Safety of cardiac surgery without blood transfusion: a retrospective study in Jehovah’s Witness patients

Abstract

We read with interest the experience of El Azab et al. [1] of providing a cardiac surgery service to Jehovah’s Witness patients. We agree that patients who refuse allogeneic blood products present both moral and ethical challenges, especially in cardiac surgery where significant blood loss and allogeneic blood product transfusion are common. We noted that the pre-operative haemoglobin concentrations were very similar in both groups, despite 3 weeks' treatment with erythropoietin, and the number of patients in the control group who received blood product transfusion was very high. We work in a busy cardiothoracic centre with a blood product transfusion rate of 20–25% compared to 65% in the control group in their article. Knowledge of their patients’ postoperative haemoglobin concentrations would have been interesting, but this information was not provided. Cell salvage and autologous transfusion is an important component of blood conservation, but this was not part of this hospital’s protocol for managing Jehovah’s Witness patients. Cell salvage is usually acceptable to Jehovah’s Witnesses, but consent needs to be obtained on an individual basis. The 2009 Association of Anaesthetists of Great Britain and Ireland guidelines recommend the use of cell salvage in cases where patients have objections to receiving allogeneic blood product transfusions [2]. In cardiac surgery cell salvage can be used both intra- and postoperatively. The benefits of intra-operative cell salvage are the salvage of blood before and after cardiopulmonary bypass and reduction of the volume of cardiotomy blood that is returned to the patient. The re-infusion of cardiotomy blood has been implicated with the development of a coagulopathy and increased blood loss [3], increased incidence of postoperative neurocognitive dysfunction [4] and the development of systemic inflammatory response syndrome [5]. Blood can also be salvaged postoperatively from surgical drains. We feel that cell salvage is an essential component of blood conservation and should be used in all Jehovah’s Witness patients who consent to its use. No external funding and no competing interests declared. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com.