Jehovah’s Witnesses

1. Jehovah’s Witnesses Exploring the Transfusion Alternatives Heather Winslow, RN, BSN, SRNA Raleigh School of Nurse Anesthesia

2. Who are Jehovah’s Witnesses? • Religious group founded by Charles Taze Russell in Allegheny, PA in 1869 • Currently the most rapidly growing religious group in the western world • 6.7 million members worldwide; more than one million members in the US • Members pledge allegiance to God’s Kingdom and believe it to be an authentic government unto itself • Members do not salute flags, join service organizations, enlist in the military , vote in public elections, or take interest in civil government

3. What are their beliefs about blood? • In July of 1945 a doctrine was developed that asserted that blood transfusion should be forbidden because it violated God’s law • Equated transfusing blood as = “eating” blood • Genesis 9:3-4, Leviticus 17:10-16, & Acts 15: 28-29 • Feel that accepting blood will lead to eternal damnation • Believe that blood contains one’s moral and physical characteristics and accepting transfusion will “pollute” oneself with the world’s ideas, thus losing one’s holiness • Also believe that “the time gained on earth from a blood transfusion is inconsequential to the eternal spiritual damnation that results from it.”

4. Beliefs continued… • Refuse transfusions of whole blood or of any of its 4 primary components • PRBCs, WBCs, plasma, platelets • Autologous blood if predeposited (given during the preoperative period) • Generally accept autologous blood if it is maintained in continuous contact with the patient’s vasculature • e.g. intraoperativeautotransfusion with no disruption or interruption of the tubing circuit • Recently in 2006, the Watchtower Society (governing body for the religion) stated that it was feasible to accept certain components of blood, but that careful consideration and prayerful meditation must accompany one’s choice • May accept albumin, recombinant human erythropoietin, immunoglobulins, factor concentrates, etc.

5. “Not only as a descendant of Noah, but now also as one bound by God’s law to Israel which incorporated the everlasting covenant regarding the sanctity of life-sustaining blood, the stranger was forbidden to eat or drink blood, whether by transfusion or by the mouth.” The Watchtower: December 1, 1944

8. Confidentiality • Often members of the Jehovah’s Witness community may send a representative to stand watch and ensure no transfusions are administered; a member may be with patient in preoperative holding room • Patient may decide to accept blood; interview privately if possible • 1995 study found that up to 10% of Witness patients or guardians are willing to accept blood transfusions • Confidentiality is of the utmost importance • Telling members could have potential social and religious ramifications – members are shunned for accepting blood

9. What are the transfusion alternatives? • Albumin • Recombinant Human Erythropoietin • Recombinant Human Activated Factor VIIa • Hemoglobin-Based Oxygen Carriers • Acute NormovolemicHemodilution • Autologous Autotransfusion • Pharmacological techniques • Hypotensive anesthesia

10. Albumin • Expands plasma volume by maintaining plasma oncotic pressure • Also has protective effects on the microcirculation, antioxidant and free-radical scavenging properties, and anticoagulant and antiinflammatory effects • Recent studies suggest that use of albumin has no benefit when compared to conventional crystalloid replacement • A multicenter, double-blind, randomized trial found no difference in mortality between ICU patients receiving either 4% albumin or normal saline for fluid resuscitation • Routine use among any patients, including Jehovah’s Witnesses, shows no economical benefit

11. Recombinant Human Erythropoietin • Erythropoietin is secreted by the kidneys and stimulates bone marrow to produce RBCs • rHuEPO contains albumin and stimulates erythropoiesis consequently decreasing the chance that a transfusion may be necessary • Can also augment erythropoiesis with iron, vitamin B12, and folate supplementation • May be an option to administer prior to operative period if surgery is scheduled • May not be effective in critically ill patients • Have increased concentrations of endogenous EPO • Have abnormal iron metabolism (iron deficiency or decreased iron availability secondary to sequestration) • Surge of proinflammatory cytokines • Decreases production and survival of RBCs • Bone marrow suppression • Decreased iron availability • Reduced production of EPO

12. Recombinant Human Activated Factor VIIa • Binds to tissue factor at the site of endothelial injury, triggering a local coagulation process, ultimately resulting in production of additional thrombin, platelet activation, and stability of clot formation • Does not appear to pose a thromboembolic risk or cause the development of intravascular thrombosis • Common side effects: rash, fever, nausea

13. Hemoglobin-Based Oxygen Carriers • Synthetic colloid with advantages including: • Rapid and widespread availability • Fewer requirements with regard to storage, transport, and compatibility testing • Longer shelf life • More consistent supply • Less antigenic • Less risk of disease transmission

14. Hemoglobin-Based Oxygen Carriers • Hemopure is a polymerized form of bovine hemoglobin solution • PolyHeme is derived from pyridoxylated polymerized outdated hemoglobin from human blood • In general, these products reduce or eliminated the need for allogeneic blood transfusions in patients undergoing orthopedic surgery, elective abdominal surgery, and CABG • Disadvantage is that these products have a short half life; thus frequent re-administration is needed and this is costly

15. Acute NormovolemicHemodilution • Patient blood withdrawn and placed in collection bags before or shortly after the induction of anesthesia • Normovolemia maintained with crystalloid or colloid replacement • Circulating blood volume remains constant given that the reduction in red cell mass is compensated for with an increase in plasma volume • The patient’s blood can be reinfused at any time during or after surgery • Advantages • Safe • Easy • Inexpensive • Circulating blood has a lower hct blood loss represents a saving relative to quantitative red cell mass • Reduces blood viscosity  decreases SVR and allows for increase in CO without an increase in myocardial oxygen consumption • Reinfusion gives pt back his/her own platelets and inherent coagulation factors

16. Autologous Autotransfusion • May consent to use of blood management techniques and procedures involving temporary diversion of autologous blood as long as allogeneic blood is not used • Must be seen as an extension of their own circulatory system and tubing must remain in continuous contact with the patient’s intravascular compartment • Generally accept (must clarify with individual): • Cardiopulmonary bypass & Heart-Lung Machine (low prime CPB circuits or retrograde autologous priming) • Dialysis • Intraoperative blood salvage • Reinfusion • Epidural Blood Patch • Plasmapheresis • Labeling or Tagging • Acceptance of autologousautotransfusion remains at the discretion of each individual • Conventional cell saver may not be accepted because the salvaged blood is processed in batches, thereby interrupting contact with the vasculature

17. Pharmacologic Techniques • Aprotinin - A serine protease inhibitor that reduces bleeding through its effects on the fibrinolytic and clotting pathways, the inflammatory response, and platelet function • Risks • Anaphylaxis • Potential nephrotoxicity • DVT and pulmonary emboli • Currently suspended by FDA • Other pharmacologic agents shown to decrease perioperative blood loss • Aminocaproic acid (Amicar®) - antifibrinolytic • Tranexaminic acid (Cyklokapron®) - competitive inhibitor of plasminogen activation • Surgifoam • Surgicel

18. Hypotensive Anesthesia • In one study, hypotensive anesthesia decreased EBL by nearly 55%, and reduced need for transfusion by 53% in scoliosis surgery • Numerous risks and pt must be carefully monitored • Ischemic threshold varies from patient to patient • Is the brain being perfused?

19. A Summary Jehovah’s witnesses-position overview (2007). Retrieved September 24, 2009, from http://pennhealth.com/health_info/bloodless/000206.html.

20. A Case Study • 21yo male Jehovah’s Witness presenting with thoraco-abdominal aneurysm • Preop treatment with erythropoeitin and ferrous sulfate for 3 weeks to raise hgb from 14.6 to 17.4 • Intraoperative acute normovolemichemodilution, aprotinin, controlled hypotension, restricted heparinization, and recombinant factor VIIa • The patient did accept use of autologous fibrin sealant • At discharge, hgb was 10.1, the patient was continued on erythropoeitin and was doing well one year post-op repair

21. A Case Study • 39 yo Jehovah’s Witness presenting with placental abruption and intrauterine fetal demise at 31 weeks • Delivery at outlying hospital complicated by DIC • Hgb at outlying hospital was 11.8, dropped to 2.9 on admission to tertiary care center • Patient was markedly symptomatic requiring intubation • Patient received a total of 18 units of PolyHeme during the hospital course • The patient survived the abruption, and an eventual total abdominal hysterectomy (EBL 800 ml) with the use of PolyHeme, erythropoeitin, and ferrous sulfate • PolyHeme served as a bridge, providing adequate oxygen transport, until the patient’s body could compensate for RBC loss

22. Conclusion • Jehovah’s witnesses represent a unique population for the nurse anesthetist • Effective patient-anesthetist communication is essential • Surgeries with expected large blood losses may require advanced multi-disciplinary planning • Explanation of the risks and benefits of all alternatives should be discussed; be honest, but try not to coerce or use scare tactics • Patient’s choice of alternatives and decision to accept blood should be made privately and confidentially • Administration of blood to those who refuse could lead to criminal or civil proceedings

23. QUESTIONS?

24. References Cothren, C.C., Moore, E.E., Long, J.S., Haenel, J.B., Johnson, J.L., & Ciesla, D.J. (2004). Large volume polymerized haemoglobin solution in a Jehovah’s Witness following abruptioplacentae. Transfusion medicine, 14, 241-246. Duncan, B.H., Brant, W.U., & Philip, S.B. (2008). The contemporary approach to the care of jehovah’s witnesses. The Journal of Trauma, Injury, Infection, and Critical Care, 65 (1), 237-247. Elder, L. (2009). Jehovah’s witnesses accepting blood transfusion. Retrieved July 20, 2009, from http://www.ajwrb.org/Jehovah_s_Witnesses_Accept_Blood_Transfusion.pdf. Hua, M., Muson, R., Lucas, A., Rovelstad, S., Klingensmith, M., & Kodner, I.J. (2008). Medical treatment of jehovah’s witnesses. Surgery, 143, 463-465. Jehovah’s witnesses-position overview (2007). Retrieved September 24, 2009, from http://pennhealth.com/health_info/bloodless/000206.html. Joseph, S.A., Berekashvili, K., Mariller, M.M., Rivlin, M., Sharma, K., Casden, A., et al. (2008). Blood conservation techniques in spinal deformity surgery. Spine, 33, 2310-2315. Rahman, I.A., Hoth, T., Doughty, H., & Bonser, R.S. (2007). Thoraco-abdominal aneurysm repair in a jehovah’s witness: Maximising blood conservation. Perfusion, 22, 363-364. Sniecinski, R., & Levy, J.H. (2007). What is blood and what is not? Caring for the jehovah’s witness patient undergoing cardiac surgery. International Anesthesia Research Society, 101, 753-754.