Jehova’s Winesses: A Background
Jehovah’s Witnesses believe that the Bible prohibits ingesting blood and that Christians should therefore not accept blood transfusions or donate or store their own blood for transfusion. Watch Tower Society publications teach that the Witnesses’ refusal of transfusions of whole blood or its four primary components—red cells, white cells, platelets and plasma—is a non-negotiable religious stand and that those who respect life as a gift from God do not try to sustain life by taking in blood, even in an emergency. Witnesses are taught that the use of fractions such as albumin, immunoglobulins and hemophiliac preparations are “not absolutely prohibited” and a matter of personal choice. The belief is based on an interpretation of several scriptures that differs from that of mainstream Christianity. Although accepted by the majority of Jehovah’s Witnesses, a minority does not endorse this doctrine.
The doctrine was introduced in 1945, and has undergone some changes since then. It is one of the doctrines for which Jehovah’s Witnesses are most well known. Members of the religion who voluntarily accept a transfusion are regarded as having disassociated themselves from the religion by abandoning its doctrines and are subsequently shunned by members of the organization.
The Watch Tower Society has established Hospital Information Services to provide education and facilitate bloodless surgery. This service also maintains Hospital Liaison Committees, whose function is to provide support to adherents.
As It Pertains To Perfusion
Jehovah’s Witness patients are at increased risk for morbidity and mortality associated with blood loss due to their refusal, on religious grounds, of both homologous blood transfusion and autologous blood that has been removed from continuity with the body. They believe that it is wrong to accept or receive any type of blood product.
Even though it is commonly accepted that the Jehovah’s Witnesses will not receive any blood products, this does quite often vary from patient to patient. Therefore, it is recommended that each individual patient be presented with all possible options, including Albumin, in an effort to better assess the individuals personal convictions in relation to transfusion.
II. EXCLUSION CRITERIA:
A. Patients with significant coagulopathies
B. Patients with an expanding hematoma
C. Patients on thrombolytic therapy
D. Patients that are anemic for a known or unknown reason
E. Patients with a hemoglobinopathy
III. POTENTIAL PERFUSION TECHNIQUES:
A. Semi-Continuous Flow Centrifugation – Autotransfusion.
B. The use of perfluorocarbons
C. Hemoconcentration (this would include Modified Ultrafiltration)
IV. REGIMEN FOR OPEN-HEART SURGERY:
A. Fluids: Crystalloid fluid only, colloid administration should be Hespan or Dextran.
(Caution should be used with Dextran due to its theoretical effect on platelet function)
B. If possible, patients should be placed on Erythropoietin as far in advance of surgery as possible. Hematocrit should be > 36% prior to surgery and Erythropoietin continued until patient discharge for a hematocrit less than 30%.
C. If the patient will allow autologous blood donation in the O.R. suite, this procedure should be maximized to sequester as much blood as possible, only to be reinfused after the protamine.
D. Any and all excess tubing should be removed from the CPB circuit and the pump pushed as close to the table as possible. The smallest diameter tubing allowed by individual flow requirements should be substituted for the standard perfusion circuit.
E. Priming volume should be kept to a minimum. Consider Retrograde Autologous Prime (RAP).
F. Diuretics and hemoconcentration should be aggressively used during CPB. Mannitol may be used: 12.5 Gm in prime, 12.5 Gm when beginning to rewarm, 12.5 Gm just prior to coming off CPB.
G. Exclusive use of intraoperative cell saver. All blood salvaged and continuously reinfused through the cell saver in a closed circuit. Minimize use of laps, sponges and discard suckers. The entire bypass circuit should also be processed.
H. Modified Ultrafiltration (MUF) has proven to be quite effective in the Jehovah’s Witnesses population. It is not uncommon to raise the patient’s hematocrit 3-7% with MUF in a 20 minute time period. (Eg. Raised from Hct 23% to 28% in 20 minutes.)
I. All chest tube drainage should be reinfused if chest drainage is > 50 ml/hr. for the first 8 hours post-op.
J. If the patient has well preserved ventricular function, SVR should be maintained at > 1000 in an attempt to decrease the circulating vascular volume.
K. Great attention should be given to anticoagulation and heparin reversal to prevent heparin rebound post operation.