Bleeding in a Jehovah’s Witness patient undergoing a redo aortic valve replacement controlled with cryoprecipitate and a prothrombin complex concentrate

Abstract

This is a case report involving a middle-aged Jehovah's Witness patient who underwent a redo aortic valve replacement, coronary artery bypass graft, and Maze procedure facilitated by cardiopulmonary bypass. The consent process included a discussion of the management of bleeding and hemostasis in the perioperative period in the context of the patients' religious choice and the possible consequences of avoiding transfusion in massive bleeding. The medical team agreed to abide by the patient's wishes with respect to the blood and blood products deemed unacceptable by the patient irrespective of the consequences. The consent included a discussion of manufactured hemostatic agents that are designated by the Hospital Liaison Committee Network for Jehovah's Witnesses as subject to personal decision. There was also a discussion of recombinant agents available, all of which are acceptable to Jehovah's Witness patients. The patient accepted the use of cryoprecipitate, prothrombin complex concentrate, and recombinant factor VIIa. After separation from cardiopulmonary bypass and protamine administration, blood loss was 350mL over a ten-minute period. The international normalized ratio (INR) was 3.5 at that time. Cryoprecipitate 15 U, 1-deamino-8-D-arginine vasopressin 16 U, and a prothrombin complex concentrate, Octaplex®, 60mL were administered. Blood loss improved significantly. The INR in the cardiac surgical intensive care unit was 1.3. The sample was taken approximately one hour following the administration of the hemostatic agents. The patient's chest was closed, and chest tube drainage was 310mL over the next 12 hr. This is a novel case involving the use of prothrombin complex concentrate in the setting of a Jehovah's Witness patient undergoing a complex operative procedure.