FRCA Notes

Jehovah's Witnesses

This patient cohort isn't explicitly mentioned in the curriculum, but is a common Primary FRCA viva topic and could easily form the basis of a question on patient blood management.

Resources

  • Jehovah's witnesses are a branch of Christianity founded in the USA in the 1870s
  • They interpret passages from the Bible as prohibting the 'consumption' of blood
  • They have strong beliefs based upon this, namely they are unable to accept transfusion of whole blood ± its components, and blood which has been removed from their body is 'unclean'
  • Transgressing said beliefs may compromise their relationship with god and they may feel life is meaningless
  • Giving blood products against their will is assault and subject to GMC, civil and criminal action

Unacceptable May be acceptable Generally acceptable
Whole blood Cell salvage Crystalloids
pRBCs Albumin Recombinant EPO
White blood cells Immunoglobulins Recombinant factor VIIa
Platelets Clotting factor concentrates Artificial blood substitutes
Plasma (FFP) Cryoprecipitate
Acute normovolaemic haemodilution Acute hypervolaemic haemodilution
Platelet fractions
Dialysis
Cardiopulmonary bypass (crystalloid prime)
Plasmapheresis
Epidural blood patches
Organ transplants
  • Some interventions may be acceptable to certain individuals but not others
  • One should discuss and document the patients beliefs surrounding products prior to anaesthetic
  • Patients themselves can liaise with a committee of 'elders' called the Hospital Liaison Committee for Jehovah's Witnesses

Perioperative management of the Jehovah's witness


Planning

  • Flag patient early to discuss their wishes and optimise anaesthetic/surgical technique
  • Consultant-led anaesthetic, surgical and other (e.g. haematology) teams
  • Consider alternative surgical or non-operative techniques (e.g. IR) if risk of major blood loss is high
  • Staggering operations can allow haematological recovery in between each one
  • Surgery should take place in a suitable centre
  • Discuss risks with patient alone so they are not under duress from church members

Consent

  • Standard ethico-legal principles apply to the consenting process
  • Equally, a standard framework (benefits, risks, alternatives, doing nothing) should be used for discussions

  • There should be a frank and honest discussion about the consequences of refusing blood & blood products
  • Some patients may have advanced directives in place indicating acceptable management should they lack capacity in the future
  • Decisions made should be entered in the notes (date, time, signed by patient and doctor) ± sign special consent forms
Potential consequences of refusing blood transfusion/anaemia
Haemodynamic instability
Organ failure
Requirement for mechanical ventilation
Higher mortality (short-term and 30-day)
Delayed wound healing
↑ risk of wound infection
Unanticipated ICU admission
Prolonged hospital stay

Optimisation

  • Investigate and identify anaemia, thrombocytopaenia or coagulopathy early
  • Review and, where possible, stop antiplatelet or anticoagulant drugs

  • Enhance haemoglobin and RBC production through consideration of:
    • Dietician referral for optimisation of nutritional status e.g. vitamin B12, folate
    • Iron supplementation in those with functional iron deficiency or outright iron deficiency anaemia
    • ± Recombinant erythropoietin (rEPO) - need to instigate at least 4 weeks before surgery

Emergency surgery

  • Same as elective procedure but with time constraints
  • Patients without capacity due to pathological processes may have advanced directives
    • GP often has access to them
    • Efforts must be made to find advanced directive

  • If lack capacity and no advanced direct, must act in perceived best interests of patients
    • Can give blood (products) if believed to be life saving
    • Decision-making process should involve multiple consultant(s) and be meticulously documented

General

  • Ensure patient is highlighted at team brief
  • Discuss methods to be used to minimise blood loss

Minimise blood loss


Anaesthetic Surgical
Limit phlebotomy & use paediatric blood bottles Prompt, aggressive management of blood loss
Avoid venous congestion Arterial tourniquets
Limit intra-thoracic pressure Meticulous haemostasis
Consider hypotensive anaesthesia Minimally invasive surgical techniques
Avoid hypercapnoea Biological haemostats to aid coagulation and reduce blood loss (e.g. Kaltostat, Tisseal)
Avoid acidosis, hypothermia
Cell salvage
Acute hypervolaemic haemodilution
Use regional anaesthesia
Hypotensive anaesthesia (if appropriate)

Optimise anaemia tolerance

  • Optimise DO2 with:
    • Supplemental oxygen
    • Adequate cardiorespiratory support
    • Consideration of CPB or other extra-corporeal oxygenation
    • Red blood cell substitutes

Promote haemostasis and correct coagulopathy

  • Use point-of-care testing such as VBG, Haemocue and TEG/ROTEM
  • Use drugs which promote clotting e.g. vitamin K, TXA, aprotinin, desmopressin and products which are acceptable

  • Comprehensive written and verbal handovers
  • ± HDU setting for monitoring

  • Minimise ongoing blood loss:
    • Normothermia
    • Correct coagulopathy
    • Ongoing use of anti-fibrinolytics
    • Minimise blood sampling
  • May need ongoing cardiorespiratory support to optimise oxygen delivery and mitigate the effects of anaemia
  • Optimise nutrition to encourage endogenous haemopoiesis