There are over 8 million Jehovah’s Witnesses (JWs) worldwide who routinely do not accept whole blood, packed red blood cells, fresh frozen plasma, platelets, or cryoprecipitate. This stems from their interpretation of Biblical scripture. This can present unique challenges to me in both the OR and ICU during large cardiothoracic surgeries, acute GI bleeds, etc.
For elective surgeries, JWs are often started on erythropoetin, iron, B12, and folate weeks in advance to boost their hematocrit. On the day of surgery, this extra buffer allows my perfusion colleagues and I to perform closed-loop autologous blood donation, closed-loop CellSaver, or acute normovolemic hemodilution (ANH). In ANH, 500-1000 cc of blood are drained from a central line prior to surgery, left in continuity with the patient, replaced with crystalloid to maintain intravascular volume, and reinfused after the surgery is completed. Furthermore, anticoagulation needs to be carefully optimized before surgery. Coagulopathies should be corrected (ie, Vitamin K) and antifibrinolytics like TXA should be strongly considered.
Most importantly, I have a candid, private conversation with JWs regarding the specific blood components they will accept. Some patients are amenable to albumin as it crosses the placenta in utero. More often, others are fine with synthetic factor concentrates like KCentra and NovoSeven. Hemoglobin-based oxygen carriers (HBOCs, or “artificial blood”) are also becoming more widely available. Some will even err on the side of receiving whole blood products under emergent circumstances. I’m not there to judge either way. I’m there to provide my clinical reasoning and honor my patients’ wishes while keeping them informed of my realistic concerns.
Here’s an image of “closed-loop” Cell Saver. I have my crystalloid fluid bag (on the right) and Cell Saver bag (left) connected to the patient from the beginning of surgery to infuse their washed red blood cells.
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