5% +/- 1.0%) between the preoperative Hct (mean value, 42.7% +/- 3.5%) and the lowest Hct on CPB (mean value, 18.4% +/- 1.4%). The Hct at discharge was 31.8% +/- 1.1%. The median postoperative blood loss was 9 mL/kg. There was no perioperative mortality. The median stay in the intensive care unit and the hospital was 2 days and 6 days, respectively.

(3) Coselli JS, Buket S, Van Cleve GD SUCCESSFUL REOPERATION FOR ASCENDING AORTA AND ARCH ANEURYSM IN A JEHOVAH'S WITNESS. Ann Thorac Surg 1994 Sep;58(3):871-3

Department of Surgery, Baylor College of Medicine, Houston, Texas. A young woman of the Jehovah's Witness faith presented with a rupturing aneurysm of the ascending aorta and transverse aortic arch. She had Marfan syndrome and previous aortic valve


replacement. Despite reoperation conditions, successful operation via median sternotomy was carried out using deep hypothermia and circulatory arrest.

(4) Stein JI, Gombotz H, Rigler B, Metzler H, Suppan C, Beitzke A OPEN HEART SURGERY IN CHILDREN OF JEHOVAH'S WITNESSES: EXTREME HEMODILUTION ON CARDIOPULMONARY BYPASS. Pediatr Cardiol 1991 Jul;12(3):170-4

Department of Pediatric Cardiology, University of Graz, Austria. Between January 1979 and July 1989, 15 children of Jehovah's Witnesses underwent corrective open surgery for congenital heart disease (CHD) on cardiopulmonary bypass (CPB). Ages ranged from 1.5-17 years and body weight from 9.1-63 kg, with five patients weighing less than 15 kg. Eight children were cyanotic, and two of them had had previous thoracic operations. All operations were performed in moderate to deep hypothermia using a modified version of isovolemic hemodilution with bloodless priming technique of extracorporeal circulation. Mean hematocrit levels decreased from 47.3% (36.9-70%) to 34.6% (27.2-49.1%) after hemodilution, and then to 17.9% (10.5-25.6%) during bypass. They increased again to 34.1% (24.4-50%) at the end of the operation and to 33.4% (25.1-40%) on day 12. All intra- and postoperative hematocrit levels were significantly lower (p less than 0.001). There was one postoperative death, not related to the technique. Our results demonstrate that bloodless cardiac surgery on bypass is feasible in children as shown in this special group of children of Jehovah's Witnesses. Knowing the risks of homologous blood transfusion this technique should be used more extensively in the future.

(5) Gombotz H, Rigler B, Matzer C, Metzler H, Winkler G, Tscheliessnigg KH [10 YEARS' EXPERIENCE WITH HEART SURGERY IN JEHOVAH'S WITNESSES]. [ARTICLE IN GERMAN] Anaesthesist 1989 Aug;38(8):385-90

Klinik fur Anaesthesiologie der Universitat Graz. As a result of their interpretation of the Bible, members of Jehovah's Witnesses do not accept blood transfusions under any circumstances. Consequently, they present moral and ethical problems to surgeons and anesthetists, especially in cardiac surgery. PATIENTS and METHODS. From November 1978 to November 1988, 66 members Jehovah's Witnesses were scheduled for cardiac surgery; 57 patients were operated upon (mean age 33.3 years, 14 days to 70.4 years; mean body weight 51 kg, 0.7 to 95.5 kg); 21 were younger than 14 years. Patients with hematocrit (Hct) less than 35%, expected high intra- and postoperative blood loss, compromised left ventricular function, ST-segment alterations, critical aortic stenosis, severe unstable angina pectoris, complex heart defects, especially in children, extreme body weight, severe diabetes, renal insufficiency, coagulopathies, severe pulmonary disease, and heavy smokers were excluded from operation. Whereas in nonbypass patients no special blood-saving techniques were used, in bypass patients a modified version of isovolemic hemodilution, with a hypothermic, bloodless priming technique of extracorporeal circulation (ECC) was performed after induction of anesthesia. At the end of the ECC all blood collected in the pericardial and pleural cavities was returned to the oxygenator and the entire content of the extracorporeal circuit was infused into the patient through the aortic cannula. All patients receiving ECC were ventilated for 24 h postoperatively and received dopamine (2-5 micrograms/kg) and antibiotics routinely. RESULTS: Due to the above mentioned contraindications, 9 patients were not accepted for surgery, 10 were operated upon without cardiopulmonary bypass or blood-saving techniques. In 47 patients open heart surgery with ECC and moderate or deep hypothermia was performed. In the adult patients (n = 36) Hct values decreased from 44.4% (35-70%) preoperatively to 32.1% (21-46%) after hemodilution, reached their lowest levels during cardiopulmonary bypass at 17.9% (9.9-43%), and increased to 33.7% (22%-43%) at the end of the operation. Hct averaged 28.2% (20%-39%) on the 3rd and 33.2% (23%-46%) on the 12th postoperative day. In children (n = 11) Hct decreased from 47.2% (36.9%-70%) to 33.6% (27.2%-49.1%) after hemodilution, during bypass to 16.1% (10.5%-25.5%) and increased to 32.1% (24.4%-37.4%) at the end of the operation. On the 3rd postoperative day Hct was 25% (21.4%-39%) and increased to 29.4% (25.1%-40%) on the 12th postoperative day. No statistical differences in Hct values were found between both groups.


D. Spinal Anesthesia (1) Matsuki M, Muraoka M, Oyama T.

TOTAL SPINAL ANAESTHESIA FOR A JEHOVAH�S WITNESS WITH PRIMARY ALDOSTERONISM. Anaesthesia 1988; 43: 164-65 This method has been used widely since 1969 in many pain clinics in Japan to treat various pain syndromes. Total spinal anaesthesia is often considered to be the most dangerous complication following spinal anaesthesia and epidural anaesthesia but the method can be applied safely in clinical practice, provided that adequate care is taken of the cardiorespiratory systems.

(2) Bonnett CA, Lapin R, Docuyanan GB TOTAL HIP REPLACEMENT IN JEHOVAH'S WITNESSES UNDER SPINAL ANESTHESIA WITHOUT TRANSFUSION. Orthop Rev 1987 Jan;16(1):43-7

Department of Orthopaedics, Fountain Valley Regional Hospital, California. Ninety patients who were Jehovah's Witnesses underwent 107 total hip replacements without transfusion; all procedures were performed under spinal anesthesia. Of these 90, 87 had not previously undergone hip replacement surgery. They sustained an average intraoperative blood loss of 300 mL, which was a significant reduction compared with that in controlled groups of patients reported by other authors. Factors other than spinal anesthesia that aided in reducing blood loss were posterior surgical exposure of the hip without capsulectomy or removal of the greater trochanter, hemostasis without electrocauterization, and rapidly performed surgery. There were three operative complications and one death, none of which were related to spinal anesthesia.

E. Acute Hemodilution (1) Hiraki T, Hamada N, Kano T, Isamoto Y

[INTRAOPERATIVE HEMODILUTIONAL AUTOTRANSFUSION USING A CLOSED CIRCUIT FOR PATIENTS OF JEHOVAH'S WITNESS]. [ARTICLE IN JAPANESE] Masui 2000 May;49(5):535-539. We conducted hemodilutional autotransfusion using a closed circuit combined with a cell washing reinfusing system (Cell Saver) for two surgical patients of Jehovah's Witness. One was a 12 yr-old boy for extirpation of the teratoma in the anterior mediastinum and another was a 44 yr-old woman for left total hip replacement. The patients and their relatives had consented to the use of blood substitues, hemodilutional autotransfusion using a closed circuit and Cell Saver. We devised a closed circuit system for hemodilutional autotransfusion combined with Cell Saver, in which two pumps for blood transfusion were used; one was for drawing blood from the femoral or the internal jugular vein and the other for returning blood to the peripheral vein. Blood volume in a bag interposed in the closed circuit was easily controlled by adjusting the speed of each pump. Blood collected from the surgical field by Cell Saver was also led to the bag. Acid citrate dextrose solution was infused into the closed circuit from the site close to the blood drawing. Both of our surgical patients were safely managed without homologus blood transfusion, although there remained some problems concerning the use of anticoagulants.

(2) Neff TA, Stocker R, Wight E, Spahn DR EXTREME INTRAOPERATIVE BLOOD LOSS AND HEMODILUTION IN A JEHOVAH'S WITNESS: NEW ASPECTS IN POSTOPERATIVE MANAGEMENT.

Anesthesiology. 1999 Dec;91(6):1949-51.

Institute of Anesthesiology, University Hospital, Zurich, Switzerland.


(3) Fabre P, Paut O, Camboulives J [PROFOUND NORMOVOLEMIC HEMODILUTION IN A PEDIATRIC JEHOVAH'S WITNESS PATIENT AND ORGAN DONATION: WHAT ARE THE LIMITATIONS]? [ARTICLE IN FRENCH] Ann Fr Anesth Reanim 1998;17(2):198-9

(4) Ross JH, Kay R, Alexander F MANAGEMENT OF BILATERAL WILMS' TUMORS IN THE DAUGHTER OF JEHOVAH'S WITNESSES. J Pediatr Surg 1997 Dec;32(12):1759-60

Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, Ohio 44195, USA. Surgical treatment of the children of Jehovah's Witnesses is a challenging problem both ethically and technically. The authors recently operated on such a child who had bilateral Wilms' tumors. Techniques used to minimize blood loss included erythropoietin, hemodilution, and the argon beam coagulator. A full understanding of the religious, legal, and ethical issues is essential when treating the children of Jehovah's Witnesses.

(5) Rosenblatt MA, Cantos EM Jr, Mohandas K INTRAOPERATIVE HEMODILUTION IS MORE COST-EFFECTIVE THAN PREOPERATIVE AUTOLOGOUS DONATION FOR PATIENTS UNDERGOING PROCEDURES ASSOCIATED WITH A LOW RISK FOR TRANSFUSION. J Clin Anesth 1997 Feb;9(1):26-29

Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY, USA. STUDY OBJECTIVE: To determine the utilization and cost of autologous blood that was donated preoperatively, and to compare it to the cost of employing intraoperative hemodilution to provide autologous blood for patients undergoing surgical procedures with a low risk for the need for transfusion. DESIGN: Retrospective chart review. SETTING: University medical center. PATIENTS: All ASA physical status I and II patients who underwent nononcologic gynecologic procedures and preoperatively donated autologous blood between July 1993 and June 1994. MEASUREMENTS AND MAIN RESULTS: The utilization and overall cost of predonated autologous blood was determined. The cost for employing intraoperative hemodilution and potential cost saving was then calculated. Of the 234 units of preoperatively donated autologous blood, 38 units were returned to patients who had an estimated blood loss of at least 500 ml, 32 units returned to patients who had an estimated blood loss less than 500 ml, and 164 units were wasted. No patient received allogeneic blood. The estimated total cost for all preoperatively donated autologous blood was $23,274.62. Employing hemodilution for those same patients would have cost $5,574.74, and resulted in a potential 75.6% savings. CONCLUSIONS: Inappropriate selection of patients for preoperative blood donation is costly. For those patients scheduled to undergo surgical procedures associated with a low probability for the need for blood transfusion, but who desire that autologous blood be available, hemodilution provides fresh whole blood, free from the possibility of processing or clerical errors, while decreasing blood bank utilization and affording substantial cost savings.

(6) Innerhofer P, Luz G SYSTEMIC HAEMODYNAMICS AND OXYGENATION DURING HAEMODILUTION IN CHILDREN. Lancet 1996 Feb 10;347(8998):398-9 Comment on: Lancet 1995 Oct 28;346(8983):1127-9

(7) Cooley DA CONSERVATION OF BLOOD DURING CARDIOVASCULAR SURGERY. Am J Surg 1995 Dec;170(6A Suppl):53S-59S

Texas Heart Institute, Houston 77225-0345, USA.


Conservative use of allogeneic red blood cell (RBC) transfusion is a growing trend in cardiovascular surgery. Recent advances in blood conservation measures have reduced, and in some cases eliminated, the need for allogeneic RBC transfusions in some of these patients. Reduced reliance on allogeneic RBC transfusion requires close collaboration among the clinical pathology, anesthesia, and surgery services managing the patient. Preoperative conservation measures include donation of autologous blood and treatment with recombinant human erythropoietin (Epoetin alfa). Meticulous surgical technique, moderate hemodilution, aprotinin, hemostatic techniques, blood salvage, and autotransfusion are intraoperative measures that can reduce blood loss. Postoperatively, even severe blood deficits can often be restored with adequate diet and rest and the use of actinics.

(8) van Daele ME, Trouwborst A, van Woerkens LC, Tenbrinck R, Fraser AG, Roelandt JR TRANSESOPHAGEAL ECHOCARDIOGRAPHIC MONITORING OF PREOPERATIVE ACUTE HYPERVOLEMIC HEMODILUTION. Anesthesiology 1994 Sep;81(3):602-9

Thoraxcenter, University Hospital Rotterdam-Dijkzigt. BACKGROUND: Preoperative acute hypervolemic hemodilution is used in anesthesia to reduce the loss of blood cells during intraoperative bleeding. Indications for use of the technique might be broadened if it can be shown to be safe in older as well as younger patients. Few data are available describing heart function in humans subjected to hypervolemic hemodilution. METHODS: Nineteen anesthetized Jehovah's Witnesses (ages 22-70 yr) without evidence of heart disease had hypervolemic hemodilution before surgery in three stages, each consisting of an infusion of 500 ml dextran 40 (50 g/l) and 500 ml Ringer's lactate over a 10-min period. After each stage, the size and function of the left ventricle were recorded by transesophageal cross-sectional echocardiography in the short-axis view. Simultaneously heart rate, arterial blood pressure, pulmonary arterial and wedge pressures and cardiac output were recorded, to compare the echocardiographic and hemodynamic data. RESULTS: No complications occurred. Hypervolemic hemodilution resulted in an increased cardiac output by increasing the stroke volume from 48 ml in basal conditions to 67, 71, and 72 ml over the three stages, whereas heart rate did not increase. There was an initial increase in end-diastolic volume of the left ventricle, as assessed from the cross-sectional end-diastolic area from 12.9 to 15.5, 16.6, and 16.9 cm2 followed by a decrease in the in cross-sectional end-systolic area from 6.3 to 6.8, 6.0, and 5.7 cm2. The increase in wedge pressures (from 5.9 to 12.4, 17.9, and 22.6 mmHg) did not lead to progressive cardiac dilation. There was a curvilinear relation between wedge pressure and cross-sectional end-diastolic area. Stroke volume did not decrease, nor did cross-sectional end-systolic area increase; instead, a decrease in end-systolic area was a common observation. CONCLUSIONS: The described regimen of acute hypervolemic hemodilution is well tolerated during anesthesia by patients without heart disease and does not lead to cardiac failure. It leads to an increase in stroke volume that is generated initially from an increase in end-diastolic volume, followed in many patients by a decrease in end-systolic volume, the mechanism of which is as yet unclear.

(9) Nussbaum W, deCastro N, Campbell FW PERIOPERATIVE CHALLENGES IN THE CARE OF THE JEHOVAH'S WITNESS: A CASE REPORT. AANA J 1994 Apr;62(2):160-4 Same day admissions for surgery represent a growing portion of the operating room workload. Vigilance during preanesthetic evaluation and standards of preoperative preparation must be maintained for patients who are undergoing elective procedures. This case study reports the preanesthetic evaluation and perioperative management of a Jehovah's Witness who bled to a hematocrit of 9.0% during a myomectomy. The discussion considers the need for preoperative preparation and conservation of circulating red blood cells. Perioperative management modalities to conserve red blood cells including deliberate, controlled hypotension; autotransfusion; and normovolemic and hypervolemic hemodilution, are presented.


(10) van Woerkens EC, Trouwborst A, van Lanschot JJ PROFOUND HEMODILUTION: WHAT IS THE CRITICAL LEVEL OF HEMODILUTION AT WHICH OXYGEN DELIVERY-DEPENDENT OXYGEN CONSUMPTION STARTS IN AN ANESTHETIZED HUMAN? Anesth Analg 1992 Nov;75(5):818-21

Department of Anesthesiology and General Surgery, University Hospital Dijkzigt, Erasmus University, Rotterdam, The Netherlands. Comment in: Anesth Analg 1992 Nov;75(5):651-3 Comment in: Anesth Analg 1993 Jun;76(6):1371-2

(11) Trouwborst A, van Woerkens ECSM, van Daele M, Tenbrinck R. ACUTE HYPERVOLAEMIC HAEMODILUTION TO AVOID BLOOD TRANSFUSION DURING MAJOR SURGERY. Lancet 1990 Nov 24; 336: 1295-97 16 patients underwent acute hypervolaemic haemodilution with dextran 40 and Ringers lactate, to see whether this procedure could avoid preoperative blood transfusion. Packed cell volume (PCV) and oxygen extraction decreased, and cardiac index and pulmonary wedge pressure increased, although end-systolic area was unchanged. PCV was not significantly different between patients who lost less than or greater than 20% of their initial blood volume. This preoperative manoeuvre, which reduces loss of red blood cells, allowed major surgery to be completed safely without blood transfusion.

(12) Trouwborst A, Hagenouw RR, Jeekel J, Ong GL HYPERVOLAEMIC HAEMODILUTION IN AN ANAEMIC JEHOVAH'S WITNESS. Br J Anaesth 1990 May;64(5):646-8

Department of Anaesthesiology, Erasmus University, Rotterdam, The Netherlands. We report the effects of acute hypervolaemic haemodilution, induced before operation, on haemodynamics and systemic oxygenation. Major surgery in an anaemic Jehovah's Witness patient was facilitated with this technique. Some hours after operation, a perioperative decrease in haemoglobin concentration of less than 5% was observed, in spite of a blood loss of nearly 50% of the calculated blood volume.

(13) Adzick NS, deLorimier AA, Harrison MR, Glick PL, Fisher DM MAJOR CHILDHOOD TUMOR RESECTION USING NORMOVOLEMIC HEMODILUTION ANESTHESIA AND HETASTARCH. J Pediatr Surg 1985 Aug;20(4):372-5 Acute normovolemic hemodilution is a safe technique for minimizing operative blood loss during major tumor resection in children. Based on our experience using hemodilution anesthesia in 14 successful extensive tumor resections, we conclude the following: (1) this is an effective means of reducing use of bank blood and thus avoiding the risks of multiple transfusions; (2) it facilitates surgical dissection due to increased visibility with dilute blood, and decreased bleeding due to controlled hypotension; (3) this technique is acceptable for Jehovah's Witnesses; (4) hetastarch is an effective, inexpensive colloid hemodiluent which minimized perioperative edema compared to crystalloid hemodilution.

(14) Schaller RT Jr, Schaller J, Morgan A, Furman EB HEMODILUTION ANESTHESIA: A VALUABLE AID TO MAJOR CANCER SURGERY IN CHILDREN. Am J Surg 1983 Jul;146(1):79-84 Since 1974, 25 children had 27 major cancer operations with the aid of hemodilution anesthesia. This includes operations for Wilms' tumors, liver tumors, adrenal tumors, pancreatic tumors, ovarian tumors, and resection of metastatic thoracoabdominal tumors. With the use of this method, operative blood loss has been greatly reduced and operative technique improved. At the beginning of surgery, whole blood is removed from the patient and replaced with three times the volume of a balanced


electrolyte solution to maintain intravascular volume. After the time of significant blood loss has ceased, the patient's own blood is returned and diuresis stimulated with furosimide to remove the infused electrolyte solution. Hypothermia, allowing the temperature to drift down to just below 32 degrees C, helps protect vital organs against hypoxia and arterial hypotension to a mean of 50 torr systolic pressure is well tolerated and further reduces blood loss. Adequate tissue oxygenation can be maintained safely during hemodilution to a hematocrit value of 14 percent. Use of bank blood transfusion was necessary in only 6 of 25 patients. It was given when the calculated postoperative hematocrit value would be less than 30 percent. The diluted blood lost during surgery has a low red blood cell volume per milliliter and each milliliter lost depletes the total red blood cell volume by a lesser amount. Also, the ease and speed of surgery may be facilitated by the nearly bloodless operative field. Provided respiratory support is maintained, these children showed only minor clinical effects from this large fluid infusion. The majority of patients who are Jehovah's Witnesses accept this technique with the modification that we keep the blood moving and in direct contact with the patient's vascular system. Carefully planned and meticulously applied short-term hemodilution anesthesia provides a safe method for minimizing operative blood loss and reduces the difficulty of major cancer surgery in children.

(15) Wong KC, Webster LR, Coleman SS, Dunn HK HEMODILUTION AND INDUCED HYPOTENSION FOR INSERTION OF A HARRINGTON ROD IN A JEHOVAH'S WITNESS PATIENT. Clin Orthop 1980 Oct;(152):237-40 The case of a 28-year-old Jehovah's Witness illustrates the feasibility of using a combined technique of induced hypotension and hemodilution to minimize the surgical loss of red blood cells during the insertion of a Harrington rod. A Swan-Ganz catheter with thermister tip was inserted to measure pulmonary arterial pressure, pulmonary arterial wedge pressure and cardiac output. Other intraoperative monitoring included continuous arterial pressure, electrocardiography, oropharyngeal temperature, esophageal stethoscope, arm-cuff blood pressure and urinary output from an indwelling Foley catheter. A total of 10 L of crystalloid was infused over a 2 1/2-hour period while hypotension was induced by intravenous nitroprusside and enflurane anesthesia. Hematocrit was diluted from 46% to 26% intraoperatively with an estimated surgical blood loss of 2,740 ml. The 24-hour postoperative hematocrit was 30% and recovery was uneventful. This method may be useful in any orthopedic procedure in which heavy blood loss is anticipated and the patient refuses transfusion of blood or blood products. However, the patient must be in good health and have an uncompromised cardiopulmonary system.

F. Hyper Baric Oxygen Therapy (HBO) 1. HBO General Aspects of Anemia Treatments

(1) Bell MD THE USE OF HYPERBARIC OXYGEN IN THE MANAGEMENT OF SEVER ANAEMIA IN A JEHOVAH'S WITNESS. Anaesthesia 2000 Mar;55(3):293-294.

(2) Thompson JC LESSONS FROM A LIFE IN SURGERY. I. DO YOU WANT THE HIGH FIGURE OR THE LOW? Surgery 1999 Mar;125(3):345-6

Department of Surgery, University of Texas Medical Branch at Galveston 77555, USA

(3) Youn BA, Burns JR MANAGEMENT OF THE SEVERELY ANEMIC JEHOVAH'S WITNESS. Ann Intern Med 1993 Jul 15;119(2):170 Comment on: Ann Intern Med 1992 Dec 15;117(12):1042-8


(4) Berger MR JEHOVAH'S WITNESSES AND THE PROBLEM WITH BLOOD. Orthop Nurs 1982 Jul-Aug;1(4):17-21

2. HBO for massive Antepartum Haemorrhage

(1) McLoughlin PL, Cope TM, Harrison JC HYPERBARIC OXYGEN THERAPY IN THE MANAGEMENT OF SEVERE ACUTE ANAEMIA IN A JEHOVAH'S WITNESS. Anaesthesia 1999 Sep;54(9):891-5

Department of Anasthesia, University Hospital Aintree NHS Trust, Lower Lane, Liverpool L9 7AL, UK. A case is described in which a Jehovah's Witness patient who refused blood transfusion suffered massive antepartum haemorrhage, her haemoglobin falling as low as 2.0 g.dl(-1). She was treated on an intensive care unit with intermittent positive pressure ventilation and general supportive measures, pulsed hyperbaric oxygen therapy and recombinant human erythropoietin.

G. Cell salvage-Autotransfusion 1. AUTO General Aspects

(1) Dasen KR, Niswander DG, Schlenker RE AUTOLOGOUS AND ALLOGENIC BLOOD PRODUCTS FOR UNANTICIPATED MASSIVE BLOOD LOSS IN A JEHOVAH'S WITNESS. Anesth Analg 2000 Mar;90(3):553-555.

Departments of Anesthesiology and Autotransfusion Services, Kaiser Permanente Medical Center, Sacramento, California, USA. [email protected]

(2) Waters JH, Potter PS CELL SALVAGE IN THE JEHOVAH'S WITNESS PATIENT. Anesth Analg 2000 Jan;90(1):229-230 Comment on: Anesth Analg 1999 Jul;89(1):262-3

(3) Rosengart TK, Helm RE, DeBois WJ, Garcia N, Krieger KH, Isom OW OPEN HEART OPERATIONS WITHOUT TRANSFUSION USING A MULTIMODALITY BLOOD CONSERVATION STRATEGY IN 50 JEHOVAH'S WITNESS PATIENTS: IMPLICATIONS FOR A "BLOODLESS" SURGICAL TECHNIQUE. J Am Coll Surg 1997 Jun;184(6):618-29

Department of Cardiothoracic Surgery, New York Hospital-Cornell University Medical Center, NY, USA. BACKGROUND: Blood transfusion persists as an important risk of open heart operations despite the recent introduction of a variety of new pharmacologic agents and blood conservation techniques as independent therapies. A comprehensive multimodality blood conservation program was developed to minimize this risk. STUDY DESIGN: To provide a strategy for operating without transfusion, this program was prospectively applied to 50 adult patients who are Jehovah's Witnesses and have undergone open heart operation at our institution since 1992. The blood conservation program used for these patients included the use of high-dose erythropoietin (800 U/kg load, 500 U/kg every other day), aprotinin (6 million U total dose full Hammersmith regimen), "maximal" volume intraoperative autologous blood donation, intraoperative cell salvage, continuous shed blood reinfusion, and drawing as few blood specimens as possible. RESULTS: Procedures performed included first-time coronary bypass operations (n = 30) and more complex operations, including reoperations, valve replacements, and multiple valve replacements with or without coronary bypass


(n = 20). Despite the absence of transfusion, the mean discharge hematocrit in these patients was greater than 30 percent, and there was no anemia-related mortality rate in this group. The overall in-hospital mortality for the group was 4 percent. A subset analysis was performed between the 30 first-time coronary bypass patients (group 1) and a control group of 30 consecutive patients who were not Jehovah's Witnesses but had undergone first-time coronary bypass during the same period (group 2). The blood conservation program described in the previous paragraph was not used in group 2 patients and specific transfusion criteria were prospectively applied. The chest tube output in group 1 patients was less than 40 percent of that for group 2 patients at all points measured after operation (p < 0.01). Postoperative hematocrit levels in group 1 were greater than those for group 2, despite the absence of red blood cell transfusion and despite a significantly lower admission hematocrit and red blood cell mass in group 1. The average length of stay and ancillary costs for the two groups were equivalent. Although group 1 and 2 patients were well matched for preoperative transfusion risk factors, none of the group 1 patients required transfusion, but 17 (57 percent) group 2 patients met transfusion criteria and received 3.0 +/- 4.8 U (mean plus or minus standard deviation) of homologous blood or blood products. CONCLUSIONS: These results suggest that even complex open heart operations can be performed without homologous transfusion by optimally applying available blood conservation techniques. More generalized application of these measures may increasingly allow "bloodless" operations in all patients.

(4) Cooley DA CONSERVATION OF BLOOD DURING CARDIOVASCULAR SURGERY. Am J Surg 1995 Dec;170(6A Suppl):53S-59S Texas Heart Institute, Houston 77225-0345, USA. Conservative use of allogeneic red blood cell (RBC) transfusion is a growing trend in cardiovascular surgery. Recent advances in blood conservation measures have reduced, and in some cases eliminated, the need for allogeneic RBC transfusions in some of these patients. Reduced reliance on allogeneic RBC transfusion requires close collaboration among the clinical pathology, anesthesia, and surgery services managing the patient. Preoperative conservation measures include donation of autologous blood and treatment with recombinant human erythropoietin (Epoetin alfa). Meticulous surgical technique, moderate hemodilution, aprotinin, hemostatic techniques, blood salvage, and autotransfusion are intraoperative measures that can reduce blood loss. Postoperatively, even severe blood deficits can often be restored with adequate diet and rest and the use of actinics.

(5) Kunz J, Mahr R MANAGEMENT OF SEVERE BLOOD LOSS AFTER TUMOR RESECTION IN A JEHOVAH'S WITNESS. Gynakol Geburtshilfliche Rundsch 1995;35(1):34-7

Division of Obstetrics and Gynecology, Schweizerische Pflegerinnenschule, Zurich, Switzerland. This report describes the peri- and postoperative management of a patient with a critical blood loss (hemoglobin of 22 g/l) as a consequence of a surgical intervention, i.e. a radical resection of an advanced malignant gynecological tumor. The patient refused autologous and homologous blood transfusions for religious reasons (Jehovah's Witness). During surgery, hemodilution and cell salvage were used. Postoperatively she developed coagulopathy and hemorrhage with the lowest hemoglobin value of 22 g/l. The patient recovered under a therapy regimen of recombinant human erythropoietin and parenteral iron. The hemoglobin values returned to the lower normal range within 4 weeks. Consequences of hypoxia could not be seen.

(6) Malan TP Jr, Whitmore J, Maddi R REOPERATIVE CARDIAC SURGERY IN A JEHOVAH'S WITNESS: ROLE OF CONTINUOUS CELL SALVAGE AND IN-LINE REINFUSION. J Cardiothorac Anesth 1989 Apr;3(2):211-4

Department of Anesthesia, Brigham and Women's Hospital, Boston, MA 02115.


(7) Popovsky MA, Devine PA, Taswell HF INTRAOPERATIVE AUTOLOGOUS TRANSFUSION. Mayo Clin Proc 1985 Feb;60(2):125-34 Intraoperative autologous transfusion is a technique that was first used almost 2 centuries ago but that has realized its potential only in the past 5 years. A growing national awareness of transfusion-related morbidity, of the need for alternative blood sources, and of improved methods for red blood cell recovery has led to an increased frequency of use of autologous transfusion. Most hospital programs use semicontinuous flow centrifugation or canister technology for the intraoperative salvage and reinfusion of shed blood. This technique is particularly valuable for cardiovascular surgical procedures but has been useful in many other types of surgical procedures as well. Deleterious effects formerly attributed to this technique have been eliminated by methodologic improvements. Concerns about use of autologous transfusion in patients who have an infection or a malignant lesion persist. Most hematologic aberrations are related to massive transfusions and should not be considered a contraindication to the general use of autologous blood.

2. AUTO Trans and EPO

(1) Roure P, Hayem C, Daoud A [HEMORRHAGIC SURGERY IN TWO JEHOVA'S WITNESS CHILDREN REFUSING PROGRAMMED AUTOTRANSFUSION: A PLACE FOR ERYTHROPOIETIN]. [ARTICLE IN FRENCH] Ann Fr Anesth Reanim 1998;17(4):310-4

Service d'anesthesie-reanimation, hopital R-Poincare, Garches, France. We report two cases of haemorrhagic surgery in a 6-year-old and 16-year-old girl, respectively, whose parents were Jehovah's witnesses and therefore opposed to preoperative blood donation, but accepting intraoperative blood salvage. Erythropoietin and intravenous iron were administered preoperatively to increase red cell mass. Intraoperative blood salvage, including normovolaemic haemodilution and intraoperative autologous transfusion, avoided homologous blood transfusion.

(2) Rosengart TK, Helm RE, Klemperer J, Krieger KH, Isom OW COMBINED APROTININ AND ERYTHROPOIETIN USE FOR BLOOD CONSERVATION: RESULTS WITH JEHOVAH'S WITNESSES. Ann Thorac Surg 1994 Nov;58(5):1397-403

Department of Cardiothoracic Surgery, New York Hospital-Cornell University Medical Center, New York 10021. Despite recent advances in blood conservation techniques, major risks persist for excessive bleeding and blood transfusion after open heart operations. We reviewed the records of 100 consecutive patients undergoing first-time coronary artery bypass grafting at our institution to define these risks and develop a multimodality blood conservation program based on the results. This program was subsequently applied on a prospective basis to a select group of patients who refuse blood transfusion on religious grounds (Jehovah's Witnesses [JW]) (n = 15). Encouraging initial results with coronary artery bypass grafting in this group (n = 8) led to the application of the program to more complex operations (n = 7), including repeat bypass grafting with use of the internal mammary artery, repeat mitral valve replacement, aortic and mitral valve replacement with coronary artery bypass grafting, mitral valve replacement with bypass grafting, chronic type 1 dissection repair, aortic valve replacement, and atrial septal defect repair in 1 patient each. The blood conservation program employed in these patients included the use of (1) aprotinin (full Hammersmith regimen), (2) high-dose erythropoietin, (3) "maximal"-volume intraoperative autologous blood donation, (4) low-prime cardiopulmonary bypass, (5) exclusive use of intraoperative cell salvage, and (6) continuous reinfusion of shed mediastinal blood. There were no deaths in the JW group. Thromboembolic complications consisted of a transient posterior circulation stroke in only 1 patient (dissection repair). No blood or blood products were transfused compared with the transfusion of 5.1 +/- 7.8 units (mean +/- standard deviation) in the 100 primary coronary bypass patients in whom the blood conservation program was not employed.


3. AUTO and Heparin Coated Circuits

(1) von Segesser LK, Weiss BM, Garcia E, Turina MI CLINICAL APPLICATION OF HEPARIN-COATED PERFUSION EQUIPMENT WITH SPECIAL EMPHASIS ON PATIENTS REFUSING HOMOLOGOUS TRANSFUSIONS. Perfusion 1991;6(3):227-233.

Clinic for Cardiovascular Surgery, University Hospital, Zurich, Switzerland. Clinical application of heparin-coated cardiopulmonary bypass equipment during perfusion with low systemic heparinization is reported with special emphasis on patients refusing any transfusion of homologous blood or blood products. Using the described technique, coronary artery revascularization was successfully performed in three Jehovah's witnesses. During perfusion, the activated clotting time (ACT) was maintained above 180 seconds. Prebypass haematocrit was 38 +/- 3% and dropped to 22 +/- 1% after seven days. Hence, cardiopulmonary bypass with low systemic heparinization may further reduce bypass induced morbidity and improve the final outcome in selected patients.

H. Perfluorocarbons (PFCs) A. PFC First Generation Experiences

(1) Marelli TR USE OF A HEMOGLOBIN SUBSTITUTE IN THE ANEMIC JEHOVAH'S WITNESS PATIENT. Crit Care Nurse 1994 Feb;14(1):31-38. Fluosol DA is an experimental means of supplementing oxygen delivery in the anemic patient. The drug's ability to improve oxygen transport appears to improve SVO2. Blood transfusion is the first choice for acute anemia secondary to hemorrhage; however, perfluorochemicals offer an alternative for the patient who cannot accept transfusion therapy. This article reports a case of severe anemia in which transfusion was refused because of the patient's religious convictions. Perfluorochemicals represented an effective medical treatment that was compatible with this patient's religious beliefs. Continued research in artificial oxygen transporters may lead to even more effective drugs for the treatment of acute anemia, possibly decreasing the need for blood transfusion for all patients.

(2) Kale PB, Sklar GE, Wesolowicz LA, DiLisio RE FLUOSOL: THERAPEUTIC FAILURE IN SEVERE ANEMIA. Ann Pharmacother 1993 Dec;27(12):1452-1454.

Department of Pharmacy Practice, Wayne State University, Detroit, MI. OBJECTIVE: To report the use of Fluosol in the management of a severe anemia and to review the literature regarding the use of Fluosol. CASE REPORT: A 40-year-old woman, at 40.5 weeks gestation, was admitted for induction of labor. Her hospital course was complicated by a postpartum hemorrhage and severe anemia. Because the patient was a Jehovah's Witness, she received non-blood products including hetastarch, iron dextran, and erythropoietin, and a total of 33 mL/kg of Fluosol, but she did not survive. DISCUSSION: Fluosol is an oxygen-carrying, perfluorochemical blood substitute. It was administered to our patient, who presented with the lowest hemoglobin (Hb) (11 g/L) and hematocrit (0.31 fraction of 1.00) of all reported cases. Almost all patients with an Hb < 20 g/L do not survive. CONCLUSIONS: Although the use of Fluosol as a blood substitute appears theoretically promising, its use in the management of severe anemia cannot be recommended.

(3) Spence RK, Costabile JP, Young GS, Norcross ED, Alexander JB, Pello MJ, Atabek UM, Camishion RC IS HEMOGLOBIN LEVEL ALONE A RELIABLE PREDICTOR OF OUTCOME IN THE SEVERELY ANEMIC SURGICAL PATIENT? Am Surg 1992 Feb;58(2):92-95.


Department of Surgery, Cooper Hospital/University Medical Center, Camden, New Jersey 08103. The relationship between outcome and hemoglobin (Hgb), oxygen extraction ratio (ER), history of cardiac, renal, pulmonary, and/or hepatic disease, diabetes, malignancy, sepsis, hypertension, and active bleeding was analyzed in 47 patients with severe anemia (Hgb less than 7.0 gm/dl, mean = 4.6 +/- .2 gm/dl) to evaluate the effect of Hgb on survival and to look for other predictors of outcome. All patients had refused blood transfusion on religious grounds and were participants in a randomized, controlled study of the blood substitute Fluosol DA-20 per cent. Patients were analyzed as a group and after stratifying by Hgb into four levels: (Hgb less than 3.0 gm/dl, N = 7; Hgb less than 3.5 gm/dl, N = 12; Hgb less than 4.0 gm/dl, N = 17; Hgb less than 4.5 gm/dl, N = 23) and by ER into two levels of less than 50 per cent and greater than 50 per cent. Only Hgb, ER, sepsis and active bleeding were predictors of outcome, with sepsis being the only significant, independent predictor of outcome at all levels (P less than .01). Active bleeding was a predictor for levels of Hgb below 4.0 gm/dl. Hgb level alone was a significant predictor only at levels below 3 gm/dl (P less than .05). Extraction ratio interacted with Hgb only below 3 gm/dl (P less than .05). Multiple independent factors influence outcome in the severely anemic patient, the strongest being sepsis and active bleeding. Prevention of sepsis and early intervention to stop bleeding should improve survival in the patient who refuses transfusion.

(4) Frackiewicz EJ, Lee R USE OF A BLOOD SUBSTITUTE IN A PATIENT WHO REFUSES TO ACCEPT A TRANSFUSION. Am J Hosp Pharm 1991 Oct;48(10):2176.

University of Southern California, Los Angeles.

Am J Hosp Pharm 1991 Oct;48(10):2176-2180 (Discussion)

(5) Nyberg SL, Cerra FB TREATMENT OF SEVERE ANAEMIA WITH PERFLUOROCARBON BLOOD SUBSTITUTES: A CLINICAL OVERVIEW. Clin Intensive Care 1991;2(4):226-232.

Department of Surgery, University of Minnesota, Minneapolis 55455.

(6) Spence RK, McCoy S, Costabile J, Norcross ED, Pello MJ, Alexander JB, Wisdom C, Camishion RC FLUOSOL DA-20 IN THE TREATMENT OF SEVERE ANEMIA: RANDOMIZED, CONTROLLED STUDY OF 46 PATIENTS. Crit Care Med 1990 Nov;18(11):1227-1230.

Department of Surgery, Cooper Hospital/University Medical Center, Robert Wood Johnson Medical School, Camden 08103. We evaluated the safety and efficacy of Fluosol DA-20% (FDA) as a blood substitute in the treatment of severe anemia. Thirty-six patients received either FDA (n = 21) or crystalloid/hydroxyethyl starch (CHS) (n = 15) as part of a randomized, controlled trial. Ten patients received FDA as part of a humanitarian protocol. All were Jehovah's Witnesses who refused transfusion, had bled recently, and had average Hgb levels of 4.3 g/dl. After pulmonary artery catheter insertion, each patient was infused with CHS to attain a pulmonary artery wedge pressure (WP) of 10 to 18 mm Hg. FDA was given as a one-time dose of 30 ml/kg. Data were collected at baseline, 12, 24, and 48 h. None of the patients with negative reactions to a 0.5-ml test dose of FDA had adverse reactions to the subsequent infusion. The plasma or dissolved component of oxygen content was significantly higher in the FDA group at 12 h (FDA group 1.58 +/- 0.47 ml/dl, control group 1.01 +/- 0.31 ml/dl, p less than .02, t-test). Nineteen patients died: 12 (37.5%) FDA, seven (46.6%) control. The difference was not significant. We conclude the following: a) FDA can be given safely to severely anemic patients in doses of 30 ml/kg; b) FDA significantly increased the dissolved component of oxygen content after 12 h but the effect did not persist; c) severely anemic patients can survive without transfusion although mortality


is high. In this study, inability of FDA to sustain increased oxygen content was due in part to the rapid elimination of FDA and also to the limited amount given.

(7) Gould SA, Rosen AL, Sehgal LR, Sehgal HL, Langdale LA, Krause LM, Rice CL,Chamberlin WH, and Moss GS. FLUOSOL-DA AS A RED-CELL SUBSTITUTE IN ACUTE ANEMIA N Engl J Med 1986 Jun 26;314(26):1653-1656. We assessed the safety and efficacy of Fluosol-DA as red-cell substitute in acute anemia. Twenty-three surgical patients with blood loss and religious objections to receiving blood transsfusions were evaluated. Fifteen moderately anemic patients with a mean hemoglobin level(+-SE) of 7.2+-0.5 g per deciliter had no evidence of a physiologic need for increased arterial oxygen content and did not receive Fluosol-DA. Eight severily anemic patients with a mean hemoglobin level of 3.0+-0.4 g per deciliter met the criteria of need and received the drug until the physiologic need disappeared or a maximal dose of 40ml per kilogram of body weigth was reached. We observed no adverse reactions to Fluosol-DA. The average peak increment in arterial oxygen content with the drug was only 0.7+-0.1 ml per deciliter. There were no appreciable beneficial effects of Fluosol-DA, perhaps because of the small increase in arterial oxygen content, the brief half-life of the drug (24.3+-4.3hours), and the limited total dose. Six of the eight patients receiving Fluosol-DA died. One of the survivors received red-cell transfusions against his wishes, under a court order,after his total Fluosol-DA dose. Fourteen of the 15 moderately anemic patients survived. The data in this selected group of patients refusing blood products suggest that, after blood loss, Fluosol-DA is unnecessary in moderate anemia and ineffective in severe anemia.

(8) Police AM, Waxman K, Tominaga G PULMONARY COMPLICATIONS AFTER FLUOSOL ADMINISTRATION TO PATIENTS WITH LIFE-THREATENING BLOOD LOSS. Crit Care Med 1985 Feb;13(2):96-98. Fluosol-DA 20% (Fluosol), a perfluorochemical emulsion capable of improving oxygen transport, was used to treat three patients with life-threatening hemorrhage. In each case a decreased partial pressure of oxygen, an increased alveolar-arterial oxygen gradient, fever, an increased white blood cell count, and chest x-ray abnormalities occurred at similar time intervals after treatment with Fluosol. In one patient, pulmonary complications were fatal. Similar adverse reactions to treatment with Fluosol have not been previously reported. Possible explanations for these pulmonary complications are the adult respiratory distress syndrome, oxygen toxicity, or direct toxic effects of Fluosol.

(9) Karn KE, Ogburn PL Jr, Julian T, Cerra FB, Hammerschmidt DE, Vercellotti G USE OF A WHOLE BLOOD SUBSTITUTE, FLUOSOL-DA 20%, AFTER MASSIVE POSTPARTUM HEMORRHAGE. Obst Gynecol 1985 Jan;65(1):127-130 Two patients with severe postpartum hemorrhage refused blood product transfusion for religious reasons. The patients' hemoglobin level had dropped to 3.0% or less after operative intervention, and the cardiac indexes on transfer to the tertiary care center were 8.0 and 7.3 L/minute per m2, respectively. Each received an infusion of Fluosol-DA 20% according to research protocol after obtaining informed written consent. Pulse rates and cardiac outputs dropped after the infusions. They were discharged from the hospital 17 and 15 days later with hemoglobins of 7.0 and 5.1%, respectively. Fluosol-DA 20% may be a useful adjunct for therapy of postpartum hemorrhage in women who refuse blood products for religious reasons.

(10) Waxman K, Tremper KK, Cullen BF, Mason GR PERFLUOROCARBON INFUSION IN BLEEDING PATIENTS REFUSING BLOOD TRANSFUSIONS. Arch Surg 1984 Jun;119(6):721-724. Six severely anemic surgical patients who refused blood products were treated with a perfluorochemical (PFC) emulsion (Fluosol-DA 20%). When these patients received high inspired oxygen concentrations, the emulsion resulted in moderate increases of arterial oxygen content but


considerable increases of oxygen consumption, suggesting improved microcirculatory oxygen distribution. The mean +/- SD percentages of consumed oxygen transported by dissolved oxygen in PFC and PFC plus plasma emulsions were 22% +/- 5% and 60% +/- 12%, respectively. Several adverse clinical effects were seen, however, including transient decreases in leukocyte counts, hypotension, and abnormal hepatic and pulmonary function.

(11) Brown AS, Reichman JH, Spence RK FLUOSOL-DA, A PERFLUOROCHEMICAL OXYGEN-TRANSPORT FLUID FOR THE MANAGEMENT OF A TROCHANTERIC PRESSURE SORE IN A JEHOVAH'S WITNESS. Ann Plast Surg 1984 May;12(5):449-453. A 54-year-old paraplegic with a right trochanteric pressure sore was refused reconstructive surgery because of his hemoglobin count of 6 gm/dl and his refusal to accept blood transfusions because of religious beliefs. Utilization of Fluosol-DA, a perfluorochemical oxygen-transport fluid that has recently become available to us for clinical trial, enabled us to deal successfully with this man's problem despite the profound anemia, since tissue oxygen delivery was provided with arterial oxygen partial pressures as high as 500 torr after infusion. Patients previously denied operations on the basis of their blood counts and their refusal to receive blood transfusions may in the future be offered the option of an oxygen-carrying fluid such as Fluosol to allow them to safely undergo reconstructive procedures.

(12) Ohyanagi H, Nakaya S, Okumura S, Saitoh Y SURGICAL USE OF FLUOSOL-DA IN JEHOVAH'S WITNESS PATIENTS. Artf Organs 1984 Feb;8(1):10-18. The effects of Fluosol-DA 20% on circulating blood cells, hemodynamic parameters, blood gases, and organs are described and compared with the results of phase I human studies and animal experiments. Bleeding of preoperative anemia and/or surgical bleeding, Fluosol-DA 20% was administered to 7 of 10 Jehovah's Witness patients treated in this hospital. Six received 1,000 ml and the seventh received 2,000 ml. Hematological changes were examined after the administration of a 1-ml test dose and at early and late stages of Fluosol-DA 20% administration. Hemodynamics and blood gases were measured before and after infusion of Fluosol-DA 20%. Hepatic function was also determined. A drop in neutrophils and platelets was observed in some patients after the injection of a 1-ml test dose. This transient reaction was of short term, and the neutrophil and platelet levels recovered spontaneously. Both the efficacy and the safety of Fluosol-DA 20% were demonstrated in these patients.

(13) Tremper KK, Cullen BF U.S. CLINICAL STUDIES OF THE TREATMENT OF ANEMIA WITH FLUOSOL-DA 20%. Artif Organs 1984 Feb;8(1):19-24. This article describes the progress of clinical studies of the perfluorochemical (PFC) emulsion Fluosol-DA 20% in the United States. To date, two studies have been completed and one is in progress. All three studies have been restricted to the treatment of acute anemia in patients who refused blood transfusions on religious grounds, i.e., Jehovah's Witnesses. The first protocol, referred to as the "Humanitarian Protocol" (no. 79006), was initiated in November 1979. Jehovah's Witness patients who were considered to have a lethal degree of anemia were treated with Fluosol to supplement oxygen transport. Collection of specific data was not mandated in this protocol. Six patients were treated under this protocol until it was replaced by the "Medical Use Protocol" (no. 79007). In this second study, hemodynamic and oxygen transport data were collected while patients breathed room air and 100% inspired oxygen before and after a Fluosol infusion. Seven patients were treated under this protocol and it was concluded that the PFC was transporting the expected amount of oxygen based on its known oxygen solubility. This increased oxygen transport by the PFC resulted in increased oxygen consumption and arterial and mixed venous blood oxygenation. Two of the seven patients had adverse reactions to a 0.5-ml test dose of Fluosol, manifested by an increase in pulmonary artery systolic pressure. The third and current anemia protocol as of this writing is a randomized controlled study with data collection similar to the Medical Use Protocol.


(14) Gonzalez ER FLUOSOL A SPECIAL BOON TO JEHOVAH'S WITNESSES... JAMA 1980 Feb 22-29;243(8):720,724.

(15) Gonzalez ER THE SAGA OF 'ARTIFICIAL BLOOD'. JAMA 1980 Feb 22-29;243(8):719-720.

B. Second Generation of PFC

(1) Standl T ARIFICIAL OXYGEN CARRIERS AS RED BLOOD CELL SUBSTITUTES - PERFLUOROCARBONS AND CELL-FREE HEMOGLOBIN. Infusionther Transfusionsmed 2000 May;27(3):128-137. Forthcoming shortfall of blood products and persisting concerns about viral transmission and immunosuppressive side effects of allogeneic blood transfusion have reinforced the studies with alternative oxygen carriers in the last years. Modern perfluorochemicals and cell-free hemoglobin solutions can be applied without prior cross-matching and are now available as stable formulations with long shelf life. Both groups of oxygen carriers have shown their effectivity and tolerability in numerous animal studies. An emulsion of perflubron which has a 60% weight/volume relation is actually undergoing phase III studies with respect to its effectivity in augmented acute normovolemic hemodilution since it has been shown to reverse hemodynamic transfusion triggers. While clinical studies with human cross-linked hemoglobin (DCLHb) have been stopped last year because of the results of two clinical trials showing an increased mortality in patients with stroke and multiple injury shock being treated with DCLHb in comparison with saline, a phase III study with polymerized bovine hemoglobin HBOC-201 is actually being performed in noncardiac patients with perioperative bleeding. The objective of this multicenter study is to show that treatment with HBOC-201 can reduce or avoid allogeneic RBC transfusion. Besides its use in clinical transfusion protocols, artificial oxygen carriers have a unique potential to deliver oxygen to the tissues by plasmatic transport due to its different physiology of oxygenation when compared with conventional oxygenation provided by red blood cells. Future studies must show if these modern oxygen carriers are able to improve outcome of patients with impaired perfusion and organ oxygenation. Copyright 2000 S. Karger GmbH, Freiburg

(2) Frietsch T, Lenz C, Waschke KF [INTRAVENOUS PERFLUOROCARBONS. ARTIFICIAL OXYGEN CARRIERS AND THEIR MEDICAL APPLICATIONS]. [ARTICLE IN GERMAN] Dtsch Med Wochenschr 2000 Apr 14;125(15):465-472.

Institut fur Anasthesiologie und Operative Intensivmedizin, Fakultat fur Klinische Medizin Mannheim, Ruprecht-Karls-Universitat Heidelberg. [email protected] Comment in: Dtsch Med Wochenschr 2000 Apr 14;125(15):444

(3) Habler OP, Messmer KF TISSUE PERFUSION AND OXYGENATION WITH BLOOD SUBSTITUTES. Adv Drug Deliv Rev 2000 Feb 28;40(3):171-184.

Institute of Anesthesiology, Ludwig-Maximilians-University, Munich, Germany. [email protected] As an alternative to transfusion of red blood cells, intravenously (iv) administered artificial oxygen (O(2)) carriers are intended to increase the reduced O(2) carrying capacity of blood in the case of acute severe anemia, i.e. hemorrhagic shock or extreme normovolemic hemodilution (ANH). Actually, two groups of artificial O(2) carriers are investigated: ultrapurified, stroma-free hemoglobin solutions (SFH) of human or bovine origin and synthetically produced perfluorocarbons (PFC). SFH may be administered in large amounts and are suitable for 1:1 replacement of blood losses in case of hemorrhage as well as for isovolemic exchange of blood


during ANH. In both situations SFH solutions effectively restore (hemorrhagic shock) and maintain (extreme ANH) tissue oxygenation despite extremely low hematocrit values. The vasopressor property of the isolated Hb molecule leads to a species-dependent (rodent>pig>human) increase in systemic and pulmonary vascular resistance, but leaves overall distribution of cardiac output uninfluenced. Due to the particulate nature of PFC emulsions, iv administration has to be restricted to small doses (3-4.5 ml/kg body weight for the actually investigated 60% w/v perflubron emulsion) in order to avoid overload of the reticuloendothelial system. Thus PFC emulsions are unsuitable for isovolemic blood replacement in hemorrhagic shock or ANH. Low-dose iv PFC administration in already hemodiluted subjects, however, creates an additional margin of safety to guarantee adequate tissue oxygenation which allows for further, extreme ANH, without risking tissue hypoxia.

(4) Spahn DR CURRENT STATUS OF ARTIFICIAL OXYGEN CARRIERS. Adv Drug Deliv Rev 2000 Feb 28;40(3):143-151.

Institut fur Anasthesiologie, UniversitatsSpital, Zurich, Switzerland. [email protected] Artificial oxygen carriers may be grouped into modified hemoglobin solutions and fluorocarbon emulsions. In animal experiments, both have been shown to be efficacious in improving tissue oxygenation and as substitutes for blood transfusions. Advantages and disadvantages are being discussed in this article as well as the latest steps in the clinical development.

(5) Lowe KC PERFLUORINATED BLOOD SUBSTITUTES AND ARTIFICIAL OXYGEN CARRIERS. Blood Rev. 1999 Sep;13(3):171-184.

School of Biological Sciences, University of Nottingham, University Park, UK. Blood transfusion is a remarkably safe, routine clinical procedure. However, the need for sophisticated blood processing, storage and cross-matching, coupled with increasing concerns about the safety of blood products, has fuelled the search for safe and efficacious substitutes. Candidate materials based on modified haemoglobin (including recombinant molecules) or highly inert, respiratory gas-dissolving perfluorinated liquids (perfluorochemicals) have been developed. The latter are immiscible in aqueous systems and must, therefore, be injected as emulsions. Second-generation perfluorochemical emulsions are available and in clinical trials as temporary intravascular oxygen carriers during surgery, thereby reducing patient exposure to donor blood. One commercial product is currently under Phase III clinical evaluation, with regulatory approval expected within 1 2 years. Other biomedical applications for perfluorochemicals and their emulsions include their use as pump-priming fluids for cardiopulmonary bypass, lung ventilation fluids, anti-cancer agents, organ perfusates and cell culture media supplements, diagnostic imaging agents and ophthalmologic tools. Novel applications for perfluorochemicals as immunomodulating agents are also being explored.

(6) Spahn DR, van Brempt R, Theilmeier G, Reibold JP, Welte M, Heinzerling H, Birck KM, Keipert PE, Messmer K, Heinzerling H, Birck KM, Keipert PE, Messmer K PERFLUBRON EMULSION DELAYS BLOOD TRANSFUSIONS IN ORTHOPEDIC SURGERY. EUROPEAN PERFLUBRON EMULSION STUDY GROUP. Anesthesiology 1999 Nov;91(5):1195-1208.

Department of Anesthesiology, University Hospital Zurich, Switzerland. [email protected] BACKGROUND: Fluorocarbon emulsions have been proposed as temporary artificial oxygen carriers. The aim of the present study is to compare the effectiveness of perflubron emulsion with the effectiveness of autologous blood or colloid infusion for reversal of physiologic transfusion triggers. METHODS: A multinational, multicenter, randomized, controlled, single-blind, parallel group study was performed in 147 orthopedic patients. Patients underwent acute normovolemic hemodilution with colloid to a target hemoglobin of 9 g/dl with an inspiratory oxygen fraction (FIO2) of 0.40. Patients were then randomized into one of four treatment groups after having reached any of the


protocol-defined transfusion triggers including tachycardia (heart rate > 125% of posthemodilution rate or > 110 bpm), hypotension (mean arterial pressure < 75% of posthemodilution level or < or = 60 mmHg), elevated cardiac output (> 150% of posthemodilution level) or decreased mixed venous oxygen partial pressure (PVO2; < 38 mmHg). Treatments in the four groups were 450 ml autologous blood harvested during acute normovolemic hemodilution given at FO2 = 0.40; 450 ml colloid at FIO2 = 1.0; 0.9 g/kg perflubron emulsion with colloid (total = 450 ml) at FIO2 = 1.0; and 1.8 g/kg perflubron emulsion with colloid (total = 450 ml) at FIO2 = 1.0. The primary endpoint was duration of transfusion-trigger reversal. A secondary end-point was percentage of transfusion-trigger reversal. RESULTS: Perflubron emulsion was well tolerated with no serious adverse event attributed to drug treatment. Duration of reversal was longest in the 1.8 g/kg perflubron group (median, 80 min; 95% confidence interval, 60-100 min; P = 0.014 vs. autologous blood, P < 0.001 vs. colloid) followed by the 0.9 g/kg perflubron group (median, 59 min; 95% confidence interval, 40-90 min), the autologous blood group (median, 55 min; 95% confidence interval, 30-70 min) and the colloid group (median, 30 min; 95% confidence interval, 27-60 min). Percentage of reversal was also highest in the 1.8 g/kg perflubron group (97%; P < 0.001 vs. autologous blood; P = 0.014 vs. colloid), followed by 0.9 g/kg perflubron (82%), colloid (76%), and autologous blood (60%). CONCLUSIONS: Perflubron emulsion (1.8 g/kg) combined with 100% oxygen ventilation is more effective than autologous blood or colloid infusion in reversing physiologic transfusion triggers.

Comment in: Anesthesiology 1999 Nov;91(5):1185-7

I.Epidural Blood Patch for Cerebrospinalfluid leakage

(1) Brimacombe J, Clarke G, Craig L. EPIDURAL BLOOD PATCH IN THE JEHOVAH�S WITNESS. Anaesth Intensive Care 1994 June; 22(3): 319

(2) Kanumilli V, Kaza R, Johnson C, Nowacki C. EPIDURAL BLOOD PATCH FOR JEHOVAH�S WITNESS PATIENT. Anesth Analg 1993 October; 77(4): 872-73

(3) Bearb ME, Pennant JH. EPIDURAL BLOOD PATCH IN A JEHOVAH�S WITNESS. Anesth Analg 1987 October; 66(10): 1052 Jehovah�s Witnesses pose special ethical, legal, and moral dilemmas in anesthesiology because of their refusal to accept transfusions of blood or blood products even in circumstances in which their lives may be at risk. Many Witnesses refuse transfusion of their own blood if it loses physical continuity with their circulation. There are no reports of how to solve this problem in a Jehovah�s Witness who needs an epidural blood patch. We describe a novel technique of performing an epidural blood patch that was accepted to a member of this sect because continuity with her circulating blood volume was maintained. Continued cerebrospinalfluid leakage through a dural puncture is often incapacitating and occasionally serious. Epidural blood patching is a simple, safe and effective procedure that, with our minor modification, is theologically acceptable to Jehovah�s Witnesses.

J. Iatrogenic Anemia 1. Minimizing Iatrogenic Phlebotomy induced Anemia


(1) Dech ZF, Szaflarski NL NURSING STRATEGIES TO MINIMIZE BLOOD LOSS ASSOCIATED WITH PHLEBOTOMY. AACN Clin Issues 1996 May;7(2):277-287 Blood loss associated with phlebotomy is significant in critically ill adults. Iatrogenic anemia may result and impose unnecessary stress on the cardiovascular and respiratory systems and may require allogeneic blood transfusions. Many strategies exist under nursing's direct control to decrease blood loss associated with phlebotomy. In the past, nursing effectively implemented many of these strategies in patients at high risk of anemia, such as pediatric, neonatal, transplant, or chronic renal failure patients, as well as patients who are Jehovah's Witnesses. Implementation of these strategies are needed for all critically ill patients because allogeneic blood transfusions carry infectious risk and because complications and chronic critical illness cannot be predicted reliably. Incorporation of these strategies into daily practice as well as the development of blood conservation programs represent imminent challenges for nursing.

K. Anesthesia for Laparoscopic Surgery

1. Anesthesia for Laparoscopic Adrenalectomy

(1) Chiu M, Crosby ET, Yelle JD ANESTHESIA FOR LAPAROSCOPIC ADRENALECTOMY (PHEOCHROMOCYTOMA) IN AN ANEMIC ADULT JEHOVAH'S WITNESS. Can J Anaesth 2000 Jun;47(6):566-571.

Department of Anesthesiology, University of Ottawa and the Ottawa Hospital, Ontario, Canada. PURPOSE: To report the anesthetic management of an anemic Jehovah's Witness patient presenting for laparoscopic adrenalectomy for pheochromocytoma. CLINICAL FEATURES: A 49-yr-old woman presented with hemodynamic instability progressing to cardiogenic shock and subsequent acute renal failure. Her course was complicated by anemia. An adrenal pheochromocytoma was diagnosed. Preoperatively, alpha- and beta-adrenergic blockade was instituted with phenoxybenzamine and metoprolol therapy and her anemia was treated with erythropoietin. She underwent laparoscopic resection of the adrenal tumour. A cell saver device was employed and attached to the laparoscopic suction-irrigation apparatus to provide salvage capability in the event of a major hemorrhage. The surgical intervention was uneventful and well tolerated. The patient was discharged home and well on follow-up. CONCLUSIONS: Cell salvage is the only mechanism currently acceptable to Jehovah's Witnesses which will allow for perioperative salvage and replacement of blood loss. Its use is encouraged in all situations in which surgical hemorrhage is anticipated.

IV. PERISURGICAL ERYTHROPOIETIN 1. EPO for those Refusing Blood Transfusions

(1) Bourantas KL, Xenakis TA, Hatzimichael EC, Kontogeorgakos V, Beris AE PERI-OPERATIVE USE OF RECOMBINANT HUMAN ERYTHROPOIETIN IN JEHOVAH'S WITNESSES. Haematologica 2000 Apr;85(4):444-445.


Associate Professor of Hematology, 1 Kiprou, Anatoli, 455 00 Ioannina, Greece. [email protected]



(3) Boursas M, Benhassine L, Paris F, Kempf J, Vuillemin F [TREATMENT OF PERIOPERATIVE ACUTE ANEMIA BY HUMAN RECOMBINANT ERYTHROPOIETIN IN A JEHOVAH'S WITNESS]. ARTICLE IN FRENCH] [Ann Fr Anesth Reanim 1997;16(3):312-3

(4) Wolff M, Fandrey J, Hirner A, Jelkmann W PERIOPERATIVE USE OF RECOMBINANT HUMAN ERYTHROPOIETIN IN PATIENTS REFUSING BLOOD TRANSFUSIONS. PATHOPHYSIOLOGICAL CONSIDERATIONS BASED ON 5 CASES. Eur J Haematol 1997 Mar; 58(3): 154-159

Department of Surgery, University of Bonn, Germany. The efficacy of the administration of recombinant human erythropoietin (rHuEPO) in the treatment of anaemia in critically ill surgical patients refusing red cell transfusions requires further documentation. Herein, we report the outcome of 5 consecutive severely anaemic Jehovah�s Witness patients (lowest haemoglobin concentration 27 g/1), who were discharged from the hospital in good condition after treatment. RHuEPO (50-280 U/kg body weight) was daily administered to 4 of the patients, who either exhibited preoperative anaemia or developed postoperative anaemia refractory to endogenous EPO probably due to inflammation. RHuEPO treatment was followed by a steep rise in reticulocytes and haemoglobin concentration. The fifth patient, who exhibited no signs of systemic inflammation following emergency hemicolectomy, was also treated with intravenous iron, but not with rHuEPO. His blood haemoglobin concentration rose from 27 g/I to 92 g/I in 3 wk. These observations indicate that the administration of rHuEPO is justified in the management of life-threatening anaemia, although only on a humanitarian basis, because there is no predictor for the possible spontaneous recovery.

(5) Ford PA, Henry DH. USING R-HUEPO IN PATIENTS UNWILLING TO ACCEPT BLOOD TRANSFUSIONS. Erythropoiesis 1996; 7: 63-68 There are many individuals unwilling to accept blood transfusions because of the fear of disease transmission or religious beliefs, such as Jehovah's Witnesses. Bloodless care programs have been developed to provide the best alternative care for these individuals. Physicians need to have an understanding of blood conservation measures and techniques that will stimulate erythropoiesis and maximise oxygen delivery. A combination of these approaches can be utilised to avoid blood exposure. Many of the individuals unwilling to accept blood transfusions are seen in the perioperative setting and require intraoperative measures to limit the amount of blood lost during surgery. This includes meticulous haemostasis, normovolaemic haemodilution, autotransfusion of shed blood and prophylactic drug therapy. The administration of recombinant human erythropoietin (r-HuEPO) in the perioperative period increases RBC mass and prevents profound postoperative anaemia. Intensive iron supplementation appears essential for the optimisation of the effects or r-HuEPO. Short-term regimens of r-HuEPO can be life-saving for those individuals refusing blood transfusion.


(6) Koenig HM, Levine EA, Resnick DJ, Meyer WJ. USE OF RECOMBINANT HUMAN ERYTHROPOIETIN IN A JEHOVAH�S WITNESS. J Clin Anesth 1993 May/June; 5: 244-47 We report the case of a Jehovah�s Witness who bled massively, refused blood transfusion, and survived profound anemia (hematocrit = 5.6%) intact. The patient was treated with recombinant erythropoietin, parenteral iron, and oxygen. The pharmacology and hematopoietic response to erythropoietin are discussed. We suggest considering this therapy for acutely anemic patients who refuse transfusion to decrease the duration of the most severe anemia.

(7) Fullerton DA, Campbell DN, Whitman GJ. USE OF HUMAN RECOMBINANT ERYTHROPOIETIN TO CORRECT SEVERE PREOPERATIVE ANEMIA. Ann Thorac Surg 1991 May; 51(5): 825-26 The risks of homologous blood transfusion are well known. Herein, we describe the successful preoperative use of human recombinant erythropoietin to correct severe anemia in a patient refusing transfusion. This case report emphasizes the important perioperative role human recombinant erythropoietin may play in the future.

(8) JA, Nelson LD, Morris JA, Safcsak K. USE OF RECOMBINANT HUMAN ERYTHROPOIETIN IN A JEHOVAH�S WITNESS REFUSING TRANSFUSION OF BLOOD PRODUCTS: CASE REPORT. J Trauma 1990 November; 30(11): 1406-08 Recombinant human erythropoietin (r-HuEPO) administration to a Jehovah�s witness refusing blood transfusion increased her nadir packed cell volume from 13% to 37% and reticulocyte count from 2% to 17.7%. R-HuEPO may provide an alternative safe and effective therapy in life-threatening anemia when blood transfusions are unacceptable to the patient.

(9) Davis HP. ERYTHROPOIETIN FOR PATIENT REFUSING BLOOD TRANSFUSION. Lancet 1990; 336: 384-5 Dr. Heinz and colleagues (March 3, p 542) report that erythropoietin (EPO) was effective in raising the haemoglobin of an anaemic Jehovah�s Witness with Hodgkin�s disease. The anemia was not the result of bone-marrow infiltration. We report the use of EPO in an anaemic Jehovah�s Witness with advanced resistant multiple myeloma. Despite extensive plasma cell infiltration of the bone marrow a useful rise in haemoglobin was achieved.

(10) Heinz R, Reisner R, Pittermann E. ERYTHROPOIETIN FOR CHEMOTHERAPY PATIENT REFUSING BLOOD TRANSFUSION. Lancet 1990 March; 355: 542-43 This case demonstrates the efficacy of EPO both for tumour-induced anaemia and for anaemia secondary to cytostatic therapy. Therapy was well tolerated despite severe cardiac dysfuntion, and the blood pressure did not rise. Without the use of EPO chemotherapy for this patient�s Hodgkin�s disease would have failed.

2. EPO in Orthopedic surgery

(1) Trovarelli T, Kahn B, Vernon S TRANSFUSION-FREE SURGERY IS A TREATMENT PLAN FOR ALL PATIENTS. AORN J 1998 Nov;68(5):773-8, 780-4

Ortho Biotech, Cliffside Park, NJ, USA. Due to the increased risks associated with allogenic blood transfusion, blood management in surgical procedures, especially in orthopedic settings, should include reduction of perioperative blood loss. Preoperative nursing assessment will help define patients at increased risk for transfusion. Both


nonpharmacologic and pharmacologic techniques can help minimize allogenic transfusion by reducing blood loss. One such method of managing anemia and reducing patient exposure to allogenic transfusion is the perioperative use of recombinant human erythropoietin--erythropoietin alfa--an innovative surgical blood management tool. Increased awareness by perioperative nurses of the use of erythropoietin alfa and patient implications can contribute to the overall blood conservation goal.

(2) Sparling EA, Nelson CL, Lavender R, Smith J. THE USE OF ERYTHROPOIETIN IN THE MANAGEMENT OF JEHOVAH'S WITNESSES WHO HAVE REVISION TOTAL HIP ARTHROPLASTY. J Bone Joint Surg Am 1996 October; 78(19): 1548-52 Five Jehovah's Witnesses (on man and four women) were managed with revision total hip arthroplasty. The average age of the patients at the time of the index operation was 66.4 years (range, fifty-eight to seventy-eight years). All of the patients received subcutaneous injections of recombinant human erythropoietin before the operation, at an initial dose of 100 international units per kilogram of body weight three times a week. The duration of preoperative treatment was determined by the hematocrit at the time of presentation. The hematocrit was monitored weekly, beginning with the second week of treatment, and the dose was adjusted accordingly until the time of the operation. Erythropoietin therapy was discontinued if the hematocrit exceeded 0.45 at any time. The hematocrit before the erythropoietin therapy was begun, at the time of admission to the hospital (one or two days preoperatively), immediately postoperatively, and at the time that the patient was discharged were recorded for this study. All five revision total hip arthroplasties were performed successfully without a blood transfusion. No patient had any complications associated with an excessive loss of blood or a low hematocrit. The average hematocrit was 0.395 (range, 0.317 to 0.447) before the erythropoietin therapy was begun and was 0.476 (range, 0.431 to 0.509) after treatment with erythropoietin and before the operation (that is, at the time of admission to the hospital). The average duration of erythropoietin therapy was twenty-six days preoperatively and 3.6 days postoperatively. The average hematocrit was 0.368 (range, 0272 to 0.424) immediately after the operation and was 0.308 (range, 0294 to 0.327) at the time of discharge from the hospital. No patient had evidence of deep venous thrombosis. This study illustrates that it is possible and apparently safe to optimize the hematocrit, by use of erythropoietin, in a patient who is scheduled for an operation. This may be particularly beneficial to a patient with anemia who has failure of a total hip arthroplasty. A relatively high hematocrit (0.45 to 0.50) preoperatively provides a relative margin of safety to a procedure that frequently involves a great deal of intraoperative blood loss. The use of erythropoietin preoperatively is particularly suited to joint replacements and revisions because of their elective nature and the moderately flexible timing associated with these procedures.

(3) Soukup J, Menzel M, Roth S, Radke J [THE PERIOPERATIVE USE OF RECOMBINANT ERYTHROPOIETIN (RHEPO) IN JEHOVAH'S WITNESSES]. Anaesthesist 1996 Aug; 45(8): 745-749

Klinik fur Anasthesie und operative Intensivmedizin, Martin-Luther-Universitat Halle-Wittenberg. Erythropoietin, the hematopoietic growth factor, is synthesised in the kidneys and liver and regulates red blood cell production. Within the last few years, recombinant DNA technology has produced synthetic erythropoietin (rhEPO). Some patients, especially Jehovah�s Witnesses, will not accept blood transfusion. The perioperative administration of rhEPO increases the patients' hematocrit (HCt) to a higher than physiological level. METHODS AND RESULTS: Wc report a case of a 66-year-old female Jehovah's Witness who, refused blood transfusions and responded favourably to rhEPO treatment. A total hip arthroplasty was planned. A pretreatment hemoglobin level (Hb) of 13.7 g/dl and HCt of 43% were documented. After preoperative subcutaneous application of 5000 LE. rhEPO three times per week and daily oral substitution of 300 mg ferrous sulfate over a period of 3 weeks, the Hb increased to 15.5 g/dl and the HCt to 49%. The operation was carried out after the ninth application of rhEPO. Postoperatively, the Hb concentration was 11.8 g/dl and the HCt 35%. Therefore, postoperative administration of rhEPO was not considered indicated. No side effects of rhEPO application were noted. The patient left hospital on the l Oth postoperative day. CONCLUSIONS: The case report describes perioperative management using human rhEPO in Jehovah�s Witnesses. Treatment with rhEPO increases preoperative Hb levels to a point making it possible to compensate for operative blood loss. RhEPO


combined with daily iron substitution may be useful in patients who refuse transfusion based on religious convictions.

(4) Streef C, Charpentier C, Audibert G, Laxenaire MC. USE OF RECOMBINANT HUMAN ERYTHROPOIETIN (R-HUEPO) IN AN INJURED JEHOVAH�S WITNESS PATIENT. [ARTICLE IN FRENCH] Ann Fr Anesth Ré 1996; 15:1199-1202 Use of recombinant human erythropoietin (r-HuEPO) in an injured Jehovah's Witness patient. A 20-year-old Jehovah's Witness patient experienced a femur fracture, with a section of the femoral artery and vein. On admission, haemoglobin concentration was 5.8 g/dL and haematocrit 17%. Because of aponevrotomy, blood losses persisted. As the patient refused blood transfusion, recombinant human erythropoietin and parenteral iron were administered, associated with mild hypothermia, sedation and mechanical ventilation. After 21 days, the haemoglobin concentration increased to 10.9 g/dL and haematocrit to 33%. Recombinant human erythropoietin and parenteral iron may provide an alternative safe and effective therapy in life-threatening anaemia when blood transfusions are not accepted by the patient.

(5) Rothstein P, Roye D, Verdisco L, Stern L PREOPERATIVE USE OF ERYTHROPOIETIN IN AN ADOLESCENT JEHOVAH�S WITNESS. Anesthesiology 1990 September; 73(3): 570-72 We report the preoperative use of recombinant DNA erythropoietin in an adolescent of the Jehovah�s Witness faith who required placement of Cotrel-Dubousset rods for correction of scoliosis.

3. EPO in Hemipelvectomy for Cancer

(1) Meyers MO, Heinrich S, Kline R, Levine EA EXTENDED HEMIPELVECTOMY IN A JEHOVAH'S WITNESS WITH ERYTHROPOIETIN SUPPORT. Am Surg 1998 Nov;64(11):1074-6

Section of Surgical Oncology, Louisiana State University Medical Center, New Orleans, USA. The care of patients refusing blood transfusion who require major ablative surgery for malignancy is a continuing challenge. The use of recombinant human erythropoietin is clearly efficacious in patients with renal disease and may be useful in anemic patients who refuse transfusion. Herein, we report a successful extended hemipelvectomy in a Jehovah's Witness using recombinant human erythropoietin support.

4. EPO in Postsurgical Anemia

(1) Boursas M, Benhassine L, Paris F, Kempf J, Vuillemin F [TREATMENT OF PERIOPERATIVE ACUTE ANEMIA BY HUMAN RECOMBINANT ERYTHROPOIETIN IN A JEHOVAH'S WITNESS]. [ARTICLE IN FRENCH] Ann Fr Anesth Reanim 1997;16(3):312-3

(2) Busuttil D, Copplestone A. MANAGEMENT OF BLOOD LOSS IN JEHOVAH�S WITNESSES. RECOMBINANT HUMAN ERYTHROPOIETIN HELPS BUT IS EXPENSIVE. BMJ 1995 October 28; 311: 1115-16 Some people suggest that Jehovah�s Witnesses should take financial responsibility for the excess expenses incurred by their choice not to have transfusions. However, other patients who require treatment for the effects of self harm � for example, from smoking � are not excluded from expensive treatments, and the treatment of anaemia in a Jehovah�s Witness should be seen in a similar context.


(3) Atabek U, Alvarez R, Pello MJ, Alexander JB, Camishion RC, Curry C, Spence RK. ERYTHROPOIETIN ACCELERATES HEMATOCRIT RECOVERY IN POST-SURGICAL ANEMIA. The American Surgeon 1995 January; 61: 74-7 We evaluated the role of recombinant human erythropoietin (RHE) for treatment of severe postsurgical anemia (Hct < 25%) in 40 Jehovah�s Witness (JW) patients refusing transfusion. Twenty patients (group E) received RHE either at a loading dose of 300 U/kg iv 3 times/week for 1 week followed by 150 U/kg 3 times/week in accordance with an IRB approved protocol (N-13), or at a dose of 100 U/kg 3 times/week for humanitarian reasons (N = 7). This group was compared to 20 similar JW patients who did not receive RHE (group C). All patients received iron restoration and nutritional support. Non-parametric analysis (Mann-Whitney) was used because of sample size. Entry hematocrit was similar for both groups: HE(0) = 15.8% +/- 1.1 SEM (8.5-23.4) vs HC(0) = 12.8% +/- 0.9 SEM (7.3-20.6), P = 0.09. After one week, hematocrit was significantly higher in group E (HE(1) = 19.3% +/- 1.1 vs HC(1) = 12.5% +/- 0.9, P = 0.005) as was the increase in hematocrit for group E (3.6% +/- 0.9 for E vs �0.4 +/- 0.8 for C, P< 0.005. Hematocrit change in Week 2 showed an increase for both groups (2.9% +/- 0.6 for E vs 4.9% +/- 1.2 for C, P = 0.12). Conclusions: Hct recovery shows a 1-week lag in severely anemic postsurgical patients treated without RHE. Exogenous RHE appears to accelerate hematocrit recovery in the first week. Use of RHE in the immediate postoperative period may help avoid or reduce homologous blood transfusion.

(4) Connor JP, Olsson CA. THE USE OF RECOMBINANT HUMAN ERYTHROPOIETIN IN A JEHOVAH�S WITNESS REQUIRING MAJOR RECONSTRUCTIVE SURGERY. The Journal of Urology 1992 January; 147: 131-2 We report on a new approach to the anemic Jehovah�s Witness patient requiring a major operation using preoperative and perioperative erythropoietin. The use of recombinant human erythropoietin in this and other clinical situations is discussed.

(5) Johnson PWM, King R, Slevin ML, White H.. THE USE OF ERYTHROPOIETIN IN A JEHOVAH�S WITNESS UNDERGOING MAJOR SURGERY AND CHEMOTHERAPY. Br J Cancer 1991; 63: 476 We report the case of a man whose religious beliefs prevented him from accepting transfusions who was able to recover from major surgery and undergo intensive myelotoxic chemotherapy using erythropoietin to maintain near-normal haemoglobin level. The use of erythropoietin in this situation has not been reported previously.

(6) Green D, Handley E. ERYTHROPOIETIN FOR ANEMIA IN JEHOVAH�S WITNESSES. Annals of Internal Medicine 1990 November; 113(9): 720 Patients whose religious beliefs preclude acceptance of blood transfusions have been denied major surgery and usually have a protracted convalescence after blood loss. In three Jehovah�s Witnesses, we observed that treatment with erythropoietin raised hemoglobin levels pre-operatively to levels that compensated for operative blood loss and enhanced recovery after major hemorrhage.

(7) Kyger ER, Blakestad ER. MANAGEMENT OF JEHOVAH�S WITNESS PATIENTS. [LETTER] The Annals of Thoraric Surgery 1990 July; 50(1): We have recently pretreated 3 members of the Jehovah�s Witness sect with synthetic erythropoietin. All of these were elderly patients who were anemic and required a cardiovascular surgical procedure. Two required coronary artery bypass and 1, resection of an abdominal aneurysm. Pretreatment with Epogen stimulated the bone marrow as evidenced by an increase in the reticulocyte count and a rising hemoglobin level. Treatment was carried through into the postoperative period until hemoglobin level returned to nearly normal. We believe this is a safe and useful adjunct in dealing with patients of the Jehovah�s Witness sect who require an operation in which blood loss and shortened red cell half-life can result in profound postoperative anemia. We recommend it as a safe and useful adjunct.


5. EPO in Neurosurgery

(1) Barczewska M [VASCULAR INTRACRANIAL PROCEDURES IN JEHOVAH'S WITNESSES. ERYTHROPOIETIN IN THE PREPARATION FOR THE SURGERY]. [ARTICLE IN POLISH] Neurol Neurochir Pol 1997 Mar-Apr;31(2):271-80

Katedry i Kliniki Neurochirurgii AM, Warszawie. Intraoperative haemorrhage or major bleeding may still cause serious problem in present-day neurosurgery, especially with reference to major vascular procedures despite the improving surgical techniques and methods of performing bloodless procedures. This is why certain neurosurgical procedures are not attempted without prior preparation of a major amount of blood. Jehovah's Witnesses refuse their consent to be subjected to blood transfusion of their own or foreign blood despite their full awareness of a potential danger to their lives. This paper describes three patients subjected to the major vascular intracranial procedures (two cases of clipping intracranial aneurysms, and one case of removal of arteriovenous intracranial angioma in anaemic patient), and one case of endovascular neuroradiosurgical procedure in intracranial aneurysm. This last method is presented as alternative procedure to decrease complications that are related to bloodless interventions suggest certain management methods which may decrease the surgical risk. One of those methods erythropoietin in treatment of postoperative anaemia and in preparing anaemic patients to vascular intracranial procedures.

(2) Kantrowitz AB, Spallone A, Taylor W, Chi TL, Strack M, Feghali JG. ERYTHROPOIETIN-AUGMENTED ISOVOLEMIC HEMODILUTION IN SKULL-BASE SURGERY. CASE REPORT. J Neurosurg 1994 April; 80(4): 740-44 Human erythropoietin in concert with intraoperative hemodilution, tumor embolization, and surgical staging was used to manage a red blood cell mass in an anemic Jehovah�s Witness patient with a hypervascular meningoma. Erythropoietin (3000 U thrice weekly) and oral iron (1300 mg daily) were given for 1 month prior to surgery, raising the hemoglobin level from 11.8 to 14.1 gm/100 ml. A posterior fossa craniectomy, combined with a temporal craniectomy was then performed so that partial petrosectomy, section of the transverse sinus, incision of the tentorium, and exposure of the lesion could be carried out. The first stage of the surgery was terminated immediately prior to tumor mobilization. Isovolemic hemodilution was initiated just before the skin incision. Postoperatively, the hemoglobin concentration dropped to 11.5 gm/100 ml. The erythropoietin dose was doubled and administration of oral iron continued, leading to a hemoglobin level of 14.0 gm/100 ml at 1 month after the first operation. The tumor was embolized using superselective catheterization. The next day, at the second stage of the surgery, the tumor was extirpated, again employing isovolemic hemodilution. By the 4th postoperative day, the hemoglobin level had dropped to 9.4 gm/100 ml. The patient made an uncomplicated recovery. Erythropoietin therapy contributed substantially to the successful outcome of this case. Since erythropoietin therapy contributed to augment all other forms of autologous banking, its role in elective neurosurgery may become increasingly important in an era of heightened concern about heterologous transfusion.

(3) Schiff SJ, Weinstein SL. USE OF RECOMBINANT HUMAN ERYTHROPOIETIN TO AVOID BLOOD TRANSFUSION IN A JEHOVAH�S WITNESS REQUIRING HEMISPHERECTOMY. CASE REPORT. J Neurosurg 1993 October; 79(4): 600-02 The use of perioperative human recombinant erythropoietin is described in a Jehovah�s Witness patient. Despite significant anemia, the child�s hematocrit was sufficiently increased by the use of erythropoietin so that a two-stage hemispherectomy could be performed without blood transfusion.

6. EPO in Gastrointestinal Surgery


(1) Madura JA USE OF ERYTHROPOIETIN AND PARENTERAL IRON DEXTRAN IN A SEVERELY ANEMIC JEHOVAH�S WITNESS WITH COLON CANCER. Arch Surg 1993 October; 128(10): 1168-70 A Jehovah�s Witness presented with colon cancer and profound anemia. On admission, her hemoglobin level was 30 g/L (3.0 g/dL). She refused all transfusions and failed to respond to oral iron therapy. She was ultimately prepared for surgery using recombinant human erythropoietin, iron dextran, and total parenteral nutrition. It took nearly 1 month to increase her hemoglobin level to an acceptable preoperative level of 110 g/L (11 g/dL). During the postoperative period, erythropoietin and parenteral iron therapy were briefly continued and a follow-up hemoglobin level of greater than 120 g/L (12 g/dL) was observed. Recombinant human erythropoietin, along with parenteral iron and adequate nutrition, may be useful in patients who refuse transfusion or cannot be transfused because of difficult cross-reacting antibodies.

(2) Smith SN, Milov DE. USE OF ERYTHROPOIETIN IN JEHOVAH�S WITNESS CHILDREN � FOLLOWING ACUTE GASTROINTESTINAL BLOOD LOSS. J Florida M.A. 1993 February; 80(2): 103-05 The decision to transfuse children in families practising the Jehovah�s Witness faith with human blood products raises medical, legal, and moral questions. Two cases are presented in which recombinant human erythropoietin was used in pediatric patients as an alternative following acute gastrointestinal hemorrhage. The patients demonstrated increased hematocrit levels obviating the need for blood transfusion. Although erythropoietin is not an alternative to hemotransfusion in the unstable patient, it may be an option in the hemodynamically uncompromised Jehovah�s Witness patient following acute blood loss.

(3) Pousada L, Fiorito J, Smyth C. ERYTHROPOIETIN AND ANEMIA OF GASTROINTESTINAL BLEEDING IN A JEHOVAH�S WITNESS. [LETTER] Ann Intern Med 1990 Apr 1; 112(7): 552

7. EPO in Gynecologic and Obstetric Surgery

(1) Huch A. et al. RECOMBINANT HUMAN ERYTHROPOIETIN IN THE TREATMENT OF POSTPARTUM ANEMIA. Obstet Gynecol 1992 July; 80(1): 127-31 Postpartum maternal anemia (hemoglobin concentration below 10 g/dl) is a common problem in obstetrics. Human recombinant erythropoietin, which has been shown to correct the anemia of end-stage renal disease and eliminate the need for transfusions, was used in a comparatively study of women with postpartum hemoglobin concentrations below 10 g/dl. Five daily doses of 4000 IU were given. Hematologic and clinical data were compared on days 5, 14, 42 after therapy in the treated women and in untreated women. Both groups received the same iron and folic acid supplements. Significantly greater increases in reticulocytes, hemoglobin, and hematocrit were seen by day 5 for the treated subjects compared with controls. Ferritin levels were significantly lower in the therapy group than in controls. No differences were seen between the groups in the platelet counts or clinical characteristics. No negative side effects were observed. As in other studies in populations without renal disease, recombinant human erythropoietin enhanced endogenous erythropoiesis over and above the normal physiologic recovery rate. Recently, rHuEPO was used in a pregnant woman who, because of her religious beliefs as a Jehovah�s Witness, refused a blood transfusion. McGregor et al. also reported using rHuEPO during pregnancy for an amemic patient on hemodialysis. We are not aware of any other experiences with the use of rHuEPO during pregnancy or postpartum.

8. EPO in Cardio-Vascular Surgery


(1) Podesta A, Carmagnini E ERYTHROPOIETIN IN JEHOVA'S WITNESS HEART SURGERY. Minerva Cardioangiol 1999 Jul-Aug;47(7-8):261-7

Cattedra di Cardiochirurgia, Universita degli Studi, Genova. The patients, reported here, needed open heart surgery, but religion obliged them to refuse blood transfusion. Three of the four patients suffered from obstructive coronary diseases and one from mitral valvular disease, prevalently stenosis. All of them refused blood transfusions. One of the three patients presented, was refused by an other Cardiovascular Surgery Center because of his low blood values (Haemoglobin 9.2--Haematocrit 26.7). All these patients had been treated with subcutaneus injection of epoetin alfa 10,000 U twice a week and ferrous sulphate 525 mg three time a day per os, for three weeks before operation. Haemoglobin, haematocrit and reticulocytes values were controlled in pre, postoperative and at discharge. With this treatment the authors found haemoglobin and haematocrit values so increased to allow sugery without blood transfusion during and in the post operative period.

(2) Sawada Y, Asada K, Matsuyama N, Hasegawa S, Sasaki S [OPEN HEART SURGERY IN A JEHOVAH'S WITNESS BOY--A CASE REPORT OF SUCCESSFUL MANAGEMENT OF AORTIC REGURGATATION AND ANEURYSM OF SINUS VALSALVA DUE TO INFECTIVE ENDOCARDITIS]. [ARTICLE IN JAPANESE] Nippon Kyobu Geka Gakkai Zasshi 1997 Dec;45(12):2006-10

Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Takatsuki, Japan. Jehovah's Witness who require operation represent a challenge to the physician because of the patients' refusal to accept blood transfusion. We report an 8-year-old male of Jehovah's Witness who underwent a surgical treatment of infective endocarditis. He was transferred to our hospital because of high fever and heart murmur. Echocardiogram revealed a developing vegetation of aortic cusps and an aneurysmal change of the non-coronary sinus Valsalva. On admission he was complicated by anemia, purulent meningitis and suppurative arthritis of left knee. There were no signs of cardiac failure. Erythropoietin (6000 U thrice weekly) and iron (60 mg daily) were given for 11 weeks prior to surgery, raising the hemoglobin level from 9.2 g/dl to 18.4 g/dl. Aortic valve replacement and plasty of the sinus Valsalva were then performed. Intraoperatively hemoglobin concentration dropped to 10.3 g/dl and it raised to 15 g/dl postoperatively. We also used Cell-Saver to reduce blood loss. The patient made an uncomplicated recovery. Erythropoietin therapy contributed substantially to the successful outcome of this case.

(3) Nishimoto M, Sawada Y, Asada K, Hasegawa S, Sasaki S [A CASE OF JEHOVAH'S WITNESS UNDERWENT DOUBLE VALVES REPLACEMENT IN REOPERATION]. [ARTICLE IN JAPANESE] Nippon Kyobu Geka Gakkai Zasshi 1997 Aug;45(8):1165-8

Department of Thoracic and Cardiovascular Surgery, Osaka Medical School, Japan. The patient was a sixty five-year-old woman and Jehovah's Witness who refused either homologous or autologous blood transfusion on the ground of her faith. At the age of 47, she had closed commissurotomy for mitral valve stenosis. This time, because mitral valve restenosis and tricuspid valve regurgitation were found, double valve replacement, mitral and tricuspid, was performed on her, with an excellent result. It is expected that, in the near future, the indication for open heart surgery without blood transfusion will be increased by means of the following considerations as to blood loss preservation; 1. to shorten the time necessitating for an operation and reduce preoperative blood loss, 2. to improve cardio-pulmonary bypass system (Heparin coating etc), and 3. to augment the erythropoiesis (administration of EPO at the patient's own expense, etc.) and so on.



Department of Cardiothoracic Surgery, New York Hospital-Cornell University Medical Center, NY, USA. BACKGROUND: Blood transfusion persists as an important risk of open heart operations despite the recent introduction of a variety of new pharmacologic agents and blood conservation techniques as independent therapies. A comprehensive multimodality blood conservation program was developed to minimize this risk. STUDY DESIGN: To provide a strategy for operating without transfusion, this program was prospectively applied to 50 adult patients who are Jehovah's Witnesses and have undergone open heart operation at our institution since 1992. The blood conservation program used for these patients included the use of high-dose erythropoietin (800 U/kg load, 500 U/kg every other day), aprotinin (6 million U total dose full Hammersmith regimen), "maximal" volume intraoperative autologous blood donation, intraoperative cell salvage, continuous shed blood reinfusion, and drawing as few blood specimens as possible. RESULTS: Procedures performed included first-time coronary bypass operations (n = 30) and more complex operations, including reoperations, valve replacements, and multiple valve replacements with or without coronary bypass (n = 20). Despite the absence of transfusion, the mean discharge hematocrit in these patients was greater than 30 percent, and there was no anemia-related mortality rate in this group. The overall in-hospital mortality for the group was 4 percent. A subset analysis was performed between the 30 first-time coronary bypass patients (group 1) and a control group of 30 consecutive patients who were not Jehovah's Witnesses but had undergone first-time coronary bypass during the same period (group 2). The blood conservation program described in the previous paragraph was not used in group 2 patients and specific transfusion criteria were prospectively applied. The chest tube output in group 1 patients was less than 40 percent of that for group 2 patients at all points measured after operation (p < 0.01). Postoperative hematocrit levels in group 1 were greater than those for group 2, despite the absence of red blood cell transfusion and despite a significantly lower admission hematocrit and red blood cell mass in group 1. The average length of stay and ancillary costs for the two groups were equivalent. Although group 1 and 2 patients were well matched for preoperative transfusion risk factors, none of the group 1 patients required transfusion, but 17 (57 percent) group 2 patients met transfusion criteria and received 3.0 +/- 4.8 U (mean plus or minus standard deviation) of homologous blood or blood products. CONCLUSIONS: These results suggest that even complex open heart operations can be performed without homologous transfusion by optimally applying available blood conservation techniques. More generalized application of these measures may increasingly allow "bloodless" operations in all patients.

(5) 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

Department of Medicine, Hartford Hospital, CT 06102, USA. Bloodless cardiac surgery would be optimal for all patients undergoing major or complex heart surgery; however, for Jehovah's Witnesses it involves a religious law and is fundamentally mandated. In this context, we review a case of unstable angina with associated anemia requiring catheterization and definitive intervention in a Jehovah's Witness patient. Coronary stenting to stabilize the acute coronary syndrome is described with definitive total revascularization performed by coronary artery bypass graft surgery after utilizing erythropoietin and aggressive blood conservation techniques.

(6) Chikada M, Furuse A, Kotsuka Y, Yagyu K OPEN-HEART SURGERY IN JEHOVAH'S WITNESS PATIENTS. Cardiovasc Surg 1996 Jun;4(3):311-4


Department of Cardiothoracic Surgery, University of Tokyo, Japan. Open-heart surgery has been performed since 1975 on 25 patients who are Jehovah's Witnesses by religion. The patients' ages ranged from 6-60 years, and their body weights from 18-51 kg. Surgical procedures included correction of congenital heart disease in 14 patients and valve repair or replacement in 11. Six procedures were reoperations. The lowest mean haematocrits, during perfusion and the postoperative period, were 22.7% (range 15.0-31.0%) and 27% (range 16.0-36.0%), respectively. Twenty-four patients survived and are alive and well. One patient died of low output failure before discharge. The blood return system reduced blood loss. Five of the patients who underwent cardiac surgery received recombinant erythropoietin before and after surgery, leading to higher postoperative haematocrits. In one patient, a haematocrit which fell to 16.9% after surgery was raised to 27% by administration of erythropoietin, without blood transfusion. In two recent cases, high doses of aprotinin were used during surgery, resulting in better haemostasis after cardiopulmonary bypass

(7) Gaudiani VA, Mason HDW. PREOPERATIVE ERYTHROPOIETIN IN JEHOVAH�S WITNESSES WHO REQUIRE CARDIAC PROCEDURES. Ann Thorac Surg 1991 May; 51(5): 823-24 This report details the preoperative use of recombinant human erythropoietin in 2 Jehovah�s Witnesses who required elective cardiac operations. Preoperative use of recombinant human erythropoietin adds to the safety of a cardiac procedure by raising the hematocrit and preparing the bone marrow for high-volume red cell production.

(8) Haldén E, Birgegård G, Duvernoy O, Henze A. ERYTHROPOIETIN MÖJLIGGJORDE OPERATION AV COARCTATIO AORTAE HOS JEHOVAS VITTNE. [ARTICLE IN SWEDISH] Läkartidningen 1991; 88(49): 4245-6 För at möjliggöra operation av en total coarctatio aortae (CA) hos en vuxen patient tillhörande Jehovas vittnen höjdes hemoglobinvärdet preoperativt med erythropoietin behandling. Risken för stor blödning i samband med en dylik operation är betydande. Avsikten med erytropoietinbehandlingen var att kunna genomföra normovolemisk hemodilution och att ha tillgång till en stor volym autologt blod. Efter vensectio och plasmaferes av totalt 2330 ml autologa blodprodukter kunde operationen genomföras med liten risk.

9. EPO in Trauma

(1) Streef C, Charpentier C, Audibert G, Laxenaire MC. USE OF RECOMBINANT HUMAN ERYTHROPOIETIN (R-HUEPO) IN AN INJURED JEHOVAH�S WITNESS PATIENT. [ARTICLE IN FRENCH] Ann Fr Anesth Ré 1996; 15:1199-1202 Use of recombinant human erythropoietin (r-HuEPO) in an injured Jehovah's Witness patient. A 20-year-old Jehovah's Witness patient experienced a femur fracture, with a section of the femoral artery and vein. On admission, haemoglobin concentration was 5.8 g/dL and haematocrit 17%. Because of aponevrotomy, blood losses persisted. As the patient refused blood transfusion, recombinant human erythropoietin and parenteral iron were administered, associated with mild hypothermia, sedation and mechanical ventilation. After 21 days, the haemoglobin concentration increased to 10.9 g/dL and haematocrit to 33%. Recombinant human erythropoietin and parenteral iron may provide an alternative safe and effective therapy in life-threatening anaemia when blood transfusions are not accepted by the patient

(2) Soukup J, Menzel M, Roth S, Radke J. THE PERIOPERATIVE USE OF RECOMBINANT ERYTHROPOIETIN (RHEPO) IN JEHOVAH'S WITNESSES. Anaesthesist 1996; 45: 745-49 We report a case of a 66-year-old female Jehovah's Witness who refused blood transfusions and responded favourably to rhEPO treatment. A total hip arthroplasty was planned. A pretreatment


hemoglobin level (Hb) of 13.7 g/dl and HCt of 43% were documented. After preoperative subcutaneous application of 5000 I.E. rhEPO three times per week and daily oral substitution of 300 mg ferrous sulfate over a period of 3 weeks, the Hb increased to 15.5 g/dl and the HCt to 49%. The operation was carried out after the ninth application of rhEPO. Postoperatively, the Hb concentration was 11.8 g/dl and the HCt 35%. Therefore, postoperative administration of rhEPO was not considered indicated. No side effects of rhEPO application were noted. The patient left hospital on the 10th postoperative day. Conclusions. The case report describes perioperative management using human rhEPO in Jehovah's Witnesses. Treatment with rhEPO increases preoperative Hb levels to a point making it possible to compensate for operative blood loss. RhHEPO combined with daily iron substitution may be useful in patients who refuse transfusion based on religious convictions.

(3) Kraus P, Lipman J. ERYTHROPOIETIN IN A PATIENT FOLLOWING MULTIPLE TRAUMA. Anaesthesia 1992 Nov; 47(11): 962-964

Department of Anaesthesia and Intensive Care Unit, Baragwanath Hospital, South Africa. We report on a Jehovah's Witness who had severe blood loss following major trauma. The problems of her management without blood transfusion, and with the use of recombinant human erythropoietin therapy for severe anaemia, are described.

10. EPO for Urologic Surgery

(1) Connor JP, Olsson CA THE USE OF RECOMBINANT HUMAN ERYTHROPOIETIN IN A JEHOVAH'S WITNESS REQUIRING MAJOR RECONSTRUCTIVE SURGERY. J Urol 1992 Jan;147(1):131-132.

Department of Urology, Columbia University, College of Physicians and Surgeons, New York, New York. We report on a new approach to the anemic Jehovah's Witness patient requiring a major operation using preoperative and perioperative erythropoietin. The use of recombinant human erythropoietin in this and other clinical situations is discussed.

V. NEUROSURGERY 1. EPO in Skull Surgery

(1) Barczewska M. VASCULAR INTRACRANIAL PROCEDURES IN JEHOVAH�S WITNESSES. ERYTHROPOIETIN IN THE PREPARATION FOR THE SURGERY(ARTICLE IN POLISH). Neurol Neurochir Pol 1997 March; 31(2): 271-80 Intraoperative haemorrhage or major bleeding may still cause serious problem in present-day neurosurgery, especially with reference to major vascular procedures despite the improving surgical techniques and methods of performing bloodless procedures. This is why certain neurosurgical procedures are not attempted without prior preparation of a major amount of blood. Jehovah�s Witnesses refuse their consent to be subjected to blood transfusion of their own or foreign blood despite their full awareness of a potential danger to their lives. This paper describes three patients subjected to the major vascular intracranial procedures (two cases of clipping intracranial aneurysms, and one case of removal of arteriovenous intracranial angioma in anaemic patient), and one case of endovascular neuroradiosurgical procedure in intracranial aneurysm. This last method is presented as alternative procedure to decrease complications that are related to bloodless interventions suggest certain management methods which may decrease the surgical risk. One of those methods erythropoietin in


treatment of postoperative anaemia and in preparing anaemic patients to vascular intracranial procedures.

(2) Kantrowitz AB, Spallone A, Taylor W, Chi TL, Strack M, Feghali JG ERYTHROPOIETIN-AUGMENTED ISOVOLEMIC HEMODILUTION IN SKULL-BASE SURGERY. CASE REPORT. J Neurosurg 1994 Apr;80(4):740-4

New York Center for Cranial Base Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx. Human erythropoietin in concert with intraoperative hemodilution, tumor embolization, and surgical staging was used to manage a red blood cell mass in an anemic Jehovah's Witness patient with a hypervascular meningioma. Erythropoietin (3000 U thrice weekly) and oral iron (1300 mg daily) were given for 1 month prior to surgery, raising the hemoglobin level from 11.8 to 14.1 gm/100 ml. A posterior fossa craniectomy combined with a temporal craniectomy was then performed so that partial petrosectomy, section of the transverse sinus, incision of the tentorium, and exposure of the lesion could be carried out. The first stage of the surgery was terminated immediately prior to tumor mobilization. Isovolemic hemodilution was initiated just before the skin incision. Postoperatively, the hemoglobin concentration dropped to 11.5 gm/100 ml. The erythropoietin dose was doubled and administration of oral iron continued, leading to a hemoglobin level of 14.0 gm/100 ml at 1 month after the first operation. The tumor was embolized using superselective catheterization. The next day, at the second stage of the surgery, the tumor was extirpated, again employing isovolemic hemodilution. By the 4th postoperative day, the hemoglobin level had dropped to 9.4 gm/100 ml. The patient made an uncomplicated recovery. Erythropoietin therapy contributed substantially to the successful outcome of this case. Since erythropoietin has the potential to augment all other forms of autologous banking, its role in elective neurosurgery may become increasingly important in an era of heightened concern about heterologous transfusion.

(3) Schiff SJ, Weinstein SL USE OF RECOMBINANT HUMAN ERYTHROPOIETIN TO AVOID BLOOD TRANSFUSION IN A JEHOVAH'S WITNESS REQUIRING HEMISPHERECTOMY. CASE REPORT. J Neurosurg 1993 Oct;79(4):600-2

Department of Neurosurgery, Children's National Medical Center, Washington, D.C. The use of perioperative human recombinant erythropoietin is described in a Jehovah's Witness patient. Despite significant anemia, the child's hematocrit was sufficiently increased by the use of erythropoietin so that a two-stage hemispherectomy could be performed without blood transfusion.

2. Neurosurgery monitoring for Cerebral Trauma

(1) Logemann F, Schulze K, Verner L [NONINVASIVE MONITORING OF CEREBRAL OXYGEN SATURATION AFTER SEVERE CRANIOCEREBRAL TRAUMA IN A JEHOVAH'S WITNESS]. [ARTICLE IN GERMAN] Anasthesiol Intensivmed Notfallmed Schmerzther 1997 Jun;32(6):385-90

Zentrum Anasthesiologie der Medizinischen Hochschule Hannover. Patients with severe head injury run a high risk of developing secondary cerebral defects. Various methods have so far been described which vary in their continuity, invasiveness and technical aspects for the early detection and treatment of complications. Within this group of patients Jehovah's witnesses pose a particular problem due to their restriction concerning therapeutical possibilities. That may mean an additional danger to the cerebral O2-delivery. This case report highlights on the value of continuous, non-invasive cerebral O2-saturation measurement and its combination with the fiberoptical monitoring of mixed venous O2-saturation. It has been possible to recognize episodes of imbalance between O2-delivery and its demand owing to a variety of causes. Other measured parameters were unable to reliably detect the development of critical complications. Further latrogenic loss of blood by laboratory tests was significantly reduced. Despite partially insufficient circulation and anemia


with a hemoglobin value of 49 g/l we were able to discharge the patient from ICU without recognizable neurological sequelae.

VI. HEAD AND NECK

1. Epistaxis (1) Sperati G

[THERAPY OF EPISTAXIS DURING THE AGES]. [ARTICLE IN ITALIAN] Acta Otorhinolaryngol Ital 1994 Sep-Oct;14(5):561-3

2. Floor of Mouth and Mandibular surgery (1) Van Hemelen G, Avery CM, Venn PJ, Curran JE, Brown AE, Lavery KM

MANAGEMENT OF JEHOVAH'S WITNESS PATIENTS UNDERGOING MAJOR HEAD AND NECK SURGERY. Head Neck 1999 Jan;21(1):80-4


(2) Genden EM, Haughey BH. HEAD AND NECK SURGERY IN THE JEHOVAH'S WITNESS PATIENT. Otolaryngol Head Neck Surg 1996 April; 11(4): 669-72 Head and neck resection and free tissue transfer often entail relatively lengthy surgery in two or more operative sites, requiring blood transfusion during the perioperative period. Appropriate hemoglobin levels and adequate tissue perfusion are essential to systemic oxygenation, flap survival, and wound healing. Although colloid expanders may be used for perioperative volume replacement, hemodilution and resultant free flap hypoperfusion may occur. We report herein the resection of a stage III anterior floor-of-mouth squamous cell carcinoma, segmental mandibulectomy, and staged fibula free flap reconstruction with concomitant placement of osseointegrated dental implants in a Jehovah's Witness patient, without the use of blood products.


3. Maxillofacial Surgery (1) Pogrel MA, McDonald A.

THE USE OF ERYTHROPOIETIN IN A PATIENT HAVING A MAJOR ORAL AND MAXILLOFACIAL SURGERY AND REFUSING BLOOD TRANSFUSION. J Oral Maxillofac Surg 1995 August; 53(8): 943-45

(2) Polley JW, Berkowitz RA, McDonald TB, Cohen M, Figueroa A, Penney DW. CRANIOMAXILLOFACIAL SURGERY IN THE JEHOVAH'S WITNESS PATIENT. Plast Reconstr Surg 1994 May; 93(6): 1258-63 The reconstruction of severe craniofacial anomalies in patients who will not accept blood transfusions presents a considerable challenge to the craniofacial team. Traditionally, these patients have been refused major reconstructions, receiving no treatment or a highly compromised substitute. A management protocol was developed utilizing preoperative erythropoietin and ferrous sulfate therapy, intraoperative in-line normovolemic hemodilution, and meticulous intraoperative hemostasis which allows us to perform major craniomaxillofacial reconstructions in Jehovah's Witness patients without the use of homologous or predonated autologous blood transfusions.

(3) Singelenherg R JEHOVAH'S WITNESS. Br J Oral Maxillofac Surg 1993 Jun; 31(3): 195

(4) McDermott PJ JEHOVAH'S WITNESS: A MANAGEMENT DILEMMA IN SEVERE MAXILLOFACIAL TRAUMA. Br J Oral Maxillofac Surg 1992 October; 30(5): 331-34 The fundamentalist beliefs of a Jehovah's Witness can create major clinical and medicolegal problems when blood or blood products are needed to sustain life. The continuing expansion of Jehovah's Witnesses (¼ million in UK; 4 million worldwide) means that encounters with the sect and surgeons in clinically critical situations are likely to increase. This paper describes such a case in which a 24-year-old male died from maxillofacial injuries because blood transfusion was denied. The special clinical and ethical management criteria are emphasized and the legal vulnerability of the clinician is discussed. It is no longer possible for clinicians in the UK to act independently in the management of such cases without risking censure of indemnity from the employing health authority.

4. Tonsillar Surgery (1) Morrison JE Jr, Lane G, Kelly S, Stool S

THE JEHOVAH'S WITNESS FAMILY, TRANSFUSIONS, AND PEDIATRIC DAY SURGERY. Int J Pediatr Otorhinolaryngol 1997 Jan 3;38(3):197-205; discussion 207-13

Department of Anesthesiology, Children's Hospital, University of Colorado Health Science, Denver 80218, USA. [email protected] The pediatric otolaryngologist and anesthesiologist, when encountering a family of the Jehovah's Witness (JW) faith, should be aware of the potential problems which may arise when deciding to proceed with surgery. Two case reports are presented which illustrate the difficult situations which can occur when unanticipated complications (i.e. profound bleeding) arise perioperatively. An overview of the history and common tenets of the JW faith, previous legal perspectives, pertinent clinical information from the medical literature, and the protocol of The Children's Hospital, Denver, for dealing with this sensitive issue (drafted with the cooperation of the local JW Hospital Liaison Committee) are presented.


(2) Hall GM CAUTERY TONSILLECTOMY � SAVES TIME. Laryngoscope 1984 October; 94: 1381-82 In 1982 Goycoolea et al.1 reported the use of a �suction coagulator� for tonsillectomy which resulted in an essentially bloodless operation. Initially they found their technique to be more time consuming but with practice it became shorter since there was no need to spend time achieving hemostasis. They noted good results in 200 cases with no increase in postoperative pain and no immediate or delayed hemorrhage. Following Goycoolea's report I tried the suction coagulator and found this instrument to be cumbersome. I thereupon tried the standard cautery blade tip (Valley Lab Lectrochuck Surgical Pencil) and found immediately that the entire operation could be quickly accomplished with almost no bleeding.

(3) Gill G, Ritter FN. ADENOTONSILLECTOMY IN A JEHOVAH'S WITNESS WITH BLOOD DYSCRASIA. Arch Otolaryngol 1975 June; 101(6): 392-94 A case is used to illustrate a method of management of three unusual problems all simultaneously appearing in the same patient. Urgent surgical intervention was necessary for a child with a bleeding disorder, but the parents religious doctrine prohibited the use of whole blood or its products. The combined efforts of the legal, medical, and allied medical professionals led to a successful resolution on the patient's multiple problems

5. ORL Surgery in Children (1) Roure P, Hayem C, Daoud A

[HEMORRHAGIC SURGERY IN TWO JEHOVA'S WITNESS CHILDREN REFUSING PROGRAMMED AUTOTRANSFUSION: A PLACE FOR ERYTHROPOIETIN]. [ARTICLE IN FRENCH] Ann Fr Anesth Reanim 1998;17(4):310-4


(2) Morrison JE Jr, Lane G, Kelly S, Stool S THE JEHOVAH'S WITNESS FAMILY, TRANSFUSIONS, AND PEDIATRIC DAY SURGERY. Int J Pediatr Otorhinolaryngol 1997 Jan 3;38(3):197-205; discussion 207-13

Department of Anesthesiology, Children's Hospital, University of Colorado Health Science, Denver 80218, USA. [email protected] The pediatric otolaryngologist and anesthesiologist, when encountering a family of the Jehovah's Witness (JW) faith, should be aware of the potential problems which may arise when deciding to proceed with surgery. Two case reports are presented which illustrate the difficult situations which can occur when unanticipated complications (i.e. profound bleeding) arise perioperatively. An overview of the history and common tenets of the JW faith, previous legal perspectives, pertinent clinical information from the medical literature, and the protocol of The Children's Hospital, Denver, for dealing with this sensitive issue (drafted with the cooperation of the local JW Hospital Liaison Committee) are presented.


VII. CARDIAC SURGERY IN ADULTS

1. Blood ConservationTechnique for Adults 1. General Aspects

(1) Podesta A, Carmagnini E ERYTHROPOIETIN IN JEHOVA'S WITNESS HEART SURGERY. Minerva Cardioangiol 1999 Jul-Aug;47(7-8):261-267.

Cattedra di Cardiochirurgia, Universita degli Studi, Genova. The patients, reported here, needed open heart surgery, but religion obliged them to refuse blood transfusion. Three of the four patients suffered from obstructive coronary diseases and one from mitral valvular disease, prevalently stenosis. All of them refused blood transfusions. One of the three patients presented, was refused by an other Cardiovascular Surgery Center because of his low blood values (Haemoglobin 9.2--Haematocrit 26.7). All these patients had been treated with subcutaneous injection of epoetin alfa 10,000 U twice a week and ferrous sulphate 525 mg three time a day per os, for three weeks before operation. Haemoglobin, haematocrit and reticulocytes values were controlled in pre, postoperative and at discharge. With this treatment the authors found haemoglobin and haematocrit values so increased to allow surgery without blood transfusion during and in the post operative period.

(2) Furuse A Jr, Kotsuka Y, Kawauchi M, Tanaka O, Hirata K. CARDIAC SURGERY IN JEHOVAH'S WITNESSES. Kyobu Geka 1998 February; 51(2), 89-94 Clinical experience of 35 cardiothoraric operations in Jehovah's Witness patients were presented with special reference to a method of taking informed consent for surgery. At first the surgeon explained the details of the proposed surgery including its risks and benefits. He should also express his confidence in accomplishing the operation without blood transfusion. Otherwise he should not dare to perform operation. The surgeon asked the patient to talk about his or her religious belief in transfusion denial. Then the surgeon was allowed to talk about his professional duty and ethical belief in saving the patient at all costs. Finally, both the patient and the surgeon would sign the document of informed consent without fully determining whether or not the patient would undergo transfusion at an unexpected situation since the possibility of such unexpected necessity of blood transfusion was believed extremely low by both the surgeon and the patient. The trust of the patient in the technique of the surgeon was the key to this agreement.

(3) Oliveira SA, Bueno RM, Souza JM, Senra DF, Rocha-e-Silva M EFFECTS OF HYPERTONIC SALINE DEXTRAN ON THE POSTOPERATIVE EVOLUTION OF JEHOVAH'S WITNESS PATIENTS SUBMITTED TO CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS. Shock 1995 Jun;3(6):391-4

Surgical Division, Faculdade de Medicina, Universidade de Sao Paulo, Brazil. Hypertonic saline-dextran (HSD) solutions have been used for hemorrhagic shock, aortic aneurysm, and cardiopulmonary bypass surgery (CPB). Jehovah's Witness patients refuse blood and derivatives even under life-threatening conditions. A negative fluid balance for Jehovah's Witnesses would avoid further hemodilution. In this study we compared clinical, hemodynamic, laboratory evolution, and fluid balance of 20 Jehovah's Witnesses over the first 72 h following CPB. Ten received 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. HSD pretreatment is now used routinely for Jehovah's Witnesses undergoing CPB in our facility.


2. Aortic Surgery

(1) Baker CE, Kelly GD, Perkins GD PERIOPERATIVE CARE OF A JEHOVAH'S WITNESS WITH A LEAKING ABDOMINAL AORTIC ANEURYSM. Br J Anaesth 1998 Aug;81(2):256-9

Anaesthetic Department, Royal Shrewsbury Hospital. We describe a Jehovah's Witness patient who survived emergency repair of a leaking abdominal aortic aneurysm. In accordance with his beliefs, the patient expressed a wish not to be given blood and this was respected. At completion of surgery, his haemoglobin was 2.8 g dl-1 and his albumin was 8 g l-1. He was kept heavily sedated in the intensive care unit and treated with i.v. iron, folinic acid and s.c. epoetin alfa. He was discharged to the high dependency unit 18 days after surgery with a haemoglobin of 6.4 g dl-1 and an albumin of 27 g l-1. After rehabilitation, he was discharged home approximately 14 weeks after surgery.

(2) Sweeney MS, Young DJ, Frazier OH, Adams PR, Kapusta MO, Macris MP. TRAUMATIC AORTIC TRANSECTIONS: EIGHT-YEAR EXPERIENCE WITH THE �CLAMP-SEW� TECHNIQUE. Ann Thorac Surg 1997 August; 64(2): 384-87 BACKGROUND: Because traumatic aortic transection is associated with high mortality rates, great debate exists about the appropriate operative technique for treatment of patients who have acute traumatic aortic transection. METHODS: To determine the safety and efficacy of the �clamp-sew� method, we retrospectively reviewed our 8-year experience treating 75 patients who had aortic injuries secondary to blunt trauma. Seventy-one of these patients were treated surgically. The �clamp-sew� method was used in all of these operations. RESULTS: Aortic cross-clamp time averaged 24 minutes (range, 14 to 36 minutes), with 4/71 having times in excess of 30 minutes. One patient (clamp time, 28 minutes) became paraplegic. Significant associated injuries were seen in 51/75 patients (48/71 patients with operation), including intrathoraric (35 patients), orthopedic (28 patients), intraabdominal (24 patients), and central nervous system (17 patients) damage. No patient died within 24 hours of operation. Overall 30-day mortality was 12% (9/75), with 7/9 having two or more aforementioned associated injuries. Of these 7, 5 had central nervous system injuries. Two of 9 died within 30 days without two or more associated injuries: 1 Jehovah's Witness of low hemoglobin, and 1 patient of sepsis. CONCLUSIONS: Although any of several maneuvers may be appropriate in managing traumatic aortic injuries, the simple �clam-sew� technique is a safe and effective method for the treatment of traumatic aortic transections.

(3) Gutowski P, Dybkowska K, Szumilowicz G [OPERATION FOR RUPTURED ABDOMINAL AORTIC ANEURYSM WITHOUT CONSENT FOR BLOOD TRANSFUSION--CASE REPORT]. [ARTICLE IN POLISH]

Wiad Lek 1997;50(4-6):120-2

Kliniki Chirurgii Ogolnej i Naczyniowej, Pomorskiej Akademii Medycznej w Szczecinie. Successful operation for ruptured abdominal aortic aneurysm (AAA) in a Jehovah's Witness 66-year-old man was presented. The patient was urgently operated for symptomatic AAA. We found during surgery that that aneurysm was ruptured. Bifurcated PTFE aorto-bi-iliac prosthesis was implanted. The patient did not receive any blood or blood-origin products while staying in our Hospital.

3. Open Heart Surgery

(1) Peterffy A, Horvath G, Tamas C, Bodnar F, Szokol M, Vaszily M [OPEN-HEART SURGERY IN JEHOVAH'S WITNESSES]. [ARTICLE IN HUNGARIAN] Orv Hetil 2000 Apr 30;141(18):959-961


Debreceni Egyetem, Orvos- es Egeszsegtudomanyi Centrum, Altalanos Orvostudomanyi Kar, Szivsebeszeti Klinika. The religious community Jehovah's Witnesses was founded in 1870. They hold that blood transfusion is against God's law. Surgical treatment of a Jehova witness is a great challenge for every surgeon, especially for cardiac surgeons because blood transfusion is frequently needed during such operations. Authors have been trying to reduce the utilization of preserved blood for ten years. This study is about the experience with Jehovah's Witnesses who have undergone open heart surgery in Debrecen. Twenty-four patients underwent open heart surgery from 1989 till May 1999. 7 of them were males and 17 were females. The mean age was 53 years (40-70 yrs). Three patients had congenital heart disease, 11 had acquired valve disease and 7 had coronary stenosis. In 3 cases the patients had combined coronary and valve disease. Authors used a complete procedure for reducing blood loss during the operations. Two patients (8.3%) died during the early postoperative period. Preoperative mean haemoglobin level was 134.2 g/l (112-166) and haematocrit value varied between 36-50% (mean 38%). On the first postoperative day significant decrease was registrated in these values. From the second day a slow but significant increase of haemoglobin and haematocrit levels were detected. The mean follow up time was 37.6 months (2-144), and the NYHA classification of 21 longtime survivors improved from 3.06 to 1.62. At the Department of Cardiac Surgery in Debrecen as well as worldwide more and more operations are done without blood or preserved blood products, so it could be said that nowadays surgical treatment of Jehovah's Witnesses has lower risk than before.

(2) Rosengart TK, Helm RE, DeBois WJ, Garcia N, Krieger KH, Isom OW. OPEN HEART OPERATIONS WITHOUT TRANSFUSION USING A MULTIMODALITY BLOOD CONSERVATION STRATEGY IN 50 JEHOVAH'S WITNESS PATIENTS: IMPLICATIONS FOR A �BLOODLESS� SURGICAL TECHNIQUE. J Am Coll Surg 1997 June; 184(6): 618-29 BACKGROUND: Blood transfusion persists as an important risk of open heart operations despite the recent introduction of a variety of new pharmacologic agents and blood conservation techniques as independent therapies. A comprehensive multimodality blood conservation program was developed to minimize this risk. STUDY DESIGN: To provide a strategy for operating without transfusion, this program was prospectively applied to 50 adult patients who are Jehovah's Witnesses and have undergone open heart operation at our institution since 1992. The blood conservation program used for these patients included the use of high-dose erythropoietin (800 U/kg load, 500 U/kg every other day), aprotinin (6 million U total dose full Hammersmith regimen), �maximal� volume intraoperative autologous blood donation, intraoperative cell salvage, continuous shed blood reinfusion, and drawing as few blood specimens as possible. RESULTS: Procedures performed included first-time coronary bypass operations (n = 30) and more complex operations, including reoperations, valve replacements, and multiple valve replacements with or without coronary bypass (n = 20). Despite the absence of transfusion, the mean discharge hematocrit in these patients was greater than 30 percent, and there was no anemia-related mortality rate in this group. The overall in-hospital mortality for the group was 4 percent. A subset analysis was performed between the 30 first-time coronary bypass patients (group 1) and a control group of 30 consecutive patients who were not Jehovah's Witnesses but had undergone first-time coronary bypass during the same period (group 2). The blood conservation program described in the previous paragraph was not used in group 2 patients and specific transfusion criteria were prospectively applied. The chest tube output in group 1 patients was less than 40 percent of that for group 2 patients at all points measured after operation (p < 0.01). Postoperative hematocrit levels in group 1 were greater than those for group 2, despite the absence of red blood cell transfusion and despite a significantly lower admission hematocrit and red blood cell mass in group 1. The average length stay and ancillary costs for the two groups were equivalent. Although group 1 and 2 patients were well matched for preoperative transfusion risk factors, non of the group1 patients required transfusion, but 17 (57 percent) group 2 patients met transfusion criteria and received 3.0 +/- 4.8 U (means plus or minus standard deviation) of homologous blood or blood products. CONCLUSIONS: These results suggest that even complex open heart operations can be performed without homologous transfusion by optimally applying available blood conservation techniques. More generalized application of these measures may increasingly allow �bloodless� operations in all patients.


(3) 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):195-199.


(4) Grebenik CR, Sinclair ME, Westaby S HIGH RISK CARDIAC SURGERY IN JEHOVAH'S WITNESSES. J Cardiovasc Surg (Torino) 1996 Oct;37(5):511-5

Department of Cardiothoracic Anaesthesia and Oxford Heart Centre Cardiac Surgery, John Radcliffe Hospital, England. Much routine cardiovascular surgery can be performed without blood transfusion. Complex cardiac surgical procedures, however, especially reoperations, are often associated with heavy blood loss and large transfusion requirements. Anaesthetists and surgeons caring for patients who are Jehovah's Witnesses may be unwilling to offer such high risk surgery without recourse to blood transfusion. We report six such cases which were successfully performed without the use of blood or blood products and discuss the techniques used. Three of the patients described had been refused surgery, on their terms, at other centres. We believe that no patient should be denied potentially life saving surgery on the grounds of excessive risk without blood transfusion.

(5) Sowade O, Warnke H, Scigalla P [OPERATIONS WITH A HEART-LUNG MACHINE IN ADULT MEMBERS OF JEHOVAH'S WITNESSES]. [ARTICLE IN GERMAN] Anaesthesist 1995 Apr;44(4):257-64

Klinik und Poliklinik fur Herzchirurgie des Universitatsklinikums Charite der Humboldt-Universitat zu Berlin. Members of Jehovah's Witnesses refuse blood transfusions and blood products under any circumstances. Because of an improvement in blood salvage techniques in our centre, they are not excluded from open-heart surgery. In recent years recombinant human erythropoietin (rhEPO) has been applied to correct perioperative anemia in these patients. METHODS. Seventeen members of Jehovah's Witnesses who were more than 18 years of age were operated on using various blood salvage technique, e.g., haemoseparation and a high dose of Aprotinin. We present the first three patients treated with 4 x 500 U of i.v. rhEPO/kg body wt. given within 11 days preoperatively. Thirteen of the patients operated on had elevated preoperative risk factors, for instance poor left ventricle, severe aortic valve stenosis, metabolic syndrome, age older than 70 years, etc. In other centres that perform cardiac operations on members of Jehovah's Witnesses, these risk factors represent contraindications for open-heart surgery in these patients. RESULTS. Patients with rhEPO treatment showed a preoperative hematocrit increase of 7 Vol.% within 10 days and no postoperative complications. At the 6th postoperative hour the hematocrit returned to the starting values; in patients without rhEPO, however, the hematocrit generally had not increased to preoperative values even by the 8th day after operation. In 9 patients with preoperative elevated risk factors and a postoperative relative decrease in hematocrit below 33% we observed an uncomplicated postoperative period. Four patients with these risk factors, a pronounced decrease in hematocrit and blood loss postoperatively had various severe complications. CONCLUSIONS. Preoperative treatment with a high dose of rhEPO to enhance the hematocrit and maturity by precursor red blood cells in patients with a hematocrit below 45 Vol.% is a possibility to compensate for the blood loss perioperatively and to avoid complications from a


decrease in oxygen transport capacity. The anaemia and high blood loss postoperatively are the main causes for a slightly elevated operation risk in members of Jehovah's Witnesses in all heart centres that perform cardiac operations on these patients. Nevertheless, Jehovah's Witnesses should be not excluded from cardiac operations, since open-heart surgery without use of homologous blood is becoming a routine procedure.

(6) Olsen JB, Alstrup P, Madsen T OPEN-HEART SURGERY IN JEHOVAH'S WITNESSES. Scand J Thorac Cardiovasc Surg 1990;24(3):165-9 Department of Thoracic Surgery, University Hospital, Odense, Denmark. During a 7-year period, 11 adult members of the religious sect Jehovah's Witnesses underwent cardiac surgery with extracorporeal circulation. No homologous blood transfusions were given. Blood-conserving procedures were employed, viz. initial collection of autologous blood, haemofiltration or processing (Cell Saver) of blood collected during extracorporeal circulation and reinfusion of shed mediastinal blood. The total perioperative blood loss averaged 1080 ml (15 ml/kg body weight), equalling 19% of total body blood volume. The mean haemoglobin on discharge from hospital was 11.0 g/100 ml. There was no perioperative mortality. Postoperative pulmonary function was good and there was no serious morbidity. Jehovah's witnesses with serious, surgery-necessitating heart disease can be offered operation comprising recognized blood-conserving procedures.

(7) Zaorski JR, Hallman GL, Cooley DA. OPEN HEART SURGERY FOR ACQUIRED HEART DISEASE IN JEHOVAH�S WITNESSES. A REPORT OF 42 OPERATIONS. The American Journal of Cardiology 1972 Febr; 29: 186-89 Patients belonging to the Jehovah�s Witness faith may represent a special problem when undergoing open heart surgery since they steadfastly refuse blood transfusion. Using a bloodless prime technique of extracorporeal circulation, we performed during an 8-year period 42 open heart operations for acquired heart disease in a consecutive series of 40 patients who were Jehovah�s Witnesses. Three patients (7 percent) died, and only 1 death was caused by anemia. The favorable results we attribute in part to the brief periods of cardiopulmonary bypass used. In more than 70 percent of cases pump time was less than 40 minutes. We believe that our experience demonstrates the feasibility of open heart surgery in Jehovah�s Witnesses and, moreover, indicates that blood transfusion can and should be used sparingly to reduce morbidity and mortality in all patients.

4. Coronary Surgery and Stenting

(1) Dougherty JE, Gallagher RC, Hirst JA, Rinaldi MJ, Biskup J, 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 April; 61(4): 195-99 Bloodless cardiac surgery would be optimal for all patients undergoing major or complex heart surgery; however, for Jehovah's Witnesses it involves a religious law and is fundamentally mandated. In this context, we review a case of unstable angina with associated anemia requiring catheterization and definitive intervention in a Jehovah's Witness patient. Coronary stenting to stabilize the acute coronary syndrome is described with definitive total revascularization performed by coronary artery bypass graft surgery after utilizing erythropoietin and aggressive blood conservation techniques.

(2) Vaska PL CARDIAC SURGERY IN SPECIAL POPULATIONS, PART 1: OCTOGENARIANS, PATIENTS WITH NEUROPSYCHIATRIC DISORDERS, AND BLACKS. AACN Clin Issues 1997 February; 8(1): 50-58 This is the first of a series of articles that discusses the pertinent issues involved in caring for patients undergoing surgery who belong to special populations. Octogenarians have higher mortality, more comorbidities, and special needs regarding convalescence. Patients with neuropsychiatric disorders may have exacerbations of their mental illness after surgery and require special care and patience by the nurse.


Survival after cardiac surgery is significantly and proportionately lower than whites, suggesting either a referral bias or a problem with access to care. Subsequent articles discuss cardiac surgery in women, during pregnancy, in Jehovah's Witnesses and in patients with Down's Syndrome.

(3) Vaska PL CARDIAC SURGERY IN SPECIAL POPULATIONS, PART 2: WOMEN, PREGNANT PATIENTS, AND JEHOVAH'S WITNESSES. AACN Clin Issues 1997 Feb;8(1):59-66; quiz 166-8

Sioux Valley Hospital, South Dakota, USA. This is the second in a series of articles that discusses cardiac surgery in patients who belong to special populations. Women are often the victims of sex bias regarding their referral to cardiac testing, and are consequently sicker when they present for heart surgery. Pregnant women undergoing cardiac surgery require vigilant care while undergoing surgery, with anticoagulant administration and valve selection to achieve positive maternal and fetal outcomes. Progressive improvements in technology, perioperative care, and pharmaceutical development has made cardiac surgery in Jehovah's Witnesses safer than in the past.

(4) Carson JL, Duff A, Poses RM, Berlin JA, Spence RK, Trout R, Noveck H, Strom BL EFFECT OF ANAEMIA AND CARDIOVASCULAR DISEASE ON SURGICAL MORTALITY AND MORBIDITY. Lancet 1996 Oct 19; 348 (9034): 1055-1060

Department of Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson. Medical School, New Brunswick 08903-0019, USA. BACKGROUND: Guidelines have been offered on haemoglobin thresholds for blood transfusion in surgical patients. However, good evidence is lacking on the haemoglobin concentrations at which the risk of death or serious morbidity begins to rise and at which transfusion is indicated. METHODS: A retrospective cohort study was performed in 1958 patients, 18 years and older, who underwent surgery and declined blood transfusion for religious reasons. The primary outcome was 30-day mortality and the secondary outcome was 30-day mortality or in-hospital 30-day morbidity. Cardiovascular disease was defined as a history of angina, myocardial infarction, congestive heart failure, or peripheral vascular disease. FINDINGS: The 30-day mortality was 3.2% (95% CI 2.4-4.0). The mortality was 1.3% (0.8-2.0) in patients with preoperative haemoglobin 12 g/dL or greater and 33.3% (18.6-51.0) in patients with preoperative haemoglobin less than 6 g/dL. The increase in risk of death associated with low preoperative haemoglobin was more pronounced in patients with cardiovascular disease than in patients without (interaction p < 0.03). The effect of blood loss on mortality was larger in patients with low preoperative haemoglobin than in those with a higher preoperative haemoglobin (interaction p < 0.001). The results were similar in analyses of postoperative haemoglobin and 30-day mortality or in-hospital morbidity. INTERPRETATION: A low preoperative haemoglobin or a substantial operative blood loss increases the risk of death or serious morbidity more in patients with cardiovascular disease than in those without. Decisions about transfusion should take account of cardiovascular status and operative blood loss as well as the haemoglobin concentration.

(5) Botero C, Smith CE, Morscher AH ANEMIA AND PERIOPERATIVE MYOCARDIAL ISCHEMIA IN A JEHOVAH'S WITNESS PATIENT. J Clin Anesth 1996 Aug; 8(5): 386-391



(6) Grebenik CR, Sinclair ME, Westaby S HIGH RISK CARDIAC SURGERY IN JEHOVAH'S WITNESSES. J Cardiovasc Surg (Torino) 1996 Oct;37(5):511-515

Department of Cardiothoracic Anaesthesia and Oxford Heart Centre Cardiac Surgery, John Radcliffe Hospital, England. Much routine cardiovascular surgery can be performed without blood transfusion. Complex cardiac surgical procedures, however, especially reoperations, are often associated with heavy blood loss and large transfusion requirements. Anaesthetists and surgeons caring for patients who are Jehovah's Witnesses may be unwilling to offer such high risk surgery without recourse to blood transfusion. We report six such cases which were successfully performed without the use of blood or blood products and discuss the techniques used. Three of the patients described had been refused surgery, on their terms, at other centres. We believe that no patient should be denied potentially life saving surgery on the grounds of excessive risk without blood transfusion.

(7) Oliveira SA, Bueno RM, Souza JM, Senra DF, Rocha-e-Selva M. EFFECTS OF HYPERTONIC SALINE DEXTRAN ON THE POSTOPERATIVE EVOLUTION OF JEHOVAH'S WITNESS PATIENTS SUBMITTED TO CARDIAC SURGERY WITH CARDIOPULMONARY BYPASS. Shock 1995 June; 3(6): 391-94 Hypertonic saline-dextran (HSD) solutions have been used for hemorrhagic shock, aortic aneurysm, and cardiopulmonary bypass surgery (CPB). Jehovah's Witnesses patients refuse blood and derivatives even under life-threatening conditions. A negative fluid balance for Jehovah's Witnesses would avoid further hemodilution. In this study we compared clinical, hemodynamic, laboratory evolution, and fluid balance of 20 Jehovah's Witnesses over the first 72 h following CPB. Ten received 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. HSD preteatment is now used routinely for Jehovah's Witnesses undergoing CPB in our facility.

(8) Henderson AM, Maryniak JK, Simpson JC. CARDIAC SURGERY IN JEHOVAH�S WITNESSES. A REVIEW OF 36 CASES. Anaesthesia 1986 July; 41(7): 748-53 Between January 1971 and January 1985, 31 Jehovah�s Witnesses underwent 24 bypass and 12 non-bypass cardiothoraric operations at the National Heart Hospital. Fifty-eight % of the group were under 16 years of age. There was one death in the non-bypass group unrelated to blood loss. Six deaths occurred in the bypass group. In one of these, blood loss contributed to the cause of death and in two patients, blood loss was directly related to the cause of death. The anaesthetic management of Jehovah�s Witnesses undergoing cardiac surgery is discussed.

(9) Lilleaasen P, Frøyskaer T, Stokke O. CARDIAC SURGERY IN EXTREME HAEMODILUTION WITHOUT DONOR BLOOD, BLOOD PRODUCTS OR ARTIFICIAL MACROMELOCULES. Scand J Thor Cardiovasc Surg 1978; 12(3): 249-51 A triple aorto-coronary vein bypass was performed in a 56-year-old Jehovah�s Witness. Neither donor blood, albumin, nor artificial macromolecules were used. Ten litres of non-haemic fluid were given during surgery and an additional 4 litres during the first 18 postoperative hours. During perfusion the haematocrit fell to 19 vol% and total protein in serum to 29 g/l. Eighteen hours after surgery, the patient was extubated without any signs of oedema and with a positive water balance of only 2.2 l. Diuretics were not given. Acid-base and electrolyte values were within normal limits both during and after operation. This and similar cases reported in the literature show that during extracorporeal circulation it is possible to reduce the concentrations of red cells and plasma proteins to below 40% of pre-operative values without serious complications.


(10) Gollub S, Sigvals R, Bailey CP, Hirose T, Schaefer C. ELECTROLYTE SOLUTION IN SURGICAL PATIENTS REFUSING TRANSFUSION. JAMA 1971 March; 215(13): 2077-83 Major blood loss in 13 surgical patients was treated by infusion of crystalloid solution alone, supplemented by colloid plasma expander when necessary. Neither whole blood nor any of its components or fractions was employed at any time. For losses of 21% to 66% of blood volume, Ringer�s solution, administered in three to five times the volume of blood loss, produced physiologically significant intravascular fluid increments equalling one fifth to three fifths of the shed blood. Colloid solutions were required to sustain blood volumes or blood pressure for patients with blood losses in excess of 1,200 ml, otherwise clinically significant edema was manifested. One week after surgery, blood volumes averaged 90% of original values. The death rate was three thirteenths. The average hospital stay was prolonged 3.4 days.

(11) Simmons CW, Messmer BJ, Hallman GL, Cooley DA. VASCULAR SURGERY IN JEHOVAH�S WITNESSES. JAMA 1970 August 10; 213(6): 1032-34 Twenty Jehovah�s Witnesses (age range: 17 months to 76 years) underwent central or peripheral vascular surgery for congenital or acquired disease. Two patients died: one (74 years old) from myocardial infarction, the other after a subsequent open heart operation. Hemoglobin concentration and hematocrit readings were not low enough in any patient to urge blood transfusion. Hospital convalescence averaged one week. Overall results compared favorably with results in other patients, indicating that a good outcome can be obtained in vascular surgery without blood transfusion.

(12) Bailey CP, Hirose T, Gollub S, Everett HB, Folk FS. OPEN HEART SURGERY WITHOUT BLOOD TRANSFUSION. Vascular Disease 1968 December; 5(4): 179-87 Since September 18, 1964, when a Starr-Edwards prosthesis was used successfully to replace a destroyed aortic valve in a patient of the Jehovah�s Witness religious faith without the use of blood, 19 additional patients have been submitted to similar open heart surgery at the St. Barnabas Hospital in New York City. Thirteen of the series were Jehovah�s Witnesses.

(13) Gollub S, Bailey CP. MANAGEMENT OF MAJOR SURGICAL BLOOD LOSS WITHOUT TRANSFUSION. JAMA 1966 Dec 12; 198(11): 1171-74 Six patients of the Jehovah�s Witness faith underwent open-heart surgery without receiving blood at any time. Marked acute decreases in red blood cell mass and low absolute levels of hematocrit followed exclusive use of crystalloid sulutions for priming the extracorporeal apparatus and to replace blood loss postoperatively. Sequential studies of renal, cerebral, cardiac, and hepatic function showed no significant impairment up to one week after surgery. There was one operative fatality. The other five patients were discharged ambulatory and improved. Maintenance of blood volume appeared to be a significant factor in prevention of morbidity and mortality.

(14) Cooley DA, Strawford ES, Howell JF, Beall AC. OPEN HEART SURGERY IN JEHOVAH�S WITNESSES. The American Journal of Cardiology 1964 June; 13: 779-81 Open heart surgery using cardiopulmonary bypass has not been used for Jehovah�s Witnesses because of their religious convictions and a church law forbidding blood transfusion. Development of bypass techniques which utilize only blood substitutes for priming have made such procedures acceptable to these patients.

2.Valve Replacements 1. General Aspects of Complicated Operations



Department of Cardiothoracic Surgery, New York Hospital-Cornell University Medical Center, NY, USA. BACKGROUND: Blood transfusion persists as an important risk of open heart operations despite the recent introduction of a variety of new pharmacologic agents and blood conservation techniques as independent therapies. A comprehensive multimodality blood conservation program was developed to minimize this risk. STUDY DESIGN: To provide a strategy for operating without transfusion, this program was prospectively applied to 50 adult patients who are Jehovah's Witnesses and have undergone open heart operation at our institution since 1992. The blood conservation program used for these patients included the use of high-dose erythropoietin (800 U/kg load, 500 U/kg every other day), aprotinin (6 million U total dose full Hammersmith regimen), "maximal" volume intraoperative autologous blood donation, intraoperative cell salvage, continuous shed blood reinfusion, and drawing as few blood specimens as possible. RESULTS: Procedures performed included first-time coronary bypass operations (n = 30) and more complex operations, including reoperations, valve replacements, and multiple valve replacements with or without coronary bypass (n = 20). Despite the absence of transfusion, the mean discharge hematocrit in these patients was greater than 30 percent, and there was no anemia-related mortality rate in this group. The overall in-hospital mortality for the group was 4 percent. A subset analysis was performed between the 30 first-time coronary bypass patients (group 1) and a control group of 30 consecutive patients who were not Jehovah's Witnesses but had undergone first-time coronary bypass during the same period (group 2). The blood conservation program described in the previous paragraph was not used in group 2 patients and specific transfusion criteria were prospectively applied. The chest tube output in group 1 patients was less than 40 percent of that for group 2 patients at all points measured after operation (p < 0.01). Postoperative hematocrit levels in group 1 were greater than those for group 2, despite the absence of red blood cell transfusion and despite a significantly lower admission hematocrit and red blood cell mass in group 1. The average length of stay and ancillary costs for the two groups were equivalent. Although group 1 and 2 patients were well matched for preoperative transfusion risk factors, none of the group 1 patients required transfusion, but 17 (57 percent) group 2 patients met transfusion criteria and received 3.0 +/- 4.8 U (mean plus or minus standard deviation) of homologous blood or blood products. CONCLUSIONS: These results suggest that even complex open heart operations can be performed without homologous transfusion by optimally applying available blood conservation techniques. More generalized application of these measures may increasingly allow "bloodless" operations in all patients.

2. Aortic Valve

(1) Sawada Y, Asada K, Matsuyama N, Hasegawa S, Sasaki S [OPEN HEART SURGERY IN A JEHOVAH'S WITNESS BOY--A CASE REPORT OF SUCCESSFUL MANAGEMENT OF AORTIC REGURGATATION AND ANEURYSM OF SINUS VALSALVA DUE TO INFECTIVE ENDOCARDITIS]. [ARTICLE IN JAPANESE] Nippon Kyobu Geka Gakkai Zasshi 1997 Dec;45(12):2006-10

Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Takatsuki, Japan. Jehovah's Witness who require operation represent a challenge to the physician because of the patients' refusal to accept blood transfusion. We report an 8-year-old male of Jehovah's Witness who underwent a surgical treatment of infective endocarditis. He was transferred to our hospital because of high fever and heart murmur. Echocardiogram revealed a developing vegetation of aortic cusps and an aneurysmal change of the non-coronary sinus Valsalva. On admission he was complicated by anemia, purulent meningitis and suppurative arthritis of left knee. There were no signs of cardiac failure. Erythropoietin (6000 U thrice weekly) and iron (60 mg daily) were given for 11 weeks prior to surgery, raising the hemoglobin level from 9.2 g/dl to 18.4 g/dl. Aortic valve replacement and plasty of the sinus Valsalva were then performed. Intraoperatively hemoglobin concentration


dropped to 10.3 g/dl and it raised to 15 g/dl postoperatively. We also used Cell-Saver to reduce blood loss. The patient made an uncomplicated recovery. Erythropoietin therapy contributed substantially to the successful outcome of this case.

3. Mitral valve Replascement

(1) St Rammos K, Bakas AJ, Panagopoulos FG. MITRAL VALVE REPLACEMENT IN A JEHOVAH'S WITNESS WITH DEXTROCARDIA AND SITUS SOLITUS. J Heart Valve Dis 1996 November; 5(6): 673-74 BACGROUND AND AIMS OF THE STUDY: Dextrocardia with situs solitus and mitral valve insufficiency requiring surgical treatment is a rare presentation. Jehovah's Witnesses (JW), a specific religious group, deny any blood transfusion and for this reason the cardiac surgeon has to plan his operation well in advance, particularly in the case of adhesions from previous thoraric procedures. MATERIALS AND METHODS: A 50-year-old white female Jehovah's Witness with dextrocardia and situs solitus was referred for surgical treatment of massive mitral valve insufficiency of rheumatic etiology. Due to multiple adhesions from previous bilateral thoracotomies and the inverted position of the heart, cardiopulmonary bypass (CPB) was initiated with an aortic and a left common femoral vein cannulae. CPB was completed with an additional SVC cannula. The surgeon, having excellent exposure from the opposite side of the table, was able to perform a mitral valve replacement (MVR) with a 31 mm St. Jude Medical valve prosthesis, through a giant left atrium under moderate hypothermia and crystalloid cardioplegia. The operation was bloodless, with only two units of autotransfused blood being used with a postoperative hematocrit of 34%. RESULTS: The Patient had an uneventful recovery and has been in NYHA class I for 24 months now. CONCLUSIONS: The case is presented for the safety of the approach, the excellent exposure from the left side in a dextrocardia case and the avoidance of blood transfusion in a Jehovah's Witness patient.

4. Double Valves Replacement

(1) Nishimoto M, Sawada Y, Asada K, Hasegawa S, Sasaki S. A CASE OF JEHOVAH'S WITNESS UNDERWENT DOUBLE VALVES REPLACEMENT REOPERATION. Nippon Kyobu Geka Gakkai Zasshi 1997 August; 45(8): 1165-68 The patient was a sixty five-year-old woman and Jehovah's Witness who refused either homologous or autologous blood transfusion on the ground of her faith. At the age of 47, she had closed commissurotomy for mitral valve stenosis. This time, because mitral valve restenosis and tricuspid valve regurgitation were found, double valve replacement, mitral and tricuspid, was performed on her, with an excellent result. It is expected that, in the near future, the indication for open heart surgery without blood transfusion will be increased by means of the following considerations as to blood loss preservation; 1. to shorten the time necessitating for an operation and reduce preoperative blood loss, 2. to improve cardio-pulmonary bypass system (Heparin coating etc), and 3. to augment the erythropoiesis (administration of EPO at the patient's own expense, etc.) and so on.

5. Triple Valve Replacement

(1) Lang M, Youngsson GG, McKenzie FN, Reimbecker RO. SEQUENTIAL TRIPLE-VALVE REPLACEMENT IN A JEHOVAH�S WITNESS. CMA Journal 1980 February 23; 122: 433-35 Obligatory avoidance of blood transfusion during a major operation presents a challenge to the surgeon. Potential difficulties in the face of this constraint are considerable when open heart surgery is performed. However, refinements in patient care and in extracorporeal pump technology have now progressed to the point that an operation for surgically treatable cardiac disease need never be avoided on the sole basis of the unavailability or unacceptability of blood transfusions. These points are illustrated in the following report of sequential triple-valve replacement in a Jehovah�s Witness � the first case in the world to our knowledge.


3. Coronary Artery Surgery: (1) Helm RE, Rosengart TK, Gomez M, Klemperer JD, DeBois WJ, Velasco F, Gold JP,

Altorki NK, Lang S, Thomas S, Isom OW, Krieger KH COMPREHENSIVE MULTIMODALITY BLOOD CONSERVATION: 100 CONSECUTIVE CABG OPERATIONS WITHOUT TRANSFUSION. Ann Thorac Surg 1998 Jan;65(1):125-36

Department of Cardiothoracic Surgery, The New York Hospital-Cornell Medical Center, New York 10021, USA. BACKGROUND: Despite the recent introduction of a number of technical and pharmacologic blood conservation measures, bleeding and allogeneic transfusion remain persistent problems in open heart surgical procedures. We hypothesized that a comprehensive multimodality blood conservation program applied algorithmically on the basis of bleeding and transfusion risk would provide a maximum, cost-effective, and safe reduction in postoperative bleeding and allogeneic blood transfusion. METHODS: One hundred consecutive patients undergoing coronary artery bypass grafting were prospectively enrolled in a risk factor-based multimodality blood conservation program (MMD group). To evaluate the relative efficacy and safety of this comprehensive approach, comparison was made with a similar group of 90 patients undergoing coronary artery bypass grafting to whom the multimodality blood conservation program was not applied but in whom an identical set of transfusion guidelines was enforced (control group). To evaluate the cost effectiveness of the multimodality program, comparison was also made between patients in the MMD group and a consecutive series of contemporaneous, diagnostic-related group-matched patients. RESULTS: One hundred consecutive patients in the MMD group underwent coronary artery bypass grafting without allogeneic transfusion. This compared favorably with the control population in whom a mean of 2.2 +/- 6.7 units of allogeneic blood was transfused per patient (34 patients [38%] received transfusion). In addition, the volume of postoperative blood loss at 12 hours in the control group was almost double that of the MMD group (660 +/- 270 mL versus 370 +/- 180 mL [p < 0.001]). Total costs for the MMD group in each of the three major diagnostic-related groups were equivalent to or significantly less than those in the consecutive series of diagnostic-related group-matched patients. CONCLUSIONS: Comprehensive risk factor-based application of multiple blood conservation measures in an optimized, integrated, and algorithmic manner can significantly decrease bleeding and need of allogeneic transfusion in coronary artery bypass grafting in a safe and cost-effective manner.

(2) Martin Gonzalvez JA, Vergara Serrano JC, Ulibarrena Sainz MA, Boado Varela V, Sainz-Pardo Lerma N, Ballestero Zarraga JJ, Martin Gonzalez JA. MYOCARDIAL REVASCULARIZATION SURGERY WITHOUT EXTRACORPOREAL CIRCULATION. Rev Esp Cardiol 1995 March; 48(3): 211-13 The number of patients who need coronary artery surgery growth every year. Most of these surgical operations are with extracorporeal circulation (ECC). Recently in our hospital this surgery is realized without ECC in selected patients. Some studies shows that this surgery is an alternative in the treatment of coronary artery disease, especially for aged patients with associated disease and in Jehovah's witness faith. A coronary artery diameter at the anastomotic site of 2 mm or greater and satisfactory hemodynamics with the cardiac manipulation are needed to realize this surgery. Given these limitations this technique has proved useful in selected patients requiring revascularization of the left anterior descending, circumflex or right coronary artery (not for grafting the posterior descending branch). The need for mechanical ventilation, days at ICU, blood required, morbidity and mortality, in our experience as in other studies, were fewer than surgery with CEC.

(3) Garcia Rinaldi R, Pagan JL, Melendez FJ, Porro R, Barcelo J, Rivera M. CARDIAC SURGERY ON JEHOVAH'S WITNESSES AT INSTITUTO CARDIOVASCULAR-HOSPITAL PAVIA. Bol Asoc Med P R 1992 April; 84(4): 132-33


Jehovah's Witnesses (J.W.) can undergo successful cardiac operations. We have operated five J.W. patients. Of these patients, two had coronary artery bypass surgery and three had correction of congenital anomalies. These included an atrial septal defect. Our treatment protocol includes a meticulous surgery, the use of early heparinization to collect all shed blood into the pump oxygenator, observation in the operating room for early exploration if the patient bleeds and administration of iron preparations. Recombinant human erythropoietin, although available and in our treatment protocol, has not been used yet. All patients survived the operation and left the hospital with an excellent hemoglobin and hematocrit. The length of stay varied from 7 to 15 days

4. Coronary stent Placement (1) 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


5. Heparin-Bonded Circuits (1) Aldea GS, Shapira OM, Treanor PR, Lazar HL, Shemin RJ.

EFFECTIVE USE OF HEPARIN-BONDED CIRCUITS AND LOWER ANTICOAGULATION FOR CORONARY ARTERY BYPASS GRAFTING IN JEHOVAH'S WITNESSES. J Card Surg 1996 January; 11(1): 12-17 Despite many advances in blood conservation techniques, a significant proportion of patients undergoing primary coronary revascularization still require homologous transfusions. Based on a large clinical experience with high-risk patients during coronary artery bypass, a comprehensive strategy to diminish perioperative blood loss was developed by integrating many individual components. An integral component in this strategy is the use of lower heparinization (activated clotting time [ACT] > 280 sec) in conjunction with �tip-to-tip� heparin-bonded cardiopulmonary bypass (CPB) circuits (HBC). This technique was prospectively applied to a group of Jehovah's Witnesses (JW) patients who refused blood transfusion on religious grounds (n = 9). Outcome was compared to a matched group of patients treated with full heparinization (ACT > 480 sec) used with conventional, nonheparin-bonded CPB circuits (NHBC) performed within the same academic year (n = 455). There were no complications in JW patients who had a significantly lower mediastinal and pleural tube output in the first 24 hours (323 67 mL vs 984 616 mL, p < 0.01). In comparison to JW patients who received no transfusions, 68.1 % of patients treated with NHBC were transfused ( p 0.0001). In summary, HBC in conjunction with lower anticoagulation was effectively and safely applied to JW patients undergoing coronary artery bypass grafting. This technique should be considered for broader clinical use.

(2) Gallagher JM, Brown ME, Gasior TA. COMBINED USE OF APROTININ AND A HEPARIN-BONDED CARDIOPULMONARY BYPASS SYSTEM FOR AORTIC ANEURYSM REPAIR. J Cardiothorac Vasc Anesth 1995 December; 9(6): 728-30


(3) Sowade O, Warnke H, Scigalla P. OPERATIONS WITH AT HEART-LUNG MACHINE IN ADULT MEMBERS OF JEHOVAH'S WITNESSES. Anaesthesist 1995 April; 44(4): 257-64 Members of Jehovah's Witnesses refuse blood transfusions and blood products under any circumstances. Because of an improvement in blood salvage techniques in our centre, they are not excluded from open-heart surgery. In recent years recombinant human erythropoietin (rh-EPO) has been applied to correct perioperative anemia in these patients. METHODS. Seventeen members of Jehovah's Witnesses who were more than 18 years of age were operated on using various blood salvage technique, e.g., haemoseparation and high dose Aprotinin. We present the first three patients treated with 4 x 500 U of i.v. rh-EPO/kg body wt. given within 11 days preoperatively. Thirteen of the patients operated on had elevated preoperative risk factors, for instance poor left ventricle, severe aortic valve stenosis, metabolic syndrome, age older than 70 years, etc. In other centres that perform cardiac operations on members of Jehovah's Witnesses, these risk factors represent contraindications for open-heart surgery in these patients. in patients without rh-EPO, however, the hematocrit generally had not increased to preoperative values even by the 8th postoperative day after operation. In 9 patients with preoperative elevated risk factors and a postoperative relative decrease in hematocrit below 33% we observed an uncomplicated postoperative period. Four patients with these risk factors, a pronounced decrease in hematocrit and blood loss postoperatively had various severe complications. CONCLUSIONS. Preoperative treatment with high dose of rh-EPO to enhance the hematocrit and maturity by precursor red blood cells in patients with a hematocrit below 45 Vol.% is a possibility to compensate for the blood loss perioperatively and to avoid complications from a decrease in oxygen transport capacity. The anaemia and high blood loss postoperatively are the main causes for a slightly elevated operation risk in members of Jehovah's Witnesses in all heart centres that perform cardiac operations on these patients. Nevertheless, Jehovah's Witnesses should not be excluded from cardiac operations, since open-heart surgery without the use of homologous blood is becoming a routine procedure.

6. Aprotinin in Cardiac Surgery: (1) Chikada M, Furuse A, Kotsuka Y, Yagyu K.

OPEN-HEART SURGERY IN JEHOVAH'S WITNESS PATIENTS. Cardivasc Surg 1996 June; 4(3): 311-14 Open-heart surgery has been performed since 1975 on 25 patients who are Jehovah's Witnesses by religion. The patient's ages ranged from 6 - 60 years, and their body weights from 18 - 51 kg. Surgical procedures included correction of congenital heart disease in 14 patients and valve repair or replacement in 11. Six procedures were reoperations. The lowest mean hematocrits, during perfusion and the postoperative period, were 22.7% (range 15.0 - 31.0%) and 27% (range 16.0 - 36.0%), respectively. Twenty-four patients survived and are alive and well. One patient died of low output failure before discharge. The blood return system reduced blood loss. Five of the patients who underwent cardiac surgery received recombinant erythropoietin before and after surgery, leading to higher postoperative haematocrits. In one patient, a haematocrit which fell to 16.9% after surgery was raised to 27% by administration of erythropoietin, without blood transfusion. In two recent cases, high doses of aprotinin were used during surgery, resulting in better haemostasis after cardiopulmonary bypass.

(2) Rosengart TK, Helm RE, Klemperer J, Krieger KH, Isom Ow. COMBINED APROTININ AND ERYTHROPOIETIN USE FOR BLOOD CONSERVATION: RESULTS WITH JEHOVAH'S WITNESSES. Ann Thorac Surg 1994 November; 58(5): 1397-1403 Despite recent advances in blood conservation techniques, major risks persist for excessive bleeding and blood transfusion after open heart operations. We reviewed the records of 100 consecutive patients undergoing first-time coronary artery bypass grafting at our institution to define these risks and develop a multimodality blood conservation program based on the results. This program was subsequently applied on a prospective basis to a select group of patients who refuse blood transfusion on religious grounds (Jehovah's Witnesses [JW]) (n = 15). Encouraging initial results with coronary artery bypass grafting in this group (n = 8) led to the application of the program to more complex operations (n = 7), including repeat bypass grafting with use of the internal mammary artery, repeat mitral valve replacement, aortic and mitral valve replacement with coronary artery bypass grafting, mitral valve replacement with


bypass grafting, chronic type 1 dissection repair, aortic valve replacement, and atrial septal defect repair in 1 patient each. The blood conservation program employed in these patients included the use of (1) aprotinen (full Hammersmith regimen), (2) high-dose erythropoietin, (3) �maximal�-volume intraoperative autologous blood donation, (4) low-prime cardiopulmonary bypass, (5) exclusive use of intraoperative cell salvage, and (6) continuous reinfusion of shed mediastinal blood. There were no deaths in the JW group. Thromboembolic complications consisted of a transient posterior circulatory stroke in only 1 patient (dissection repair). No blood or blood products were transfused compared with the transfusion of 5.1 +/- 7.8 units (mean +/- standard deviation) in the 100 primary coronary bypass patients in whom the blood conservation program was not employed.

(3) Litvan H, Santacana E, Casas JI, Aris A, Villar Landeira JM APROTININ THERAPY TO REDUCE BLOOD LOSS IN JEHOVAH'S WITNESSES. Can J Anaesth 1994 Jan;41(1):77-8

(4) Alajmo F, Calamai G, Perna AM, Melissano G, Pretelli P, Palmarini MF, Carbonetto F, Noferi D, Boddi V, Palminiello A, et al. HIGH-DOSE APROTININ: HEMOSTATIC EFFECTS IN OPEN HEART OPERATIONS. Ann Thorac Surg 1989 October; 48(4): 536-39 Two groups of patients were prospectively studied to evaluate the hemostatic effects of high-dose aprotinin in open heart operations. Group A patients (n = 22) received aprotinin during the entire surgical procedure. Group B patients (n = 12) served as controls. The groups were homogenous for base variables and for cardiopulmonary bypass duration. Postoperative bleeding was lower in group A (mean, 486 mL) than in group B (830 mL) (p less than 0.01). The need for banked blood decreased by approximately half in the aprotinin patients (mean: group A, 213 mL; group B, 409 mL). Hemoglobin levels were similar in the two groups (postoperative day 7: group A, 11.29 g/100 mL; group B, 11.26 g/100 mL; NS). Platelet count decreased at the end of operation in both groups (99,000 and 95,000/mL, respectively; NS) and then increased beyond baseline levels before discharge. No complications were observed that could be attributed to aprotinin. In conclusion, we believe that the use of high-dose aprotinin is safe and effective. It decreases blood loss and reduces the need for banked blood in cardiac operations, particularly in select groups of patients (eg, those undergoing reoperation, Jehovah's Witnesses, those with renal failure).

(5) von Segesser LK, Weiss BM, Garcia E, Turina MI CLINICAL APPLICATION OF HEPARIN-COATED PERFUSION EQUIPMENT WITH SPECIAL EMPHASIS ON PATIENTS REFUSING HOMOLOGOUS TRANSFUSIONS. Perfusion 1991;6(3):227-33

Clinic for Cardiovascular Surgery, University Hospital, Zurich, Switzerland. Clinical application of heparin-coated cardiopulmonary bypass equipment during perfusion with low systemic heparinization is reported with special emphasis on patients refusing any transfusion of homologous blood or blood products. Using the described technique, coronary artery revascularization was successfully performed in three Jehovah's witnesses. During perfusion, the activated clotting time (ACT) was maintained above 180 seconds. Prebypass haematocrit was 38 +/- 3% and dropped to 22 +/- 1% after seven days. Hence, cardiopulmonary bypass with low systemic heparinization may further reduce bypass induced morbidity and improve the final outcome in selected patients.

7. Desmopressin in Cardiac Surgery: (1) Martens P.

DESMOPRESSIN AND JEHOVAH�S WITNESSES. Lancet 1989; June 10: 1322 Despite the concern about prothrombotic potential we recommend the use of desmopressin in Jehovah�s Witnesses undergoing surgery involving large blood losses.


(2) Stone DJ, DiFazio CA. DDAVP TO REDUCE BLOOD LOSS IN JEHOVAH�S WITNESSES. Anesthesiology 1988 December; 69(6): 1028 DDAVP (desmopressin) has been employed to reduce bleeding after cardiopulmonary bypass. DDAVP also reduces bleeding time in normal persons and has been used to reduce bleeding in patients undergoing Harrington Rod insertion. Doses 0.3 µµµµg/kg given intravenously over 20 min have been used. If severe intraoperative bleeding is a possibility in a Jehovah�s Witness patient, the prophylactic administration of DDAVP to reduce bleeding may be reasonable. This measure may make the occurrence of single digit hematocrits less likely in these patients.

8. Erythropoietin in Cardiac Surgery (1) Podesta A, Carmagnini E

ERYTHROPOIETIN IN JEHOVA'S WITNESS HEART SURGERY. Minerva Cardioangiol 1999 Jul-Aug;47(7-8):261-7

Cattedra di Cardiochirurgia, Universita degli Studi, Genova. The patients, reported here, needed open heart surgery, but religion obliged them to refuse blood transfusion. Three of the four patients suffered from obstructive coronary diseases and one from mitral valvular disease, prevalently stenosis. All of them refused blood transfusions. One of the three patients presented, was refused by an other Cardiovascular Surgery Center because of his low blood values (Haemoglobin 9.2--Haematocrit 26.7). All these patients had been treated with subcutaneous injection of epoetin alfa 10,000 U twice a week and ferrous sulphate 525 mg three time a day per os, for three weeks before operation. Haemoglobin, haematocrit and reticulocytes values were controlled in pre, postoperative and at discharge. With this treatment the authors found haemoglobin and haematocrit values so increased to allow surgery without blood transfusion during and in the post operative period.

(2) Cooley DA CONSERVATION OF BLOOD DURING CARDIOVASCULAR SURGERY. Am J Surg 1995 December; 170(6A Suppl): 53S-59S Conservative use of allogeneic red blood cell (RBC) transfusion is a growing trend in cardiovascular surgery. Recent advances in blood conservation measures have reduced, and in some cases eliminated, the need for allogeneic RBC transfusions in some of these patients. Reduced reliance on allogeneic RBC transfusion requires close collaboration among the clinical pathology, anesthesia, and surgery services managing the patient. Preoperative conservation measures include donation of autologous blood and treatment with recombinant human erythropoietin (Epoetin alfa). Meticulous surgical technique, moderate hemodilution, aprotinin, hemostatic techniques, blood salvage, and autotransfusion are intraoperative measures that can reduce blood loss. Postoperatively, even severe blood deficits can often be restored with adequate diet and rest and the use of actinics.

(3) Neustein SM, Bronheim D, Galla J, Litwak R, Rand J, Scott BH, Hartman AR, Poppers PJ, Bert AA, Feng WC, et al. CASE 1 � 1993. THE ROLE OF ERYTHROPOIETIN IN JEHOVAH'S WITNESSES REQUIRING CARDIAC SURGERY. J Cardiothorac Vasc Anesth 1993 February; 7(1): 95-102. Five case reports. For the Jehovah's Witness patient, erythropoietin can clearly be life saving. Although many of these patients can tolerate surgery without difficulty, the use of erythropoietin is the prudent approach to their treatment.

(4) Garcia Rinaldi R, Pagan JL, Melendez FJ, Porro R, Barcelo J, Rivera M CARDIAC SURGERY ON JEHOVA'S WITNESSES AT INSTITUTO CARDIOVASCULAR-HOSPITAL PAVIA. Bol Asoc Med P R 1992 Apr-May;84(4-5):132-3


Instituto Cardiovascular, Hospital Pavia, San Juan, Puerto Rico. Jehovah's Witnesses (J.W.) can undergo successful cardiac operations. We have operated five J.W. patients. Of these patients, two had coronary artery bypass surgery and three had correction of congenital anomalies. These included an atrial septal defect with infundibular pulmonic stenosis, a tetralogy of Fallot and a patient with a ventricular septal defect. Our treatment protocol includes a meticulous surgery, the use of early heparinization to collect all shed blood into the pump oxygenator, observation in the operating room for early exploration if the patient bleeds and administration of iron preparations. Recombinant human erythropoietin, although available and in our treatment protocol, has not been used yet. All patients survived the operation and left the hospital with an excellent hemoglobin and hematocrit. The length of stay varied from 7 to 15 days.

(5) Gaudiani VA, Mason HDW. PREOPERATIVE ERYTHROPOIETIN IN JEHOVAH�S WITNESSES WHO REQUIRE CARDIAC PROCEDURES. Ann Thorac Surg 1991 May; 51(5): 823-24 This report details the preoperative use of recombinant human erythropoietin in 2 Jehovah�s Witnesses who required elective cardiac operations. Preoperative use of recombinant human erythropoietin adds to the safety of a cardiac procedure by raising the hematocrit and preparing the bone marrow for high-volume red cell production.

9. Ventricular Assist Device (1) Sweeney MS, Frazier OH.

DEVICE-SUPPORTED MYOCARDIAL REVASCULARIZATION: SAFE HELP FOR SICK HEARTS. Ann Thorac Surg 1992 December; 54(6): 1065-70 Although advances in both the technology of artificial oxygenation and our understanding of myocardial preservation have made aortocoronary bypass operations safer, clinical settings remain where even these improvements have limited efficacy. We have recently treated 43 severely ill patients with aortocoronary bypass, using a ventricular assist device for intraoperative hemodynamic support and ventricular decompression. For 34 patients, preoperative ejection fractions (multigated acquisition) ranged from 0.12 to 0.28 (average, 0.22); 6 patients manifested cardiogenic shock preoperatively, and emergency operations precluded multigated acquisition studies. Twenty-nine patients had preoperative evidence of congestive heart failure, 10 had a prior bypass operation, 9 had major chronic obstructive pulmonary disease, and 2 were Jehovah's Witnesses. The operative technique involved minimal doses of heparin (1 to 1.5 mg/kg), no cardioplegia, and no cardiopulmonary bypass. Revascularization was accomplished on beating, nonworking hearts, with right (40 of 43) and left (43 of 43) ventricles supported by Nimbus Hemopumps (4 of 43) or Bio-Medicus centrifugal ventricular assist devices for an average of 112 minutes. In each case, the patient's lungs were used as the oxygenator. An average of 3.7 bypass grafts per patient was constructed. The left internal mammary artery was used in 41 patients, whereas at least one coronary endarterectomy was required in 20. Six patients had concomitant placement of an automatic implantable cardioverter defibrillator. Two patients (4.6%) died: 1 (with preoperative cardiogenic shock) of low cardiac output on postoperative day 1, and 1 of a severe neurologic deficit on day 8. Follow-up ranged from 2 to 18 months (average, 8.9 months), with all survivors demonstrating improvement in cardiac function in both early and late postoperative periods.

(2) Spence RK, Alexander JB, DelRossi AJ, Cernaianu AD, Cilley J Jr, Pello MJ, Atabek U, Camishion RC, Vertrees RA. TRANSFUSION GUIDELINES FOR CARDIOVASCULAR SURGERY: LESSONS LEARNED FROM OPERATIONS IN JEHOVAH'S WITNESSES. J Vasc Surg 1992 December; 16(6): 825-29 Patients undergoing cardiovascular surgery are among the top users of homologous blood transfusion (HBT). Awareness of the risks of disease transmission and immune system modulation from HBT has prompted us to find alternatives such as autologous predonation (APD) and intraoperative autotransfusion (IAT). However, these latter options are not appropriate for all patients. We reviewed our experience with 59 Jehovah's Witnesses patients who underwent 63 elective cardiovascular procedures


without either HBT or APD to determine the safety of operation without these modalities and to develop revised maximum surgical blood-ordering schedule guidelines for cardiovascular surgery. Estimated blood loss averaged 870 ml, but one third to one half of losses were replaced by IAT. IAT was not needed in lower extremity bypass operations in which the estimated blood loss was less than 150 ml. Three of 59 patients died (5.1%), but only one died of operative bleeding complications. We conclude that (1) elective cardiovascular operations can be done safely without the use of either HBT or APD, (2) HBT is not necessary in leg bypass procedures, and (3) maximum surgical blood-ordering schedule guidelines for HBT in major cardiovascular operations can re reduced to near zero by the use of intraoperative autotransfusion and acceptance of a postoperative hemoglobin nadir of 7.0 gm/dl.

10. "REDO" Reoperation Surgery (1) 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):251-255

Department of Anaesthesia, The General Infirmary at Leeds, UK. Although Jehovah's Witnesses present a particular problem when undergoing surgery because of their refusal to accept stored blood, it is now quite common to undertake uncomplicated cardiac surgery in these patients. Complex or redo cardiac surgery however, is often associated with major blood loss, and is conventionally contraindicated in Jehovah's Witnesses. We describe the perioperative management of a Jehovah's Witness who underwent a resternotomy for mitral valve replacement and coronary artery bypass grafting having previously had an aortic valve replacement and mitral valve repair. The importance of a multidisciplinary approach to blood conservation is discussed.

(2) Estioko MR, Litwak RS, Rand JH. REOPERATION, EMERGENCY AND URGENT OPEN CARDIAC SURGERY IN JEHOVAH�S WITNESSES. Chest 1992 July; 102(1): 50-3 Progressive advances in perfusion technology and perioperative supportive management have made it possible for members of the Jehovah�s Witnesses religious group to undergo open cardiac operations with remarkable safety. However, hospital mortality remains high in (1) patients requiring reoperation (in whom both technical and bleeding problems tend to be more frequent) and (2) patients with significantly compromised cardiac performance requiring urgent or emergency operation. Employing a member of perioperative measures designed to minimize blood loss and maintain hematocrit levels (including use of the recently available recombinant human erythropoietin in two patients whose cases are reported herein), 13 reoperations and five urgent or emergency operations were performed. The one death in the entire series occurred in a patient (reoperation group) who died of a cerebrovascular accident of presumed embolic etiology, having undergone combined debridement of a stenotic heavily calcified aortic valve and a second coronary artery revascularization procedure. None of the patients required surgical exploration for bleeding. We suggest that currently available methodology permits Jehovah�s Witnesses to undergo reoperation, emergency surgery, or urgent open cardiac operation at a level of risk not dissimilar to that seen in patients who permit use of homologous blood and products in their treatment.

(3) Lewis CTP, Murphy MC, Cooley DA. RISK FACTORS FOR CARDIAC OPERATIONS IN ADULT JEHOVAH�S WITNESSES. Ann Thorac Surg 1991; 51: 448-50 During a 27-year-period, 663 adults of the Jehovah�s Witness faith underwent open heart procedures at the Texas Heart Institute. To determine the effect of recent changes in operative techniques and in the patient population itself on early mortality, we reevaluated the surgical outcome in this special group of patients. We reviewed charts of 88 consecutive Jehovah�s Witness patients who had an open heart operation between January 1986 og March 1989 and compared demographic variables in this group with those of 575 patients who underwent operation between May 1963 og January 1986. In our recent series, patients were older (mean age, 61 years versus 54 years), and 16% were seen for repeat procedures. Early


mortality (30 days postoperatively) was lower in the recent series than in the earlier series (7.0% versus 10.7%), but the difference between the groups was not statistically significant. We identified several important factors associated with an increased risk of early death in the recent group of patients. These factors included repeat cardiac operations (p < 0.01), especially for valvar dysfunction, severe left ventricular dysfunction, and a hemoglobin level lower than 80 g/l (8 g/dl) (p < 0.01) on postoperative day 1. Although blood loss remains the leading cause of death in these patients, cardiac operations can be performed with an acceptable mortality.

(4) Olsen JB, Alstrup P, Madsen T OPEN-HEART SURGERY IN JEHOVAH�S WITNESSES. Scand J Thorac Cardiovasc Surg 1990; 24(3): 165-169 During a 7-year period, 11 adult members of the religious sect Jehovah�s Witnesses underwent cardiac surgery with extracorporeal circulation. No homologous blood transfusions were given. Blood-conserving procedures were employed, viz. initial collection of autologous blood, haemofiltration or processing (Cell Saver) of blood collected during extracorporeal circulation and reinfusion of shed mediastinal blood. The total perioperative blood loss averaged 1080 ml (15 ml/kg body weight), equalling 19% of total body blood volume. The mean haemoglobin on discharge from hospital was 11.0 g/100 ml. There was no perioperative mortality. Postoperative pulmonary function was good and there was no serious morbidity. Jehovah�s witnesses with serious, surgery-necessitating heart disease can be offered operation comprising recognized blood-conserving procedures.

(5) Gombotz H, Rigler B, Matzer C, Metzler H, Winkler G, Tscheliessnigg KH. TEN YEARS� EXPERIENCE WITH JEHOVAH�S WITNESSES IN CARDIAC SURGERY. [ARTICLE IN GERMAN] Anaesthesist 1989; 38: 385-90 The results of this study demonstrate the feasibility of heart surgery with and without cardiopulmonary bypass in Jehovah�s Witnesses.

(6) Malan TP Jr, Whitmore J, Maddi R REOPERATIVE CARDIAC SURGERY IN A JEHOVAH'S WITNESS: ROLE OF CONTINUOUS CELL SALVAGE AND IN-LINE REINFUSION. J Cardiothorac Anesth 1989 Apr;3(2):211-4

Department of Anesthesia, Brigham and Women's Hospital, Boston, MA 02115.

(7) Seifert PE, Auer JE, Hohensee P. MYOCARDIAL REVASCULARIZATION IN JEHOVAH�S WITNESSES Wis Med J 1989 April; 88(4): 19-20 The refusal of certain patients to accept blood transfusions need not be a deterrent to surgery. We report on nine Jehovah�s Witnesses who over a one-year period underwent myocardial revascularization without significant blood loss or decrease in hematocrit values.

(8) Gombotz H, Metzler H, Hiotakis K, Dacar D. OPEN HEART SURGERY IN JEHOVAH'S WITNESSES. Wien Klin Wochenschr 1985 June; 97(12): 525-30 Patients who are Jehovah's Witnesses present a special problem when undergoing open heart surgery since they refuse blood transfusion. We performed 15 open heart operations for both acquired and congenital heart disease using a modified version of isovolaemic haemodilution and bloodless prime technique of extracorporeal circulation. Two patients died. One death might have been at least indirectly related to the regimen which excludes blood substitution. We believe that our experience demonstrates the feasibility of open heart procedures in Jehovah's Witnesses, although the mortality risk is increased in these patients.


(9) Calthorpe DAD, Finegan BA, Moriarty DC, Neligan MC. THE USE OF THE CELL SAVER IN A JEHOVAH�S WITNESS UNDERGOING MAJOR CARDIAC SURGERY � CASE REPORT AND REVIEW. Irish Med J 1983 November; 76(11): 460-1 Thus, performing major cardiac surgery on Jehovah�s Witnesses with all its inherent problems, has proved a daunting challenge and accordingly only essential major surgery is undertaken. However, the use of colloid or crystalloid replacement fluids, hypothermia, hypotensive anaesthesia, the �cell saver�, and scrupulous attention to surgical technique, have significantly reduced the operative risk to these patients and the following case report encompassing these measures serves to illustrate their use in the successful management of a difficult case.

(10) Ottesen S, Frøysaker T. USE OF HAEMONETICS CELL SAVER FOR AUTOTRANSFUSION IN CARDIOVASCULAR SURGERY. Scand J Thorac Cardiovasc Surg 1982; 16(3): 263-68 The Haemonetics Cell Saver was evaluated as a tool for the refining of blood shed during cardiovascular surgery. After blood filtration the red cells are concentrated, washed and re-infused as red cells suspended in normal saline (CS blood) with haematocrit around 60%. Platelets and plasma with desired and undesired components are removed. In 50 patients undergoing elective but complicated cardiovascular surgery an average of 4.4 units CS blood were produced. In three Jehovah's Witnesses the method was used in combination with immediate preoperative prebleeding and dextran infusion. No blood products were given. The haematocrit was maintained at a safe level subsequent to retransfusion. Platelet counts were never critically low and extremely low total protein did not lead to peripheral or pulmonary oedemas or coagulation problems. In an in vitro study it was shown that extreme dilution of coagulation factors is well tolerated before the clotting time (ACT) is affected. The Cell Saver proved to be an effective, reliable and safe device for autotransfusion of salvaged blood during cardiovascular surgery.

(11) Kamat PV, Baker CB, Wilson JK, Finlayson DC. OPEN-HEART SURGERY IN JEHOVAH�S WITNESSES: EXPERIENCE IN A CANADIAN HOSPITAL. The Annals of Thoraric Surgery 1977 April; 23(4): 367-70 Jehovah�s Witnesses have religious beliefs precluding the use of blood. Few centers have attempted open-heart surgery bound by such strictures; as a result, availability of therapy for such patients have been limited. Many groups that have extensive experience with hemodilution for cardiopulmonary bypass have noted that these procedures can often be done with little or no use of blood. Our experience with 21 adult patients is presented in this paper.

(12) Sandiford FM. AORTOCORONARY BYPASS IN JEHOVAH�S WITNESSES: REVIEW OF 46 PATIENTS. The American Surgeon 1976 January; 42(1): 17-22 Between January 1971 and April 1974, 46 consecutive aortocoronary bypass procedures were performed in Jehovah�s Witnesses at Texas Heart Institute of St. Luke�s Episcopal Hospital. The 34 men and 12 women ranged in age from 28 to 69 years, with an average age of 54. Of these, two patients died, representing a mortality of 4.3 per cent. Neither patient�s death was related to lack of blood transfusions. The hospital stay and recovery time of all the other patients was not affected by failure to transfuse blood.

11. Cardiac Surgery in Pregnancy (1) Vaska PL

CARDIAC SURGERY IN SPECIAL POPULATIONS, PART 2: WOMEN, PREGNANT PATIENTS, AND JEHOVAH'S WITNESSES. AACN Clin Issues 1997 Feb;8(1):59-66; quiz 166-8


Sioux Valley Hospital, South Dakota, USA. This is the second in a series of articles that discusses cardiac surgery in patients who belong to special populations. Women are often the victims of sex bias regarding their referral to cardiac testing, and are consequently sicker when they present for heart surgery. Pregnant women undergoing cardiac surgery require vigilant care while undergoing surgery, with anticoagulant administration and valve selection to achieve positive maternal and fetal outcomes. Progressive improvements in technology, perioperative care, and pharmaceutical development has made cardiac surgery in Jehovah's Witnesses safer than in the past.

VIII. CARDIAC SURGERY IN CHILDREN

1. General Aspects (1) Montiglio F, Dor V, Lecompte J, Fourquet D, Negrel A, Dauvilliers GN.

CARDIAC SURGERY IN ADULTS AND CHILDREN WITHOUT USE OF BLOOD. Ann Thorac Cardiovasc Surg 1998 February; 4(1): 3-11 Since 1968, following Cooley's and Zubiate's group presentation, our team has been using extracorporeal circulation (ECC) with hemodilution without use of blood for priming of the circuit. Progressively this technique, that was only reserved to the Jehovah's Witnesses, became routine. Whereas in 1980, 30% of the patients operated by our group had not received any blood products during their stay in hospital, in the last few years, 1987-95, more than 80% of the patients could benefit from this technique. So, out of 15,573 cardiac surgeries under ECC performed between 1972 and 1997, 14 798 (95%) were done in auto-perfusion, and 314 to Jehovah's Witnesses. The results of this routine technique, not using blood, was analysed in the adult as well as the child. More precisely, 100 adults operated on consecutively in 1995 and 50 children of less than 15 kilos operated on in 1994 were closely examined clinically and biologically. In adults, biology was studied in the 90 patients who did not receive any blood, and showed, as already quoted in previous studies on identical or larger series, the following evolution of the different parameters: Hematocrit went from 41% in a preoperative mean value to 33% at the 10th day, which is a decrease of 20%. Hemoglobin went form 14 gr to 11 gr, that is a decrease of 21%. Proteinemia which was at 73 gr preoperatively decreased to 58 gr at the first day to reach 60 gr at the 10th day (decrease 13%). In children, blood was necessary in 20 among 28 patients below 8 kg (group 1), and no blood was used for the 22 patients above 8 kg (group II). Regarding the biological results, in the group I, hematocrit showed a decrease of 18% between the day before surgery and 1 day after. Hemoglobin a decrease of 17%, platelets a decrease of 56% and Protides 3%. Fibrine showed a decrease of 43% the day of surgery, and an increase of 15% at day 1; and the Prothrombine time finally decreased by 24%. The results are very similar in group II. In conclusion, cardiac surgery without any pre or postoperative use of blood is therefore possible, simply, without predonation or without any particular treatment in 90% of adults of all ages and pathologies, and in over 50% of children (78% if category is over 7 kg) and has satisfactory results.




(3) Rosengart TK, Lang S, Helm R, Friedman D. OPEN HEART SURGERY IN THE PEDIATRIC JEHOVAH'S WITNESS POPULATION: NO LONGER �RUSSIAN ROULETTE�. Pediatr Cardiol 1997 May; 18(3): 245-46

(4) Grebenik CR, Sinclair ME, Westaby S. HIGH RISK CARDIAC SURGERY IN JEHOVAH'S WITNESSES. J Cardiovasc Surg (Torino) 1996 October; 37(5): 511-15 Much routine cardiovascular surgery can be performed without blood transfusion. Complex cardiac surgical procedures, however, especially reoperations, are often associated with heavy blood loss and large transfusion requirements. Anaesthetics and surgeons caring for patients who are Jehovah's Witnesses may be unwilling to offer such high risk surgery without recourse to blood transfusion. We report six such cases which were successfully performed without the use of blood or blood products and discuss the techniques used. Three of the patients described had been refused surgery, on their terms, at other centres. We believe that no patient should be denied potentially life saving surgery on the grounds of excessive risk without blood transfusion.

(5) Tanaka K et al. CARDIAC OPERATIONS IN CHILDREN OF JEHOVAH�S WITNESSES. Japanese Journal of Thoraric Surgery 1989 March; 42(3): 185-88 (Article in Japanese) The perioperative courses of 5 open heart operations in children of Jehovah�s Witnesses are reviewed. The age of patients ranged from 6 to 13 years old and the body weight, from 21.5 kg to 38.5 kg. All the patients survived and are doing well now. The cardiopulmonary bypasses, primed with lactated Ringer�s solution, were performed safely with the use of moderate hypothermia. Hemodilution techniques are the key for the safe exocorporeal circulation and we set the lowest limit of body weight to 20 kg. Postoperative bleeding occurred in one case and was treated by early exploration. All the cases did not receive any blood or blood products during hospitalization. Therefor we can conclude that cardiac operations over 20 kg of body weight can be safely performed without any blood or blood products. With regard to social aspects, especially in case of emergency, we should make the decision regarding transfusion under the guidance proposed by the Japanese Medical Association.

(6) Henderson AM, Maryniak JK, Simpson JC CARDIAC SURGERY IN JEHOVAH'S WITNESSES. A REVIEW OF 36 CASES. Anaesthesia 1986 Jul;41(7):748-53 Between January 1971 and January 1985, 31 Jehovah's witnesses underwent 24 bypass and 12 non-bypass cardiothoracic operations at the National Heart Hospital. Fifty-eight% of the group were under 16 years of age. There was one death in the non-bypass group unrelated to blood loss. Six deaths occurred in the bypass group. In one of these, blood loss contributed to the cause of death and in two patients, blood loss was directly related to the cause of death. The anaesthetic management of Jehovah's witnesses undergoing cardiac surgery is discussed.

(7) Henling CE, Carmichael MJ, Keats AS, Cooley DA. CARDIAC OPERATION FOR CONGENITAL HEART DISEASE IN CHILDREN OF JEHOVAH'S WITNESSES. J Thorac Cardiovasc Surg 1985 June; 89(6): 914-20 We reviewed the perioperative courses of 110 children of members of the Jehovah's Witness faith who underwent 112 operations for complete repair of congenital heart disease with cardiopulmonary bypass. Operations were performed over a 20 year period, ending June, 1983. The children ranged in age from 6 months to 12 years and weighed 5.2 to 42.3 kg. Thirty-nine (34.8%) of the patients weighed less than 15 kg, 36 (32.1%) were polycythemic preoperatively, and 26 (23%) had previous thoracic operations. All operations were performed during normothermic cardiopulmonary bypass with glucose crystalloid prime. No patient received any blood or blood products during hospitalization. Perioperative mortality was 5.4%. Only one of the deaths could be attributed to failure to transfuse. The results demonstrate that cardiac operations can be safely performed in children denied transfusion and suggest that hemodilutin techniques might be used more extensively in children undergoing cardiac operations.


(8) Carmichael MJ, Cooley DA, Kuykendall RC, Walker WE. CARDIAC SURGERY IN CHILDREN OF JEHOVAH�S WITNESSES. Texas Heart Institute Journal 1985 March; 12(1): 57-63 A retrospective study was done of 73 consecutive Jehovah�s Witness children less than 2 years of age who were operated on (between May 1963 and April 1983) for lesions of the heart and major vessels. The series was divided into three groups: (1) neonates less than 31 days old, (2) children between 31 days and 2 years, (3) children requiring cardiopulmonary bypass. The overall mortality rate for the series was 12.3% (9/73). Only three of the nine deaths were complicated by blood loss and anemia. The mortality rate for group I was 18.2% (2/11). Only one of the two deaths was partly attributable to anemia. The overall mortality rate for Group II was 14.9% (7/47). Only two of these seven deaths were complicated by anemia. No deaths occurred among the 15 patients in Group III. Bloodless prime hemodilution techniques were used in all patients. Based upon our data, we have concluded that cardiac surgery can be performed when indicated on children of Jehovah�s Witnesses with acceptable mortality rates and relatively straightforward perioperative care.

(9) Kawaguchi A, Bergsland J, Subramanian S. TOTAL BLOODLESS OPEN HEART SURGERY IN THE PEDIATRIC AGE GROUP. Circulation 1984 September; 70 (suppl. I): I-30-37 Forty-eight pediatric open heart surgical procedures were performed with bloodless techniques regardless of surgical complexity or presence of cyanosis at the Children�s Hospital of Buffalo. Priming solution for cardiopulmonary bypass was reduced to avoid excessive hemodilution, and careful surgical techniques were used to minimize blood loss. Hypothermia compensated for decreased oxygen-carrying capacity and made it possible to reduce bypass flow safely. Tissue perfusion and oxygenation on bypass appeared comparable to or better than those in a control group that underwent open heart surgery with milder degrees of hemodilution. All patients tolerated bypass uneventfully without transfusion. Platelet counts were higher and blood loss less marked than those in the control group. Prevention of excessive dilution by priming solution seemed most important for preservation of platelets and subsequent hemostasis. Four of the smaller infants with complex cyanotic defects needed postoperative transfusion, while 44 patients did not receive transfusion at all during their hospital stay. Total blood product requirement was reduced from 11.5 to 0.35 units per patient. Intracardiac surgery without transfusion is possible in most pediatric patients without evidence of increased risk.

(10) Subramanian S. Cardiovascular News, February 1984, pp. 5, �Bloodless� open-heart surgery, originally developed for adult members of the Jehovah�s Witnesses sect because their religion forbids blood transfusions, now has been safely adapted for use in delicate cardiac procedures in infants and children. Forty-eight pediatric patients between the ages of 3 months and 8 years successfully underwent complex corrective open-heart procedures for a variety of heart defects almost entirely without transfusions of blood or blood components. Since our studies showed that our bloodless surgical procedure is not only safe but may rally be helpful, Dr. Subramanian concluded, we now use this routinely for all pediatric patients, as long as the anticipated hematocrit-hemoglobin level is not less than a third of normal.

(11) Levinsky L, Srinivasan V, Choh JH, Idbeis B, Scott CW, Ibbett M, Subramanian S. INTRACARDIAC SURGERY IN CHILDREN OF JEHOVAH�S WITNESSES. The John Hopkins Medical Journal 1981 May; 148(5): 196-98 Open-heart surgery in adult members of the Jehovah�s Witness sect has become a reality with an acceptable mortality. However, in the pediatric patient, a bloodless prime and restriction in the use of blood products poses a difficult problem. We discuss our technique in the management of this problem based on our experience with eleven pediatric patients who underwent open-heart surgery for repair of congenital heart defects.

(12) Bortolotti U, de Mozzi P, Betti D, Mazzucco A, Frugoni C, Valfre C, Gallucci V [OPEN HEART SURGERY IN JEHOVAH'S WITNESSES]. [ARTICLE IN ITALIAN] G Ital Cardiol 1979;9(9):996-1000


(13) Ott DA, Cooley DA CARDIOVASCULAR SURGERY IN JEHOVAH'S WITNESSES. REPORT OF 542 OPERATIONS WITHOUT BLOOD TRANSFUSION. JAMA 1977 September; 238(12): 1256-58 Jehovah's Witnesses who require operation represent a challenge to the physician because of the patient's refusal to accept blood transfusion. We report a 20-year experience with a consecutive series of 542 Jehovah's Witness patients ranging in age from day 1 to 89 years who underwent operation. Early mortality (within 30 days after operation) was 9.4%. In 362 patients requiring temporary cardiopulmonary bypass, early mortality was 10.7%. Mortality was 13.5% among 126 patients who had single- or double-valve replacement. The only deaths among patients who had aortic valve replacement or repair of a ventricular septal defect occurred in those who had some serious complications before operation. Preoperative or postoperative anemia was a contribution factor in 12 deaths, and loss of blood was the direct cause of three deaths. Cardiovascular operations can be performed safely without blood transfusion.

(14) Dor V, Mermet B, Kreitmann P, Etienne N, Jourdan J, Schmitt R [CARDIAC SURGERY IN JEHOVAH'S WITNESSES. APROPOS OF 47 CASES]. [ARTICLE IN FRENCH] Arch Mal Coeur Vaiss 1977 May;70(5):549-54 47 cardiac defects in Jehova's witnesses were operated on without using any blood during the operation. In 9 cases the patients were under 15 years of age. 7 cases were of congenital heart defects in which the operation could be carried out with the heart still beating or by a closed heart technique: 4 of these were adults and 3 were children. In 40 cases, extracorporeal circulation was required: 19 valve defects, 8 coronary areterial cases, 10 congenital cardiac lesions, 2 valve defects associated with coronary artery disease, and 1 aneurysm of the thoracic aorta. Of these 40 patients, 4 died. The details and limits of this total haemodilution are analysed, as are the causes of failure and complications. This technique does not worsen the postoperative prognosis appreciably, but limits the scope of the surgery, and cannot be applied to a child of less than 10 kg.

(15) Simmons CW Jr, Messmer BJ, Hallman GL, Cooley DA VASCULAR SURGERY IN JEHOVAH'S WITNESSES. JAMA 1970 Aug 10;213(6):1032-4

2. Infective Endocarditis Surgery (1) Sawada Y, Asada K, Matsuyama N, Hasegawa S, Sasaki S.

OPEN HEART SURGERY IN A JEHOVAH'S WITNESS BOY � A CASE REPORT OF SUCCESSFUL MANAGEMENT OF AORTIC REGURGITATION AND ANEURYSM OF SINUS VALSALVA DUE TO INFECTIVE ENDOCARDITIS. Nippon Kyobu Geka Gakkai Zasshi 1997 December; 45(12): 2006-10 Jehovah's Witness who require operation represent a challenge to the physician because of the patient's refusal to accept blood transfusion. We report an 8-year-old male of Jehovah's Witness who underwent a surgical treatment of infective endocarditis. He was transferred to our hospital because of high fever and heart murmur. Echocardiogram revealed a developing vegetation of aortic cusps and an aneurysmal change of the non-coronary sinus Valsalva. On admission he was complicated by anemia, purulent meningitis and suppurative arthritis of left knee. There were no signs of cardiac failure. Erythropoietin (6000 U thrice weekly) and iron (60 mg daily) were given for 11 weeks prior to surgery, raising the hemoglobin level from 9.2 to 18.4 g/dl. Aortic valve replacement and plasty of the sinus Valsalva were then performed. Intraoperatively hemoglobin concentration dropped to 10.3 g/dl and it raised to 15 g/dl postoperatively. We also used Cell-Saver to reduce blood loss. The patient made an uncomplicated recovery. Erythropoietin therapy contributed substantially to the successful outcome of this case.


3. Aortic Homograft (1) Miyaji K, Furuse A, Takeda M, Chikada M, Ono M, Kawauchi M.

SUCCESSFUL CONDUIT REPAIR USING AORTIC HOMOGRAFT IN A JEHOVAH'S WITNESS CHILD. Ann Thorac Surg 1996 August; 62(2): 590-591

Department of Cardiothoracic Surgery, Faculty of Medicine, University of Tokyo, Japan. A 10-year-old female child of the Jehovah's Witness faith presented with congenitally corrected transposition of the great arteris (S,L,L), pulmonary atresia, and a ventricular septal defect. A successful correction was performed using an aortic homograft as a valved extracardiac conduit without the use of homologous blood products. We used permanent splinting of the sternum with a methyl methacrylate resin to prevent compression of the conduit.

4. Congenital Heart Defects 1. Cardiac Surgery in JW General Aspects

(1) van Son JA, Hovaguimian H, Rao IM, He GW, Meiling GA, King DH, Starr A. STRATEGIES FOR REPAIR OF CONGENITAL HEART DEFECTS IN INFANTS WITHOUT THE USE OF BLOOD. Ann Thorac Surg 1995 February; 59(2): 384-88 Eleven infants and children with a body weight of less than 10 kg (median weight, 6.8 kg) whose parents were Jehovah's Witnesses underwent repair (n = 10) or palliation (n = 1) of congenital heart defects without the use of blood products and with (n = 9) or without ( = 2) cardiopulmonary bypass (CPB). In 1 neonate (weight, 3.2 kg) with critical aortic stenosis, moderate hypothermia and a 3.5-minute period of inflow occulsion and circulatory arrest allowed an aortic valvotomy; in another patient (weight, 7 kg) with tricuspid and pulmonary atresia, transposition of the great arteries, and persistent left superior vena cava, a bilateral bidirectional cavopulmonary shunt procedure was performed without CPB. Use of heparin-bonded tubing allowed reduction of the initial dose of heparin sodium to 1 mg/kg. Tissue perfusion and oxygenation on bypass were adequate, as evidenced by a mean lowest pH of 7.38 +/- 0.09 and a mean lowest venous oxygen tension of 65.0 +/- 36.2 mm Hg. Although the mean postoperative hematocrit (Hct) was lower than the mean preoperative Hct (p < 0.05, analysis of variance and Scheffe's F test), the Hct within 2 hours after CPB was restored to a value (mean Hct, 27.5% +/- 1.0%) between the preoperative Hct (mean value, 42.7% +/- 3.5%) and the lowest Hct on CPB (mean value, 18.4 +/- 1.4%). The Hct at discharge was 31.8% +/- 1.1%. The median postoperative blood loss was 9 mL/kg. There was no perioperative mortality. The median stay in the intensive care unit and the hospital was 2 days and 6 days, respectively.

(2) Tsang VT, Mullaly RJ, Ragg PG, Karl TR, Mee RB BLOODLESS OPEN-HEART SURGERY IN INFANTS AND CHILDREN. Perfusion 1994;9(4):257-63

Victorian Paediatric Cardiac Surgical Unit, Royal Children's Hospital, Parkville, Australia. Between October 1984 and January 1993, seven children of Jehovah's Witnesses underwent corrective open-heart surgery for congenital defects, on cardiopulmonary bypass (CPB). Age at surgery ranged from three months to 6.5 years, and weight ranged from 4.2 kg to 23.2 kg, with two children weighing less than 10 kg. The principal cardiac anomalies were tetralogy of Fallot (two), double outlet right ventricle (one), subaortic stenosis (one), transposition of the great arteries and ventricular septal defect (one), atrial septal defect and congenital heart block (one), and congenital mitral regurgitation (one). Hypothermic CPB was used in all seven operations with crystalloid priming of the extracorporeal circuit. CPB was based on our standard perfusion protocols. All surgical procedures were done without the use of blood or blood products. The mean preoperative haematocrit (Hct) was 40.9% (range 31.0-47.8%). The mean lowest intraoperative Hct was 17.3% (range 15.0-24.3%), whereas the immediate post-CPB Hct was 19.6% (range 15.3-24.0%). The Hct progressively increased to 29.2% (range 21.0-34.2%) on the first postoperative day, and 32.3%


(range 24.2-38.3%) at the time of discharge. There was no hospital mortality, and the mean hospital stay was 10 days (8-13 days). We report the safe repair of complex open-heart surgery in children, without blood transfusion, even in small infants. The successful management of these patients requires meticulous attention to surgical and perfusion technique, and sound postoperative management.

(3) Cooley DA, Burnett CM. CONSIDERATIONS IN THE SURGICAL TREATMENT OF CONGENITAL HEART DISEASE IN CHILDREN OF JEHOVAH�S WITNESSES. Texas Heart Institute Journal 1992; 19(3): 156-59 We first performed open-heart surgery in a Jehovah�s Witness patient on 16 May 1962. Since then more than 1085 patients of this faith have undergone such surgery at our institution, 338 of whom were children less than 15 years of age. The majority of the children were less than 10 years of age. We reported our experience with 663 Jehovah�s Witnesses who underwent open-heart operations before 1990. Blood or blood products were not administered to any of these patients, and death due to blood loss were rare. In 1985, 2 reports from this institution described our experience with children of Jehovah�s Witnesses. In the 1st paper we reported the successfull results of operations of 110 children between tha ages of 6 months and 12 years who had undergone correction of various anomalies. In the 2nd paper, we reviewed the charts of 73 children under tha age of 2 years who had undergone cardiovascular surgery. Among the patients of this study were children with transposition of the great wessels, tetralogy of Fallot, total anomalous pulmonary venous return, and other less complex anomalies. This experience suggest that even complex congenital anomalies can be repaired successfully without the use of blood or blood products. Recent advantages in surgical technology have led to a substantial reduction in perioperative morbidity and mortality previously associated with open-heart surgery. In addition the drawing of blood is now being coordinated so that multiple tests can be done on each sample. Pediatric microsampling equipment is being used to reduce blood wastage. In this erea of heightened concern regarding the possible transmission of viral diseases such as hepatitis and AIDS, bloodless cardiac surgery is gaining favor. It is possible that the techniques designed primarily to satisfy the requirements of Jehovah�s Witnesses may ultimately become the techniques of choice for all patients undergoing cardiopulmonary bypass procedures. In conclusion, operations performed on Jehovah�s Witness children who are physically impaired by heart disease can be successfull and can enable these children to live healthy lives. A surgeon who undertakes and assumes the responsibility of performing cardiac operation on such children, however, should be prepared to respect their faith, to exercise a special effort to control blood loss and to use especially meticulous techniques.

(4) Halden E, Birgegard G, Duvernoy O, Henze A [ERYTHROPOIETIN MADE SURGERY FOR AORTIC COARCTATION POSSIBLE IN A JEHOVAH'S WITNESS PATIENT]. [ARTICLE IN SWEDISH] Lakartidningen 1991 Dec 4;88(49):4245-6

Thoraxanestesi-sektionen, samtliga vid Akademiska sjukhuset, Uppsala

(5) Stein JI, Gombotz H, Rigler B, Metzler H, Suppan C, Beitzke A. OPEN HEART SURGERY IN CHILDREN OF JEHOVAH'S WITNESSES: EXTREME HEMODILUTION ON CARDIOPULMONARY BYPASS. Pediatr Cardiol 1991 July; 12(3): 170-74 Between January 1979 and July 1989, 15 children of Jehovah's Witnesses underwent corrective open surgery for congenital heart disease (CHD) on cardiopulmonary bypass (CPB). Ages ranged from 1.5 � 17 years and body weight from 9.1 � 63 kg, with five patients weighing less than 15 kg. Eight children were cyanotic, and two of them had had previous thoraric operations. All operations were performed in moderate to deep hypothermia using a modified version of isovolemic hemodilution with bloodless priming technique of extracorporeal circulation. Mean hematocrit levels decreased from 47.3% (36.7-70%) to 34.6% (27.2-49.1%) after hemodilution, and then to 17.9% (10.5-25.6%) during bypass. They increased again to 34.1% (24.4-50%) at the end for the operation and to 33.4% (25.1-40%) on day 12. All intra- and postoperative hematocrit levels were significantly lower (p less than 0.001). There was one


postoperative death, not related to the technique. Our results demonstrate that bloodless cardiac surgery on bypass is feasible in children as shown in this special group of children of Jehovah's Witnesses. Knowing the risks of homologous blood transfusion this technique should be used more extensively in the future.

(6) Ashraf H, Subramanian S. BLOODLESS CARDIAC SURGERY IN CHILDREN Saudi Heart Bulletin 1990 July; 1(2): 15-22 Bloodless intracardiac surgery in children is not only feasible, it is also advantageous because it entirely eliminates the risks associated with the transfusion of blood or blood products. In this series, intracardiac repair of most congenital defects has been safely completed regardless of complexity of the disease without the use of blood or blood products.

(7) Gombotz H, Rigler B, Matzer C, Metzler H, Winkler G, Tscheliessnigg KH. 10 YEARS' EXPERIENCE WITH HEART SURGERY IN JEHOVAH'S WITNESSES. Anaesthesist 1989 August; 38(8): 385-90 As a result of their interpretation of the Bible, members of Jehovah's Witnesses do not accept blood transfusions under any circumstances. Consequently, they present moral and ethical problems to surgeons and anesthetists, especially in cardiac surgery. PATIENTS and METHODS: From November 1978 to November 1988, 66 members of Jehovah's Witnesses were scheduled for cardiac surgery; 57 patients were operated upon (mean age 33.3 years, 14 days to 70.4 years; mean body weight 51 kg, 0.7 to 95.5 kg); 21 were younger than 14 years. Patients with hematocrit (Hct) less than 35%, expected high intra- and postoperative blood loss, compromised left ventricular function, ST-segment alterations, critical aortic stenosis, severe unstable angina pectoris, comlex heart defects, especially in children, extreme body weight, severe diabetes, renal insufficiency, coagulopathies, severe pulmonary disease, and heavy smokers were excluded from operation. Whereas in nonbypass patients no special blood-saving techniques were used, in bypass patients a modified version of isovolemic hemodilution, with a hypothermic, bloodless priming technique of extracorporeal circulation (ECC) was performed after induction of anesthesia. At the end of the ECC all blood collected in the pericardial and pleural cavities was returned to the oxygenator and the entire content of the extracorporeal circuit was infused into the patient through the aortic cannula. All patients receiving ECC were ventilated for 24 h postoperatively and received dopamin (2-5 micrograms/kg) and antibiotics routinely. RESULTS: Due to the above mentioned contraindications, 9 patients were not accepted for surgery, 10 were operated upon without pulmonary bypass or blood-saving techniques. In 47 patients open heart surgery with ECC and moderate or deep hypothermia was performed. In the adult patients (n = 36) Hct values decreased from 44.4% (35-70%) preoperatively to 32.1% (21-46%) after hemodilution, reached their lowest levels during cardiopulmonary bypass at 17.9% (9.9-43%), and increased to 33.7% (22%-43%) at the end of the operation. Hct averaged 28.2% (20%-39%) on the 3rd and 33.2% (23%-46%) on the 12th postoperative day. In children (n = 11) Hct decreased from 47.2% (36.9%-70%) to 33.6% (27.2-49.1%) after hemodilution, during bypass to 16.1% (10.5%-25.5%) and increased to 32.1% (24.4%-37.4%) at the end of the operation. On the 3rd postoperative day Hct was 25% (21.4%-39%) and increased to 29.4% (25.1%-40%) on the 12th postoperative day. No statistical differences in Hct values were found between both groups.

2. Cardiac Surgery in JW Children "Ross Operation"

(1) Miyaji K, Hannan RL, Ojito JW, White JA, Burke RP THE ROSS OPERATION IN A JEHOVAH'S WITNESS: A PARADIGM FOR HEART SURGERY IN CHILDREN WITHOUT TRANSFUSION. Ann Thorac Surg 2000 Mar;69(3):935-937.

Division of Cardiovascular Surgery, Miami Children's Hospital, Florida 33155-4069, USA. A 3-year-old 18 kg male child of the Jehovah's Witness faith presented with severe aortic regurgitation. A successful Ross procedure was performed using a pulmonary autograft, without the use of blood or blood product transfusion. Blood conservation strategy included: (1) preoperative treatment with recombinant human erythropoietin; (2) intraoperative strategies, including technical modifications to the Ross procedure, and the prophylactic use of fibrin glue; (3) utilization of a heparin-bonded cardiopulmonary bypass circuit and assisted venous drainage; and 4) the use of


prebypass phlebotomy, cell-saving device and autotransfusion. The patient was discharged home on postoperative day 7 with a hemoglobin level of 11.9.

IX. Vascular Surgery 1. Aneurysm Repair General Aspects

(1) Gallagher JM, Brown ME, Gasior TA COMBINED USE OF APROTININ AND A HEPARIN-BONDED CARDIOPULMONARY BYPASS SYSTEM FOR AORTIC ANEURYSM REPAIR. J Cardiothorac Vasc Anesth 1995 Dec;9(6):728-30

University of Pittsburgh Medical Center, PA, USA.

(2) Ottesen S, Froysaker T USE OF HAEMONETICS CELL SAVER FOR AUTOTRANSFUSION IN CARDIOVASCULAR SURGERY. Scand J Thorac Cardiovasc Surg 1982;16(3):263-8 The Haemonetics Cell Saver was evaluated as a tool for the refining of blood shed during cardiovascular surgery. After blood filtration the red cells are concentrated, washed and re-infused as red cells suspended in normal saline (CS blood) with haematocrit around 60%. Platelets and plasma with desired and undesired components are removed. In 50 patients undergoing elective but complicated cardiovascular surgery an average of 4.4 units CS blood were produced. In 3 Jehovah's Witnesses the method was used in combination with immediate preoperative prebleeding and dextran infusion. No blood products were given. The haematocrit was maintained at a safe level subsequent to retransfusion. Platelet counts were never critically low and extremely low total protein did not lead to peripheral or pulmonary oedemas or coagulation problems. In an in vitro study it was shown that extreme dilution of coagulation factors is well tolerated before the clotting time (ACT) is affected. The Cell Saver proved to be an effective, reliable and safe device for autotransfusion of salvaged blood during cardiovascular surgery.

(3) Simmons CW Jr, Messmer BJ, Hallman GL, Cooley DA VASCULAR SURGERY IN JEHOVAH'S WITNESSES. JAMA 1970 Aug 10;213(6):1032-4

(4) Thomas GI, Edmark KW, Jones TW SOME ISSUES INVOLVED WITH MAJOR SURGERY ON JEHOVAH'S WITNESSES. Am Surg 1968 Jul;34(7):538-44

(5) Posnikoff J CURE OF INTRACRANIAL ANEURYSM WITHOUT USE OF BLOOD TRANSFUSION. Calif Med 1967 Feb;106(2):124-7

2. Ascending Aorta Aneurysm

(1) Miyaji K, Furuse A, Takeda M, Chikada M, Ono M, Kawauchi M SUCCESSFUL CONDUIT REPAIR USING AORTIC HOMOGRAFT IN A JEHOVAH'S WITNESS CHILD. Ann Thorac Surg 1996 Aug;62(2):590-1

Department of Cardiothoracic Surgery, Faculty of Medicine, University of Tokyo, Japan. A 10-year-old female child of the Jehovah's Witness faith presented with congenitally corrected transposition of the great arteries (S,L,L), pulmonary atresia, and a ventricular septal defect. A successful surgical correction was performed using an aortic homograft as a valved extracardiac


conduit without the use of homologous blood or blood products. We used permanent splinting of the sternum with a methyl methacrylate resin plate to prevent compression of the conduit.


Department of Surgery, Baylor College of Medicine, Houston, Texas. A young woman of the Jehovah's Witness faith presented with a rupturing aneurysm of the ascending aorta and transverse aortic arch. She had Marfan syndrome and previous aortic valve replacement. Despite reoperation conditions, successful operation via median sternotomy was carried out using deep hypothermia and circulatory arrest.

(3) Bricker DL, Parker TM, Mistrot JJ, Dalton ML Jr REPAIR OF ACUTE DISSECTION OF THE ASCENDING AORTA, ASSOCIATED WITH COARCTATION OF THE THORACIC AORTA IN A JEHOVAH'S WITNESS. J Cardiovasc Surg (Torino) 1980 May-Jun;21(3):374-8 A twenty-year-old white man, with acute dissection of the ascending aorta, underwent emergency resection with dacron graft replacement, utlizing cardiopulmonary bypass. Subsequent repair of coarctation of the thoracic aorta was performed. No blood was administered due to the patient's religious preference. The problems of emergency surgery in Jehovah's Witness patients are discussed.

3. Descending Aorta Aneurysm

(1) Westaby S, Parry AJ, Lamont P, Grebenik C MASSIVE DESCENDING THORACIC ANEURYSM IN A JEHOVAH'S WITNESS: TREATMENT BY THROMBOEXCLUSION. Ann Thorac Surg 1993 May;55(5):1233-5

Department of Cardiac Surgery, Oxford Heart Centre, England. The thromboexclusion technique was used to treat a massive thoracic aneurysm in a Jehovah's witness. Preoperative erythropoietin therapy was used. At operation a Hemashield graft was used to bypass the aneurysm before the mouth was stapled closed. The hemoglobin level fell from 13.5 to 10.6 g/dL.

(2) Taguchi S, Sugihara K, Muraoka M, Wakayama S, Matsuki A [AN EMERGENCY OPERATION FOR A JEHOVAH'S WITNESS WITH RUPTURED THORACIC SACCULAR ANEURYSM]. [ARTICLE IN JAPANESE] Masui 1993 Mar;42(3):445-9

Department of Anesthesiology, Aomori Rohsai Hospital, Hachinohe. A 49-year-old male "Jehovah's Witness" was transferred to our hospital with hypotension, abdominal pain, and abdominal distension, and a diagnosis of ruptured thoracic saccular aneurysm was made. He and his family insisted on having an emergency operation for his ruptured aneurysm without blood transfusion. After an intensive discussion among the patient, his family, surgeons, and the director of the hospital, we performed the operation without blood transfusion. The operation using cardiopulmonary bypass took about five hours under enflurane anesthesia, but he died of circulatory collapse fifteen hours after the end of operation. As there may be various opinions concerning how we should take care of Jehovah's Witness patients, we have to manage them case by case.

(3) Dor V, Mermet B, Kreitmann P, Etienne N, Jourdan J, Schmitt R [CARDIAC SURGERY IN JEHOVAH'S WITNESSES. APROPOS OF 47 CASES]. [ARTICLE IN FRENCH] Arch Mal Coeur Vaiss 1977 May;70(5):549-54


47 cardiac defects in Jehova's witnesses were operated on without using any blood during the operation. In 9 cases the patients were under 15 years of age. 7 cases were of congenital heart defects in which the operation could be carried out with the heart still beating or by a closed heart technique: 4 of these were adults and 3 were children. In 40 cases, extracorporeal circulation was required: 19 valve defects, 8 coronary areterial cases, 10 congenital cardiac lesions, 2 valve defects associated with coronary artery disease, and 1 aneurysm of the thoracic aorta. Of these 40 patients, 4 died. The details and limits of this total haemodilution are analysed, as are the causes of failure and complications. This technique does not worsen the postoperative prognosis appreciably, but limits the scope of the surgery, and cannot be applied to a child of less than 10 kg.

4. Abdominal Aneurysm Surgery

(1) Baker CE, Kelly GD, Perkins GD PERIOPERATIVE CARE OF A JEHOVAH'S WITNESS WITH A LEAKING ABDOMINAL AORTIC ANEURYSM. Br J Anaesth 1998 Aug;81(2):256-9


(2) Gutowski P, Dybkowska K, Szumilowicz G [OPERATION FOR RUPTURED ABDOMINAL AORTIC ANEURYSM WITHOUT CONSENT FOR BLOOD TRANSFUSION--CASE REPORT]. [ARTICLE IN POLISH] Wiad Lek 1997;50(4-6):120-2

Kliniki Chirurgii Ogolnej i Naczyniowej, Pomorskiej Akademii Medycznej w Szczecinie. Successful operation for ruptured abdominal aortic aneurysm (AAA) in a Jehovah's Witness 66-year-old man was presented. The patient was urgently operated for symptomatic AAA. We found during surgery that that aneurysm was ruptured. Bifurcated PTFE aorto-bi-iliac prosthesis was implanted. The patient did not receive any blood or blood-origin products while staying in our Hospital.

(3) Taguchi S, Sugihara K, Muraoka M, Wakayama S, Matsuki A [AN EMERGENCY OPERATION FOR A JEHOVAH'S WITNESS WITH RUPTURED THORACIC SACCULAR ANEURYSM]. [ARTICLE IN JAPANESE] Masui 1993 Mar;42(3):445-9

Department of Anesthesiology, Aomori Rohsai Hospital, Hachinohe. A 49-year-old male "Jehovah's Witness" was transferred to our hospital with hypotension, abdominal pain, and abdominal distension, and a diagnosis of ruptured thoracic saccular aneurysm was made. He and his family insisted on having an emergency operation for his ruptured aneurysm without blood transfusion. After an intensive discussion among the patient, his family, surgeons, and the director of the hospital, we performed the operation without blood transfusion. The operation using cardiopulmonary bypass took about five hours under enflurane anesthesia, but he died of circulatory collapse fifteen hours after the end of operation. As there may be various opinions concerning how we should take care of Jehovah's Witness patients, we have to manage them case by case.


(4) Simms GR, Hensley FA Jr, Atnip RG CASE CONFERENCE 6--1990. A 70-YEAR-OLD MAN WITH AN ABDOMINAL AORTIC ANEURYSM PRESENTS SOME OF THE CONFLICTS IN THE CARE OF JEHOVAH'S WITNESSES. J Cardiothorac Anesth 1990 Dec;4(6):751-5

Department of Family and Community Medicine, Pennsylvania State University College of Medicine, Hershey 17033.

(5) Byrne MP ABDOMINAL AORTIC ANEURYSM SURGERY IN THE JEHOVAH'S WITNESS. USE OF AUTO TRANSFUSION. IMJ Ill Med J 1976 Jul;150(1):87, 90

(6) Yashar JJ, Hallman GL, Cooley DA FISTULA BETWEEN ANEURYSM OF AORTA AND LEFT RENAL VEIN. REPORT OF A CASE. Arch Surg 1969 Oct;99(4):546-8

X. Lung Surgery (1) Nishimoto M, Tachibana S, Kawakami M, Orino T, Nakao K, Tokitsu K, Morita T,

Hashimoto T, Sasaki S [INFORMED CONSENT AND SURGICAL TREATMENT IN A 38-YEAR-OLD FEMALE, JEHOVAH'S WITNESS WITH LUNG CANCER]. [ARTICLE IN JAPANESE] Kyobu Geka 1998 Jul;51(7):558-60


XI. OBSTETRICS AND GYNECOLOGY

A. General Aspects (1) Muramoto O

JEHOVAH'S WITNESSES AND BLOODLESS SURGERY Am J Obstet Gynecol 2000 Jan;182(1 Pt 1):251. Comment on: Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1491-8


(2) deCastro RM BLOODLESS SURGERY: ESTABLISHMENT OF A PROGRAM FOR THE SPECIAL MEDICAL NEEDS OF THE JEHOVAH'S WITNESS COMMUNITY-THE GYNECOLOGIC SURGERY EXPERIENCE AT A COMMUNITY HOSPITAL. Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1491-1498

Departments of Obstetrics and Gynecology, Legacy Good Samaritan Hospital and Oregon Health Sciences University. OBJECTIVE: My purpose was to describe the rationale behind the establishment of a hospital-based program instituted to enhance the health of the Jehovah's Witness community and to evaluate patient profiles and outcomes of gynecologic patients treated surgically at our institution, during the past 5 years, whose intake was through the Bloodless Surgery Program and who were not accepting of blood or most blood products. I further describe how a coordinated program dedicated to serving this particular population might improve outcomes and patient satisfaction. STUDY DESIGN: A retrospective review of the charts of 89 patients, all Jehovah's Witnesses, who were enrolled through the Bloodless Surgery Program and underwent gynecologic surgery involving at least 1 night's hospitalization at our institution between January 1, 1993, and December 31, 1997, was performed. A comparison of patient length of stay, hospital charges, and surgical blood loss, in a subset of 41 patients who underwent abdominal hysterectomy, with a cohort of patients not affiliated with the Jehovah's Witnesses or the Bloodless Surgery Program was performed. Data regarding patient satisfaction were obtained through surveys and are presented. RESULTS: Patients enrolled through the Bloodless Surgery Program and undergoing abdominal hysterectomy were significantly younger (average age 43.4 vs 47.7 years) and incurred significantly lower hospital charges (average cost $8754 vs $9539). No significant difference between the group studied and the control group could be found in average length of stay or the average change between preoperative and postoperative hemoglobin levels. Data from patient satisfaction surveys suggest a high level of satisfaction with the Bloodless Surgery Program. CONCLUSION: A program dedicated to the special needs of the Jehovah's Witness community can be instituted in a community-based hospital with no evidence of increased morbidity, as evidenced by length of stay, hospital charges, and surgical blood loss, in a gynecologic patient population. Development of such programs is associated with a high level of patient satisfaction and the potential for improved patient care.

B. Special Situation 1. Postpartum Anemia

(1) Rasanayagam SR, Cooper GM. TWO CASES OF SEVERE POSTPARTUM ANAEMIA IN JEHOVAH'S WITNESSES. Intensive 1996; 5: 202- Two cases of severe postpartum anaemia are presented in Jehovah's Witnesses who refused blood transfusion. Despite haemoglobin concentrations of less than 3 g/dl both women survived. General management was directed to maximizing oxygen delivery and minimizing oxygen comsumption. The use of an emulsified perfluorocarbon was organized for one of the cases, but was not administrated because a snow storm prevented its delivery to the hospital. In the other case, recombinant human erythropoietin was used to encourage red cell production. The recovery of haemoglobin concentration in the two cases is compared.

(2) Soutoul JR, Gromb S [THE GYNECOLOGIST-OBSTETRICIAN AND JEHOVAH'S WITNESSES]. [ARTICLE IN FRENCH] J Gynecol Obstet Biol Reprod (Paris) 1995; 24(3): 327-329

Faculte de Medecine de Tours.

2. Surgical Strategies for Blood Conservation in Gynecology


(3) deCastro RM BLOODLESS SURGERY: ESTABLISHMENT OF A PROGRAM FOR THE SPECIAL MEDICAL NEEDS OF THE JEHOVAH'S WITNESS COMMUNITY--THE GYNECOLOGIC SURGERY EXPERIENCE AT A COMMUNITY HOSPITAL. Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1491-8

Department of Obstetrics and Gynecology, Legacy Good Samaritan Hospital, Portland, USA. OBJECTIVE: My purpose was to describe the rationale behind the establishment of a hospital-based program instituted to enhance the health of the Jehovah's Witness community and to evaluate patient profiles and outcomes of gynecologic patients treated surgically at our institution, during the past 5 years, whose intake was through the Bloodless Surgery Program and who were not accepting of blood or most blood products. I further describe how a coordinated program dedicated to serving this particular population might improve outcomes and patient satisfaction. STUDY DESIGN: A retrospective review of the charts of 89 patients, all Jehovah's Witnesses, who were enrolled through the Bloodless Surgery Program and underwent gynecologic surgery involving at least 1 night's hospitalization at our institution between January 1, 1993, and December 31, 1997, was performed. A comparison of patient length of stay, hospital charges, and surgical blood loss, in a subset of 41 patients who underwent abdominal hysterectomy, with a cohort of patients not affiliated with the Jehovah's Witnesses or the Bloodless Surgery Program was performed. Data regarding patient satisfaction were obtained through surveys and are presented. RESULTS: Patients enrolled through the Bloodless Surgery Program and undergoing abdominal hysterectomy were significantly younger (average age 43.4 vs 47.7 years) and incurred significantly lower hospital charges (average cost $8754 vs $9539). No significant difference between the group studied and the control group could be found in average length of stay or the average change between preoperative and postoperative hemoglobin levels. Data from patient satisfaction surveys suggest a high level of satisfaction with the Bloodless Surgery Program. CONCLUSION: A program dedicated to the special needs of the Jehovah's Witness community can be instituted in a community-based hospital with no evidence of increased morbidity, as evidenced by length of stay, hospital charges, and surgical blood loss, in a gynecologic patient population. Development of such programs is associated with a high level of patient satisfaction and the potential for improved patient care.

(4) Loos W, Kuhn W, Prechtl A, Schmalfeldt B, Hipp R, Kycia J. BLOOD TRANSFUSION IN SURGICAL GYNECOLOGY. STRATEGIES FOR PREVENTING HOMOLOGOUS BLOOD TRANSFUSION. Fortschr Med 1994 October; 112(29): 405-09 A statistical evaluation of homologous blood transfusions is imperative in any gynecological surgical department, to be able to define the transfusion-associated risk of the individual interventions. On the basis of our own statistical data and reports in the literature, strategies for limiting the use of homologous blood are discussed. So far, experience with autologous blood transfusion in surgical gynecology is limited, and clinical studies are needed to better define its role. In special cases, the use of erythropoietin and gonadotropin-releasing hormone (GnRH) analogues extends the possibilities for reducing homologous blood transfusion.

(5) Sacks DA, and Koppes RH. CARING FOR THE FEMAL JEHOVAH�S WITNESS:BALANCING MEDICINE, ETICS, AND THE FIRST AMENDMENT Am J Obstet Gynecol 1994 February, Volume 170, Number 2, pp.452-455.

Bellflower and Sacramento, California When a patient declines a lifesaving transfusion, a conflict is generated between the physician�s autonomy-based and beneficeence-based obligations to the patient. This conflict is intensified when the patient is a woman who has minor dependent children, either in utero or already born. A spectrum of opinion exists regarding the resolution of this conflict.As one of society�s repositories of moral and legal values, the court is the most appropriate forum in which religious, medical, and ethical viewpoints may receive a fair and impartial hearing. We therefore recommend that each hospital�s legal counsel and ethics committee, together with the local judiciary and Jehovah�s Witnesses hospital liaison


committee, establish a mechanism wherby, when necessary, a hearing may be rapidly carried out.We belive that such a hearing provides maximum assurance that the intrests of the patient, her loved ones, and the society in which they live will be best represented and protected.

(6) Thomas JM. THE WORLDWIDE NEED FOR EDUCATION IN NONBLOOD MANAGEMENT IN OBSTETRICS AND GYNAECOLOGY. Journal SOGC 1994; 16: 1483-7 As more patients object to receiving blood transfusions, the time has come to update both undergraduate and postgraduate education to reflect present knowledge of nonblood management in obstetrics and gynaecology. Respect for the patient�s informed choice is recommended. Methods of handling cases are outlined. A fresh management approach is recommended: (1) plan in advance for possible haemorrhage, (2) be prepared to use every indicated, available, and patient-accepted method to limit blood loss, (3) promptly institute measures to stop the bleeding, (4) use every idicated, available, and patient-accepted treatment to improve her hematological status rapidly. Thereby, all women refusing blood transfusion can benefit.

3. Severe Anemia in Gynecologic ond Obstetric Emergencies

(1) Brimacombe J, Skippen P, Talbutt P. ACUTE ANAEMIA TO A HAEMOGLOBIN OF 14 G/L WITH SURVIVAL. Anaesthesia and Intensive Care 1991 November; 19(4): 581-83 We conclude that optimizing oxygen delivery to the periphery without compromising the myocardium can best be achieved by insertion of a Swan-Ganz catheter and continual ST segment analysis. This is useful in patients with critically low haemoglobin levels since it allows inotropes to be titrated, oxygen-supply demand to be monitored and myocardial impairment to be detected early.

(2) Howell JP, Bamber PA. SEVERE ACUTE ANAEMIA IN A JEHOVAH�S WITNESS: SURVIVAL WITHOUT BLOOD TRANSFUSION. Anaesthesia 1987 January; 42(1): 44-8 A case is described in which a Jehovah�s Witness underwent emergency surgery following which her haemoglobin fell to 1.8 g/dlitre. She was successfully treated in an intensive care unit with intermittent positive pressure ventilation of the lungs, high inspired oxygen concentrations and transfusions of large volumes of gelatin solution.

(3) Sacks DA, Koppers RH BLOOD TRANSFUSION AND JEHOVAH�S WITNESSES: MEDICAL AND LEGAL ISSUES IN OBSTETRICS AND GYNECOLOGY. Am J Obstet Gynecol 1986 Mar;154(3):483-486 Jehovah's Witnesses are members of a religious denomination whose beliefs prohibit the use of blood or blood products. Plasma volume expanders and extracorporeal hemodilution of the patient's own blood are theologically acceptable. Acute massive hemorrhage in which only blood is lifesaving may be encountered in obstetrics and gynecology. Either withholding or administering blood in such circumstances may have legal consequences for the physician and hospital. Factors to be considered include fetal viability, the presence of dependent children, and rules of informed consent. Whenever possible, the potential for transfusion should be anticipated and clearly discussed with the patient. When appropriate, the physician and hospital should move rapidly to obtain judicial resolution.

(4) Reid MF, Nohr K, Birks RJS. ECLAMPSIA AND HAEMORRHAGE IN A JEHOVAH'S WITNESS. Anaesthesia 1986 January; 41(1): 324-25 Reports of death from haemorrhage occurring in Jehovah�s Witnesses refusing blood products has drawn attention to the difficulties in treating these patients. We have recently managed a case of disseminated intravascular coagulation (DIC) and serious haemorrhage in a Jehovah�s Witness following


eclampsia. This case describes the successful management of serious haemorrhage and coagulopathy in a Jehovah's Witness, without the use of blood products.

(5) Harris TJB, Parikh NR, Rao YK, Oliver RHP. EXSANGUINATION IN A JEHOVAH�S WITNESS. Anaesthesia 1983; 38: 989-92 A case report in which death occurred after a patient�s adamant refusal to accept blood transfusion, despite prompt control of blood loss. The management of this situation is discussed. Reconstitution of the circulating volume was followed by survival for 2 hours after surgery. The haemoglobin level fell to 1.8 g/dl.This death was avoidable, and it may have been prevented by autotransfusion.

(6) Bonakdar MI, Eckhous AW, Bacher BJ, Tabbilos RH, Peisner DB. MAJOR GYNECOLOGIC AND OBSTETRIC SURGERY IN JEHOVAH'S WITNESSES. Obstetrics and Gynecology 1982 November; 60(5): 587-90 A retrospective study of 165 Jehovah's Witnesses and 164 control patients compared the morbidity and mortality associated with major obstetric and gynecologic surgery in the 2 groups. There were no deaths and few complications in either group. There were few differences in preoperative and postoperative hemoglobin values. Medicolegal implications of performing major surgery without blood transfusions are discussed. The study adds evidence that major operative procedures can be carried out on Jehovah's Witness patients without blood transfusions or blood products.

4. Cervical Cancer Surgery and Pregnancy

(1) Tewari K, Cappuccini F, Balderston KD, Rose GS, Porto M, Berman ML PREGNANCY IN A JEHOVAH'S WITNESS WITH CERVICAL CANCER AND ANEMIA. Gynecol Oncol 1998 Nov;71(2):330-2

Department of Obstetrics & Gynecology, Irvine-Medical Center, University of California, 101 The City Drive, Orange, California, 92868, USA. A 34-year-old Jehovah's Witness presented with vaginal bleeding and anemia at 23 weeks gestation. She was diagnosed with a FIGO Stage IB2 squamous cell carcinoma of the cervix. The patient refused transfusion of blood products and strongly desired to continue the pregnancy. She was hospitalized and at 33 weeks gestation underwent a Cesarean-radical hysterectomy with measures that minimized blood loss. Copyright 1998 Academic Press.

5. EPO in Obstetrics and Gynecology

(1) Loos W, Kuhn W, Prechtl A, Schmalfeldt B, Hipp R, Kycia J [BLOOD TRANSFUSION IN SURGICAL GYNECOLOGY. STRATEGIES FOR PREVENTING HOMOLOGOUS BLOOD TRANSFUSION]. [ARTICLE IN GERMAN] Fortschr Med 1994 Oct 20;112(29):405-9

Frauenklinik und Poliklinik, Klinikum rechts der Isar, Technischen Universitat Munchen. A statistical evaluation of homologous blood transfusions is imperative in any gynecological surgical department, to be able to define the transfusion-associated risk of the individual interventions. On the basis of our own statistical data and reports in the literature, strategies for limiting the use of homologous blood are discussed. So far, experience with autologous blood transfusion in surgical gynecology is limited, and clinical studies are needed to better define its role. In special cases, the use of erythropoietin and gonadotropin-releasing hormone (GnRH) analogues extends the possibilities for reducing homologous blood transfusion.

(2) Koenig HM, Levine EA, Resnick DJ, Meyer WJ. USE OF RECOMBINANT HUMAN ERYTHROPOIETIN IN A JEHOVAH�S WITNESS. J Clin Anesth 1993 May/June; 5: 244-47


We report the case of a Jehovah�s Witness who bled massively, refused blood transfusion, and survived profound anemia (hematocrit = 5.6%) intact. The patient was treated with recombinant erythropoietin, parenteral iron, and oxygen. The pharmacology and hematopoietic response to erythropoietin are discussed. We suggest considering this therapy for acutely anemic patients who refuse transfusion to decrease the duration of the most severe anemia.

(3) Larson B, Clyne N. ERYTHROPOIETIN ERSATTE BLODTRANSFUSION [ARTICLE IN SWEDISH] Läkertidningen 1993; 90(17): 1662 En 35-årig kvinna, tillhörande Jehovas vittne, drabbades av en akut massiv obstetrisk blödning. Hon motsatte sig blodtransfusion men accepterade behandling med erytropoietin. Efter nio dagars postoperativ behandling med högdos erytropoietin ökade Hb från 29 g/l till 82 g/l utan biverkningar.

(4) Huch A. et al. RECOMBINANT HUMAN ERYTHROPOIETIN IN THE TREATMENT OF POSTPARTUM ANEMIA. Obstet Gynecol 1992 July; 80(1): 127-31 Postpartum maternal anemia (hemoglobin concentration below 10 g/dl) is a common problem in obstetrics. Human recombinant erythropoietin, which has been shown to correct the anemia of end-stage renal disease and eliminate the need for transfusions, was used in a comparatively study of women with postpartum hemoglobin concentrations below 10 g/dl. Five daily doses of 4000 IU were given. Hematologic and clinical data were compared on days 5, 14, 42 after therapy in the treated women and in untreated women. Both groups received the same iron and folic acid supplements. Significantly greater increases in reticulocytes, hemoglobin, and hematocrit were seen by day 5 for the treated subjects compared with controls. Ferritin levels were significantly lower in the therapy group than in controls. No differences were seen between the groups in the platelet counts or clinical characteristics. No negative side effects were observed. As in other studies in populations without renal disease, recombinant human erythropoietin enhanced endogenous erythropoiesis over and above the normal physiologic recovery rate. Recently, rHuEPO was used in a pregnant woman who, because of her religious beliefs as a Jehovah�s Witness, refused a blood transfusion. McGregor et al. also reported using rHuEPO during pregnancy for an amemic patient on hemodialysis. We are not aware of any other experiences with the use of rHuEPO during pregnancy or postpartum.

(5) Koenig HM, Levine EA, Resnick DJ, Meyer WJ. USE OF RECOMBINANT HUMAN ERYTHROPOIETIN IN A JEHOVAH�S WITNESS PATIENT. Anest Analg 1992; 74(2): 368 A 39 y/o Jehovah�s Witness presented with in utero fetal demise and brisk vaginal bleeding at 28 weeks gestation. A diagnosis of placenta praevia was made. Emergency cesarean section was performed under general anesthesia. Intravascular volume was maintained with crystalloids and hetastarch. Hematocrit on admission was 37%. It reached a nadir of 5.6% on the first postoperative day. She was kept at rest, given oxygen, parenteral iron, and hyperalimentation. She was informed of the potential risks and benefits of r-Hu EPO, and with her consent, intravenous r-Hu EPO was initiated at 600 u/kg/day and was continued for 11 days. She responded with a brisk rise in Hct and a sustained elevation of reticulocytes count. No complications of the r-Hu EPO therapy were encountered. She was discharged home on vitamins and iron.

6. Autotransfusion in Gynecology and Obstetrics

(1) Rees SG, Boheimer NO AUTOLOGOUS BLOOD TRANSFUSION. Br J Anaesth 1998 Apr;80(4):563 Comment on: Br J Anaesth 1997 Jun;78(6):768-71 Comment in: Br J Anaesth 1999 Jan;82(1):154


(2) Jackson SH, Lonser RE. SAFETY AND EFFECTIVENESS OF INTRACESAREAN BLOOD SALVAGE. Transfusion 1993 February; 33(2): 181 Obstetric hemorrhage is the third leading cause of maternal mortality, and postpartum hemorrhage � stemming from disorders of placental implantation, uterine atony, retained placenta, and obstetric trauma � accounts for one-third of such deaths. Marternal mortality and morbidity attributable to hemorrhage are in fact a little greater then reported because of the additional risk introduced by the transmission of infectious diseases with allogeneic transfusions. Autologous transfusions should be a consideration for appropriately selected and managed patients undergoing a cesarean delivery. Three options are available: 1) preoperative donation of blood for autologous use, a modality of proven safety but with limited applicability in the setting of severe hemorrhage; 2) acute normovolemic hemodilution, a method that is difficult to apply in the cesarean setting because of both the physiologic hemodilution associated with pregnancy and the intravascular volume fluxes associated with regional anesthesia; and 3) intraoperative blood salvage (IBS), a technique heretofore not employed because of the concern that amniotic fluid from the surgical field might contaminate the salvaged blood and subsequently cause disseminated intravascular coagulation and/or cardiovascular collapse. Independent evaluation of current IBS technology by each of us prompted our application of this technology to cesarean surgery. Amniotic fluid is eliminated by 1) a separate suctioning of the cumulative surgical field fluids, which are then discarded, following delivery of the fetus and before initiation of the IBS canister-collecting system and 2) incorporation of a centrifuge-based IBS technology that uses a washing device. Clinically, this is a rational approach, because severe obstetric hemorrhage usually does not commence until after the fetus has been extracted from the uterus and most of the amniotic fluid has been suctioned from the field. Furthermore, the clinical decision to use the processing equipment (centrifuge basin and washing device) is a separate decision that is made after that of initiating the collection apparatus, and therefore it serves to contain costs. Laboratory studies demonstrated that the complete removal of biologic markers (alpha-fetoprotein and fetal debris) from washed salvaged red cells supports the safety for IBS during cesarean surgery. We practice in community hospitals with 3000 to 4000 deliveries per year. At both hospitals, IBS has been employed as outlined above. At Hinsdale Hospital from 1980 through 1991, IBS was made available for 109 parturients: 60 of these patients received a total of 127 salvaged units. At Good Samaritan Hospital from 1989 through 1991, IBS was made available for 10 parturients: 4 of these patients received a total of 9 salvaged units. There has been no instance of clinical amniotic fluid embolism nor the occurrence of other adverse responses to transfusions of salvaged red cells in either series. We conclude that IBS can be a safe and effective method for autologous blood transfusion in the hemorrhaging cesarean patient.

(3) Zichella L, Gramolini R. AUTOTRANSFUSION DURING CESAREAN SECTION. American Journal of Obstetrics and Gynecology 1990 January; 162(1): 295 We used autotransfusion in eight women undergoing elective cesarean section to verify the ability of a machine to clear amniotic fluid from centrifuged blood, which then was transfused back to the patient. Procoagulant activity of amniotic fluid is well known and so are the resulting risks of mixing this biologic fluid with the recovered blood. We evaluated the presence of amniotic fluid both by direct technique, searching for one of its specific components �phosphatidylglycerol�, and by indirect technique, analyzing its clotting activity. The data obtained allow us to demonstrate an absolute lack of coagulant activity in centrifuged blood and the near disappearance of phosphatidylglycerol in it; the very small amounts we found was mainly because of red cell hemolysis (phosphatidylglycerol is present on erythrocyte membranes) during the procedure. Therefore, we believe that autotransfusion with blood obtained during cesarean section is without risk. We also think it may be a useful, although not a money-saving procedure, for the mother and perhaps the fetus to avoid a potential source of infection through a heterologous transfusion. In conclusion, we believe that autotransfusion should be performed at the time of cesarean section only when the membranes are not ruptured, to avoid bacterial contamination, and, in case of blood incompatibility, maternal isoimmunization will be easily avoided with Rhogam immune globulin injection.


(4) Durand F, Duchesne-Gueguen M, Le Bervet JY, Marcorelles P, Tardivel R, Vovan JM, Le Goff MC, Genetet B. ETUDE RHÉOLOGIQUE ET CYTOLOGIQUE DU SANG AUTOLOGE RECUEILLI PAR LE �CELL SAVER 4� AU COURS DE CÉSARIENNE. Rev Fr Transfus Hémobiol 1989; 32: 179-91 Intraoperative autologous transfusion has been frequently used in vascular and traumatic surgery for about ten years. The technique would be justified in other procedures when intra-operative bleeding is significant and the quality of retrieved blood is satisfactory. We have studied the potential use of intra-operative autologous transfusion during caesarean section of 15 parturients. The quality of autologous blood (at different stages of the procedure) was assessed after being recovered and washed by �Cell Saver 4� (Haemonetics). Blood quality was assessed through 1) measuring the following: erythrocyte deformability with Erythrometer and Hemorheometer; blood and plasma viscosities; ATP, 2.3 DPG and plasma hemoglobin rates; and RBC morphology through SEM; 2) bacterial detection and identification; 3) detection of foetal cells which could create immunological disturbances if reinjected into the mother. The results showed: 1) little variation in RBC deformability properties with ATP and 2.3 DPG rates which, apart from a slight decrease, remained within the normal range; 2) a 20 fold increase in plasma hemoglobin persisting, despite successive whashes, in 80 % of cases; 3) positive Staphyllococcus epidermidis hemoculture clinically irrelevant in the reinjectable bag in 90 % of cases; 4) close to 1% foetal cells in the reinjactable bag in 20 % of cases; 5) 8 % abnormal cells as seen on SEM (Stage I echinocytes) and a slight swelling of the RBCs, which could account for their fragility. These preliminary results show that intraoperative autologous transfusion could be used in obstetrical surgery provided that certain precautions are taken to minimize the aforesaid drawbacks.

(5) Grimes DA. A SIMPLIFIED DEVICE FOR INTRAOPERATIVE AUTOTRANSFUSION. Obstetrics and Gynecology 1988 December; 72(6): 947-50 Intraoperative autotransfusion, a widely accepted adjunct in many surgical disciplines, has been underused in obstetrics and gynecology. This report describes a new device for autotransfusion that is simpler to operate than traditional system requiring a technician. The device was used successfully in two obstetric patients with life-threatening intraoperative hemorrhage, one with abdominal pregnancy and the other with postpartum hemorrhage.

7. Anesthetic and Intensive Care Techniques in Gynecology and Obstretics

(1) Rasanayagam SR, Cooper GM. TWO CASES OF SEVERE POSTPARTUM ANAEMIA IN JEHOVAH'S WITNESSES. Intensive 1996; 5: 202- Two cases of severe postpartum anaemia are presented in Jehovah's Witnesses who refused blood transfusion. Despite haemoglobin concentrations of less than 3 g/dl both women survived. General management was directed to maximizing oxygen delivery and minimizing oxygen comsumption. The use of an emulsified perfluorocarbon was organized for one of the cases, but was not administrated because a snow storm prevented its delivery to the hospital. In the other case, recombinant human erythropoietin was used to encourage red cell production. The recovery of haemoglobin concentration in the two cases is compared.

(2) Karn KE, Hammerschmidt DE, Julian T, Ogburn PL jr, Vercelloti G. USE OF A WHOLE BLOOD SUBSTITUTE, FLUOSOL-DA 20%, AFTER MASSIVE POSTPARTUM HEMORRHAGE. Obstet Gynecol 1985 Jan; 65(1): 127-30 Two patients with severe postpartum hemorrhage refused blood product transfusion for religious reasons. The patients� hemoglobin level had dropped to 3.0 % or less after operative intervention, and the cardiac indexes on transfer to the tertiary care center were 8.0 and 7.3 L/minute per m2, respectively. Each received an infusion of Fluosol-DA 20% according to research protocol after obtaining informed written consent. Pulse rates and cardiac outputs dropped after the infusion. They were discharged from the hospital 17 and 15 days later with hemoglobins of 7.0 and 5.1%, respectively. This perfluorcarbon


suspension may prove to be useful or even life-saving in postpartum patients for whom blood transfusion is unnacceptable or unavailable.

(3) Powell JL, Mogelnicke SR, Franklin EW, Chambers DA, Burrell MO. A DELIBERATE HYPOTENSIVE TECHNIQUE FOR DECREASING BLOOD LOSS DURING RADICAL HYSTERECTOMY AND PELVIC LYMPHADENECTOMY. Am J Obstet Gynecol 1983; 147: 196-202 Nitroglycerin was utilized in combination with general anesthesia in order to reduce mean arterial blood pressure with the objective of reducing operative blood loss in 25 consecutive patients undergoing radical hysterectomy and pelvic lymphadenectomy. This deliberate hypotensive technique added no morbidity and compared to a control group decreased the blood loss by 70%, shortened operating time by 29.5%, and decreased the percentage of patients requiring blood transfusions from 81% to 11.5%. The indications for controlled hypotension are still controversial and somewhat dependent upon the expertise of the anesthesia and surgery teams, availability of blood, and the risk of transfusion hepatitis. Cerebrovascular disease, myocardial ischemia, peripheral vascular disease, severe renal or hepatic disease, and hypovolemia are relative contraindications to deliberate hypotension.

(4) Cundy JM. JEHOVAH�S WITNESSES AND HEMORRHAGE(LETTER) Anesthesia 1980, Volume 35, page1013. There are two possible ways in which a Witness may be helped, particularly before elective surgery. The technique of autotransfusion or peri-operative haemodilution could be applied.Perioperative haemodilution is a technique popularised by Messmer which has received scant attention in the United Kingdom anaesthetic litterature.Dormandy & Bouhoustos have shown respectively that woud healing and the risk of complications following surgery on patients with peripheral vascular disease is improved by reducing the hematocrit to around 30%.

XII. UROLOGIC (1) Chen RN, Moore RG, Micali S, Kavoussi LR

RETROPERITONEOSCOPIC RENAL BIOPSY IN EXTREMELY OBESE PATIENTS. Urology 1997 Aug; 50(2): 195-198

James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA. OBJECTIVES: Retroperitoneoscopic renal biopsy can be technically challenging in extremely obese patients because of loss of surgical landmarks and difficulty in identifying the kidney within retroperitoneal adipose tissue. We present our experience with retroperitoneoscopic renal biopsy in extremely obese patients and describe our surgical technique. METHODS: We performed retroperitoneoscopic renal biopsies on 8 extremely obese patients (body mass index greater than 40). Mean patient weight was 144.3 kg. Three patients presented with acute renal failure and 5 presented with nephrotic range proteinuria. Retroperitoneoscopic renal biopsy was indicated based on extreme obesity alone in 3 patients, 2 patients had failed previous attempts at percutaneous biopsy, I patient had a solitary kidney, I patient required chronic anticoagulation, and I patient was a Jehovah's Witness. Intraoperative ultrasonography and an anatomic approach facilitated the dissection and identification of the kidney. RESULTS: All eight retroperitoneoscopic renal biopsies were completed successfully without complication and all patients were discharged within 24 hours of the procedure. Sufficient tissue for pathologic diagnosis was obtained in all cases. Mean operating room time was 153 minutes and mean estimated blood loss was 71 mL. The patients returned to normal activity at a mean of 1.8 weeks. CONCLUSIONS: With the use of intraoperative ultrasonography and a systematic, anatomic approach, retroperitoneoscopic renal biopsy can be successfully completed in extremely obese patients. This procedure can be reliably performed on an outpatient basis with minimal morbidity and should be considered a viable alternative to open renal biopsy.


(2) Roen PR, Velcek F. EXTENSIVE UROLOGIC SURGERY WITHOUT BLOOD TRANSFUSION. NY State Journal of Medicine 1972 October 15; 72: 2524-27 For religious reasons, Jehovah�s Witnesses refuse to receive blood transfusions. Many hospitals have refused surgery to these patients. Although a variety of methods have been used to decrease blood loss while performing surgery on these patients, the authors believe that normal surgical procedures can be performed without the use of special techniques if particularly attention is paid to the stoppage of bleeding. Several case reports of major urologic operations performed without special techniques or blood transfusion are given.

XIII. ABDOMINAL 1. Liver, Gallbladder

(1) Detry O, Honore P, Delwaide J, Dondelinger RF, Meurisse M, Jacquet N LIVER TRANSPLANTATION IN A JEHOVAH'S WITNESS. Lancet 1999 May 15;353(9165):1680

(2) Rees M, Plant G, Wells J, Bygrave S ONE HUNDRED AND FIFTY HEPATIC RESECTIONS: EVOLUTION OF TECHNIQUE TOWARDS BLOODLESS SURGERY. Br J Surg 1996 Nov; 83(11): 1526-1529

Hepatobiliary Unit, North Hampshire Hospital, Basingstoke, UK. A technique of hepatic resection is described and the results of 150 resections are reviewed. Hepatic transection was performed, under intermittent portal inflow occlusion, using ultrasonic aspiration to skeletonize portal branches and venous tributaries. Control of venous haemorrhage during resection was optimized by argon beam coagulation and lowering central venous pressure to between 0 and 4 cmH20 by extradural blockade and systemic nitroglycerine infusion. One patient with jaundice died in hospital, giving a mortality rate of 0.7 per cent. There were no deaths in patients without jaundice and cirrhosis. Fifteen patients (10.0 per cent) had significant complications, nine medical and six surgical, including three bile leaks (2.0 per cent). Mean blood loss was 814 ml for the whole study but only 434 ml in the last 4 years. During this latter period mean blood transfusion in hospital was 0.5 units and mean postoperative haemoglobin value fell by 0.7 g per 100 ml. Hepatic resection can be performed with the same degree of confidence and similar low morbidity as any other major surgical procedure.

(3) Snook NJ, O'Beirne HA, Enright S, Young Y, Bellamy MC USE OF RECOMBINANT HUMAN ERYTHROPOIETIN TO FACILITATE LIVER TRANSPLANTATION IN A JEHOVAH'S WITNESS. Br J Anaesth 1996 May;76(5):740-3

Intensive Care Unit, St James's University Hospital, Leeds. A 46-yr-old woman with rapidly progressing primary biliary cirrhosis presented for liver transplantation. The use of preoperative recombinant human erythropoietin enabled this to be achieved without prohibited blood products. Perioperative management of this patient and general principles of management of Jehovah's Witnesses undergoing major surgery are discussed.

(4) Ramos HC, Todo S, Kang Y, Felekouras E, Doyle HR, Starzl TE LIVER TRANSPLANTATION WITHOUT THE USE OF BLOOD PRODUCTS. Arch Surg 1994 May;129(5):528-32; discussion 532-3

Department of Surgery, University of Pittsburgh, School of Medicine. Pa. OBJECTIVES: To examine the techniques and the outcome of liver transplantation with maximal conservation of blood products and to analyze the potential benefits or drawbacks of blood


conservation and salvage techniques. DESIGN: Case series survey. SETTING: Tertiary care, major university teaching hospital. PATIENTS AND METHODS: Four patients with religious objections to blood transfusions who were selected on the basis of restrictive criteria that would lower their risk for fatal hemorrhage, including coagulopathy, a thrombosed splanchnic venous system requiring extensive reconstruction, active bleeding and associated medical complications. All patients were pretreated with erythropoietin to increase production of red blood cells. All operations were performed at the same institution, with a 36-month follow-up. INTERVENTIONS: Orthotopic liver transplantation that used blood salvage, plateletpheresis, and autotransfusion and the withholding of the use of human blood products with the exception of albumin. MAIN OUTCOME MEASURES: Survival and postoperative complications, with the effectiveness of erythropoietin and plateletpheresis as secondary measures. RESULTS: All patients are alive at 36 months after orthotopic liver transplantation. One patient, a minor (13 years of age), was transfused per a state court ruling. Erythropoietin increased the production of red blood cells as shown by a mean increase in hematocrit levels of 0.08. Platelet-pheresis allowed autologous, platelet-rich plasma to be available for use after allograft reperfusion. Three major complications were resolved or corrected without sequelae. Only one patient developed postoperative hemorrhage, which was corrected surgically. The mean charge for bloodless surgery was $174,000 for the three patients with United Network for Organ Sharing (UNOS) status 3 priority for transplantation. This result was statistically significant when these patients were compared with all the patients with UNOS status 3 priority during the same period who met the same restrictive guidelines (P < .05). Only 19 of 1009 orthotopic liver transplantations performed at our institution were similar according to the UNOS status and the fulfillment of the guidelines. The mean charge for these comparison patients was $327,000, 3.8% of which was related to transfusions. CONCLUSIONS: Orthotopic liver transplantation without the use of blood products is possible. Blood conservation techniques do not increase morbidity or mortality and can result in fewer transfusion-related, in-hospital charges.

(5) Fletcher JL Jr, Perez JC, Jones DH SUCCESSFUL USE OF SUBCUTANEOUS RECOMBINANT HUMAN ERYTHROPOIETIN BEFORE CHOLECYSTECTOMY IN AN ANEMIC PATIENT WITH RELIGIOUS OBJECTIONS TO TRANSFUSION THERAPY. Am Surg 1991 Nov; 57(11): 697-700

Department of Family Medicine, Medical College of Georgia, Augusta. Use of recombinant human erythropoietin has been advocated for therapy in anemic patients with end-stage renal disease and to enhance the harvesting of autologous red blood cells from healthy patients scheduled for elective orthopedic surgery. The authors report the case of a diabetic patient with moderate chronic renal failure and cholelithiasis but whose religious beliefs forbade the use of transfusion therapy. She underwent successful cholecystectomy only after treatment with recombinant human erythropoietin.

2. Haemodilution Anaesthesia in Abdominal Surgery

a) Adults Abdominal Surgery

(1) Bragg LE, Thompson JS. MANAGEMENT STRATEGIES IN THE JEHOVAH�S WITNESS PATIENT. Contemp Surg 1990 March; 36: 45-49 Our experience with major noncardiac operations in Jehovah�s Witness patients was reviewed to evaluate their management and outcome and to review techniques that may improve survival in patients who refuse blood transfusion. Thirty-three operations were performed in 29 Jehovah�s Witnesses. The most frequent operations were colectomy, cholecystectomy, and appendectomy. There were four complications and one death. Major operations can be performed safely in patients who refuse blood transfusion. Early operation in emergent cases, particularly those manifested by hemorrhage, will conserve red cell mass. Staging complex procedures minimizes blood loss and allows correction of anemia. Aggressive nutritional support and administration of iron and other substrates will help stimulate erythropoieses. The consequences of excessive blood loss can be devastating. In the profoundly anemic patient, measures to maximize delivery and minimize oxygen consumption will help assure adequate tissue oxygenation.


(2) Spence RK. THE EFFECTS OF HEMOGLOBIN LEVELS AND BLOOD LOSS ON SURGICAL MORTALITY. Infections in Surgery 1989 July; pp 262, 264, 266, 268. Surgery can be performed safely without transfusion with preoperative hemoglobin levels as low as 6 g/dL. The mortality rate appears to be related to the amount of blood lost rather than to the preoperative hemoglobin level. Early surgery improved survival from 25% to 80% in 1 small series of patients who were bleeding actively from the GI tract. This approach of early diagnosis and intervention, essential for Jehovah�s Witnesses, may lead to improved survival for other patients. The decision to transfuse blood should be based on demonstrated need and clinical conditions.

(3) Grubbs PE, Marini CP, Fleischer AF. ACUTE HEMODILUTION IN AN ANEMIC JEHOVAH�S WITNESS DURING EXTENSIVE ABDOMINAL WALL RESECTION AND RECONSTRUCTION. Annals Plastic Surgery 1989 May; 22(5): 448-51 A 47-year-old anemic Jehovah�s Witness with Gardner�s syndrome presented with a large abdonimal wall desmoid tumor requiring extensive resection with a musculocutaneous flap reconstruction. At surgery a technique of acute limited normovolemic hemodilution (ALNH) was used to minimize blood loss and avoid blood transfusions. Complications that follow transfusions of homologous blood are reviewed, and a recommendation is made to use ALNH because of its advantages in those patients in whom significant blood loss is expected

b) Children Abdominal Surgery

(1) Kraft M, Dedrick D, Goudsouzian N. HAEMODILUTION IN AN EIGHT-MONTH-OLD INFANT. Anaesthesia 1981; 36: 402-04 Transient haemodilution was carried out in an 8-month-old infant whose parents were Jehovah�s Witnesses during an abdominoperineal pull-through procedure. Aduld ACD blood packs were altered to suit the needs of the child. With judicious fluid management, the child was extubated and did well postoperatively.

3. Major Abdominal Surgery

(1) Kamboris AA. MAJOR ABDOMINAL OPERATIONS ON JEHOVAH�S WITNESSES. The American Surgeon 1987 June; 53(6): 350-56 Thirteen major operations have been successfully performed on 11 Jehovah�s Witnesses, without complications. After detailed preadmission assessment, all patients received pretreatment assurances that their religious beliefs would be respected, regardless of the circumstances in the operating room. There were no untoward effects of this policy. Whereas the religious and legal aspects of the issue may be confusing and unaccetable to some surgeons, those undertaking to treat such patients must use ancillary means, technical variations, and alternatives to standard procedures in order to minimize risks and achieve acceptable results. Preoperative agreement should be viewed as binding by the surgeon and should be adhered to regardless of events developing during and after operation. Such an approach constitutes the best preoperative preparation, orients the patients positively toward their surgical treatment, and diverts the surgeon�s attention from the legal and philosophical considerations to the surgical and technical ones, thus, allowing him to perform optimally and serve his patient�s best interests. The recovery phase in this small series of electively performed operations occurred at anticipated rates and no postoperative complications developed.

(2) Dudrick SJ, O�Donnell JJ, Raleigh DP, Matheny RG, Unkel SP. RAPID RESTORATION OF RED BLOOD CELL MASS IN SEVERELY ANEMIC SURGICAL PATIENTS WHO REFUSE TRANSFUSION. Arch Surg 1985 June; 120: 721-27


Optimal parenteral nutritional support, concomitant with replacement doses of intravenous iron dextran, can be safe, effective, and lifesaving for severely anemic patients who are unable to receive blood transfusions. Six patients who had sustained massive acute blood loss and two who had severe chronic anemia received as much as 140 mL of iron dextran injection intravenously. The average initial hemoglobin level in the acute group was 5.0 g/dL (range, 2.6 to 8.4 g/dL) and increased to an average of 10.6 g/dL (range, 7.5 to 12.8 g/dL) in 23 days (range, 17 to 30 days); the hemoglobin level in the chronic group was 3.8 g/dL and increased to 10.6 g/dL over an average period of 121 days. Two abdominal colectomies, a right transverse colectomy and fistulectomy, a pyloroplasty and vagotomy, and a highly selective vagotomy were accomplished without complications in five of the patients. There were no adverse reactions to the hematopoietic therapy.

(3) Nearman HS, Eckhauser ML. POSTOPERATIVE MANAGEMENT OF A SEVERELY ANEMIC JEHOVAH�S WITNESS. Crit Care Med 1983; 11(2): 142-43 Preoperative preparation and intraoperative techniques to minimize blood loss comprise standard therapy for the patient who refuses blood products on religious grounds. The severe anemic postoperative patient presents a particular problem in dealing with oxygen transport and consumption. The management of a Jehovah�s Witness with a hematocrit of 6.6 % is presented. Oxygen consumption (VO2) was decreased 30-50 % by the use of body surface cooling, neuromuscular blocking agents, and narcotic-barbiturate administration.

(4) Eichner ER. CLINICAL PROBLEMS IN THE USE OF BLOOD AND BLOOD SUBSTITUTES. Surgery Annual 1982; 14: 85-89 Experience with Jehovah�s Witnesses has shown that crystalloids alone can maintain volume in the face of major blood loss. I recently treated three Witnesses with major upper gastrointestinal hemorrhages. Two were men, aged 19 and 52, respectively, who bled massively from peptic ulcers. Initial hemoglobin levels dropped from 10 to 11 gm/100 ml to 3 to 4 gm/100 ml at the nadir, but with generous amounts of crystalloids the patients recovered smoothly. The third was a 46-year-old woman who bled from esophageal varices secondary to chronic biliary cirrhosis. On crystalloid replacement, her hemoglobin level reached a low of 3.2 gm/100 ml on the fourth day. At that time bleeding had stopped, and a bout of mild pulmonary edema responded promptly to cessation of crystalloids and to diuretics. She recovered smoothly.

4. Splenic injury and Treatment

a) Surgical Splenectomy

(1) Pivalizza EG, Tjia IM, Juneja HS, Cohen AM, Duke JH Jr ELECTIVE SPLENECTOMY IN AN ANEMIC JEHOVAH'S WITNESS PATIENT WITH CIRRHOSIS. Anesth Analg 1998 Sep;87(3):529-30

Department of Anesthesiology, University of Texas Health Science Center at Houston, 77030, USA. [email protected]

b) Non operative Management of Splenic tear

(1) Zieg PM, Cohn SM, Beardsley DS NONOPERATIVE MANAGEMENT OF A SPLENIC TEAR IN A JEHOVAH'S WITNESS WITH HEMOPHILIA. J Trauma 1996 February; 40(2): 299-301 Splenic laseration, the most common visceral lesion following blunt abdominal trauma, can be treated in a nonoperative fashion in only a select group of stable patients with minimal injury. We report a case of life-threatening splenic trauma in a Jehovah's Witness with hemophilia that was successfully managed without surgery.Using recombinant factor VIII treatment.


5. Laparoscopic Surgery

a) Laparoscopic Trauma Surgery

(1) Zantut LF, Machado MA, Volpe P, Poggetti RS, Birolini D AUTOTRANSFUSION WITH LAPAROSCOPICALLY SALVAGED BLOOD IN TRAUMA: REPORT ON 21 CASES. Surg Laparosc Endosc 1996 Feb;6(1):46-8

Department of Surgery, University of Sao Paulo School of Medicine, Brazil. Autotransfusion is being increasingly used to avoid the complications of homologous blood transfusion. In abdominal trauma, however, the collected blood may be contaminated by intestinal contents when digestive or urinary lesions are present. In such situations, the reinfusion of blood is contraindicated. We present our experience with autotransfusion of blood collected by laparoscopy from the abdominal cavity of 21 trauma patients. Laparoscopy allowed the aspiration of blood and, at the same time, permitted diagnosis of visceral lesions, avoiding reinfusion of contaminated blood. No complications occurred, and hematocrit values were significantly elevated. This procedure may represent the only possible method of blood transfusion in Jehovah's Witnesses, as with one patient in our series.

1) Laparoscopic Adrenalectomy

(1) Chiu M, Crosby ET, Yelle JD ANESTHESIA FOR LAPAROSCOPIC ADRENALECTOMY (PHEOCHROMOCYTOMA) IN AN ANEMIC ADULT JEHOVAH'S WITNESS. Can J Anaesth 2000 Jun;47(6):566-571.

Department of Anesthesiology, University of Ottawa and the Ottawa Hospital, Ontario, Canada. PURPOSE: To report the anesthetic management of an anemic Jehovah's Witness patient presenting for laparoscopic adrenalectomy for pheochromocytoma. CLINICAL FEATURES: A 49-yr-old woman presented with hemodynamic instability progressing to cardiogenic shock and subsequent acute renal failure. Her course was complicated by anemia. An adrenal pheochromocytoma was diagnosed. Preoperatively, alpha- and beta-adrenergic blockade was instituted with phenoxybenzamine and metoprolol therapy and her anemia was treated with erythropoietin. She underwent laparoscopic resection of the adrenal tumour. A cell saver device was employed and attached to the laparoscopic suction-irrigation apparatus to provide salvage capability in the event of a major hemorrhage. The surgical intervention was uneventful and well tolerated. The patient was discharged home and well on follow-up. CONCLUSIONS: Cell salvage is the only mechanism currently acceptable to Jehovah's Witnesses which will allow for perioperative salvage and replacement of blood loss. Its use is encouraged in all situations in which surgical hemorrhage is anticipated.

2) Laparoscopic Spleenctomy

(1) Ferzli GS, Hurwitz JB, Fiorillo MA, Hayek NE, Dysarz FA, Kiel T LAPAROSCOPIC SPLENECTOMY IN A JEHOVAH'S WITNESS WITH PROFOUND ANEMIA. Surg Endosc 1997 Aug;11(8):850-851.

Department of Laparoendoscopic Surgery, Staten Island University Hospital, NY 10304, USA. Open surgery in a severely anemic patient may be complicated by a substantial blood loss from a large incision and subsequent poor wound healing secondary to the anemia. We report our success in performing a splenectomy laparoscopically in a profoundly anemic patient. A 50-year-old white male


Jehovah's Witness who was HIV positive was referred for splenectomy after he developed profound, worsening anemia secondary to hypersplenism that was refractory to medical management. His preoperative hemoglobin and hematocrit levels were 2.7 g/dl and 8.8%, respectively, but his religious beliefs precluded transfusion. A laparoscopic splenectomy by the posterior gastric approach was performed. The patient tolerated the surgery well and experienced no additional morbidity. On postoperative day 7, his hemoglobin and hematocrit were 6.8 g/dl and 22%, respectively. We conclude that laparoscopic splenectomy is an attractive procedure in a severely anemic patient who requires splenectomy and refuses blood transfusion.

XIV. TRANSPLANTATION

1. Liver Transplantation (1) Baldry C, Backman SB, Metrakos P, Tchervenkov J, Barkun J, Moore A

LIVER TRANSPLANTATION IN A JEHOVAH'S WITNESS WITH ANKYLOSING SPONDYLITIS. Can J Anaesth 2000 Jul;47(7):642-646.

Department of Anesthesia, Royal Victoria Hospital and McGill University, Montreal, QC, Canada. PURPOSE: Orthotopic liver transplantation is typically associated with large volume blood loss. Technological and pharmacological advances permit liver transplantation in patients who formerly were not candidates for this surgery because of strict limitations on blood product administration. We describe a liver transplant in a Jehovah's Witness with ankylosing spondylitis. CLINICAL FEATURE: A 49-yr-old Jehovah's Witness with ankylosing spondylitis and end stage liver disease secondary to sclerosing cholangitis underwent orthotopic liver transplantation. Recombinant human erythropoietin (4,000 IU sc every two days for four weeks, then 4,000 IU sc every week) established a normal hemoglobin concentration preoperatively (> 140 g x L(-1) compared with 120 g x L(-1) baseline). Intraoperatively, strategies for reducing risk of blood product transfusion included avoidance of hypothermia (T>35 degrees C), minimal blood sampling (four 1 ml samples), normovolemic hemodilution (two units), administration of Aprotinin (2 million units bolus dose followed by infusion of 500,000 u x hr(-1)), and return of blood (1,500 ml) scavenged from the operative field. Estimated blood loss was 2,200 mi. The preoperative and postoperative hemoglobin concentration was 147 g x L(-1) (hematocrit 0.45) and 123 g x L(-1) (hematocrit 0.37), respectively. No blood products were required and he was discharged three weeks postoperatively without complication. CONCLUSION: Technological and pharmacological advances allow patients to undergo surgery traditionally associated with large volume blood loss with reduced risk of blood product administration.

(2) Detry O, Honore P, Delwaide J, Dondelinger RF, Meurisse M, Jacquet N LIVER TRANSPLANTATION IN A JEHOVAH'S WITNESS. Lancet 1999 May 15;353(9165):1680

(3) Seu P, Neelankanta G, Csete M, Olthoff KM, Rudich S, Kinkhabwala M, Imagawa DK, Goldstein LI, Martin P, Shackleton CR, Busuttil RW. LIVER TRANSPLANTATION FOR FULMINANT HEPATIC FAILURE IN A JEHOVAH'S WITNESS. Clin Transplant 1996 October; 10(5): 404-07 Jehovah's Witness patients who refuse transfusions have generally not been felt to be candidates for liver transplantation owing to the frequent requirement for blood transfusions during liver transplantation. This is the first report to our knowledge of successful emergent liver transplantation without the use of blood or blood products in a Jehovah's Witness. The surgical and anesthetic strategies employed in achieving a successful outcome are discussed.


(4) Snook NJ, O'Beirne HA, Enright S, Young Y, Bellamy MC. USE OF RECOMBINANT HUMAN ERYTHROPOIETIN TO FACILITATE LIVER TRANSPLANTATION IN A JEHOVAH'S WITNESS. Br J Anaesth 1996 May; 76(5): 740-43 A 46-year-old woman with rapidly progressing primary biliary cirrhosis presented for liver transplantation. The use of preoperative recombinant human erythropoietin enabled this to be achieved without prohibited blood products. Perioperative management of this patient and general principles of management of Jehovah's Witnesses undergoing major surgery are discussed.

(5) Ramos HC, Todo S, Kang Y, Felekouras E, Doyle HR, Starzl TE. LIVER TRANSPLANTATION WITHOUT THE USE OF BLOOD PRODUCTS. Arch Surg 1994 May; 129: 528-33 Four patients with religious objections to blood transfusions who were selected on the basis of restrictive criteria that would lower the risk for fatal hemorrhage, including coagulopathy, a thrombosed splanchic venous system requiring extensive reconstruction, active bleeding, and associated medical complications. All patients were pretreated with erythropoietin to increase production of red blood cells. All operations were performed at the same institution, with a 36-month follow-up. Interventions: Orthopedic liver transplantation that used blood salvage, plateletpheresis, and autotransfusion and the witholding of the use of human blood products with the exception of albumin. Results: All patients are alive at 36 months after orthotopic liver transplantation. One patient, a minor (13 years of age), was transfused per a state court ruling. Erythropoietin increased the production of red blood cells as shown by a mean increase in hematocrit levels of 0.08. Plateletpheresis allowed autologous, platelet-rich plasma to be available for use after allograft reperfusion. Three major complications were resolved or corrected without sequelae. Only one patient developed postoperative hemorrhage, which was corrected surgically. Conclusions: Orthopedic liver transplantation without the use of blood products is possible. Blood conservation techniques do not increase morbidity or mortality and can result in fewer transfusion-related, in-hospital charges. Page 530: Estimates of blood loss from inspection, recovery of red blood cells in the cell savers, and sponge weighing were approximately 250 mL for patient 1, 700 mL for patient 2, and approximately 750 mL for patients 3 and 4. Patient 1 had no transfusable blood recovered, owing to a small amount of surgical bleeding.

2. Renal Transplantation (1) van Leusen R, Deenik HE, Buskens FG.

SUCCESSFUL RENAL AUTOTRANSFUSION FOR RENAL FAILURE WITH PROLONGED OLIGURIA IN A JEHOVAH'S WITNESS WITH FIBROMUSCULAR DYSPLASIA OF THE RENAL ARTERIES. Neth J Med 1994 November; 45(5): 221-24 A young female presented with hypertension and oliguric renal insufficiency caused by fibromuscular dysplasia of the renal arteries. There was a left kidney remnant and a normal-sized right kidney with a retrograde blood supply through capsular arteries. Reconstruction of the occluded right renal artery with autotransplantation of the kidney after 60 days of oliguric renal insufficiency was followed by complete functional repair. Erythropoietin treatment was a great help in the management of this patient who refused blood transfusions because she was a Jehovah's Witness.

(2) Parker RI. AGGRESSIVE NON-BLOOD PRODUCT SUPPORT OF JEHOVAH�S WITNESSES. Critical Care Medicine 1994; 22(3): 381-2 The care of patients who are Jehovah�s Witnesses is often difficult and anxiety-producing for both the physicians and the patients; this situation is even more true when the patient is the child of Jehovah�s Witness� parents. Dr. Akingbola et al. describe their experience in caring for a critically ill child of Jehovah�s Witness parents. Out of concern for the family�s religious beliefs and the physicians� desire to maintain a good working relationship with this family, the authors elected to treat the patient, a 12-yr-old male, as an emancipation minor for medical decision-making purposes. This approach required the physicians to care for the patient without the benefit of blood or blood product support. They


were successful in doing so through the utilization of aggressive medical management techniques with which all who care for these patients should become acquinted. The use of controlled hypotermia, muscle paralysis, and pentobarbital successfully reduced the patient�s basal oxygen consumption by 40% and allowed for �adequate� oxygen delivery with a hemogobin of 2.1 g/dl. This hemoglobin value is significantly lower than those concentrations noted to produce endocardial ischemia in �normal� individuals (2). One message from this report is to reinforce the concept that we have the technology to support patients physiologically under conditions that we all would admit are not optimal.

(3) Akingbola OA, Custer JR, Bunchman TE, Sedman AB. MANAGEMENT OF SEVERE ANEMIA WITHOUT TRANSFUSION IN A PEDIATRIC JEHOVAH'S WITNESS PATIENT. Critical Care Medicine 1994; 22(3): 524-28 We report the case of a 12-year-old Jehovah's Witness who refused blood transfusion for a severe anemia which he developed after receiving a renal transplant. On postoperative day 8 the hemoglobin was 2.1 g/dL (21 g/L) and hematocrit 6%. In view of the deteriorating clinical status, the patient was intubated and mechanically ventilated. Hypothermia and pentobarbital coma was used as adjunctive therapy. Hypothermia was induced by surface cooling to maintain rectal temperature at 34 to 35°C. Pentobarbital was administered at a loading dose of 4 mg/kg, followed by a continuous infusion at 2 mg/kg/hr. Neuromuscular blockade was maintained with pancuronium bromide at 0.1 mg/kg/hr. End-tidal CO2 was monitored and maintained at 30 torr (4.0 kPa), the arterial oxygen saturation was > 95%. Blood sampling was limited to 1 to 3 ml daily for blood urea nitrogen, creatinine, hemoglobin, and hematocrit measurements. Recombinant human erythropoietin 10,000 units subcutaneous twice daily was begun. Intravenous iron (100 mg) was administered daily. Methyltestosterone (25 mg) was administered via the nasogastric tube daily for at total of 3 days. An average of 1800 kcal/day was provided by intravenous hyperalimentation, with a protein intake of 2 g/kg/day. At the 1-year follow-up, he has a hemoglobin of 13.5 g/dL (135 g/L), serum creatinine of 1.2 g/dL (106 µmol/L), and has no evidence of allograft rejection or recurrence of his nephrotic syndrome.

(4) Kaufman DB, Sutherland DE, Fryd DS, Ascher NL, Simmons RL, Najarian JS. A SINGLE-CENTER EXPERIENCE OF RENAL TRANSPLANTATION IN THIRTEEN JEHOVAH'S WITNESSES. Transplantation 1988 June; 45(6): 1045-49 The beneficial effects of pretransplant blood transfusions on the success rate of renal transplantation have been so overwhelmingly emphasized that there is virtually no information on the fate of grafts in nontransfused patients transplanted during the last decade. Since 1979, all patients who have undergone renal transplantation at the University of Minnesota have routinely received random blood transfusion except Jehovah's Witnesses. Jehovah's Witnesses refuse transfusions but will accept renal allografts. From 1979 to May 30, 1987, primary renal allografts were placed in thirteen nontransfused Jehovah's Witnesses; six patients received kidneys from mismatched living-related donors, to patients received HLA-identical sibling grafts, and five patients received cadaveric renal allografts. The range of follow-up of the thirteen patients was 3�93 months, with a mean of 45 months and a median of 50 months. The outcomes after renal transplantation in Jehovah's Witnesses were compared with those of a paired control group (n = 25) matched for age, date of transplant, donor source, and diabetic status. The overall three-year actuarial patient and graft survival rates of the Jehovah's Witnesses were 83 per cent and 66 per cent, versus 80 per cent and 77 per cent for the controls. Although the outcomes after renal transplantation in Jehovah's Witnesses were similar to those of the control group, the Jehovah's Witnesses had an increased susceptibility to rejection episodes. The cumulative percentage of incidence of primary rejection episodes was 77 per cent at three months in the Jehovah's Witnesses versus 44 per cent at 21 months in the matched control group. The consequence of early allograft dysfunction from rejection was particularly detrimental to Jehovah's Witnesses who developed severe anemia (hemoglobin (Hgb) 4.5 g per cent)- two early deaths occurred in the subgroup with this combination of problems. The overall results suggest that renal transplantation can be safely and efficaciously applied to most Jehovah's Witnesses but those with anemia who undergo early rejection episodes are a high-risk group relative to other transplant patients.


(5) Kaufman DB, Sutherland DE, Simmons RL, Ascher NA, Najarian JS. TRANSPLANTATION IN JEHOVAH'S WITNESSES. Transplant Proc 1987 October; 19(5): 3693

3. Heart Transplantation (1) Burnett CM, Duncan JM, Vega JD, Lonquist JL, Sweeney MS, Frazier OH.

HEART TRANSPLANTATION IN JEHOVAH�S WITNESSES. AN INITIAL EXPERIENCE AND FOLLOW-UP. Arch Surg 1990 November; 125: 1430-3 More than 25 years of experience performing heart surgery on Jehovah�s Witnesses has culminated in successful cardiac transplantation without administrating blood products in five patients (mean age, 44.4 +/- 8.3 years) of this faith. The use of blood-conserving methods, iron supplementation, bone marrow-sparing maintenance immunotherapy, and brisk postoperative diuresis has added to the efficacy of cardiac transplantation in these patients. No perioperative deaths occurred, and early follow-up studies have shown that these patients have not been more susceptible to higher graft rejection rates due to the lack of pretansplant blood transfusions. As more Jehovah's Witnesses undergo heart transplantation in the future, comparison with other recipients who allow pretransplant blood transfusion may lead to a better understanding of rejection immunobiology. We conclude that cardiac transplants may be safely offered to Jehovah's Witnesses without fear of a uniformly poor outcome.

(2) Corno AF, Laks H, Stevenson LW, Clark S, Drinkwater DC. HEART TRANSPLANTATION IN A JEHOVAH�S WITNESS. J Heart Transplant 1986 March/April; 5(2): 175-77 Heart transplantation has been successfully performed without blood products in a 45-year-old Jehovah�s Witness. During the entire procedure and the postoperative course, the patient received no transfusions of blood or blood products. The patients own blood was salvaged during the procedure and continuously reinfused using the Haemonetics Cell Saver System. Immunosuppression was maintained with cyclosporine and prednisone.

4. Lung Transplantation (1) Mallory GB Jr

CHALLENGING ISSUES ASSOCIATED WITH ORGAN TRANSPLANTATION FOR JEHOVAH'S WITNESS INDIVIDUALS. J Heart Lung Transpl 2000 Feb;19(2):119-120.

(2) Conte JV, Orens JB LUNG TRANSPLANTATION IN A JEHOVAH'S WITNESS. J Heart Lung Transplant 1999 Aug;18(8):796-800

Department of Surgery, Johns Hopkins University Hospital, Baltimore, Maryland 21287, USA. Patients of the Jehovah's Witness faith generally do not accept transfusions of blood or blood products but some will accept cadaveric organs for transplantation. We report a left single lung transplantation in a 48-year-old Hispanic female with idiopathic pulmonary fibrosis and secondary pulmonary hypertension. We believe this is the first reported case of lung transplantation in a Jehovah's Witness.


5. Bone Marrow Transaplantation (1) Ballen KK, Ford PA, Waitkus H, Emmons RV, Levy W, Doyle P, Stewart FM, Quesenberry

PJ, Becker PS SUCCESSFUL AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT THE USE OF BLOOD PRODUCT SUPPORT. Bone Marrow Transplant 2000 Jul;26(2):227-229.

University of Massachusetts Memorial Cancer Center, Worcester, MA, USA. We describe a successful autologous bone marrow transplant without the use of any blood products. The patient had relapsed large cell lymphoma. He was a Jehovah's Witness and would not accept transfusions of red blood cells or platelets. He enrolled in our Bloodless Medicine and Surgery Program and was maintained on a regimen of erythropoietin, iron, Amicar, and G-CSF throughout the transplant. He tolerated the transplant well and is alive with no evidence of disease 10 months after autografting.

XV. ORTHOPEDIC

1. Orthopedics General Aspects (1) Schulz R, Schmitt E.

[GERIATRIC ORTHOPEDIC TREATMENT OF JEHOVAH'S WITNESSES]?. [ARTICLE IN GERMAN] Versicherungsmedizin 1997 April; 49(2): 52-55

Orthopadischen Universitatsklinik und Poliklinik, Frankfurt am Main. The proceedings in elective surgery in �Jehovah's Witnesses� differ from customary operations. Intensive physical therapy, high complaint, internal and anesthesiologic examination, exact information about the risks and facilities as �cell-saving� etc. and postoperative planning are necessarily required ahead of the indication to operate. Additional complications may be possible. The higher costs are balanced by avoiding, respectively getting rid of disability, immobilisation and the needing of care. A religious dogma leads to a special point of view towards life, death, health and expectations towards' the life and its quality as well as social support. It is difficult undertaking in elective surgery to bring this dogma and our ethic and moral values into accord. It is not medicine vs. religion, but to point out a way and the limits by respecting the individual ideology, abstract conceptions and philosophy of life.

(2) Streef C, Charpentier C, Audibert G, Laxenaire MC [TREATMENT OF POST-TRAUMATIC ACUTE ANEMIA BY RECOMBINANT HUMAN ERYTHROPOIETIN IN JEHOVAH'S WITNESSES] [ARTICLE IN FRENCH]. Ann Fr Anesth Reanim 1996;15(8):1199-202

Service d'anesthesie chirurgicale, hopitaux urbains, CHU, hopital central, Nancy, France. A 20-year-old Jehovah's witness patient experienced a femur fracture, with a section of the femoral artery and vein. On admission, haemoglobin concentration was 5.6 g.dL-1 and haematocrit 17%. Because of aponevrotomy, blood losses persisted. As the patient refused blood transfusion, recombinant human erythropoietin and parenteral iron were administered, associated with mild hypothermia, sedation and mechanical ventilation. After 21 days, the haemoglobin concentration increased to 10.9 g.dL-1 and haematocrit to 33% Recombinant human erythropoietin and parenteral iron may provide an alternative safe and effective therapy in life-threatening anaemia when blood transfusions are not accepted by the patient.


(3) Nelson CL, Fontenot HJ TEN STRATEGIES TO REDUCE BLOOD LOSS IN ORTHOPEDIC SURGERY. Am J Surg 1995 December; 170(6A Suppl): 64S-68S In any operative procedure, careful surgical dissection with precise hemostasis is one of the most effective ways to minimize surgical blood loss and reduce the need for allogeneic red blood cell transfusion. Several other techniques contribute to reduce blood loss in major orthopedic procedures. These techniques are reviewed and include rehearsal of the procedure and positioning the patient to reduce venous engorgement. In addition, a case report is presented that demonstrates the feasibility of revision hip replacement surgery without the use of transfusion in a Jehovah's Witness patient.

(4) Spence RK, Sculco TP, Keating EM, Nelson CL. CHANGING TRANSFUSION PRACTICES IN ORTHOPEDIC SURGERY. Orthopedics 1995 September; 18(9): 842-45

(5) Bombardini T, Borghi B, Zaca F, Picano E, Caroli GC. SHORT-TERM CARDIAC ADAPTION TO SEVERE HAEMODILUTION: AN ECHOCARDIOGRAPHIC STUDY IN NORMAL AND HYPERTENSIVE SUBJECTS. Eur Heart J 1994 May; 15(5): 637-40 In order to avoid transfusion risks and optimize blood bank resources, in recent years may blood sparing techniques have been proposed, including severe haemodilution. The aim of this study is to assess the pattern of normal haemodynamic and cardiac adaption to severe haemodilution in patients undergoing major orthopaedic surgery and refusing blood transfusions for religious reasons (the patients were Jehovah�s Witnesses). Two-dimensionally guided M-mode echocardiograms were performed at baseline and 4 days after major orthopaedic surgery in 26 Jehovah�s Witnesses (age 61 +/- 11 years), with normal regional and global baseline left ventricular function and no valvular disease. Left ventricular (LV) volumes were estimated by using the Teichholz formula. From the latter, we calculated ejection fraction and stroke volume, cardiac output (stroke volume x heart rate), and total peripheral resistance estimated as mean arterial pressure by cuff sphygmomanometer x 80/cardiac output. On the basis of LV mass (ASE-cube corrected by Devereux), two groups were identified: non-hypertrophic (LV mass index < 110 g.m-2 in women and < 130 g.m-2 in males) and hypertrophic. In the 19 patients without LV hypertrophy, haemoglobin decreased from 13.5 +/- 1.6 (mean +/- standard deviation) g.dl-1 (at baseline) to 8.7 +/- 1.3 post-operation (P < 0.01), and peripheral vascular resistances fell from 2131 +/- 450 to 1278 +/- 310 (dyne.s.cm-5) (P < 0.01).

(6) Harris SL POSTOPERATIVE ORTHOPEDIC BLOOD SALVAGE AND REINFUSION. Orthop Nurs 1992 Sep-Oct;11(5):8 Comment on: Orthop Nurs 1992 May-Jun;11(3):30-8

2. Spinal Surgery (1) Vitale MG, Stazzone EJ, Gelijns AC, Moskowitz AJ, Roye DP Jr

THE EFFECTIVENESS OF PREOPERATIVE ERYTHROPOIETIN IN AVERTING ALLOGENIC BLOOD TRANSFUSION AMONG CHILDREN UNDERGOING SCOLIOSIS SURGERY. J Pediatr Orthop B 1998 Jul;7(3):203-9

New York Orthopaedic Hospital, New York, USA. Concerns about the transmission of the human immunodeficiency virus (HIV) have driven the evolution of surgical transfusion practices including the use of preoperative erythropoietin (rhEPO). Although there is significant experience documenting the efficacy of preoperative rhEPO in reducing transfusion requirements for adult patients, there is little experience in the pediatric population. With 178 pediatric patients who underwent surgery for spinal deformity, a retrospective cohort study was performed using patient charts, administrative records, and blood bank computer data. Of these patients,


44% received erythropoietin and 55% did not. From the entire population, 17.5% were in the rhEPO treatment group that received homologous blood transfusion compared with 30.6% in the untreated group (p < 0.05). Among the children with idiopathic scoliosis, this effect was more pronounced, with 3.9% of rhEPO patients receiving blood transfusion compared with 23.5% of nontreated patients (p = 0.006). Additionally, rhEPO treatment was associated with a significantly decreased length of stay only for patients in the idiopathic group (9.3 vs. 6.7, p = 0.02). Use of preoperative erythropoietin in pediatric patients undergoing scoliosis surgery resulted in higher preoperative hematocrit levels. Significantly lower rates of transfusion were noted only in the idiopathic group, however. Although there is a possibility of erythropoietin "resistance" in the neuromuscular and congenital patients, alternative explanations for the lack of effect on transfusion rates may include underdosing and biases existent in this nonrandomized retrospective study.

(2) Shulman G, Solanki DR, Nicodemus CL, Flores IM, Hadjipavlou AG AUDIT OF AUTOTRANSFUSION IN SPINE SURGERY. Int Orthop 1998;22(5):303-7

Department of Pathology, University of Texas Medical Branch, Galveston 77555-0192, USA. A prospective evaluation has been undertaken of 382 patients undergoing reconstructive spine surgery during a thirty-six month period. Acute normovolaemic haemodilution and haemapheresis for blood component sequestration was used in 80 patients in the operating theatre. An average of two units each of freshly collected autologous red cells and fresh plasma together with a therapeutic dose of a plateletpheresis product were prepared for each patient prior to surgical incision. The same supplies and equipment were subsequently used for conventional blood salvage and autotransfusion. The other 302 patients received salvaged blood only. Of the total blood transfused, autologous red cells comprised 87% of sequestration and 49% of autotransfusion-only patients. Each group received the same total perioperative red blood cell support. The cost for one red cell equivalent by intraoperative autologous transfusion was competitive with that of providing one unit of cross-matched allogeneic red cells. As compared with salvage alone, sequestration combined with salvage was even more cost effective and decreased reliance on allogenic products and preoperative autologous blood donations. The rate of transfusing autologous blood products was markedly increased.

(3) Christodoulou AG, Kapetanos G, Apostolou T, Pournaras J, Symeonides PP SEGMENTAL SPINAL CORRECTION OF IDIOPATHIC SCOLIOSIS. LUQUE RODS AND HARTSHILL RECTANGLE IN 30 PATIENTS FOLLOWED FOR 2-6 YEARS. Acta Orthop Scand Suppl 1997 Oct;275:3-7

Department of Orthopaedic Surgery, University of Thessaloniki, School of Medicine, Greece. 30 patients with idiopathic scoliosis were treated by posterior spinal arthrodesis using the Luque (8 patients) and Hartshill (22 patients) rodding systems with sublaminar segmental wiring. Patients were followed for 2 to 6 years. In most cases, postoperative correction exceeded safety correction limits (lateral bending film plus 10 degrees). Final correction was 55%, while derotation was not significant (average 3 degrees). No neurological deficit was noted. Postoperative bracing was not applied and there was 1 patient with broken rods (Luque trolley system without fusion) and 1 patient with broken wires in 4 segments. Allogenic blood transfusion was avoided in 19 patients by preoperative donation of autologous blood, in combination with salvage of intraoperative shed blood. We found segmental spinal wiring with either rods or rectangles to be a safe method for correction of scoliosis in experienced hands. It offered satisfactory stability and fusion rate with no need for external support.

(4) Hagemann A, Welte M, Habler O, Kleen M, Krodel A, Messmer K [AVOIDANCE OF HOMOLOGOUS BLOOD TRANSFUSION DESPITE EXTREME BLOOD LOSS]. [ARTICLE IN GERMAN] Anaesthesist 1997 Nov;46(11):964-8

Institut fur Anasthesiologie, Ludwig-Maximilians-Universitat, Klinikum Grosshadern, Munchen.


We report the case of a 22-year-old woman who underwent two-step scoliosis surgery without allogeneic transfusion, although the intraoperative blood loss (3500 ml) during the first procedure was higher than the calculated blood volume (3250 ml). Preoperatively the patient had donated four units of autologous blood. Intraoperatively blood-saving methods were combined. During the first operation acute normovolemic hemodilution (target hemoglobin 9.0 g/dl) was applied and during the second operation controlled hypotension (systolic blood pressure 80 mmHg). Intraoperative auto-transfusion was used in both procedures. During the first operation severe normovolemic anemia (minimal hemoglobin 3.5 g/dl) was accepted while the patient was ventilated with FiO2 1.0. The hemoglobin concentration was 8.6 g/dl after the first procedure and had increased to 11.6 g/dl 4 weeks after the second procedure. No severe complications occurred during the postoperative phase. This case report shows that also in surgical procedures with extreme blood loss any allogenic transfusion can be avoided by the combination of blood-saving methods, acceptance of low intraoperative transfusion trigger and ventilation with 100% oxygen.

(5) Feigenbaum F, Sulmasy DP, Pellegrino ED, Henderson FC. SPONDYLOPTOTIC FRACTURE OF THE CERVICAL SPINE IN A PREGNANT ANEMIC JEHOVAH'S WITNESS: TECHNICAL AND ETHICAL CONSIDERATIONS. CASE REPORT. J Neurosurg 1997 September; 87(3): 458-63 The authors present the case of a 15-year-old Jehovah's Witness with a hematocrit level of 19% who was 4 months pregnant and had a two-level spondyloptotic cervical spine fracture. The patient was transferred to Georgetown University Medical Center with C-5 quadriplegia 3 weeks after having been injured in an automobile collision. The neurosurgical issues in this case included addressing a rare cervical spine injury, assessing and treating a vertebral artery injury, and performing surgery on a pregnant minor with severe anemia who held strong Jehovah's Witness beliefs. An ethics consultation was convened to determine the validity of a pregnant minor's refusal to undergo transfusion on the grounds of her religious beliefs. This case illustrates the potential benefits of thorough technical and ethical evaluations and reveals how they may contribute to the delivery of care in complex neurosurgical cases. To the author's knowledge, this is the first two-level spondyloptotic cervical spine fracture dislocation to be reported in the literature. The added comlexities of the case, given that the patient was an anemic, adolescent, pregnant Jehovah's Witness who refused blood transfusion, also appear to be unprecedented.

(6) Safwat AM, Reitan JA, Benson D. MANAGEMENT OF JEHOVAH'S WITNESS PATIENTS FOR SCOLIOSIS SURGERY: THE USE OF PLATELETS AND PLASMAPHERESIS. J Clin Anesth 1997 September; 9(6): 510-13 Four patients whose religious beliefs prohibited accepting blood during surgery for scoliosis were anesthetized and managed successfully using plateletpheresis and plasmapheresis. Blood losses were replaced with crystalloid and hetastarch solutions. In addition, a moderate hypotensive technique was used to minimize surgical blood loss. Postoperatively, the patients received iron therapy and/or erythropoietin. Three of these patients had an uncomplicated postoperative course, however, the fourth patient had some postoperative bleeding with initial hemodynamic instability. We believe that patients who refuse to receive blood transfusion during surgery because of religious beliefs or health issues can be managed safely using other alternatives and techniques such as plateletpheresis and plasmapheresis, which conserve and minimize blood loss. Each case should be assessed on an individual basis.

(7) Phillips WA, Hensinger RN. CONTROL OF BLOOD LOSS DURING SCOLIOSIS SURGERY. Clin Orthop 1988 April; No 229: 88-93 In patients who cannot or will not receive blood transfusions, such as Jehovah�s Witnesses, it may be necessary to stage the procedure by exposing and fusing a limited part of the spine at each stage, stopping before the blood loss reaches a level that would not allow normal function.


(8) Bowen JR, Angus PD, Huxster RR, MacEwen GD. POSTERIOR SPINAL FUSION WITHOUT BLOOD REPLACEMENT IN JEHOVAH'S WITNESSES. Clin Orthop 1985 September; 198: 284-88 Posterior spinal fusion without blood replacement is a formidable procedure that most orthopedic surgeons are reluctant to attempt. This procedure has been performed without transfusion on 19 patients, all of whom were Jehovah's Witnesses. The operations were performed over four spinal segments at a time and were planned so that the procedure could be terminated when 10% of the patient's estimated total blood volume had been lost. Allogeneic donor bone was used to minimize blood loss whenever this was acceptable to the patient. The procedure was associated with a high incidence of pseudarthrosis, all cases of which occurred when allogeneic bone was used. No deaths or life-threatening complications were encountered. Thus, posterior spinal fusion can be performed in Jehovah's Witnesses without transfusion, but the procedure should be conducted only by the experienced spinal surgeon.

(9) Winter RB, Swayze C. SEVERE NEUROFIBROMATOSIS KYPHOSCOLIOSIS IN A JEHOVAH�S WITNESS. ANTERIOR AND POSTERIOR SPINE FUSION WITHOUT BLOOD TRANSFUSION. Spine 1983; 8(1): 39-42 A case is presented of a 22-year-old female Jehovah�s Witness with severe kyphoscoliosis, who was successfully treated surgically by carefully staged posterior and anterior spine fusions completed with the use of intraoperative hemodilution techniques. Three spinal procedures were carried out at intervals, and no blood transfusions was given at any of them.

(10) Wong KC, Webster LR, Coleman SS, Dunn HK. HEMODILUTION AND INDUCED HYPOTENSION FOR INSERTION OF A HARRINGTON ROD IN A JEHOVAH�S WITNESS PATIENT. Clinical Orthopaedics and Related Research 1980 Oct; No. 152: 237-40 This report represents a prospective study of a Jehovah�s Witness patient whose scoliosis was repaired by the insertion of a Harrington rod, while the combined concepts of hemodilution and induced hypotension were utilized to minimize blood loss.

(11) Bonnett C, Lapin R, Latini R, Barron R. POSTERIOR SPINAL FUSION WITH HARRINGTON INSTRUMENTATION. FOR IDIOPATHIC SCOLIOSIS IN JEHOVAH�S WITNESSES. Orthopaedic Review 1980 October; 9(10): 27-36 Eight Jehovah�s Witness patients underwent posterior spinal fusion with Harrington instrumentation for idiopathic scoliosis. In all patients there were no serious complications; specifically no intraoperative problems, wound infections, nor postoperative hemorrhage, thrombophlebitis, or peripheral nerve or spinal injuries. The procedure is recommended to surgeons who work quickly and efficiently in controlling surgical blood loss.

(12) Bonnett C, Lapin R, Latini R, Barron R. NEUROLOGICAL ORTHOPEDIC SPINAL SURGERY IN JEHOVAH�S WITNESS PATIENTS. The Journal of Neurological and Orthopaedic Surgery 1980 April; 1(2): 121-26 A total of 18 Jehovah�s Witness patients underwent spinal surgery at Fountain Valley Community Hospital from July 1976 to September 1979. Surgical indications varied from relief of pain, in patients with herniated cervical or lumbar discs, to correction of spinal deformity in scoliotic patients. The 10 females and 8 males ranged in age from 17 to 60 years. Average intra-operative blood loss accurately measured was 425cc in scoliotic operations, 100cc in lumbar laminectomys and 40cc in anterior cervical discectomy and fusions. Intra-operative replacement with an average of 2000cc of ringers lactate was performed. Minimization of surgical blood loss was accomplished using electrocoagulation cautery (BOVIE) for all surgical dissection with coagulation set at a mean of 50. There were no intra-operative complications, peripheral nerve or spinal cord injuries, nor loosening of the spinal instruments. All patients expressed personal satisfaction with their surgical results and were rated good to excellent final results.


3. Hip Surgery (1) Nelson CL, Stewart JG

PRIMARY AND REVISION TOTAL HIP REPLACEMENT IN PATIENTS WHO ARE JEHOVAH'S WITNESSES. Clin Orthop 1999 Dec;(369):251-61

University of Arkansas for Medical Sciences, Little Rock 72205, USA. The Jehovah's Witnesses do not accept allogeneic blood transfusion or certain types of autologous blood transfusion and, therefore, present the orthopaedic surgeon with a challenge in the management of perioperative blood loss. Accepting a patient who is a Jehovah's Witness as a surgical candidate requires the surgeon to be prepared medically to use known techniques to limit red blood cell loss or increase red blood cell mass, to resort to extraordinary means when necessary, and to be prepared philosophically to deal with catastrophic blood loss in a patient who may refuse even potentially life-saving transfusion. Issues pertinent to the management of intraoperative blood loss in the patient who is a Jehovah's Witness require careful delineation and specific treatment guidelines. The authors herein review their past and current experiences in the perioperative blood management of this patient population in an attempt to address this need.

(2) Sparling EA, Nelson CL, Lavender R, Smith J. THE USE OF ERYTHROPOIETIN IN THE MANAGEMENT OF JEHOVAH'S WITNESSES WHO HAVE REVISION TOTAL HIP ARTHROPLASTY. J Bone Joint Surg Am 1996 October; 78(19): 1548-52 Five Jehovah's Witnesses (on man and four women) were managed with revision total hip arthroplasty. The average age of the patients at the time of the index operation was 66.4 years (range, fifty-eight to seventy-eight years). All of the patients received subcutaneous injections of recombinant human erythropoietin before the operation, at an initial dose of 100 international units per kilogram of body weight three times a week. The duration of preoperative treatment was determined by the hematocrit at the time of presentation. The hematocrit was monitored weekly, beginning with the second week of treatment, and the dose was adjusted accordingly until the time of the operation. Erythropoietin therapy was discontinued if the hematocrit exceeded 0.45 at any time. The hematocrit before the erythropoietin therapy was begun, at the time of admission to the hospital (one or two days preoperatively), immediately postoperatively, and at the time that the patient was discharged were recorded for this study. All five revision total hip arthroplasties were performed successfully without a blood transfusion. No patient had any complications associated with an excessive loss of blood or a low hematocrit. The average hematocrit was 0.395 (range, 0.317 to 0.447) before the erythropoietin therapy was begun and was 0.476 (range, 0.431 to 0.509) after treatment with erythropoietin and before the operation (that is, at the time of admission to the hospital). The average duration of erythropoietin therapy was twenty-six days preoperatively and 3.6 days postoperatively. The average hematocrit was 0.368 (range, 0272 to 0.424) immediately after the operation and was 0.308 (range, 0294 to 0.327) at the time of discharge from the hospital. No patient had evidence of deep venous thrombosis. This study illustrates that it is possible and apparently safe to optimize the hematocrit, by use of erythropoietin, in a patient who is scheduled for an operation. This may be particularly beneficial to a patient with anemia who has failure of a total hip arthroplasty. A relatively high hematocrit (0.45 to 0.50) preoperatively provides a relative margin of safety to a procedure that frequently involves a great deal of intraoperative blood loss. The use of erythropoietin preoperatively is particularly suited to joint replacements and revisions because of their elective nature and the moderately flexible timing associated with these procedures.

(3) Josefsson G [PRIMARY HIP ARTHROPLASTY IN 14 JEHOVAH'S WITNESSES. NO COMPLICATIONS RELATED TO BLEEDING WERE REPORTED]. [ARTICLE IN SWEDISH] Lakartidningen 1996 Sep 18;93(38):3237-8

Ortopediska kliniken, Lanssjukhuset, Gavle.


Många kirurger känner tveksamhet inför ett operativt ingrepp på en patient som tillhör Jehovas vittnen, vilkas tro inte tillåter blodtransfusion. Kirurgen har sin övertygelse och vittnet sin och därmed föreligger etiske problem för båda. Med modern teknik � bl a blodtvätt � är det möjligt att utföra höfteledsplastik utan att använda homologt bankblod. Under perioden 1980�95 har 16 primära hoftledsplastiker utförts på 14 patienter, elva kvinnor och tre män. Medelålderen var 69,5 år med en spridning på 34-85 år.

(4) Wittmann PH, Wittmann FW TOTAL HIP REPLACEMENT SURGERY WITHOUT BLOOD TRANSFUSION IN JEHOVAH'S WITNESSES. Br J Anaesth 1992 March; 68(3): 306-07 Uncemented total hip replacement surgery without blood transfusion is described in 12 Jehovah's Witnesses and morbidity is compared with a group who each received 3 units of blood. There were no deaths and all the patients except two, one from each group, left hospital within 3 weeks.

(5) Bonnett CA, Lapin R, Docuyanan GB. TOTAL HIP REPLACEMENT IN JEHOVAH'S WITNESSES UNDER SPINAL ANESTHESIA WITHOUT TRANSFUSION. Orthop Rev 1987 January; 16(1): 43-47 Ninety patients who were Jehovah's Witnesses underwent 107 total hip replacements without transfusion; all procedures were performed under spinal anesthesia. Of these, 90, 87 had not previously undergone hip replacement surgery. They sustained an average intraoperative blood loss of 300 mL, which was a significant reduction compared with that in controlled groups of patients reported by other authors. Factors other than spinal anesthesia that aided in reducing blood loss were posterior surgical exposure of the hip without capsulectomy or removal of the greater trochanter, hemostasis without electrocauterization, and rapidly performed surgery. There were three operative complications and one death, none of which were related to spinal anesthesia.

(6) Mariorenzi AL, Pierik MG. QUADRUPLE MAJOR JOINT REPLACEMENT IN MEMBER OF JEHOVAH�S WITNESSES: NO BLOOD PRODUCTS, AUTOTRANSFUSION OR SUBSTITUTES USED. Orthopaedic Rev 1986 August; 15(8): 531-33. Bilateral total knee and total hip replacement were performed on a 44-year-old woman with severe unremitting rheumatoid arthritis. The patient, a Jehovah�s Witness had refused transfusion utilizing blood, blood by-products, and blood substitutes. She had also refused the use of autotransfusion, even in the event of an emergency. The authors describe successful major joint replacement carried out on four separate occasions without transfusion. The only hematologic therapy was the preoperative and postoperative administration of iron dextran.

(7) Nelson CL, Bowen WS. TOTAL HIP ARTHROPLASTY IN JEHOVAH'S WITNESSES WITHOUT BLOOD TRANSFUSION. J Bone Joint Surg [Am] 1986 March; 68(3): 350-53 One hundred patients who were Jehovah�s Witnesses underwent total hip replacement without transfusion, of which eighty-nine procedures were performed under hypotensive anesthesia. Of these eighty-nine patients, sixty-five had not had previous hip surgery and sustained an average intraoperative blood loss of 450 milliliters. This was a 43 per cent reduction in blood loss as compared with a control group of patients, who were not Jehovah's Witnesses and had total hip replacement under normotensive anesthesia. Twenty-four of the eighty-nine patients who were Jehovah's Witnesses and had had previous hip surgery underwent total hip arthroplasty under hypotensive anesthesia and sustained an average intraoperative blood loss of 680 milliliter, which was 30 per cent less than that of similar matched controls who were operated on under normotensive anesthesia. The postoperative blood loss in the patients who had had hypotensive anesthesia was not increased compared with that in the controls. Eleven Jehovah's Witnesses who were not candidates for hypotensive anesthesia had a total hip replacement under normotensive techniques. Factors other than hypotensive anesthesia that aided in reducing blood loss were


careful surgical technique, meticulous hemostasis, and well planned surgery. There were six complications, one of which was possibly related to hypotensive anesthesia, and no deaths.

(8) Cunningham AJA. CONTROLLED HYPOTENSION TO MINIMIZE BLOOD LOSS OF ANAEMIC JEHOVAH�S WITNESS PATIENT UNDERGOING TOTAL HIP AND SHOULDER REPLACEMENT. Br J Anaesth 1982; 54: 895-98 A Jehovah�s Witness with disabling rheumatoid arthritis, and a normocytic, normochromic anaemia, underwent on separate occasions a staged total hip and a shoulder replacement. Controlled hypotension with therapeutic doses of sodium nitroprusside was used to minimize blood loss, and haemodilution with crystalloid fluids was used to maintain normal cardiac output.

(9) Rab GT, Gorin LJ, Eisele JH. BILATERAL TOTAL HIP ARTHROPLASTY IN A JEHOVAH�S WITNESS WITH CHRONIC ANEMIA. Clinical Orthopaedics and Related Reseach 1982 March; No 163: 134-36 A 15-year-old girl demonstrated the ability of a youthful person with systemic disease and chronic anemia to withstand major reconstructive surgery, despite religious beliefs prohibiting blood transfusion. With careful preoperative planning and meticulous hemostasis, as well as hypotensive anesthesia, such patients need not be denied the benefits of various reconstructive procedures, provided that they and their families understand and appreciate the risks involved.

(10) Nelson CL, Martin K, Lawson N, Thompson D, Revard R. TOTAL HIP REPLACEMENT WITHOUT TRANSFUSION. Contemporary Orthopaedics 1980; 2: 655 We report our findings in a group of 119 patients undergoing total hip replacement under hypotensive anesthesia without blood transfusion, and in 116 control patients who underwent total hip replacement without hypotensive anesthesia and with blood transfusion as needed. In the hypotensive group, the 82 patients undergoing their first hip procedures had an average blood loss of 480 ml; the average loss in the control group was nearly twice this amount. With hypotensive anesthesia, the blood loss in the 37 patients undergoing a second operation on the same hip was approximately 100 ml more than for patients undergoing a first hip procedure. The lowest hemoglobin in the 82 patients undergoing initial hip procedures under hypotensive anesthesia occurred on the seventh postoperative day and averaged 9.8 gm%; by discharge this had increased to 10.6 gm%. Urine output in the hypotensive group was not compromised, and there was no tendency toward acidosis. The arterial blood gases remained normal during the period of hypotension and afterward in the recovery room. Operative time is critical, as blood loss was found to be related to the total operative time. When combined with meticulous attention to surgical hemostasis and postoperative compressive dressing, the use of hypotensive anesthesia allows patients to safely undergo reconstructive hip surgery without the transfusion of blood og blood products.

(11) (Anonymous) HYPOTENSIVE ANESTHESIA FACILITATES HIP SURGERY. JAMA 1978 January 16; 239(3): 181 We�ve now applied this technique to patients other than Jehovah�s Witnesses who are undergoing surgery � orthopedic and otherwise � because it is a superior form of anesthesia, and it�s logical not to lose all that blood. We advise it for anyone who is physiologically intact. Transfusion reactions are avoided as well.

XVI. TRAUMA AND EMERGENCY 1. Trauma and Emergency treatments

a) General Aspects


(1) Otteni JC [JEHOVAH'S WITNESS: A CASE OF A TRAFFIC ACCIDENT WITH A FATAL OUTCOME]. [ARTICLE IN FRENCH] Ann Fr Anesth Reanim 1998;17(5):432

(2) Victorino G, Wisner DH. JEHOVAH�S WITNESSES: UNIQUE PROBLEMS IN A UNIQUE TRAUMA POPULATION. J Am Coll Surg 1997 May; 184(5): 458-68 BACKGROUND: Jehovah�s Witnesses can create perplexing treatment problems by their refusal of blood transfusions. This dilemma is especially difficult for the trauma surgeon faced with critically low hemoglobin levels or life-threatening blood loss in an injured Jehovah�s Witness. STUDY DESIGN: Retrospectively review of the records of 58 Jehovah�s Witnesses admitted to a single trauma center between July 1992 and June 1995. RESULTS: There were 53 blunt and 5 penetrating injuries. Four patients (7 percent) received blood transfusions; one received banked blood and three received autotransfusions. Two patients were sedated and paralyzed to optimize oxygen utilization; one patient received erythropoietin. Eighteen patients had a general anesthetic and underwent an operative procedure; one underwent controlled hypotensive anesthesia with normovolemic hemodilution. The records of 21 patients (36 percent) included documentation of absolute refusal of blood or blood products; the exact status of consent for blood transfusion was not documented in the records of 33 patients (57 percent). One death and six complications occurred, none of which were attributed to acute blood loss or anemia. Treatment options and special techniques for the severely anemic patient refusing blood transfusions are discussed. CONCLUSIONS: Documentation of religious status and beliefs about blood transfusions, as well as knowledge of special treatment options available for anemic Jehovah�s Witnesses, is necessary to provide quality care to this unique population.

(3) Kirchgesser G, Dittmer H [THE PROBLEM OF POLYTRAUMA TREATMENT IN JEHOVAH'S WITNESSES]. [ARTICLE IN GERMAN] Chirurg 1992 Jun;63(6):523-5

Abteilung Unfallchirurgie, Stadtischen Kliniken Frankfurt a.M.-Hochst.

b) Monitoring of Trauma Patients

(1) Guertler AT CLINICAL PRACTICE OF EMERGENCY MEDICINE Emerg Med Clin North Am 1997 May; 15(2): 303-13 This article provides brief updates, pearls, and pitfalls on aspects of emergency practice that are dealt with routinely, including the application of diagnostic testing in the emergency department, ruling out subarachnoid hemorrhage, and the use of tympanic temperatures. Physician-patient and physician-physician communication skills are addressed. Finally, medicolegal and administrative topics, such as EMTALA, writing admitting orders, treating minors in the emergency department, and blood product therapy in Jehovah�s Witnesses are also discussed.

c) Phlebotomy induced Iatrogenic Anemia

(1) Dech ZF, Szaflarski NL. NURSING STRATEGIES TO MINIMIZE BLOOD LOSS ASSOCIATED WITH PHLEBOTOMY. AACN Clin Issues 1996 May; 7(2): 277-87 Blood loss associated with phlebotomy is significant in critically ill adults. Iatrogenic anemia may result and impose unnecessary stress on the cardiovascular and respiratory systems and may require allogeneic blood transfusions. Many strategies exist under nursing�s direct control to decrease blood loss associated with phlebotomy. In the past, nursing effectively implemented many of these strategies in


patients at high risk of anemia, such as pediatric, neontatal, transplant, or chronic renal failure patients, as well as patients who are Jehovah�s Witnesses. Implementation of these strategies are needed for all critically ill patients because allogeneic blood transfusions carry infectious risk and because complications and chronic critical illness cannot be predicted reliably. Incorporation of these strategies into daily practice as well as the development of blood conservation programs represent imminent challenges for nursing.

d) Myocardial Ischemia During the Perioperative Period

(1) Botero C, Smith CE, Morscher AH ANEMIA AND PERIOPERATIVE MYOCARDIAL ISCHEMIA IN A JEHOVAH'S WITNESS PATIENT. J Clin Anesth 1996 Aug;8(5):386-91


2. Cranial Trauma Management

(1) Logemann F, Schulze K, Verner L NONINVASIVE MONITORING OF CEREBRAL OXYGEN SATURATION AFTER SEVERE CRANIOCEREBRAL TRAUMA IN A JEHOVAH�S WITNESS. Anasthesiol Intensivmed Notfallmed Schmerzther 1997 June; 32(6): 385-90 Patients with severe head injury run a high risk of developing secondary cerebral defects. Various methods have so far been described which vary in their continuity, invasiveness and technical aspects for the early detection and treatment of complications. Within this group of patients Jehovah�s Witnesses pose a particular problem due to their restriction concerning therapeutical possibilities. That may mean an additional danger to the cerebral O2-delivery. This case report highlights on the value of continuous, non-invasive cerebral O2-saturation measurement and its combination with the fiberoptical monitoring of mixed venous O2-saturation. It has been possible to recognize episodes of imbalance between O2-delivery and its demand owing to a variety of causes. Other measured parameters were unable to reliably detect the development of critical complications. Further iatrogenic loss of blood by laboratory tests was significantly reduced. Despite partially insufficient circulation and anemia with a hemoglobin value of 49 g/l we were able to discharge the patient from ICU without recognizable neurologic sequele.

3. Cervical Spinal Fracture treatment

(1) Feigenbaum F, Sulmasy DP, Pellegrino ED, Henderson FC SPONDYLOPTOTIC FRACTURE OF THE CERVICAL SPINE IN A PREGNANT, FEIGENBAUM F, ANEMIC JEHOVAH'S WITNESS: TECHNICAL AND ETHICAL CONSIDERATIONS. CASE REPORT. J Neurosurg 1997 Sep;87(3):458-463

Department of Neurosurgery, and Center for Clinical Bioethics, Georgetown University Medical Center, Washington, D.C. 20007, USA. The authors present the case of a 15-year-old Jehovah's Witness with a hematocrit level of 19% who was 4 months pregnant and had a two-level spondyloptotic cervical spine fracture. The patient was transferred to Georgetown University Medical Center with C-5 quadriplegia 3 weeks after having been injured in an automobile collision. The neurosurgical issues in this case included addressing a rare cervical spine injury, assessing and treating a vertebral artery injury, and performing surgery on a pregnant minor with severe anemia who held strong Jehovah's Witness beliefs. An ethics consultation was convened to determine the validity of a pregnant minor's refusal to undergo transfusion on the grounds


of her religious beliefs. This case illustrates the potential benefits of thorough technical and ethical evaluations and reveals how they may contribute to the delivery of care in complex neurosurgical cases. To the authors' knowledge, this is the first two-level spondyloptotic cervical spine fracture dislocation to be reported in the literature. The added complexities of the case, given that the patient was an anemic, adolescent, pregnant Jehovah's Witness who refused blood transfusion, also appear to be unprecedented.

4. Thermal Trauma Management

A. Non Blood Management in Burns

a) Adult Thermal Victims

(2) McGill V, Kowal-Vern A, Gamelli RL. A CONSERVATIVE THERMAL INJURY TREATMENT PROTOCOL FOR THE APPROPRIATE JEHOVAH'S WITNESS CANDIDATE. J Burn Care Rehabil 1997 Mar/Apr; 18(2): 133-38 The Jehovah's Witness (JW) members abstain from receiving blood transfusions or blood product infusions because these treatments are considered an extension of life. A JW who incurs significant thermal injury requires a protocol defining good clinical practices in life-threatening predicaments acceptable to JW members to avoid legal proceedings. Assessment of religious commitment, competency, family resources, and respect for the patient's refusal of treatment is required. Detailed documentation of the patient's position is necessary. Medical management should include standard critical care measures, blood conservation, restricted laboratory work, utilization of pediatric blood cellection tubes, nonblood plasma expanders, erythropoietin administration, iron supplements, and aggressive nutritional support with appropriate surgical conservation measures during skin grafting procedures. With conservative management, a positive outcome can be attained without recourse to the legal system.

(3) Schumacher H [HOMOLOGOUS BLOOD TRANSFUSION IN SEVERELY BURNED JEHOVAH'S WITNESSES]. [ARTICLE IN GERMAN] Chirurg 1994 Dec;65(12):1155

(4) Schlagintweit S, Snelling CF, Germann E, Warren RJ, Fitzpatrick DG, Kester DA, Foley B. MAJOR BURNS MANAGED WITHOUT BLOOD OR BLOOD PRODUCTS. J Burn Care Rehabil 1990; 11: 214-20 Four major burns (two flame, one scald, one electrical) were managed without administration of blood or plasma. Serial changes in hemoglobin, and serum albumin and total protein measurements were compared with those of controlled patients matched in age and total body surface area burned who were treated by standard methods. Hemoglobin values were lower but within one standard deviation, although serum protein and albumin measurements fell more than one standard deviation below mean values observed in control patients at comparable times after burn injury. Important treatment principles that were instrumental to recovery include a high-calorie, high-protein diet, iron supplementation, use of pediatric blood sampling techniques, and monitoring for and prophylaxis against infection while allowing eschar to separate spontaneously rather than performing early debridement. Amputation of mummified electrically burned limbs at more proximal levels, including marginally viable muscle, is recommended to minimize infection and decrease blood loss associated with customary conservative serial debridements.

(5) Waters LM, Christensen MA, Sato RM. HETASTARCH: AN ALTERNATIVE COLLOID IN BURN SHOCK MANAGEMENT. J Burn Care Rehabil 1989 January/February; 10(1): 11-16 Hetastarch is a synthetic polysaccharide colloid that has been used clinically in the management of multiple trauma, hypovolemic shock, and postoperative cardiac patients. Our objective was to determine whether hetastarch is a safe alternative to blood products in burn shock resuscitation. Twenty-six patients received hetastarch during the colloid phase of resuscitation and were compared to matched


historical controls who received either albumin or fresh frozen plasma. Clinical and laboratory parameters were measured on admission and for 4 days after the burn. There was no significant difference in hemodynamics, respiratory status, incidence of bleeding, or renal or liver function among the three colloid groups. The advantages of hetastarch include immediate availability, no dependence on human blood donor population, no risk of serum-transmitted diseases, and lower costs. It can safely recommended for those patients who object to blood products for resuscitation, in those situations where human donors are few, and when cost is a consideration.

(6) Scheflan M, Padberg F, Aikawa N, Bruke JF. METHABOLIC AND CLINICAL CONSIDERATIONS IN AN UNUSUAL PATIENT WITH 35% BSA DEEP PARTIAL-THICKNESS THERMAL INJURY. The Journal of Trauma 1977 June; 17(6): 462-66 The treatment of a moderately large burn usually requires blood and its products to restore circulating blood volume, achieve metabolic stabilization, and promote wound healing. This case study demonstrates the remarkable metabolic response to injury in a patient refusing blood products administration.

b) Burns in Children

(1) Donner B, Tryba M, Kurz-Muller K, Vogt P, Steinau U, Zenz M, Pern U. ANESTHESIA AND INTENSIVE CARE MANAGEMENT OF SEVERELY BURNED CHILDREN OF JEHOVAH'S WITNESSES. Anaesthetist 1996 February; 45(2): 171-75 A 3.5-year-old girl suffered from a thermal injury affecting 37% of the body surface area. The parents, being Jehovah's Witnesses, refused permission for their children to receive blood transfusions. As the haemoglobin level was only 7.5% and a necrotomy was planned, the patient was likely to need blood transfusions. Indications for transfusion were defined as clinical signs of hypoxia and/or cardiovascular instability. A judicial declaration was proposed. Hb decreased during the therapy. To stimulate the erythropoiesis erythropoietin and iron were administered. During the clinical course the anaemia worsened. First, a conservation treatment with polyvidoniodine ointment for tanning was started, to avoid an operation during the acute phase after the injury, as in this case it was thought a blood transfusion would definitely be necessary. On the 19th day after the injury a necrotomy of 10% of the body surface was necessary because of fever and leucocytosis not responding to antibiotics. The most likely cause of the symptoms was an infection of he burned area. Hb was 4.6 g/dl%. General anaesthesia was performed with midazolam, ketamine and vecuronium and mechanical ventilation. No blood transfusion was required during the operation. Vital signs were stable during the preoperative period, during anaesthesia and following operation. There were no signs of tissue hypoxia. Peripheral oxygen saturation ranged between 98% and 100%, lactate and arterial blood gas samples were normal, and the child was awake and cooperative before and after anaesthesia. The lowest Hb was 3.3 g/dl on the 22th day after injury (3rd postoperative day). In this phase the patient was still playing and riding a tricycle. On the 45th day after injury the child was discharged home with Hb of 10.9 g/dl and reticulocytosis of 33%.

(2) Vogt PM, Kurz-Müller K, Peter FW, Büttemeyer R, Tryba M, Steinau HU. PREVENTING BLOOD TRANSFUSION IN A SEVERELY BURNED JEHOVAH'S WITNESS. [ARTICLE IN GERMAN] Der Chirurg 1994 November; 65(11): 1066-68

Universitatsklinik fur Plastische Chirurgie, Handchirurgie und Schwerbrandverletzte, Ruhr-Universitat Bochum. The treatment rationale of a burn victim (35% TBSA) who was a child of Jehovah�s Witnesses is described. Following a combined approach including erythropoietin and blood saving surgical techniques we were able to excise and graft the burn areas without blood transfusion. An extremely low hemoglobin of 3.4 g/dl was tolerated postoperatively and showed an increase to 10.9 g/dl 25 days later when the child was dismissed from the burn unit in stable condition. Possibilities to minimize blood loss and to avoid blood transfusions are discussed.


B. EPO in Thermal Injury

(1) Moghtader JC, Edlich RF, Mintz PD, Zachmann GC, Himel HN. THE USE OF RECOMBINANT HUMAN ERYTHROPOIETIN AND CULTURED EPITHELIAL AUTOGRAFTS IN A JEHOVAH�S WITNESSS WITH A MAJOR THERMAL INJURY. Burns 1994 April; 20(2): 176-7 Haemostatic debridement, recombinant-human erythropoietin and cultured epithelial autografts have been used successfully in a Jehovah's Witness with a major burn injury. Tourniquet ischaemia complemented by a topical haemostatic agent minimizing excisional blood loss, while recombinant-human erythropoietin accelerated erythropoiesis, thereby correcting postburn anaemia. Cultured epithelial autografts provided coverage of the granulating wounds without creating donor sites.

(2) Deitch EA, Guillory D, Cruz N. SUCCESSFUL USE OF RECOMBINANT HUMAN ERYTHROPOIETIN IN A JEHOVAH�S WITNESS WITH A THERMAL INJURY. Journal of Burn Care & Rehabilitation 1994 January; 15(1): 42�5 Options for treating the Jehovah's Witness with burns who repeatedly refuses blood are very limited. This article describes the use of human recombinant erythropoietin as an alternative to blood transfusion in a Jehovah�s Witness with 35% total body surface area burn. The combination of erythropoietin treatment, limited blood drawing, and excision and grafting under tourniquet control allowed this patient to undergo successful burn care, including four operative procedures to excise and graft 19.5% of the body surface area.

(3) Boshkov LK, Tredget EE, Janowska-Wieczorek A. RECOMBINANT HUMAN ERYTHROPOIETIN FOR A JEHOVAH�S WITNESS WITH ANEMIA OF THERMAL INJURY American Journal of Hematology 1991 May; 37(1): 53-4 We report the use of recombinant human erythropoietin (rh-Ep) as an alternative to transfusion therapy in a burn victim who was a Jehovah�s Witness and refused blood transfusion. Despite endogenous elevated erythropoietin levels, the patient was reticulocytopenic and administration of rh-Ep was accompanied by a 10-fold increase in reticulocyte response and a rise in hemoglobin from 7.4 to 10.4 g/dl over a 12-day period. We suggest that the exogenously administered erythropoietin overcame a clinically inadequate endogenous erythropoietin response.

(4) Law EJ, Still JM, Gattis CS. THE USE OF ERYTHROPOIETIN IN TWO BURNED PATIENTS WHO ARE JEHOVAH�S WITNESSES. Burns 1991 February; 17(1): 75�7 Recombinant-human erythropoietin was given to two burn patients who are Jehovah's Witnesses and hence refused blood transfusion. Anaemia developing postburn was corrected in both patients. Serum erythropoietin levels were found to be elevated prior to initiation of therapy in both patients. Anaemia is a problem that inevitably occurs in patients with large burns. Postburn anaemia is a haemolytic anaemia, which occurs following trauma to erythrocytes due to heat. Burn patients also may not make red cells at a normal rate and are subject to further loss during surgery, laboratory tests, and secondary infections.

5. Trauma and Acute Anemia Treatment

(1) Nelson BS, Heiskell LE, Cemaj S, O�Callaghan TA, Koller CE. TRAUMATICALLY INJURED JEHOVAH�S WITNESSES: A SIXTEEN-YEAR EXPERIENCE OF TREATMENT AND TRANSFUSION DILEMMAS AT A LEVEL I TRAUMA CENTER. J Trauma 1995 October; 39(4): 681-85


Traumatically injured Jehovah�s Witnesses pose difficult management problems of their refusal to accept blood transfusion. This retrospective review of all inpatient traumatically injured Jehovah�s Witnesses at a level I trauma center over the past 16 years revealed 77 patients with 92% blunt and 8% penetrating injuries. The primary physician was aware of their unique religious status in only 32% of cases. Transfusion was performed in only 4 (5.2%) cases even though it was desired by the physician in 11 (14%) cases. One transfusion was performed against the patient�s will. One minor was transfused using a court order. Two transfusions were performed in the trauma room before the patient�s religious status was known. Major changes in therapeutic plans were made as a result of the patient�s Jehovah�s Witness status in 10 cases (13%). Early knowledge of the patient�s religious status is essential to optimize patient care.

(2) van Daele ME, Throuwborst A, van Woerkens LC, Tenbrinck R, Fraser AG, Roelandt JR. TRANSESOPHAGEAL ECHOCARDIOGRAPHIC MONITORING OF PREOPERATIVE ACUTE HYPERVOLEMIC HEMODILUTION. Anesthesiology 1994 September; 81(3): 602-09

(3) Freitag P. MANAGEMENT OF A MULTIPLY INJURED JEHOVAH�S WITNESS WITH SEVERE ACUTE ANEMIA. Orthop Rev 1994 May; 23(5): 375

(4) Kelley JL, Bruke TW, Lichtiger B, Dupuis JF EXTRACORPOREAL CIRCULATION AS A BLOOD CONSERVATION TECHNIQUE FOR EXTENSIVE PELVIC OPERATIONS. J Am Coll Surg 1994 April; 178(4): 397-400 Difficult pelvic operations for malignancy or complex benign conditions can be associated with extensive blood loss. Religious beliefs that preclude transfusion and the known risks of homologous blood have prompted investigators to seek alternatives to transfusion. We used the Haemonetics-V50 Cell Separator (Haemonetics Corporation) to provide for extracorporeal circulation of the patient�s own blood with associated normovolemic hemodilution as a means of conserving blood during operations. This technique was used in eight patients undergoing extensive pelvic operations. The procedure was accepted by Jehovah�s Witnesses and was well tolerated by all patients. Estimated blood loss ranged from 75 to 2,000 milliliters. One instance of mild intraoperative disseminated intravascular coagulation was encountered. Two patients were given homologous transfusions. While clinical judgement is necessary to determine the safety of complicated operations, this technique is useful in expanding surgical options for some patients who object to blood transfusion.

(5) Rupp RE, Ebraheim NA, Saddemi SR, Wido T. MANAGEMENT OF A MULTIPLE INJURED JEHOVAH�S WITNESS WITH SEVERE ACUTE ANEMIA. Orthop Rev 1993 July; 22(7): 847-50 The refusal of blood products by Jehovah�s Witnesses creates ethical and mediocolegal dilemmas for the treating physician. Appropriate management involves some understanding of the beliefs of the Jehovah�s Witnesses and knowledge of a variety of techniques to minimize blood loss. This case report describes the treatment of a Jehovah�s Witness with severe anemia and multiple skeletal injuries. The need to keep blood loss to a minimum influenced the management of this patient.

(6) Collins SL, Timberlake GA. SEVERE ANEMIA IN THE JEHOVAH�S WITNESS: CASE REPORT AND DISCUSSION. Am J Crit Care 1993 May; 2(3): 256-59 Major blood loss following trauma is common, but severe anemia is generally not life-threatening when managed with administration of blood and blood products. Severe anemia becomes particularly challenging and potentially lethal when the patient is a Jehovah�s Witness, for whom receiving a transfusion is contrary to religious principles. This case report describes the management and hospital course of a Jehovah�s Witness who was seriously injured in an airplane crash.


(7) Author ? EMERGENCY TREATMENT OF JEHOVAH�S WITNESSES. S Afr Med J 1991 December 7; 80(11-12): 626-28

(8) Fontanarosa PB, Giorgio GT. THE ROLE OF THE EMERGENCY PHYSICIAN IN THE MANAGEMENT OF JEHOVAH�S WITNESSES. Ann Emerg Med 1989 October; 18(10): 1089-95 Patients presenting to the emergency department who refuse recommended treatment present substantial management and mediocolegal problems for the emergency physician. Members of the Jehovah�s Witness religion, who number approximately 700,000 in the United States, create specific medical, ethical, and legal challenges when they require but refuse necessary blood component therapy. Appropriate management involves timely medical intervention, an awareness of the religious rights and beliefs of Jehovah�s Witnesses and a sound understanding of the ramifications of their emergency care. A protocol is presented for responding to opposition to transfusions by Jehovah�s Witnesses. The protocol should increase the likelihood of an effective medical and ethical response by emergency physicians and should help to protect against potential legal actions.

(9) Howell JP, Bamber PA. SEVERE ACUTE ANAEMIA IN A JEHOVAH�S WITNESS: SURVIVAL WITHOUT BLOOD TRANSFUSION. Anaesthesia 1987 January; 42(1): 44-8 A case is described in which a Jehovah�s Witness underwent emergency surgery following which her haemoglobin fell to 1.8 g/dlitre. She was successfully treated in an intensive care unit with intermittent positive pressure ventilation of the lungs, high inspired oxygen concentrations and transfusions of large volumes of gelatin solution.

(10) Herbsman H TREATING THE JEHOVAH�S WITNESS Emergency Med 1980 January 15; 12(1): 73-76 A new technique that shows great promise for these patients combines reinfusion of the patient�s own blood with simultaneous infusion of physiologic fluids. At the start of the surgery about one third of the patient�s own blood is drawn off into a reservoir that allows small amounts to be constantly returned to the circulation, satisfying the religious reguirements of the Jehovah�s Witness. At the same time Ringer�s lactat is infused through another line to maintain circulatory stability. At the termination of surgery, all the blood remaining in the reservoir is reinfused. An advantage of this technique is that since it results in a hemodilution of approximately 30%, fewer red blood cells are given off with the blood that is lost.

(11) Lorhan PH, Burch J. ANESTHESIA FOR A JEHOVAH�S WITNESS WITH A LOW HEMATOCRIT. Anesthesiology 1968 July-August; 29(4): 847-48 A 34-year-old man, following palliative resection of the colon, developed massive postoperative hemorrhage requiring immediate intervention. The patient�s hemoglobin was 3.6/100 ml. At what low level of hematocrit and hemoglobin can an anesthesiologist in good conscience administer an anesthetic to a Jehovah�s Witness without predetermined resort to the use of blood? Obviously, the decision is conditioned by the oxygen-carrying capacity of the patient�s blood and the reliable assumption of optimal PO2, hemoglobin saturation and circulating blood volume. Despite the apparent simplicity of being able to predict (from tables, nomograms, etc.) minimum oxygen content of whole blood at various PO2 and hemoglobin levels, reasonable safe lower limits of the latter remain uncertain on the basis of actual clinical experience.

A. Autotransfusion 1. Autotransfusion General aspects


(1) Heimbecker RO BLOOD RECYCLING ELIMINATES NEED FOR BLOOD. CMAJ 1996 Aug 1;155(3):275-6 Comment on: Can Med Assoc J 1996 Feb 15;154(4):557-60

(2) Page P PERIOPERATIVE AUTOTRANSFUSION AND ITS CORRELATION TO HEMOSTASIS AND COAGULOPATHIES. J Extra Corpor Technol 1991;23(1):14-21

Electromedics, Inc. The use of autologous blood techniques affords the reduction or elimination of homologous blood transfusions for most patients. In addition, for certain religious faiths such as Jehovah's Witnesses or those patients with rare blood types, intraoperative salvage and return of the patient's own blood is the only source of available blood. Autologous blood salvage in the perioperative period includes: hemodilution; intraoperative salvage of lost blood; postoperative collection of shed blood. Perioperatively, autologous blood is salvaged and returned and the volumes involved do not create any hematological problems for the patient. In those cases involving large volumes of blood being processed and returned to the patient, the autotransfusionist must be aware of the possible alterations that may occur in the patient's coagulation system. The collection and reinfusion of wound drainage fluids from operative sites has the potential to cause severe bleeding problems. This paper will present an overview of autologous blood salvage techniques in the perioperative period along with a review of the clinical effects of autotransfusion on hemostasis. Also discussed will be possible coagulopathies that can be caused by returning collected autologous blood.

2. AT from Laparoscopically Salvaged Blood

(1) Zantut LF, Machado MA, Volpe P, Poggetti RS, Birolini D. AUTOTRANSFUSION WITH LAPAROSCOPICALLY SALVAGED BLOOD IN TRAUMA: REPORT ON 21 CASES. Surg Laparosc Endosc 1996 February; 6(1): 46-48 Autotransfusion is being increasingly used to avoid the complications of homologous blood transfusion. In abdominal trauma, however, the collected blood may be contaminated by intestinal contents when digestive or urinary lesions are present. In such situations, the reinfusion of blood is contraindicated. We present our experience with autotransfusion of blood collected by laparoscopy from the abdominal cavity of 21 trauma patients. Laparoscopy allowed the aspiration of blood and, at the same time, permitted diagnosis of visceral lesions, avoiding reinfusion of contaminated blood. No complications occurred, and hematocrit values were significantly elevated. This procedure may represent the only possible method of blood transfusion in Jehovah�s Witnesses, as with one patient in our series.

B. Aneurysm Surgery 1. General aspects of Aortic Aneurysm Repair

(1) Gallagher JM, Brown ME, Gasior TA COMBINED USE OF APROTININ AND A HEPARIN-BONDED CARDIOPULMONARY BYPASS SYSTEM FOR AORTIC ANEURYSM REPAIR. J Cardiothorac Vasc Anesth 1995 Dec;9(6):728-30

2. Ascending Aorta Aneurysm Surgery



Department of Surgery, Baylor College of Medicine, Houston, Texas. A young woman of the Jehovah's Witness faith presented with a rupturing aneurysm of the ascending aorta and transverse aortic arch. She had Marfan syndrome and previous aortic valve replacement. Despite reoperation conditions, successful operation via median sternotomy was carried out using deep hypothermia and circulatory arrest.

(2) Bricker DL, Parker TM, Mistrot JJ, Dalton ML. REPAIR OF ACUTE DISSECTION OF THE ASCENDING AORTA, ASSOCIATED WITH COARCTATION OF THE THORACIC AORTA IN A JEHOVAH�S WITNESS. J Cardiovasc Surg 1980 May/June; 21(3): 374-78 A twenty-year-old white man, with acute dissection of the ascending aorta, underwent emergency resection with dacron graft replacement, utilizing cardiopulmonary bypass. Subsequent repair of coarctation of the thoracic aorta was performed. No blood was administered due to the patient�s religious preference. The problems of emergency surgery in Jehovah�s Witness patients are discussed.

3. Thoracic Aorta Aneurysm Surgery

(1) Westaby S, Parry AJ, Lamont P, Grebenik C. MASSIVE DESCENDING THORARIC ANEURYSM IN A JEHOVAH�S WITNESS: TREATMENT BY THROMBOEXCLUSION. Ann Thorac Surg 1993 May; 55(5): 1233-35 The thromboexclusion technique was used to treat massive thoraric aneurysm in a Jehovah�s Witness. Preoperative erythropoietin therapy was used. At operation a Hemashield graft was used to bypass the aneurysm before the mouth was stapled closed. The hemoglobin level fell from 13.5 to 10.6 g/dL.

(2) Taguchi S, Sugihara K, Muraoka M, Wakayama S, Matsuki A. AN EMERGENCY OPERATION FOR A JEHOVAH�S WITNESS WITH RUPTURED THORARIC SACCULAR ANEURYSM. Masui 1993 March; 42(3): 445-49 A 49-year-old male Jehovah�s Witness was transferred to our hospital with hypotension, abdominal pain, and abdominal distension, and a diagnosis of ruptured thoraric saccular aneurysm was made. He and his family insisted on having an emergency operation for his ruptured aneurysm without blood transfusion. After an intensive discussion among the patient, his family, surgeons, and the director of the hospital, we performed the operation without blood transfusion. The operation using cardiopulmonary bypass took about five hours under enflurane anesthesia, but he died of circulatory collapse fifteen hours after the end of operation. As there may be various opinions concerning how we should take care of Jehovah�s Witness patients, we have to manage them case by case.

4. Abdominal Aorta Aneurysm Surgery

(1) Baker CE, Kelly GD, Perkins GD

PERIOPERATIVE CARE OF A JEHOVAH'S WITNESS WITH A LEAKING ABDOMINAL AORTIC ANEURYSM. Br J Anaesth. 1998 Aug;81(2):256-9.



(2) Gutowski P, Dybkowska K, Szumilowicz G. OPERATION FOR RUPTURED ABDOMINAL AORTIC ANEURYSM WITHOUT CONSENT FOR BLOOD TRANSFUSION � CASE REPORT. Wiad Lek 1997; 50(4-6): 120-22 Successful operation for ruptured abdominal aortic aneurysm (AAA) in a Jehovah�s Witness 66-year-old man was presented. The patient was urgently operated for symptomatic AAA. We found during surgery that that aneurysm was ruptured. Bifurcated PTFE aorto-bi-iliac prosthesis was implanted. The patient did not receive any blood or blood-origin products while staying in our Hospital.

C. Hyperbaric Oxygen Therapy (1) Bell MD

THE USE OF HYPERBARIC OXYGEN IN THE MANAGEMENT OF SEVER ANAEMIA IN A JEHOVAH'S WITNESS. Anaesthesia 2000 Mar;55(3):293-294.

(2) Thompson JC LESSONS FROM A LIFE IN SURGERY. I. DO YOU WANT THE HIGH FIGURE OR THE LOW? Surgery 1999 Mar;125(3):345-6

Department of Surgery, University of Texas Medical Branch at Galveston 77555, USA

(3) Editorial board of Merck Research Laboratories HYPERBARIC OXYGEN THERAPY The Merck Manual of Diagnosis and Therapy, 16th Edition, 1992 May; 2565-2571

Exceptional Blood loss Anemia In certain instances of blood loss (eg, in Jehovah�s Witnesses who refuse blood products for religious reasons) and in cases of severe hemolysis or a rare blood type for which no adequate cross-match may be obtained, blood transfusions may not be possible. Patients with as little as 1 gm of Hb have been salvaged when HBO has been used. Enough O2 can be physically dissolved in plasma at 3 ATA [atmospheres absolute] to support life, and there appears to be no inhibition of erythropoiesis when HBO is used intermittently.HBO may be required as often as every other hour, with 1 h spent at pressures up to 2.5 ATA. More commonly ,1 or 2 h spent at 2 ATA suffices, with a surface interval of from 2 to 6 h.

(4) Fisher B. , Jain KK, Braun E. , Lehrl S. ANEMIA AND HYPERBARIC OXYGEN Handbook of Hyperbaric Oxygen Therapy 1988, pp 180-83 It has already been mentioned in Chap. 2 that enough oxygen (6 vol%) can be dissolved in plasma to support life. The classical study on the subject of life without blood was by Boerema et al. (1959). There are difficulties in administering blood in some situations, particularly in Jehovah�s Witnesses, who do not accept any blood or blood component because of their religious beliefs. HBO can temporarily meet the oxygen needs of the body in the absence of blood and has been termed �bloodless transfusion�. Hart (1974) reported three patients who were dying of acute blood loss anemia and whom he treated successfully with HBO. All three had very low hemoglobin levels, 2-3 g/dl, hematocrit of 10-11,5% and falling blood pressure, as well as a rising pulse rate. The treatment in all was limited to intravenous fluids, intramuscular iron-dextran and HBO at 2 ATA for 60-90 min. HBO was repeated whenever the pulse rate rose above 120. All the patients improved dramatically and in one case the hemoglobin rose from 2 g to 8 g in 1 week of treatment.


(5) �Myking O, Schreiner A. HYPERBARIC OXYGEN IN HEMOLYTIC CRISIS. JAMA 1974 Mar 11; 227(10): 1161-62 Conditions with severe reduction of hemoglobin in which blood replacement is opposed for biological or religious reasons represents a therapeutic challenge. Such a challenge was presented by a Jehovah�s Witness with gastric bleeding and hemoglobin level of 2.2 gm/100 ml, who refused blood transfusion but survived after treatment with hyperbaric oxygen. This report presents the effect of hyperbaric oxygen as a new therapeutic alternative in hemolytic crisis.

(6) Hart GB. EXCEPTIONAL BLOOD LOSS ANEMIA: TREATMENT WITH HYPERBARIC OXYGEN. JAMA 1974 May; 228(8): 1028-9 All three patients were treated with fluids administered intravenously, iron dextran injection intramuscularly, and hyperbaric oxygen. The hyperbaric oxygen was administered in a singel-place chamber at to atmospheres absolute for 60 to 90 minutes each treatment. The number of treatments varied with each patient, depending on his or her condition. When the pulse rate was greater than 120 beats per minute, the blood pressure less than 100 mm Hg systolic, and the patient became confused, treatment would be resumed. The single-place chamber was used, as it affords a more efficient, economical delivery system than the complicated, expensive multiplace chamber. Patient 2 received hyperbaric oxygen for more than 35 hours without pulmonary or cerebral signs of oxygen toxicity

D. Gastrointestinal Emergencies and Surgery (1) Orr KB.

DUODENAL PAPILLARY ADENOMA IN A JEHOVAH�S WITNESS. Med J Aust 1996 February 5; 164(3): 191

(2) Atabek U, Spence RK, Pello M, Alexander J, Camishion R. PANCREATICODUODENECTOMY WITHOUT HOMOLOGOUS BLOOD TRANSFUSION IN AN ANEMIC JEHOVAH�S WITNESS. Arch Surg 1992 March; 127(3): 349-51 Whipple pancreaticoduodenectomy is an accepted procedure for management of periampullary and pancreatic carcinomas and has modern mortality rates of less than 10%. The procedure is associated with significant operative blood loss. Therefore, blood transfusion is an important supportive measure. We report the case of a bleeding ampullary carcinoma in a Jehovah�s Witness who refused transfusion of all homologous blood products. Despite a preoperative hemoglobin level of 51 g/L, curative pancreaticoduodenectomy was successfully performed. The success of the procedure can be primarily attributed to careful surgical technique, intraoperative autotransfusion, avoidance of postoperative complications, minimization of perioperative phlebotomies, use of human recombinant erythropoietin, and, possibly, the use of the perfluorocarbon emulsion Fluosol DA-20%. The case illustrates several important principles for the surgical treatment of patients with severe anemia who refuse transfusion of homologous blood products.

(3) Bloss RS, Cooley DA. PANCREATICOJEJUNOSTOMY FOR FULMINATING PANCREATITIS AND PANCREATIC ASCITES IN A JEHOVAH�S WITNESS. J Pediatr Surg 1981 February; 16(1): 79-81 Pancreatitis is generally restricted to adults, most often caused or aggravated by alcoholism or biliary tract disorders, and rarely develops in children. When the diagnosis is made, the patient usually can be treated medically; however, the disease often has nonspecific early symptoms and is not discovered until potentially fatal complications have ensued. We present an unusual case of severe posttraumatic pancreatic ascites in an anemic 3-year-old child whose parents were of the Jehovah�s Witness faith. She underwent successful surgical treatment involving distal pancreaticojejunostomy with preservation of the spleen.


(4) Gordon ME, Ramsby GR, Passarelli NM, Romero CA. PEPTIC ULCER HEMORRHAGE: VASOPRESSIN FOR A JEHOVAH�S WITNESS. Annals of Internal Medicine 1973 September; 79(3): 451-52 Selective arterial catheterizations have been used in recent years by others and by us to locate and control massive gastrointestinal hemorrhage. Indications for using vasopressin infusion are the reduction or elimination of blood transfusions, postponement of surgical intervention in emergency situations, and philosophical or religious objections to transfusions, as in the case history.

E. Transcathetral embolization and Chemoembolization 1. TAE Chemo for Metastatic Paraganglioma

(1) Mutabagani KH, Klopfenstein KJ, Hogan MJ, Caniano DA METASTATIC PARAGANGLIOMA AND PARANEOPLASTIC-INDUCED ANEMIA IN AN ADOLESCENT: TREATMENT WITH HEPATIC ARTERIAL CHEMOEMBOLIZATION. J Pediatr Hematol Oncol 1999 Nov-Dec;21(6):544-7

Division of Pediatric Surgery, The Ohio State University College of Medicine and Public Health and Children's Hospital, Columbus, USA. Mediastinal paragangliomas are rare neoplasms in children. Anemia, as a paraneoplastic syndrome, has been described in adults with metastatic paraganglioma. The management of paraneoplastic anemia from metastatic paraganglioma has been problematic, with no reports in the literature describing successful treatment. This article describes a 17-year-old Jehovah's Witness with a mediastinal paraganglioma, hepatic metastases, and severe anemia. The patient and his family refused blood products and the anemia was refractory to erythropoietin and elemental iron therapy. Serial chemoembolization of the hepatic lesions resulted in resolution of the anemia, allowing subsequent debulking of the mediastinal paraganglioma.

2. TAE and Chemoembolization of Hepatocellular Cancer

(1) Papatheodoridis GV, Chung S, Keshav S, Pasi J, Burroughs AK CORRECTION OF BOTH PROTHROMBIN TIME AND PRIMARY HAEMOSTASIS BY RECOMBINANT FACTOR VII DURING THERAPEUTIC ALCOHOL INJECTION OF HEPATOCELLULAR CANCER IN LIVER CIRRHOSIS. J Hepatol 1999 Oct;31(4):747-50

Liver Transplantation & Hepatobiliary Medicine, Royal Free Hospital, London, UK. We evaluated the efficacy of recombinant factor VII to correct impaired haemostasis in a patient with liver cirrhosis requiring an invasive procedure. A test intravenous bolus of 80 microg/kg of recombinant factor VII was given to a Jehovah's Witness, with a solitary 4.4-cm hepatocellular carcinoma and underlying hepatitis C virus cirrhosis, in an attempt to correct his haemostatic disorders and safely inject the tumour with alcohol. An extensive portal block had precluded consideration of liver transplantation. Haemostasis was evaluated by clotting assays, bleeding time and thromboelastography 10 min before and 10 min and 1, 2, 4, 8 and 24 h after factor VII infusion. Parameters of both coagulation (prothrombin time) and platelet function (bleeding time and the alpha and ma parameters of thrombelastography) were improved 10 min after factor VII infusion; improvements lasted 4 to 8 h or more. Platelet count did not change and there was no evidence of disseminated intravascular coagulation. The improvements in haemostatic parameters correlated significantly with the increases in factor VII plasma concentrations (p<0.04). Factor VII clearance was 25.1 U/h/kg and its half-life was 5.8 h. The same dose of recombinant factor VII was given to the patient 1 week later, just before the alcohol injections. The patient had no subsequent bleeding or other complication, with no change in haemoglobin levels over 24 h. Thus, recombinant factor VII represents a therapeutic advance, as it can correct fully both coagulation and platelet function defects in cirrhosis and allow invasive procedures to be performed safely.


XVII. BLOOD DISEASES

A. Hematologic Disease and Anemias 1. Anemia of Chronic Disease

a. ACD and EPO

(1) Robinson MKF ERYTHROPOIETIN: USE IN A CRITICALLY ILL PATIENT REFUSING A BLOOD TRANSFUSION. Aust J Hosp Pharm 1997; 27(1): 38-40 Objective: To present a patient with a critically low haemoglobin due to anaemia of chronic disease who was treated with recombinant human erythropoietin (rHuEPO). Anaemia of chronic disease is usually treated with blood transfusion. Studies have shown that erythropoietin can increase production of red blood cells and haemoglobin. A 35-year-old diabetic woman was admitted to Gosford Hospital Intensive Care Unit with ulcers on her right leg. Biochemistry results showed critically low haemoglobin due to anaemia of chronic disease. Blood products were not an option for this patient. She refused them as a result of her religious beliefs (Jehovah's Witness). Case progress and outcome: The clinicians decided to give iron infusions and erythropoietin to treat the anaemia. A total of 36 000 units of erythropoietin was given on three separate days. The daily doses were administered as three divided doses of 4000 units SC. Folic acid, 15 mg daily, and 6.4 iron in two equal doses were also administrated. The patient's hemoglobin increased from 32 g/L to 52 g/L 14 days after treatment commenced. The main adverse reaction of the anaemia treatment was coagulopathy presumably from excess iron. Conclusion: Erythropoietin and iron therapy resulted in a satisfactory increase in JB's haemoglobin. The high cost of the erythropoietin was considered. Intensive care specialists weighed the expense of using erythropoietin against the critical nature of the case, the limited options available for treatment of the anaemia, and the cost of the stay in Intensive Care. Its usage in the situation was justified.

b. Anemia and Fluorocarbons

(1) Kale PB, Sklar GE, Wesolowicz LA, DiLisio RE FLUOSOL: THERAPEUTIC FAILURE IN SEVERE ANEMIA. Ann Pharmacother 1993 Dec;27(12):1452-4

Department of Pharmacy Practice, Wayne State University, Detroit, MI. OBJECTIVE: To report the use of Fluosol in the management of a severe anemia and to review the literature regarding the use of Fluosol. CASE REPORT: A 40-year-old woman, at 40.5 weeks gestation, was admitted for induction of labor. Her hospital course was complicated by a postpartum hemorrhage and severe anemia. Because the patient was a Jehovah's Witness, she received non-blood products including hetastarch, iron dextran, and erythropoietin, and a total of 33 mL/kg of Fluosol, but she did not survive. DISCUSSION: Fluosol is an oxygen-carrying, perfluorochemical blood substitute. It was administered to our patient, who presented with the lowest hemoglobin (Hb) (11 g/L) and hematocrit (0.31 fraction of 1.00) of all reported cases. Almost all patients with an Hb < 20 g/L do not survive. CONCLUSIONS: Although the use of Fluosol as a blood substitute appears theoretically promising, its use in the management of severe anemia cannot be recommended.

(2) Nyberg SL, Cerra FB TREATMENT OF SEVERE ANAEMIA WITH PERFLUOROCARBON BLOOD SUBSTITUTES: A CLINICAL OVERVIEW. Clin Intensive Care 1991;2(4):226-32

Department of Surgery, University of Minnesota, Minneapolis 55455.


(3) Spence RK, McCoy S, Costabile J, Norcross ED, Pello MJ, Alexander JB, Wisdom C, Camishion RC FLUOSOL DA-20 IN THE TREATMENT OF SEVERE ANEMIA: RANDOMIZED, CONTROLLED STUDY OF 46 PATIENTS. Crit Care Med 1990 Nov;18(11):1227-30

Department of Surgery, Cooper Hospital/University Medical Center, Robert Wood Johnson Medical School, Camden 08103. We evaluated the safety and efficacy of Fluosol DA-20% (FDA) as a blood substitute in the treatment of severe anemia. Thirty-six patients received either FDA (n = 21) or crystalloid/hydroxyethyl starch (CHS) (n = 15) as part of a randomized, controlled trial. Ten patients received FDA as part of a humanitarian protocol. All were Jehovah's Witnesses who refused transfusion, had bled recently, and had average Hgb levels of 4.3 g/dl. After pulmonary artery catheter insertion, each patient was infused with CHS to attain a pulmonary artery wedge pressure (WP) of 10 to 18 mm Hg. FDA was given as a one-time dose of 30 ml/kg. Data were collected at baseline, 12, 24, and 48 h. None of the patients with negative reactions to a 0.5-ml test dose of FDA had adverse reactions to the subsequent infusion. The plasma or dissolved component of oxygen content was significantly higher in the FDA group at 12 h (FDA group 1.58 +/- 0.47 ml/dl, control group 1.01 +/- 0.31 ml/dl, p less than .02, t-test). Nineteen patients died: 12 (37.5%) FDA, seven (46.6%) control. The difference was not significant. We conclude the following: a) FDA can be given safely to severely anemic patients in doses of 30 ml/kg; b) FDA significantly increased the dissolved component of oxygen content after 12 h but the effect did not persist; c) severely anemic patients can survive without transfusion although mortality is high. In this study, inability of FDA to sustain increased oxygen content was due in part to the rapid elimination of FDA and also to the limited amount given.

2. Hemophilia and Factor treatment

a) Splenic Tear Management with Factor VIII

(1) Zieg PM, Cohn SM, Beardsley DS NONOPERATIVE MANAGEMENT OF A SPLENIC TEAR IN A JEHOVAH'S WITNESS WITH HEMOPHILIA. J Trauma 1996 February; 40(2): 299-301 Splenic laseration, the most common visceral lesion following blunt abdominal trauma, can be treated in a nonoperative fashion in only a select group of stable patients with minimal injury. We report a case of life-threatening splenic trauma in a Jehovah's Witness with hemophilia that was successfully managed without surgery.Treatment cosisted of: Desmopressin(DDAVP),but did not result in any appreciable improvement in clotting activity when given to him in the Emergency Department.Then the therapy with recombinant factor VIII (50U/kg bolus followed by 3 U/kg/h) was initiated at the Surgical Intensive Care Unit.Subsequent abdominal examination and hemoglobin values remained unchanged while factor VIII activity was maintained within a range of 50 to 200% of normal.On hospital day two the patient was moved to the hospital ward.

b) Use of Recombinant Factor VII treatment

(1) Papatheodoridis GV, Chung S, Keshav S, Pasi J, Burroughs AK CORRECTION OF BOTH PROTHROMBIN TIME AND PRIMARY HAEMOSTASIS BY RECOMBINANT FACTOR VII DURING THERAPEUTIC ALCOHOL INJECTION OF HEPATOCELLULAR CANCER IN LIVER CIRRHOSIS. J Hepatol 1999 Oct;31(4):747-50

Liver Transplantation & Hepatobiliary Medicine, Royal Free Hospital, London, UK. We evaluated the efficacy of recombinant factor VII to correct impaired haemostasis in a patient with liver cirrhosis requiring an invasive procedure. A test intravenous bolus of 80 microg/kg of recombinant factor VII was given to a Jehovah's Witness, with a solitary 4.4-cm hepatocellular carcinoma and underlying hepatitis C virus cirrhosis, in an attempt to correct his haemostatic


disorders and safely inject the tumour with alcohol. An extensive portal block had precluded consideration of liver transplantation. Haemostasis was evaluated by clotting assays, bleeding time and thromboelastography 10 min before and 10 min and 1, 2, 4, 8 and 24 h after factor VII infusion. Parameters of both coagulation (prothrombin time) and platelet function (bleeding time and the alpha and ma parameters of thrombelastography) were improved 10 min after factor VII infusion; improvements lasted 4 to 8 h or more. Platelet count did not change and there was no evidence of disseminated intravascular coagulation. The improvements in haemostatic parameters correlated significantly with the increases in factor VII plasma concentrations (p<0.04). Factor VII clearance was 25.1 U/h/kg and its half-life was 5.8 h. The same dose of recombinant factor VII was given to the patient 1 week later, just before the alcohol injections. The patient had no subsequent bleeding or other complication, with no change in haemoglobin levels over 24 h. Thus, recombinant factor VII represents a therapeutic advance, as it can correct fully both coagulation and platelet function defects in cirrhosis and allow invasive procedures to be performed safely.

c) Percutaneous Nephrolithotripsy in Hemophilia A patient supported by Factor VIII

(1) Azuno Y, Kaku K. PERCUTANEOUS NEPHROLITHOTRIPSY SUPPORTED BY RECOMBINANT FACTOR VIII IN A PATIENT WITH HEMOPHILIA A, A JEHOVAH'S WITNESS. [ARTICLE IN JAPANESE] Rinsho Ketsueki 1995 December; 36(12): 1337-1341 We reported the use of recombinant factor VIII (rF VIII). On two consecutive occasions of percutaneous nephrolithotripsy (PNL) for treatment of nephro-urethrolithiasis in a patient, a Jehovah's Witness, with hemophilia A. The patient refused blood transfusions but reluctantly accepted treatment with plasma-derived factor VIII concentrates. rF VIII was administered intravenously; 50 U/kg just prior to PNL followed by a total dose of 37,500 U of rF VIII within a week on each PNL. Hemostasis was complete on two occasions of PNL. The inhibitor to F VIII did not develop. rF VIII is considered to be an extremely useful for management of hemostasis during invasive surgery for patients with hemophilia A who refuse transfusions for religious reasons.

d) Therapy of Intracranial Hemorrhage in a Hemophilia A patient with Inhibitors

(1) Majumdar G, Savidge GF. RECOMBINANT FACTOR VIIA FOR INTRACRANIAL HAEMORRHAGE IN A JEHOVAH'S WITNESS WITH SEVERE HAEMOPHILIA A AND FACTOR VIII INHIBITORS. Blood Coagul Fibrinolysis 1993 December; 4(6): 1031-33 A Jehovah's Witness with severe haemophilia A and a high titre, high responding inhibitor to both human and porcine factor VIII (FVIII) was treated with recombinant activated factor VII (rVIIa) during an episode of intracranial bleeding. He recovered completely without any adverse effects or neurological sequelae. Treatment with rVIIa in this case was safe and effective. This therapeutic agent should be considered in haemophilia patients with inhibitors who refuse management with blood products on religious grounds and when recombinant factor VIII is not a cost-effective option.

3. Sickle Cell Anemia

(1) Pearlman ES, Ballas SK WHEN TO TRANSFUSE BLOOD IN SICKLE CELL DISEASE? LESSONS FROM JEHOVAH'S WITNESSES. Ann Clin Lab Sci 1994 September; 24(5); 396-400 Hemoglobin concentration of 7 to 8 g/dl has been considered an indication for transfusion in the general adult population and has also been frequently applied to patients with sickle cell disease (SCD). Through a review of the case histories of two patients with SCD who were also Jehovah's Witnesses and developed severe anemia, and considering as well the clinical characteristics of this population and the basic physiology of oxygen transport, the appropriateness is questioned of this


transfusion �trigger� in patients with SCD. It is suggested for the latter that a Hb of 5.5 g/dl be used as an indication for transfusion except in very specific clinical circumstances.

(2) Brooks BJ Jr, Hanson DS, Cryer PA, Hubbard WJ, Hooper D ERYTHROPOIETIN THERAPY FOR SICKLE CELL ANEMIA IN JEHOVAH'S WITNESSES. South Med J 1991 November; 84(11): 1416-17

4. Kawasaki Syndrome

(1) Roy-Bornstein C, Sagor LD, Roberts KB. TREATMENT OF A JEHOVAH'S WITNESS WITH IMMUNE GLOBULIN: CASE OF A CHILD WITH KAWASAKI SYNDROME. Pediatrics 1994 July; 94(1): 112-13

5. Thrombocytopenic Purpura (TTP)

(1) Welborn JL, O�Donnell R, Hsieh T, Eatherton J, Aspry K. VINCRISTINE FOR THROMBOCYTOPENIC PURPURA Lancet 1991 Feb 9; 337: 377-78 We describe a patient with TTP who refused transfusion therapy and was successfully managed with vincristine and antiplatelet agents. Her platelet count were 21 x 109/l. The patient refused plasma exchange as well as platelet and red cell transfusions because of her religious beliefs as a Jehovah�s Witness. Vincristine 2 mg intravenously, aspirin 325 mg, and dipyridamole 75 mg three times a day were given. Vincristine was given weekly for 1 month and her symptoms resolved during the first week. Platelet count rose to 580 x 109/l after the first week and has subsequently remained over 300 x 109/l.

6. Thrombocytopenia (ITP) and HIT

(1) Brown DM PERFUSING THE JEHOVAH'S WITNESS PATIENT WITH HEPARIN-INDUCED THROMBOCYTOPENIA.

J Extra Corp Technol 1998 Dec;30(4):193-196.

Heart Institute of Spokane, Washington 99203, USA. Heparin-induced thrombocytopenia (HIT) is an uncommon, yet dangerous side-effect of heparin therapy. The problems associated with the HIT patient while undergoing cardiopulmonary bypass increase dramatically when the patient is also of Jehovah's Witness faith. This case report depicts the techniques utilized and the decisions made over the course of a simple surgical procedure for an extremely high-risk patient.

(2) Asbill MC, Wallis RA, Apgar FA. A JEHOVAH�S WITNESS WITH THROMBOCYTOPENIA. Hosp Pract 1984 September; 82CC Intravenous corticosteroid therapy was started immediately in a young woman with platelet count of 5000. Because thrombocytopenia persisted for eight days despite treatment, vincristine was administered. Platelet recovery was dramatic.

(3) Callis M, Palacios C, Lopez A, Giralt J, Julia A SPLENIC IRRADIATION AS MANAGEMENT OF ITP. Br J Haematol 1999 Jun;105(3):843-4

7. Acquired von Willebrand Syndrome

a) Coagulopathy induced by Plasma expanders


(1) Lockwood DN, Bullen C, Machin SJ. A SEVERE COAGULOPATHY FOLLOWING VOLUME REPLACEMENT WITH HYDROXYETHYL STARCH IN A JEHOVAH'S WITNESS. Anaesthesia 1988 May; 43(5): 391-93 Blood volume was maintained by an infusion of hydroxyethyl starch 2000 ml (Hespan: HES) during and for the first 28 hours after a major orthopaedic operation in a 13-year-old girl who was a Jehovah's Witness. This was responsible for a generalised clinical haemorrhagic state, an acquired coagulopathy associated with a shortened thrombin, prolonged prothrombin and activated partial thromboplastin times, and an acquired von Willebrand syndrome. The coagulation, after cessation of the infusion of HES, did not become normal until approximately 72 hours later.

8. Kasabach-Merritt Syndrome in JW infant

(1) Kohdera U, Nishimura M, Higashino H, Murata T, Kobayashi Y KASABACH-MERRITT SYNDROME IN A JEHOVAH'S WITNESS INFANT. Pediatr Hematol Oncol 2000 Mar;17(2):191-192.

9. ABO Hemolytic Disease

(1) Lakatos L, Csathy L, Nemes E "BLOODLESS" TREATMENT OF A JEHOVAH'S WITNESS INFANT WITH ABO HEMOLYTIC DISEASE. Perinatol 1999 Oct-Nov;19(7):530-532.

Department of Pediatrics, Kenezy County Hospital, Debrecen, Hungary. An ABO-incompatible term infant girl born to parents who are Jehovah's Witnesses was admitted to our neonatal unit with a high serum bilirubin level necessitating exchange transfusion. The parents signed a request that blood should not be administered under any circumstances. However, they authorized us to apply the possible alternative treatments of orally administered D-penicillamine (300 mg/kg per day divided in three doses for 3 days), phototherapy, intravenous fluids, and recombinant human erythropoietin (200 U/kg subcutaneously on every second day for 2 weeks). Herein, we report the outcome of this baby, who was discharged from the our unit in good condition after treatment. Her physical growth and motor milestones at 14 months of age revealed no red flags for neurodevelopmental maturation. To our knowledge, this is the first case of an infant who received such a combined alternative (and "bloodless") treatment of serious ABO hemolytic disease of the newborn.

10. Other Coagulopathies

(1) Panchal HI, Ramwell J, Lawler PG SEVERE COAGULOPATHY IN JEHOVAH'S WITNESS. Anaesthesia 1989 Jan;44(1):71-2

B. Leukemia and related Diseases 1. Acute Lymphoblastic Leukemia

(1) Bueno J, Zuazu J, Villalba T, Julia A [ACUTE LEUKEMIA IN JEHOVAH'S WITNESSES]. [ARTICLE IN SPANISH] Sangre(Barc) 1999 Oct;44(5):381-382.

Servicio de Hematologia Clinica, Hospital General Vall d'Hebron, Barcelona. [email protected] Two cases of young patients, Jehova Witnesses (JW), diagnosed as having acute lymphoblastic leukaemia are presented. In one case a complete remission (CR) was obtained, lasting until now, 20 months after diagnosis; the other one died 11 months after diagnosis without achieving a CR. Three


important questions can be raised in JW: 1) the absolute respect to patients' wishes; 2) to treat or not to treat; and 3) the pertinent therapy. The answer is yes to 1) and 2), and a slight myelotoxic therapy for the last one.

(2) Takeuchi S, Utsunomiya A, Makino T, Shimotakahara S, Takatsuka Y, Kawabata H, Nakashima A SUCCESSFUL TREATMENT FOR ACUTE LYMPHOBLASTIC LEUKEMIA WITHOUT BLOOD TRANSFUSION IN A JEHOVAH'S WITNESS. Am J Hematol 1999 Feb;60(2):168-9

(3) Cullis JO, Duncombe AS, Dudley JM, Lumley HS, Apperly JF, Smith AG. ACUTE LEUKEMIA IN JEHOVAH'S WITNESSES. Br J Haematol 1998 March; 100(4): 664-68

Department of Haematology, Lewisham Hospital NHS Trust, London. The refusal of Jehovah's Witnesses with leukemia to accept transfusion provides a major clinical challenge because of the myelosuppressive effects of chemotherapy. Experience in treating five such patients is described. Two patients with acute lymphoblastic leukemia (ALL) achieved remission following chemotherapy, the first without transfusion support, the second, a minor, receiving transfusion under a court order: the first patient remains in remission 5 years later, whereas the second subsequently relapsed and died. Of three patients with acute myeloid leukaemia (AML), two received chemotherapy: one died of anaemia during induction chemotherapy whereas the second eventually consented to transfusion but died of refractory leukaemia. The third patient died of anaemia despite erythropoietin. We feel Jehovah's Witnesses should not be denied antileukaemic therapy if they fully understand the risks involved. Minimizing phlebotomy, use of antifibrinolytic agents and growth factors may make chemotherapy feasible, especially in ALL where remission may be induced with less myelosuppressive agents. The outlook for those with AML treated with conventional chemotherapy appears poor; alternative approaches to treatment should be considered in these patients.

(4) Nousiainen T, Jantunen E, Lahtinen R JEHOVAH'S WITNESSES AND ACUTE LEUKEMIA. Am J Hematol 1993 Jun;43(2):158-159

(5) Blütters-Sawatzki R, Bertram U. INTRODUCTION OF ERYTHROPOIETIN IN THE TREATMENT OF ACUTE LYMPHOBLASTIC LEUKEMIA (ALL) IN A PATIENT OF JEHOVAH�S WITNESSES PERSUASION: A CASE REPORT. Medical and Pediatric Oncology Supplement 1992; 2: 23�25 Application of erythropoietin during intensive chemotherapy for acute lymphoblastic leukemia in a 5 year old boy was effective in preventing transfusions of red blood cells. The application of intensive chemotherapy protocols in the treatment of malignant disease is often hampered by limited bone marrow reserves of the patient. This problem is even more severe in patients who, for religious or other reasons, oppose transfusions of blood products. In order to evaluate the benefit of erythropoietin in anemia caused by modern chemotherapy, we treated a boy with subcutaneous injections of erythropoietin while obtaining intensive treatment for acute lymphoblastic leukemia.

(6) Dainer PM, Knupp CL, Sartiano GP LOW-DOSE CYTOSINE ARABINOSIDE AS AN ALTERNATIVE TREATMENT FOR ACUTE LEUKEMIA IN JEHOVAH'S WITNESSES. Am J Hematol 1992 Jun;40(2):156-157

(7) Hargis JB, Waddell DJ, Diehl L, Redmond J. INDUCTION CHEMOTHERAPY IN JEHOVAH'S WITNESSES WITH LEUKAEMIA. Lancet 1990 September 1; 336(8714): 563-564 Comment in: Lancet 1990 Oct 27;336(8722):1075-6


(8) Goldberg SL, et al SHOULD JEHOVAH�S WITNESSES BE DENIED INTENSIVE CHEMOTHERAPY FOR ACUTE LEUKEMIA? The New England Journal of Medicine 1990 March 15; 322(11): 77-8 We describe a man who was a Jehovah�s Witness and who was twice treated successfully with marrow-ablative chemotherapy for his acute leukemia without blood transfusion.

(9) Cullis JO, Smith AG JEHOVAH'S WITNESSES WITH LEUKAEMIA. Lancet 1990 Oct 27;336(8722):1075-1076

Comment on: Lancet 1990 Sep 1;336(8714):563-4

(10) Boggs DR JEHOVAH'S WITNESSES WITH LEUKEMIA. Hosp Pract (Off Ed) 1985 Mar 15;20(3):92

(11) Kearney PJ LEUKEMIA IN CHILDREN OF JEHOVAH'S WITNESSES: ISSUES AND PRIORITIES IN A CONFICT OF CARE. J Med Ethics 1978 March; 4(1): 32-35 Throughout this paper PJ Kearney attempts to balance the risks and benefits of different approaches in paediatric oncology. Decisions have to be considered both in the short and the long term. Where religious beliefs, such as those held by Jehovah's Witnesses in relation to blood transfusions, conflict with normal medical practice the decision is often removed from the doctor, parents or patient to the courts. This sort of solution can be counter-productive, especially as good health care and subsequent recovery rely, to a large extent, on good relationships between and among the parties concerned. Destruction of these relationships, for whatever reason, often has a detrimental effect on the patient, in whose best interest everyone believes they are acting.

2. Acute Myeloblastic Leukemia

(1) Kaito K, Kobayashi M, Sakamoto M, Shimada T, Masuoka H, Nishiwaki K, Saeki A, Sekita T, Otsubo H, Hosoya T COMBINATION CHEMOTHERAPY WITH G-CSF, M-CSF AND EPO: SUCCESSFUL TREATMENT FOR ACUTE MYELOGENOUS LEUKEMIA WITHOUT BLOOD TRANSFUSION AT LOWER MEDICAL COSTS. Acta Haematol 1998;100(1):57-60

Central Laboratories, Jikei University School of Medicine, Tokyo, Japan. A 55-year-old Jehova's Witness was treated for acute myelogenous leukemia (AML) by intensive chemotherapy with enocitabine, 6-mercaptopurine and daunorubicin. G-CSF, M-CSF and EPO were subsequently administered. Even though no blood transfusion was given for religious reasons, complete remission was achieved without serious infection and hemorrhage. The total cost for induction chemotherapy was less expensive than is the case for elderly AML patients. This case indicates that the administration of cytokines might reduce the incidence of infection and the necessity for blood products, which would result in favorable cost effectiveness for the treatment of elderly patients with AML.

(2) Kerridge I, Lowe M, Seldon M, Enno A, Deveridge S. CLINICAL AND ETHICAL ISSUES IN THE TREATMENT OF A JEHOVAH'S WITNESS WITH ACUTE MYELOBLASTIC LEUKEMIA. Arch Intern Med 1997 August; 157(15): 1753-57


We report the first documented case of the use of peripheral blood stem cell autografting in the treatment of a Jehovah's Witness with acute myeloblastic leukemia. This case illustrates the complex ethical and clinical issues that arise in the treatment of such patients.

(3) Broccia G. LONG-TERM CONTINUOUS COMPLETE REMISSION OF ACUTE MYELOID LEUKEMIA IN A JEHOVAH�S WITNESS TREATED WITHOUT BLOOD SUPPORT. Haematologica 1994 March; 79(2): 180-1 We report the case of a young female patient, a Jehovah�s Witness, affected by peroxidase-positive acute leukemia. The patient, completely aware of the risks both of the disease and of the ususal treatment for acute myeloid leukemia, refused any transfusional support. An atypical treatment plan with low hematological toxicity but also with reduced probability of positive results was therefore proposed and accepted. Initial treatment with vincristine and prednisone induced remission; therapy was then continued for 32 months with monthly cycles of aracytin and 6-thioguanine, at accurately tailored dosages to avoid excessive hematological toxicity. The patient never needed blood support and never suffered infectious or hemorrhagic events. She is still in remission, 11 years off-therapy. The ethical and legal aspects of treatment decisions in such situations are discussed. In the author�s opinion, neither withholding all treatment nor insisting on standard measures is correct: on the contrary, as always, treatment in such cases must be tailored on the patient�s needs, which include not only his physical condition but his religious beliefs as well.

3. Acute Promyelosytic Leukemia

(1) Menendez A, Svarch E, Martinez G, Hernandez P. SUCCESSFUL TREATMENT OF ACUTE PROMYELOCYTIC LEUKEMIA USING ALL-TRANS RETINOIC ACID AND ERYTHROPOIETIN IN A JEHOVAH'S WITNESS BOY. Ann Hematol 1998 January; 76(1): 43-44

Institute of Hematology, Ciudad de la Habana, Cuba. A 10-year-old boy with acute promyelocytic leukemia (APL) was treated with all-trans-retinoic acid (ATRA) at a dose of 60 mg/m2/day. Recombinant erythropoietin was also used. The patient parents and other relatives, all Jehovah's Witnesses, refused any type of hemotherapy. After 43 days of ATRA treatment complete remission was obtained without the use of hemotherapy. This case exemplifies the advantages provided by ATRA treatment in APL.

(2) Fujita H, Maruta A, Koharazawa H, Hattori M, Tomit N, Kodama F, Mohri H, Okubo T. SUCCESSFUL TREATMENT OF A JEHOVAH'S WITNESS WITH ACUTE PROMYELOCYTIC LEUKEMIA Int J Hematol 1997 June; 65(4): 415-16

(3) Estrin JT, Ford PA, Henry DH, Stradden AP, Mason BA. ERYTHROPOIETIN PERMITS HIGH-DOSE CHEMOTHERAPY WITH PERIPHERAL BLOOD STEM-CELL TRANSPLANT FOR A JEHOVAH'S WITNESS. Am J Hematol 1997 May; 55(1): 51-52

(4) Lin CP, Huang MJ, Liu HJ, Chang IY, Tsai CH. SUCCESSFUL TREATMENT OF ACUTE PROMYELOCYTIC LEUKEMIA IN A PREGNANT JEHOVAH'S WITNESS WITH ALL-TRANS RETINOIC ACID, RHG-CSF, AND ERYTHROPOIETIN. Am J Hematol 1996 March; 51(3): 251-252

4. Acute Hairy Cell Leukemia


(1) Juliusson G IMMEDIATE OR DELAYED THERAPY WITH 2-CDA FOR HAIRY CELL LEUKEMIA IN JEHOVA'S WITNESS? Am J Hematol 1996 Sep;53(1):49

(2) Couban S, Wilson WE USE OF 2-CHLORODEOXYADENOSINE, GRANULOCYTE-COLONY-STIMULATING FACTOR, AND ERYTHROPOIETIN IN A JEHOVAH'S WITNESS WITH HAIRY CELL LEUKEMIA. Am J Hamatol 1995 July; 49(3): 255-56

5. Acute Monocytic Leukemia

(1) Dainer PM, Knupp CL, Sartino GP LOW-DOSE CYTOSINE ARABINOSIDE AS AN ALTERNATIVE TREATMENT FOR ACUTE LEUKAMIA IN JEHOVAH'S WITNESSES. American Journal of Hematology 1992 June; 40(2): 156-57 Using standard induction therapy with daunorubicin and cytosine arabinoside, Goldberg et al, induced a successful complete remission in a 64-year-old male Witness with acute monocytic leukemia . . . We report the first case of acute nonlymphocytic leukemia in a Jehovah�s Witness who received a potentially less myelosuppressive, low-dose-subcutaneous cytosine arabinoside regimen and attained a complete remission without the use of blood products.. . . An 18-year-old male Witness was referred because of leukopenia. . . The bone marrow was consistent with acute myeloblastic leukemia. . . He consented to less intensive treatment with low-dose cytosine arabinoside. . . A normal bone marrow karyotype was documented on day 35. The patient attained a complete hematologic remission.. . . Our experience suggests that patients who present with acute nonlymphocytic leukemia and refuse blood transfusion may be offered low-dose chemotherapy with some hope of attaining a remission.

6. Myelodysplastic syndrome

(1) Robb N RULING ON JEHOVAH'S WITNESS TEEN IN NEW BRUNSWICK MAY HAVE "SETTLED THE LAW" FOR MDS. CMAJ 1994 Sep 1;151(5):625-8

7. Lymphoma Maligna

1. Hodgkins Disease

2. Non Hodkin Lymphoma

(1) Kalmuk A, Sonta-Jakimczyk D, Janik-Moszant A, Bubala H, Olejnik I [THE PROBLEM OF BLOOD TRANSFUSION ++ IN JEHOVA'S WITNESSES' CHILDREN WITH ONCOLOGICAL DISEASE]. [ARTICLE IN POLISH] Wiad Lek 1998;51Suppl 4:346-350.

Katedry i Kliniki Hematologii Dzieciecej i Chemioterapii Slaskiej Akademii Medycznej w Katowicach. We present 2 cases of Jehovah's Witnesses' children suffering from oncological diseases (non-Hodgkin Lymphoma and Acute Lymphoblastic Leukaemia). During their treatment we used erythropoietin and no blood products were transfused.


(2) Ushijima A, Nishimura H, Kawakita M, Takatsuki K [ADMINISTRATION OF RECOMBINANT ERYTHROPOIETIN TO A PATIENT WITH MALIGNANT LYMPHOMA WHO REFUSED BLOOD TRANSFUSION]. [ARTICLE IN JAPANESE] Rinsho Ketsueki 1990 Oct;31(10):1698-700

Second Department of Internal Medicine, Kumamoto University Medical. A 30-year-old female patient with malignant lymphoma was admitted to the hospital because of large mass in the left pelvic cavity and of severe anemia. Since she had refused blood transfusion (Jehovah's witness), recombinant human erythropoietin (Epo) was used together with both chemotherapy and irradiation; this led to rapid recovery of the anemia and marked reduction of the mass volume. These findings may suggest the possible application of Epo administration as a supportive therapy in treatment of malignancy.

8. Peripheral Stem-Cell Transplant

(1) Estrin JT, Ford PA, Henry DH, Stradden AP, Mason BA ERYTHROPOIETIN PERMITS HIGH-DOSE CHEMOTHERAPY WITH PERIPHERAL BLOOD STEM-CELL TRANSPLANT FOR A JEHOVAH'S WITNESS. Am J Hematol 1997 May;55(1):51-2 Comment in: Am J Hematol 1998 Feb;57(2):184

C. Thrombosis and Treatments of Thromboembolism 1. Treatment of Pulmonary Embolism

(1) Blaustein HS, Schur I, Shapiro JM ACUTE MASSIVE PULMONARY EMBOLISM IN A JEHOVAH'S WITNESS: SUCCESSFUL TREATMENT WITH CATHETER THROMBECTOMY. Chest 2000 Feb;117(2):594-597.

Division of Pulmonary and Critical Care Medicine, Department of Interventional Radiology, St. Luke's-Roosevelt Hospital Center, New York, NY 10025, USA. A 71-year-old woman presented with an acute, massive pulmonary embolism. As a Jehovah's Witness, she was not willing to accept thrombolysis because of the potential risk of bleeding requiring blood transfusion. The patient was successfully treated with catheter thrombectomy, using rheolytic and fragmentation devices.

XVIII. CANCER THERAPY 1. Cancer Chemotherapy

(1) van Kaam AH, Egeler RM RECOMBINANT HUMAN ERYTHROPOIETIN FOR THE CORRECTION OF CANCER ASSOCIATED ANEMIA WITH AND WITHOUT CONCOMITANT CYTOTOXIC CHEMOTHERAPY. Cancer 1996 Sep 1;78(5):1144-5 Comment on: Cancer 1995 Dec 1;76(11):2319-29


(2) Barona Zamora P, Sierrasesumaga Ariznavarreta L, Antillon Klussmann F, Villa Elizaga I [THE USE OF HUMAN RECOMBINANT ERYTHROPOIETIN IN CHEMOTHERAPY-INDUCED ANEMIA. EXPERIENCE WITH A JEHOVAH'S WITNESS CHILD]. [ARTICLE IN SPANISH] Rev Clin Esp 1993 Dec;193(9):516-517

(3) Johnson PW, King R, Slevin ML, White H THE USE OF ERYTHROPOIETIN IN A JEHOVAH'S WITNESS UNDERGOING MAJOR SURGERY AND CHEMOTHERAPY. Br J Cancer 1991 Mar;63(3):476

(4) Heinz R, Reisner R, Pittermann E ERYTHROPOIETIN FOR CHEMOTHERAPY PATIENT REFUSING BLOOD TRANSFUSION. Lancet 1990 Mar 3;335(8688):542-543 Comment in: Lancet 1990 Aug 11;336(8711):384-5

(5) Gise LH, Israel SG, Dottino P MEDICAL PSYCHIATRIC ROUNDS ON A GYNECOLOGIC ONCOLOGY SERVICE: END-STAGE CERVICAL CARCINOMA IN A JEHOVAH'S WITNESS REFUSING TREATMENT. Gen Hosp Psychiatry 1989 Sep;11(5):372-6

Department of Psychiatry, Mount Sinai School of Medicine, New York, NY 10029. A 47-year-old single, black, nurse's aide with end-stage cervical carcinoma is especially articulate about her feelings of depression, anger, and anxiety with advancing disease. Regardless of good coping, these feelings interfere with her medical care. The patient's decision to refuse chemotherapy based on her religious beliefs presents conflicts for both the patient and the staff. (Present are psychiatrist, psychiatric resident, gynecologist, gynecology resident, social worker, and nursing staff.)

2. Childhood Cancer Therapy

(1) Barona Zamora P, Sierrasesumaga Ariznavarreta L, Antillon Klussmann F, Villa Elizaga I [THE USE OF HUMAN RECOMBINANT ERYTHROPOIETIN IN CHEMOTHERAPY-INDUCED ANEMIA. EXPERIENCE WITH A JEHOVAH'S WITNESS CHILD]. [ARTICLE IN SPANISH] Rev Clin Esp 1993 Dec;193(9):516-7

(2) Frankel LS, Damme CJ, Van Eys J. CHILDHOOD CANCER AND THE JEHOVAH�S WITNESS FAITH. Pediatrics 1977 December; 60(6): 916-21 During the past decade, medical science has accomplished particularly significant strides in the field of childhood cancer. Childhood leukemia, lymphoma, and sarcoma are now considered treatable diseases, although the outcome for any one individual is difficult to predict. Children of the Jehovah�s Witness faith were accepted as patients in full accordance with their beliefs. In this article we will discuss a series of pediatric patients of the Jehovah�s Witness faith treated at M. D. Anderson Hospital and Tumor Institute for cancer and related hematologic diseases and present the current medical, legal, and ethical context in which management must be judged.

3. Childhood Tumor Surgery and Blood Conservation


(1) Mutabagani KH, Klopfenstein KJ, Hogan MJ, Caniano DA METASTATIC PARAGANGLIOMA AND PARANEOPLASTIC-INDUCED ANEMIA IN AN ADOLESCENT: TREATMENT WITH HEPATIC ARTERIAL CHEMOEMBOLIZATION. J Pediatr Hematol Oncol 1999 Nov-Dec;21(6):544-7

Division of Pediatric Surgery, The Ohio State University College of Medicine and Public Health and Children's Hospital, Columbus, USA. Mediastinal paragangliomas are rare neoplasms in children. Anemia, as a paraneoplastic syndrome, has been described in adults with metastatic paraganglioma. The management of paraneoplastic anemia from metastatic paraganglioma has been problematic, with no reports in the literature describing successful treatment. This article describes a 17-year-old Jehovah's Witness with a mediastinal paraganglioma, hepatic metastases, and severe anemia. The patient and his family refused blood products and the anemia was refractory to erythropoietin and elemental iron therapy. Serial chemoembolization of the hepatic lesions resulted in resolution of the anemia, allowing subsequent debulking of the mediastinal paraganglioma.


Service d'anesthesie-reanimation, hopital R-Poincare, Garches, France. We report two cases of haemorrhagic surgery in a 6-year-old and 16-year-old girl, respectively, whose parents were Jehovah's witnesses and therefore opposed to preoperative blood donation, but accepting intraoperative blood salvage. Erythropoietin and intravenous iron were administered preoperatively to increase red cell mass. Intraoperative blood salvage, including normovolaemic haemodilution and intraoperative autologous transfusion, avoided homologous blood transfusion

(3) Ross JH, Kay R, Alexander F MANAGEMENT OF BILATERAL WILMS' TUMORS IN THE DAUGHTER OF JEHOVAH'S WITNESSES. J Pediatr Surg 1997 Dec;32(12):1759-60

Department of Pediatric Surgery, Cleveland Clinic Children's Hospital, Ohio 44195, USA. Surgical treatment of the children of Jehovah's Witnesses is a challenging problem both ethically and technically. The authors recently operated on such a child who had bilateral Wilms' tumors. Techniques used to minimize blood loss included erythropoietin, hemodilution, and the argon beam coagulator. A full understanding of the religious, legal, and ethical issues is essential when treating the children of Jehovah's Witnesses.

(4) McNeil SB JOHNNY'S STORY: TRANSFUSING A JEHOVAH'S WITNESS. Pediatr Nurs 1997 May;23(3):287-288

Pediatric Oncology Concentration, University of South Florida, Tampa, USA. Jehovah's Witnesses refuse blood transfusions for themselves and for their children. This action can be difficult for health professionals to understand and can lead to tensions between the staff and family. For one family, their refusal of blood for their child lead to a greater understanding of their religion and its beliefs for those who cared for them. Interspersed with their story are the medical reasons their son required blood, the reasons Jehovah's Witnesses refuse blood transfusions, and what the acceptable alternatives are to Jehovah's Witnesses. This article will share the thoughts and feelings of the family and the nursing staff who cared for the family during this crisis.



(6) Adzick et al. MAJOR CHILDHOOD TUMOR RESECTION USING NORMOVOLEMIC HEMODILUTION ANESTHESIA AND HETASTARCH. J Pediatr Surg 1985; 20: 372-75 Acute normovolemic hemodilution is a safe technique for minimizing operative blood loss during major tumor resection in children. Based on our experience using hemodilution anesthesia in 14 successful extensive tumor resections, we conclude the following: (1) this is an effective means of reducing use of bank blood and thus avoiding the risks of multiple transfusions; (2) it facilitates surgical dissection due to increased visibility with dilute blood, and decreased bleeding due to controlled hypotension; (3) this technique is acceptable for Jehovah�s Witnesses; (4) hetastarch is an effective, inexpensive colloid hemodiluent which minimized perioperative edema compared to crystalloid hemodilution. Jehovah�s Witness patients required a special closed-circuit system in which the blood removed from the jugular venous cannula was kept in constant contact with the patient through the intravenous tubing.

(7) Schaller RT Jr, Schaller J, Morgan A, Furman EB HEMODILUTION ANESTHESIA: A VALUABLE AID TO MAJOR CANCER SURGERY IN CHILDREN. Am J Surg 1983 Jul;146(1):79-84 Since 1974, 25 children had 27 major cancer operations with the aid of hemodilution anesthesia. This includes operations for Wilms' tumors, liver tumors, adrenal tumors, pancreatic tumors, ovarian tumors, and resection of metastatic thoracoabdominal tumors. With the use of this method, operative blood loss has been greatly reduced and operative technique improved. At the beginning of surgery, whole blood is removed from the patient and replaced with three times the volume of a balanced electrolyte solution to maintain intravascular volume. After the time of significant blood loss has ceased, the patient's own blood is returned and diuresis stimulated with furosimide to remove the infused electrolyte solution. Hypothermia, allowing the temperature to drift down to just below 32 degrees C, helps protect vital organs against hypoxia and arterial hypotension to a mean of 50 torr systolic pressure is well tolerated and further reduces blood loss. Adequate tissue oxygenation can be maintained safely during hemodilution to a hematocrit value of 14 percent. Use of bank blood transfusion was necessary in only 6 of 25 patients. It was given when the calculated postoperative hematocrit value would be less than 30 percent. The diluted blood lost during surgery has a low red blood cell volume per milliliter and each milliliter lost depletes the total red blood cell volume by a lesser amount. Also, the ease and speed of surgery may be facilitated by the nearly bloodless operative field. Provided respiratory support is maintained, these children showed only minor clinical effects from this large fluid infusion. The majority of patients who are Jehovah's Witnesses accept this technique with the modification that we keep the blood moving and in direct contact with the patient's vascular system. Carefully planned and meticulously applied short-term hemodilution anesthesia provides a safe method for minimizing operative blood loss and reduces the difficulty of major cancer surgery in children.

(8) Levine AH, Imai PK HYPOTHERMIA AND HEMODILUTION WITH AUTOLOGOUS TRANSFUSION. AORN J 1983 May;37(6):1060-5

(9) Ackerman TF THE LIMITS OF BENEFICENCE: JEHOVAH'S WITNESSES & CHILDHOOD CANCER. Hastings Cent Rep 1980 Aug;10(4):13-18


A. Tumor Resections A. General Aspects of Tumor Surgery

(1) Johnson PW, King R, Slevin ML, White H THE USE OF ERYTHROPOIETIN IN A JEHOVAH'S WITNESS UNDERGOING MAJOR SURGERY AND CHEMOTHERAPY. Br J Cancer 1991 Mar;63(3):476

B. Lung and/or ThoracicTumor

1. Lung Cancer

(1) Nishimoto M, Tachibana S, Kawakami M, Orino T, Nakao K, Tokitsu K, Morita T, Hashimoto T, Sasaki S [INFORMED CONSENT AND SURGICAL TREATMENT IN A 38-YEAR-OLD FEMALE, JEHOVAH'S WITNESS WITH LUNG CANCER]. [ARTICLE IN JAPANESE] Kyobu Geka 1998 Jul;51(7):558-60


2. Mediastinal Tumor

(1) Hiraki T, Hamada N, Kano T, Isamoto Y [INTRAOPERATIVE HEMODILUTIONAL AUTOTRANSFUSION USING A CLOSED CIRCUIT FOR PATIENTS OF JEHOVAH'S WITNESS]. [ARTICLE IN JAPANESE] Masui 2000 May;49(5):535-539.

Department of Anesthesiology, Kurume University School of Medicine. We conducted hemodilutional autotransfusion using a closed circuit combined with a cell washing reinfusing system (Cell Saver) for two surgical patients of Jehovah's Witness. One was a 12 yr-old boy for extirpation of the teratoma in the anterior mediastinum and another was a 44 yr-old woman for left total hip replacement. The patients and their relatives had consented to the use of blood substitutes, hemodilutional autotransfusion using a closed circuit and Cell Saver. We devised a closed circuit system for hemodilutional autotransfusion combined with Cell Saver, in which two pumps for blood transfusion were used; one was for drawing blood from the femoral or the internal jugular vein and the other for returning blood to the peripheral vein. Blood volume in a bag interposed in the closed circuit was easily controlled by adjusting the speed of each pump. Blood collected from the surgical field by Cell Saver was also led to the bag. Acid citrate dextrose solution was infused into the closed circuit from the site close to the blood drawing. Both of our surgical patients were safely managed without homologus blood transfusion, although there remained some problems concerning the use of anticoagulants.

C. Renal Tumors


(1) Ross JH, Kay R, Alexander F. MANAGEMENT OF BILATERAL WILMS� TUMORS IN THE DAUGHTER OF JEHOVAH�S WITNESSES. J Pediatr Surg 1997 December; 32(12): 1759-60 Surgical treatment of the children of Jehovah�s Witnesses is a challenging problem both ethically and technically. The authors recently operated on such a child who had bilateral Wilms� tumors. Techniques used to minimize blood loss included erythropoietin, hemodilution, and the argon beam coagulator. A full understanding of the religious, legal and ethical issues is essential when treating the children of Jehovah�s Witnesses.

(2) Adams WM, Huskinsson L, Gornall P, John PR. TEMPORARY BALLOON OCCLUSION OF THE INFERIOR VENA CAVA AS AN ALTERNATIVE TO CARDIOPULMONARY BYPASS IN RESECTION OF WILMS� TUMOUR WITH VENA CAVA EXTENSION. Pediatr Radiol 1997 March; 27(3): 236-38 Up to 10% of patients undergoing nephrectomy for Wilms� tumour have tumour thrombus involving the vena cava. A new radiological technique is described utilising a temporary occlusion balloon inserted via an open venotomy of the left internal jugular vein into the retro-hepatic cava to create a bloodless field to facilitate surgery.

D. Gastrointestinal Tumors

1. Gastric Surgery

a) Statistics of Gastric and Colorectal Cancer in far East

(1) Hart AR, Mann R, Mayberry JF GASTRIC AND COLORECTAL CANCER IN PATIENTS ATTENDING MISSION HOSPITALS IN RURAL AREAS OF SOUTH-EAST ASIA. Digestion 1993;54(3):173-7

Leicester General Hospital, UK. 25 missionaries working in Taiwan, Thailand, Indonesia and the Philippines completed questionnaires regarding their clinical practice during the year 1980. Data were collected on the numbers of both gastric and colorectal cancers diagnosed. More than 90,000 out-patients were reviewed, and over 25,000 in-patients treated. In total, 76 gastric and 118 colorectal carcinomas were seen. Surgery and radiology were available at 88% of hospitals, but histology at only 53%. In both Indonesia and the Philippines, the relative risk of developing colorectal compared with gastric cancer was 3.3 (95% confidence limits 1.8-6.2 and 1.4-8.5, respectively). In Thailand and Taiwan, these tumours occurred with similar frequencies. Thailand, Indonesia and the Philippines had similar numbers of gastric neoplasms, but Taiwan a significantly higher number than the other countries (z > or = 4.4, p < 0.0001). Thailand had lower numbers of colorectal tumours than the Philippines, (z = 2.2, p < 0.05), Taiwan (z = 3.4, p < 0.001) and Indonesia (p = 5.0, p < 0.0001). Local dietary factors probably play an important role in the development of these tumours.

2. Esophagus Surgery

(1) Bach B, Place G, Benichou J, Testas P, Noviant Y, Franc B, Mugneret P [SURGERY OF THE ESOPHAGUS UNDER HEMODILUTION AND AUTOTRANSFUSION IN A JEHOVAH'S WITNESS]. [ARTICLE IN FRENCH] Anesth Analg (Paris) 1976 Jan;33(1):133-145

3. Duodenal Surgery


(1) Orr KB. DUODENAL PAPILLARY ADENOMA IN A JEHOVAH�S WITNESS. Med J Aust 1996 February 5; 164(3): 191

(2) Atabek U, Spence RK, Pello M, Alexander J, Camishion R PANCREATICODUODENECTOMY WITHOUT HOMOLOGOUS BLOOD TRANSFUSION IN AN ANEMIC JEHOVAH'S WITNESS. Arch Surg 1992 Mar;127(3):349-51

Department of Surgery, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, Camden. Whipple pancreaticoduodenectomy is an accepted procedure for management of periampullary and pancreatic carcinomas and has modern mortality rates of less than 10%. The procedure is associated with significant operative blood loss. Therefore, blood transfusion is an important supportive measure. We report the case of a bleeding ampullary carcinoma in a Jehovah's Witness who refused transfusion of all homologous blood products. Despite a preoperative hemoglobin level of 51 g/L, curative pancreaticoduodenectomy was successfully performed. The success of the procedure can be primarily attributed to careful surgical technique, intraoperative autotransfusion, avoidance of postoperative complications, minimization of perioperative phlebotomies, use of human recombinant erythropoietin, and, possibly, the use of the perfluorocarbon emulsion Fluosol DA-20%. The case illustrates several important principles for the surgical treatment of patients with severe anemia who refuse transfusion of homologous blood products.

4. Abdominal Desmoid Tumor Resection

(1) Grubbs PE Jr, Marini CP, Fleischer A ACUTE HEMODILUTION IN AN ANEMIC JEHOVAH'S WITNESS DURING EXTENSIVE ABDOMINAL WALL RESECTION AND RECONSTRUCTION. Ann Plast Surg 1989 May;22(5):448-51; discussion 452

Department of Surgery, Maimonides Medical Center, Brooklyn, NY 11219. A 47-year-old anemic Jehovah's Witness with Gardner's syndrome presented with a large abdominal wall desmoid tumor requiring extensive resection with a musculocutaneous flap reconstruction. At surgery a technique of acute limited normovolemic hemodilution (ALNH) was used to minimize blood loss and avoid blood transfusions. Complications that follow transfusions of homologous blood are reviewed, and a recommendation is made to use ALNH because of its advantages in those patients in whom significant blood loss is expected.

5. Colon cancer Surgery

(1) Madura JA USE OF ERYTHROPOIETIN AND PARENTERAL IRON DEXTRAN IN A SEVERELY ANEMIC JEHOVAH'S WITNESS WITH COLON CANCER. Arch Surg 1993 Oct;128(10):1168-1170

Department of Surgery, Indiana University School of Medicine, Indianapolis. A Jehovah's Witness presented with colon cancer and profound anemia. On admission, her hemoglobin level was 30 g/L (3.0 g/dL). She refused all transfusions and failed to respond to oral iron therapy. She was ultimately prepared for surgery using recombinant human erythropoietin, iron dextran, and total parenteral nutrition. It took nearly 1 month to increase her hemoglobin level to an acceptable preoperative level of 110 g/L (11.0 g/dL). During the postoperative period, erythropoietin and parenteral iron therapy were briefly continued and a follow-up hemoglobin level of greater than 120 g/L (12.0 g/dL) was observed. Recombinant human erythropoietin, along with parenteral iron and adequate nutrition, may be useful in patients who refuse transfusion or cannot be transfused because of difficult cross-reacting antibodies.

6. Rectal Carcinoma Resection


(1) Haphtel L, Rephaeli Y, Zbida D, Rubin M. ANTERIOR RESECTION FOR RECTAL CARCINOMA IN AN ANEMIC JEHOVAH�S WITNESS. Harefuah 1996 April; 130(8): 517-18 (Article in Hebrew) Anterior resection is accepted treatment for tumors of the middle rectum, with mortality less than 5%. Since such surgery involves blood loss, blood transfusions is regarded as essential. We report a 69-year old anemic Jehovah�s Witness who had a bleeding rectal tumor but who refused blood transfusion, despite a hemoglobin level of 4.8 g/dl. Anterior resection of the tumor was successfully performed without substantial blood loss. Her hemoglobin level was 5.8 g/dl on discharge. Jehovah�s Witnesses do not oppose medical treatment nor do they practice faith healing. Instead, they seek good medical care but accept only proven medical alternatives to blood transfusions. Physicians, world-wide, are now successfully performing major surgery of all type on both adult and minor Witnesses. Due to their success in the use of alternatives, over 50 hospitals in North America, Europe and Australia have established �bloodless-surgery� centers to serve not only Jehovah�s Witnesses but also a growing number of other patients who wish to avoid risks associated with blood transfusion.

E. Gynecologic Tumors

(1) Kunz J, Mahr R. MANAGEMENT OF SEVERE BLOOD LOSS AFTER TUMOR RESECTION IN A JEHOVAH�S WITNESS. Gynakol Geburtshilfliche Rundsch 1995; 35(1): 34-37

Division of Obstetrics and Gynecology, Schweizerische Pflegerinnenschule, Zurich, Switzerland. This report describes the peri- and postoperative management of a patient with a critical blood loss (hemoglobin of 22 g/l) as a consequence of a surgical intervention, i.e. a radical resection of an advanced malignant gynecological tumor. The patient refused autologous and homologous blood transfusions for religious reasons (Jehovah�s Witness). During surgery, hemodilution and cell salvage were used. Postoperatively she developed coagulopathy and hemorrhage with the lowest hemoglobin value of 22 g/l. The patient recovered under a therapy regimen of recombinant human erythropoietin and parenteral iron. The hemoglobin values returned to the lower normal range within 4 weeks. Consequences of hypoxia could not be seen.

(2) Kelley JL, Burke TW, Lichtiger B, Dupuis JF EXTRACORPOREAL CIRCULATION AS A BLOOD CONSERVATION TECHNIQUE FOR EXTENSIVE PELVIC OPERATIONS. J Am Coll Surg 1994 Apr;178(4):397-400

Department of Gynecology, University of Texas M.D. Anderson Cancer Center, Houston. Difficult pelvic operations for malignancy or complex benign conditions can be associated with extensive blood loss. Religious beliefs that preclude transfusion and the known risks of homologous blood have prompted investigators to seek alternatives to transfusion. We used the Haemonetics-V50 Cell Separator (Haemonetics Corporation) to provide for extracorporeal circulation of the patient's own blood with associated normovolemic hemodilution as a means of conserving blood during operations. This technique was used in eight patients undergoing extensive pelvic operations. The procedure was accepted by Jehovah's Witnesses and was well tolerated by all patients. Estimated blood loss ranged from 75 to 2,000 milliliters. One instance of mild intraoperative disseminated intravascular coagulation was encountered. Two patients were given homologous transfusions. While clinical judgment is necessary to determine the safety of complicated operations, this technique is useful in expanding surgical options for some patients who object to blood transfusion.


(3) Loos W, Kuhn W, Prechtl A, Schmalfeldt B, Hipp R, Kycia J [BLOOD TRANSFUSION IN SURGICAL GYNECOLOGY. STRATEGIES FOR PREVENTING HOMOLOGOUS BLOOD TRANSFUSION]. [ARTICLE IN GERMAN] Fortschr Med 1994 Oct 20;112(29):405-409

Frauenklinik und Poliklinik, Klinikum rechts der Isar, Technischen Universitat Munchen. A statistical evaluation of homologous blood transfusions is imperative in any gynecological surgical department, to be able to define the transfusion-associated risk of the individual interventions. On the basis of our own statistical data and reports in the literature, strategies for limiting the use of homologous blood are discussed. So far, experience with autologous blood transfusion in surgical gynecology is limited, and clinical studies are needed to better define its role. In special cases, the use of erythropoietin and gonadotropin-releasing hormone (GnRH) analogues extends the possibilities for reducing homologous blood transfusion.

(4) Robb N RULING ON JEHOVAH'S WITNESS TEEN IN NEW BRUNSWICK MAY HAVE "SETTLED THE LAW" FOR MDS. CMAJ 1994 Sep 1;151(5):625-628

(5) Bengtsson A, Johansson S, Hahlin M, Crona N [AUTOTRANSFUSION OF BLOOD CELLS MADE SURGERY OF A JEHOVAH'S WITNESS POSSIBLE]. [ARTICLE IN SWEDISH] Lakartidningen 1992 Sep 9;89(37):2955-2957 Anestesidivisionen, Sahlgrenska sjukhuset, Goteborg. [En patient som tillhör Jehovas vittnen har under pågående heparinbehandling fått en tumör exstirperad. Det var omöjligt för patienten att acceptera blodtransfusion trots uppenbara risker för livshotande blödningar i samband med det kirurgiska ingreppet, men autolog blodkroppsåtervinning ble en framkomlig möjlighet. Fallbeskrivningen redovisar tillvägagångssätt och resultat.]

(6) Gise LH, Israel SG, Dottino P MEDICAL PSYCHIATRIC ROUNDS ON A GYNECOLOGIC ONCOLOGY SERVICE: END-STAGE CERVICAL CARCINOMA IN A JEHOVAH'S WITNESS REFUSING TREATMENT. Gen Hosp Psychiatry 1989 Sep;11(5):372-376

Department of Psychiatry, Mount Sinai School of Medicine, New York, NY 10029. A 47-year-old single, black, nurse's aide with end-stage cervical carcinoma is especially articulate about her feelings of depression, anger, and anxiety with advancing disease. Regardless of good coping, these feelings interfere with her medical care. The patient's decision to refuse chemotherapy based on her religious beliefs presents conflicts for both the patient and the staff. (Present are psychiatrist, psychiatric resident, gynecologist, gynecology resident, social worker, and nursing staff.)

(7) Matsuki M, Muraoka M, Oyama T TOTAL SPINAL ANAESTHESIA FOR A JEHOVAH'S WITNESS WITH PRIMARY ALDOSTERONISM. Anaesthesia 1988 Feb;43(2):164-165

F. Spinal Tumors


(1) Winter RB, Swayze C SEVERE NEUROFIBROMATOSIS KYPHOSCOLIOSIS IN A JEHOVAH'S WITNESS. ANTERIOR AND POSTERIOR SPINE FUSION WITHOUT BLOOD TRANSFUSION. Spine 1983 Jan;8(1):39-42 A case is presented of a 22-year-old female Jehovah's Witness with severe kyphoscoliosis, who was successfully treated surgically by carefully staged posterior and anterior spine fusions completed with the use of intraoperative hemodilution techniques. Three spinal procedures were carried out at intervals, and no blood transfusion was given at any of them.

G. Pelvic Tumors



(2) Kelley JL, Burke TW, Lichtiger B, Dupuis JF EXTRACORPOREAL CIRCULATION AS A BLOOD CONSERVATION TECHNIQUE FOR EXTENSIVE PELVIC OPERATIONS. J Am Coll Surg 1994 Apr;178(4):397-400

Department of Gynecology, University of Texas M.D. Anderson Cancer Center, Houston. Difficult pelvic operations for malignancy or complex benign conditions can be associated with extensive blood loss. Religious beliefs that preclude transfusion and the known risks of homologous blood have prompted investigators to seek alternatives to transfusion. We used the Haemonetics-V50 Cell Separator (Haemonetics Corporation) to provide for extracorporeal circulation of the patient's own blood with associated normovolemic hemodilution as a means of conserving blood during operations. This technique was used in eight patients undergoing extensive pelvic operations. The procedure was accepted by Jehovah's Witnesses and was well tolerated by all patients. Estimated blood loss ranged from 75 to 2,000 milliliters. One instance of mild intraoperative disseminated intravascular coagulation was encountered. Two patients were given homologous transfusions. While clinical judgment is necessary to determine the safety of complicated operations, this technique is useful in expanding surgical options for some patients who object to blood transfusion.

H. Head and Neck Tumors

(1) Genden EM, Haughey BH HEAD AND NECK SURGERY IN THE JEHOVAH'S WITNESS PATIENT. Otolaryngol Head Neck Surg 1996 Apr;114(4):669-672

Department of Otolaryngolgoy-Head and Neck Surgery, St. Louis, MO 63110, USA.

(2) Morgenstein SA SPHENOETHMOID MUCOCELE WITH INTRACRANIAL EXTENSION. Otolaryngol Head Neck Surg 1990 Feb;102(2):199

Comment on: Otolaryngol Head Neck Surg 1988 Mar;98(3):254-7


I. Oral and Maxillo Facial Tumors

(1) Van Hemelen G, Avery CM, Venn PJ, Curran JE, Brown AE, Lavery KM MANAGEMENT OF JEHOVAH'S WITNESS PATIENTS UNDERGOING MAJOR HEAD AND NECK SURGERY. Head Neck 1999 Jan;21(1):80-4


(2) Pogrel MA, McDonald A THE USE OF ERYTHROPOIETIN IN A PATIENT HAVING MAJOR ORAL AND MAXILLOFACIAL SURGERY AND REFUSING BLOOD TRANSFUSION. J Oral Maxillofac Surg 1995 Aug;53(8):943-5

Department of Oral and Maxillofacial Surgery, University of California, San Francisco 94143-0440, USA.

B. Cancer 1. The Use of EPO in Solid Tumors





(3) Kunz J, Mahr R MANAGEMENT OF SEVERE BLOOD LOSS AFTER TUMOR RESECTION IN A JEHOVAH'S WITNESS. Gynakol Geburtshilfliche Rundsch 1995;35(1):34-7

Division of Obstetrics and Gynecology, Schweizerische Pflegerinnenschule, Zurich, Switzerland. This report describes the peri- and postoperative management of a patient with a critical blood loss (hemoglobin of 22 g/l) as a consequence of a surgical intervention, i.e. a radical resection of an advanced malignant gynecological tumor. The patient refused autologous and homologous blood transfusions for religious reasons (Jehovah's Witness). During surgery, hemodilution and cell salvage were used. Postoperatively she developed coagulopathy and hemorrhage with the lowest hemoglobin value of 22 g/l. The patient recovered under a therapy regimen of recombinant human erythropoietin and parenteral iron. The hemoglobin values returned to the lower normal range within 4 weeks. Consequences of hypoxia could not be seen.

(4) Ushijima A, Nishimura H, Kawakita M, Takatsuki K. ADMINISTRATION OF RECOMBINANT ERYTHROPOIETIN TO A PATIENT WITH MALIGNANT LYMPHOMA WHO REFUSED BLOOD TRANSFUSION Japanese Journal of Clinical Hematology 1990 October; 31(10): 1698-1700 A 30-year-old female patient with malignant lymphoma was admitted to the hospital because of large mass in the left pelvic cavity and of severe anemia. Since she had refused blood transfusion (Jehovah�s witness), recombinant human erythropoietin (Epo) was used together with both chemotherapy and irradiation; this led to rapid recovery of the anemia and marked reduction of the mass volume. These findings may suggest the possible application of Epo administration as a supportive therapy in treatment of malignancy.

2. Hemodilution Anesthesia in Cancer Surgery

(1) Schaller RT, Schaller J, Morgan A, Furman EB. HEMODILUTION ANESTHESIA: A VALUABLE AID TO MAJOR CANCER SURGERY IN CHILDREN. Am J Surg 1983 July; 146: 79-84 Twenty-five patients had 27 successful operations utilizing hemodilution anesthesia. Fourteen were female and 11 male. All patients were under 10 years of age and 13 (52 percent) were 2 years of age or younger. The smallest and youngest patient (Jehovah�s Witness) had a 95 percent pancreatectomy for multiple adenoma at 25 days of age. She weighed 3.1 kg, and the operation began and was completed with a hematocrit value of 24 percent without the use of donor blood.

(2) Lichtiger B, Dupuis JF, Seski J. HEMOTHERAPY DURING SURGERY FOR JEHOVAH�S WITNESSES: A NEW METHOD. Anesth Analg 1982 July; 61(7): 618-19 We report a hemotherapeutic support procedure used in our institution for Jehovah�s Witnesses undergoing major cancer surgery. This involves the preoperative collection of whole anticoagulated blood, its temporary storage in a Haemonetics 30 blood cell processor (H-30), and the simultaneous reinfusion at variable rates in relation to the requirements of the surgical procedures. The extracorporeal blood is thus kept in physical continuity with the circulatory system of the patient at all times.

XIX SPECIAL BLOOD CONSERVATION PROGRAMS

1. Bloodless Surgery (BS) General Aspects


(1) Grogan TA BRINGING BLOODLESS SURGERY INTO THE MAINSTREAM. Nursing 1999 Nov;29(11):58-61.

Liver Transplant ICU, UPMC-Presbyterian, Pittsburgh, Pa., USA

(2) Trovarelli T, Kahn B, Vernon S TRANSFUSION-FREE SURGERY IS A TREATMENT PLAN FOR ALL PATIENTS. AORN J 1998 Nov;68(5):773-8, 780-4 Ortho Biotech, Cliffside Park, NJ, USA. Due to the increased risks associated with allogenic blood transfusion, blood management in surgical procedures, especially in orthopedic settings, should include reduction of perioperative blood loss. Preoperative nursing assessment will help define patients at increased risk for transfusion. Both nonpharmacologic and pharmacologic techniques can help minimize allogenic transfusion by reducing blood loss. One such method of managing anemia and reducing patient exposure to allogenic transfusion is the perioperative use of recombinant human erythropoietin--erythropoietin alfa--an innovative surgical blood management tool. Increased awareness by perioperative nurses of the use of erythropoietin alfa and patient implications can contribute to the overall blood conservation goal.

(3) Shinkman R MORE GOING BLOODLESS. TRANSFUSION-FREE SURGERY SEEN AS SAFER, CHEAPER ALTERNATIVE, WITH FASTER RECOVERIES. Mod Healthc 1998 Nov 9;28(45):57-8

(4) Tapp A A TIMELY RISK MANAGEMENT RESOURCE. Can Nurse 1998 Feb;94(2):49-50 The Hospital Information Services program and the work of the HLC members has resulted in a significant increase in the number of physicians and institutions willing to co-operate with bloodless treatment of patients. Over a five-year period the number of physicians willing to co-operate in this matter has increased from 5,000 to more than 50,000 in 65 countries. This dramatic increase in the number of informed co-operative clinicians has also resulted in the development of more than 80 bloodless surgery and medical centres in various countries.

(5) Maness CP, Russell SM, Altonji P, Allmendinger P BLOODLESS MEDICINE AND SURGERY. AORNJ 1998 Jan; 67(1): 144-152

Center for Bloodless Medicine and Surgery, Hartford Hospital, CT, USA. Our hospital is a center for bloodless medicine and surgery (CBMS). It is one of 56 such centers located in the United States. The mission of the center is to provide surgical and medical treatment without the administration of blood or blood-related products. Patients' rights to autonomy and self-determination are respected. Development of the CBMS program required the writing and implementation of specific guidelines, developing standards of care, revising existing policies and procedures, and educating staff members. The CBMS program is multifaceted and multidisciplinary.

(6) Langone J FEAR OF AIDS IS ONLY ONE REASON SOME DOCTORS ARE CALLING FOR BLOODLESS SURGERY. Time 1997 Fall;150(19):74-6

(7) Vernon S, Pfeifer GM ARE YOU READY FOR BLOODLESS SURGERY? Am J Nurs 1997 Sep; 97(9): 40-46


Center for Bloodless Medicine and Surgery, Columbia St. Vincent Charity Hospital, Cleveland, OH, USA. �Bloodless' medicine and surgery is saving lives of individuals whose religious faith forbids blood transfusions. And the innovations it comprises are introducing new considerations to the nursing care of many patients undergoing complex operations.

(8) Ford PA, Henry DH. USING R-HUEPO IN PATIENTS UNWILLING TO ACCEPT BLOOD TRANSFUSIONS. Erythropoiesis 1996; 7: 63-68 There are many individuals unwilling to accept blood transfusions because of the fear of disease transmission or religious beliefs, such as Jehovah's Witnesses. Bloodless care programs have been developed to provide the best alternative care for these individuals. Physicians need to have an understanding of blood conservation measures and techniques that will stimulate erythropoiesis and maximise oxygen delivery. A combination of these approaches can be utilised to avoid blood exposure. Many of the individuals unwilling to accept blood transfusions are seen in the perioperative setting and require intraoperative measures to limit the amount of blood lost during surgery. This includes meticulous haemostasis, normovolaemic haemodilution, autotransfusion of shed blood and prophylactic drug therapy. The administration of recombinant human erythropoietin (r-HuEPO) in the perioperative period increases RBC mass and prevents profound postoperative anaemia. Intensive iron supplementation appears essential for the optimisation of the effects or r-HuEPO. Short-term regimens of r-HuEPO can be life-saving for those individuals refusing blood transfusion.

2. BS Treatment of Anemia

(1) Spence RK. THE STATUS OF BLOODLESS SURGERY. Transfusion Medicine Reviews 1991 October; V(4): 274-86 The purpose of this article is to review the attempts to limit or completely avoid perioperative homologous transfusion , the scientific basis for limiting transfusions, and the concepts of both the optimally and the minimally acceptable Hb level.

(2) Spence RK. ELECTIVE SURGERY WITHOUT TRANSFUSION: INFLUENCE OF PREOPERATIVE HEMOGLOBIN LEVEL AND BLOOD LOSS ON MORTALITY. The American Journal of Surgery 1990 March; 159: 320-24 To clarify the widespread practice of preoperative transfusion to attain a 10 g/dl level of hemoglobin, the relationship between preoperative hemoglobin level, operative blood loss, and mortality was studied by analyzing the results of 113 operations in 107 consecutive Jehovah�s Witness patients who underwent major elective surgery. Ninety-three patients had preoperative hemoglobin values greater than 10 g/dl; 20 had preoperative hemoglobin levels between 6 to 10 g/dl. Mortality for preoperative hemoglobin levels greater than 10 g/dl was 3 of 93 (3,2%); for preoperatively hemoglobin levels between 6 to 10 g/dl, mortality was 1 of 20 (5%). Mortality was significantly increased with an estimated blood loss of greater than 500 ml, regardless of the preoperative hemoglobin level. More important, there was no mortality if estimated blood loss was less than 500 ml, regardless of the preoperative hemoglobin level. From these data we conclude that: (1) Mortality in elective surgery appears to depend more on estimated blood loss than on preoperatively hemoglobin levels; and (2) Elective surgery can be done safely in patients with a preoperatively hemoglobin level as low as 6 g/dl if estimated blood loss is kept below 500 ml.

(3) Lapin R, Bonnett CA, Giddings JC, Gough GS, Kaller S. THE USE OF INTRAVENOUS IRON DEXTRAN (IMFERON) IN THE JEHOVAH�S WITNESS PATIENT. The Journal of Neurological and Orthopaedic Surgery 1982 July; 3(2): 108-10 The use of iron dextran (Imferon) has been recognized by a number of research clinicians to be a viable therapeutic option in the treatment of iron deficiency anemia for the Jehovah�s Witness patient who steadfastly refuses blood transfusions (as might be required to correct anemia). The use of intravenous


Imferon and Folic Acid, coupled with intramuscular injections of B-12 and Deca-Durobolin (and, at time when indicated, intravenous hyperalimentation) has become a life-saving reality. It is our purpose in this report to outline the clinical result of our experience with 841 Jehovah�s Witnesses over the past nine years.

(4) Lapin R. MAJOR SURGERY IN JEHOVAH�S WITNESSES. Contemporary Orthopaedics 1980 December; 2(9): 647, 651, 653-54 Performing major surgery in Jehovah�s Witnesses represent a moral and ethical dilemma to the majority of physicians, who see only an occasional member of this religious group, and a great challenge as well as a tremendous sense of satisfaction to the few physicians who treat these patients on a regular basis. Since we believe that most physicians are not well acquainted with the moral, legal, and ethical issues involved in the surgical treatment of Jehovah�s Witness patients, we present the following combined series, which, to the best of our knowledge, is the largest ever reported either the U.S. or the world literature. It is our hope that this article will not be viewed as a mere collection of numbers and statistics, but rather as a testimony that major surgery can be carried out successfully on patients who, because of strong religious convictions, refuse to accept transfusions of blood or blood products. From 1973 to 1980, 3,856 patients ranging from 1 month to 96 years of age underwent major surgery without the use of blood or blood products. Mortality within the first 3 weeks postoperatively was 0.1%. Of the 4 deaths in this series, only 1 was directly attributable to exsanguination. Emergency and elective procedures were performed on patients whose hemoglobin levels ranged from 2.8 gm% to 16.0 gm%. Seventy-three patients were operated upon with a preoperative hemoglobin below 5.0 gm% without subsequently mortality.

3. BS Clinics for Heart Surgery

(1) Levinson RK BLOODLESS SURGERY. N J Med 1999 Aug;96(8):39-41 Doctors and nurses in the forefront of the bloodless medicine and surgery movement say that virtually all hospitals now employ at least some facet of bloodless medicine. Because the strategies generally promote good health and save money, some New Jersey hospitals have even made bloodless medicine a standard of care regardless of patients' religious or moral convictions.

(2) Robb N JEHOVAH'S WITNESSES LEADING EDUCATION DRIVE AS HOSPITALS ADJUST TO NO BLOOD REQUESTS. CMAJ 1996 Feb 15;154(4):557-60 Jehovah's Witness representatives have visited more than 10 Canadian medical schools and 200 hospitals in an attempt to educate future and practising physicians about nonblood medicine. The trend is becoming more popular since the advent of HIV, and there are now about 100 bloodless medicine and surgery centres around the world, including 52 in the US. However, a Jehovah's Witness spokesman says Canada is "conspicuously absent" from the list of countries that offer bloodless-medicine programs.

(3) Modern Healthcare 1983 December; 13(12): 50 2 HOSPITALS OFFERING PATIENTS OPTION OF �BLOODLESS� SURGERY. Two hospitals are offering �bloodless� surgery for patients who, for religious reasons, want to avoid transfusions. Graduate Hospital, Philadelphia, has begun offering bloodless surgery to heart patients. Although some religious groups require such surgery, the process is gaining popularity among the general public as people become warier of contracting diseases from transfusions.

4. BS treatment for Gynecologic disease


(1) deCastro RM BLOODLESS SURGERY: ESTABLISHMENT OF A PROGRAM FOR THE SPECIAL MEDICAL NEEDS OF THE JEHOVAH'S WITNESS COMMUNITY--THE GYNECOLOGIC SURGERY EXPERIENCE AT A COMMUNITY HOSPITAL. Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1491-8

Department of Obstetrics and Gynecology, Legacy Good Samaritan Hospital, Portland, USA. OBJECTIVE: My purpose was to describe the rationale behind the establishment of a hospital-based program instituted to enhance the health of the Jehovah's Witness community and to evaluate patient profiles and outcomes of gynecologic patients treated surgically at our institution, during the past 5 years, whose intake was through the Bloodless Surgery Program and who were not accepting of blood or most blood products. I further describe how a coordinated program dedicated to serving this particular population might improve outcomes and patient satisfaction. STUDY DESIGN: A retrospective review of the charts of 89 patients, all Jehovah's Witnesses, who were enrolled through the Bloodless Surgery Program and underwent gynecologic surgery involving at least 1 night's hospitalization at our institution between January 1, 1993, and December 31, 1997, was performed. A comparison of patient length of stay, hospital charges, and surgical blood loss, in a subset of 41 patients who underwent abdominal hysterectomy, with a cohort of patients not affiliated with the Jehovah's Witnesses or the Bloodless Surgery Program was performed. Data regarding patient satisfaction were obtained through surveys and are presented. RESULTS: Patients enrolled through the Bloodless Surgery Program and undergoing abdominal hysterectomy were significantly younger (average age 43.4 vs 47.7 years) and incurred significantly lower hospital charges (average cost $8754 vs $9539). No significant difference between the group studied and the control group could be found in average length of stay or the average change between preoperative and postoperative hemoglobin levels. Data from patient satisfaction surveys suggest a high level of satisfaction with the Bloodless Surgery Program. CONCLUSION: A program dedicated to the special needs of the Jehovah's Witness community can be instituted in a community-based hospital with no evidence of increased morbidity, as evidenced by length of stay, hospital charges, and surgical blood loss, in a gynecologic patient population. Development of such programs is associated with a high level of patient satisfaction and the potential for improved patient care.

Documents

Blood Conservation Techniques and Perioperative Planning ...The topic was only continued if the patient signalled a clear wish for this. Half the patients had a close relative present