Witness Patients Research Articles

Successful endovascular treatment for acute type A aortic dissection in a Jehovah’s Witness patient

Successful endovascular treatment for acute type A aortic dissection in a Jehovah’s Witness patient

Bloodless Total Hip Arthroplasty in Jehovah’s Witness Patients: Contemporary Strategies and Outcomes

BackgroundReported blood transfusion rates in total hip arthroplasty (THA) range between 3 and 22%. Jehovah’s Witnesses (JW) do not accept blood transfusions and make conscience decisions to accept blood derivatives. This study reports on strategies and outcomes for bloodless THA. MethodsAll JW patients undergoing primary THA at our institution between 2011 and 2022 were included in this study (94 of 110 THA). The indications for THA were osteoarthritis (92%), femoral neck fracture (6%), rheumatoid arthritis (1%), and failed open reduction and internal fixation (1%). Strategies used to optimize outcomes included erythropoietin, tranexamic acid, cell savers, intrailiac artery tourniquets, and minimizing phlebotomy. ResultsThe mean estimated blood loss was 201.2 ± 122.2 mL. Preoperative hemoglobin (Hgb) levels were 13.4 ± 1.4 g/dL, which decreased to 11.0 ± 1.3 g/dL on postoperative day 1 (POD1, P < 0.001), 10.3 ± 1.5 g/dL on POD2 (P = 0.001), and 9.8 ± 1.1 g/dL on POD3 (P = 0.171). The use of tranexamic acid significantly decreased Hgb drop on POD1 (P = 0.04). Subgroup analysis showed that preoperatively anemic patients (closed circuit, Hgb < 12 g/dL) had significantly less Hgb drop postoperatively (P = 0.003). No patients met the recommended transfusion threshold (Hgb < 7 g/dL). There were two 90-day readmissions due to falls. There was zero 90-day mortality. ConclusionsA THA can be safely performed on JW patients. Preoperatively anemic patients had a decreased Hgb drop postoperatively. JW patients make a conscious decision to accept blood derivatives, which may be present in medications including erythropoietin. We recommend maintaining an Hgb above 11 g/dL prior to surgery, as a Hgb drop of 3.1 g/dL can be expected. These findings highlight the efficacy of a multimodal approach to optimizing bloodless primary THAs.

Tranexamic Acid Led to Improved Safety of Total Knee Arthroplasty in Jehovah’s Witness Patients: A Multicentered Matched Study

BackgroundThis study aimed to evaluate the safety of total knee arthroplasty (TKA) in Jehovah’s Witness patients compared to non-Jehovah’s Witness patients using standard perioperative TKA protocols and assess the role of tranexamic acid (TXA) in managing blood loss in this population. MethodsPatients undergoing TKA between 2011 and 2021 at 2 tertiary academic centers were retrospectively reviewed. Patient demographics, preoperative and postoperative hematologic laboratory values, intraoperative TXA use, 90-day postoperative complications, and subsequent revisions were collected. These variables were then compared between propensity score–matched cohorts at a 2:1 ratio of those who did not identify as Jehovah’s Witness to those who did. Regression analysis was used to determine the effect of intraoperative TXA on hemoglobin (hgb) shift. ResultsAfter applying exclusion criteria and matching, the TKA outcomes of 316 non-Jehovah’s Witness patients and 152 Jehovah’s Witness patients were analyzed. Univariate analysis suggested that non-Jehovah’s Witness patients and Jehovah’s Witness patients had similar preoperative and postoperative hgb, hgb shift, and hematocrit. Only 1 (0.8%) Jehovah’s Witness patient reached an hgb < 8.0 mg/dL postoperatively. Multivariate logistic regression suggested that Jehovah’s Witness patients did not have increased odds of reaching an hgb < 8.0 mg/dL (odds ratio = 0.99 [0.96, 1.02]; P = 0.42). Multivariate linear regression suggested that intraoperative TXA was positively correlated with hgb shift and thus a smaller decrease in hgb from pre-TKA to post-TKA (β = 0.38 [0.06, 0.69]; P = 0.02). Additionally, Jehovah’s Witness patients had excellent revision-free (95% [91, 99]) and infection-free (98% [95, 100]) survival at 8 years. ConclusionsStandard perioperative TKA protocols are safe for Jehovah’s Witness patients who do not have the need for transfusion, especially with appropriate preoperative hgb levels and the use of intraoperative TXA. Furthermore, these patients have excellent survivorship at 5 and 8 years of follow-up. Level of EvidenceLevel III.

Gastrointestinal Bleeding and Survival After a Nadir Hemoglobin

We report 2 cases of gastrointestinal bleeding and profound anemia in Jehovah's Witness patients (with nadir hemoglobin of 2.1 and 2.8 g/dL), both of whom survived until discharge to home. Management included supportive care, antifibrinolytics, and an aggressive erythropoietic regimen. Despite previous reports of high mortality with hemoglobin concentrations less than 5 to 6 g/dL, these patients illustrate that meticulous care in selected patients with severe anemia can lead to successful outcomes, without transfusion.

Diagnostic evaluation and management of obscure overt haemorrhage in a Jehovah’s witness patient: a case report and review of the literature

Diagnostic evaluation and management of obscure overt haemorrhage in a Jehovah’s witness patient: a case report and review of the literature

Enhancing bariatric surgery safety for patients refusing blood transfusions: a specialized protocol with comprehensive technical measures.

Bariatric surgery has become a leading treatment for obesity, with techniques such as Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) demonstrating notable success in sustained weight loss and improved quality of life. Technological advancements and improved techniques have enhanced the safety of these procedures. The surgical procedures of Jehovah's Witnesses, who refuse blood transfusions as part of their beliefs, pose unique challenges and have rarely been addressed in the context of bariatric surgery. This report aimed to investigate the safety of bariatric surgery in patients who refuse blood transfusion, with an established protocol to minimize the risk of bleeding. We examined the prospectively collected data of Jehovah's Witness patients who underwent bariatric surgery from 2019 to 2023. The surgeries were conducted following a protocol that included specific measures to prevent bleeding. Data were reviewed for demographics, anthropometrics, comorbidities, preoperative medications, operative time, blood loss, length of hospital stay, hemoglobin level, drainage volume, tranexamic acid use, and postoperative 30-day complications. Eleven Jehovah's Witness patients underwent bariatric surgery, including 10 LSG and 1 LRYGB. A patient with iron deficiency anemia underwent intravenous iron treatment before the surgery. There were no intraoperative complications or major postoperative complications. All patients maintained stable hemodynamics postoperatively. Only one patient encountered nausea-vomiting, classified as a minor complication. One patient experienced a small amount of hemorrhagic drainage, which transitioned to serous after tranexamic acid infusion. Bariatric surgery can be performed safely with established protocols in patients who refuse blood transfusions.

Outcomes associated with absent blood product utilization in Jehovah's witness patients compared to the standard of care in cardiac surgery: A ten-year experience.

For Jehovah's Witness (JW) patients requiring cardiac surgery, various strategies such as preoperative use of erythropoietin stimulating agents (ESAs), intravenous iron (IVI), and non-pharmacologic interventions have emerged to prevent complications from blood loss given transfusion is not acceptable in this population. Retrospective case-control of cardiac surgeries performed by the same surgeon between 1/1/2011 and 8/30/2021. JW patients were matched to non-JW who received blood products and non-JW who did not receive blood products on a 1:2:2 basis. Patients were matched on procedure, age, gender, and Society of Thoracic Surgeons morbidity score. Eligible patients were aged >18years and had a sternotomy procedure. The primary efficacy and safety outcomes included mean hematocrit values perioperatively and thrombotic events. A total of 27 JW, 52 non-JW transfused, and 53 non-JW not transfused patients were included in the analysis. JW patients had significantly higher mean hematocrits at every time point when compared to non-JW transfused patients and at all time points except clinic and the last recorded operating room value when compared to non-JW not transfused patients. No significant differences in thrombotic rates were found between groups, however there was a numerically higher incidence in the JW population (JW: 7.4%; non-JW transfused: 0%; non-JW not transfused: 1.9%; p = .106). A blood conservation protocol in a JW population was associated with higher perioperative hematocrit values when compared to matched controls. Further prospective study is warranted before applying similar protocols to other populations given the possibility for an increased rate of venous thromboembolism.

Bloodless Cardiac Surgery in Jehovah's Witness: A Comprehensive Review.

This article explores the major challenges and specialized strategies involved in managing cardiovascular surgery patients who are Jehovah's Witnesses and refuse blood transfusions due to their religious beliefs. It delves into preoperative, intraoperative, and postoperative approaches aimed at minimizing blood loss and optimizing patient outcomes while respecting their autonomy. Preoperative measures focus on correcting anemia and coagulopathy through targeted interventions, such as iron supplementation and erythropoietin therapy, and meticulous screening for bleeding disorders. Intraoperative techniques include the use of vasoconstrictors, hemostatic agents, and innovative blood conservation methods like acute normovolemic hemodilution and cell salvage. Postoperative care emphasizes infection control, hemostasis, and judicious monitoring to prevent anemia and facilitate recovery. Through a multidisciplinary approach and adherence to evidence-based practices, healthcare providers can effectively meet the needs of Jehovah's Witness patients, ensuring safe and successful cardiovascular surgery outcomes without the use of blood transfusions.

Fear of Cancer and State Anxiety Among Women Undergoing Hysterectomy

Background Fear of cancer may develop after surgery in women who underwent surgery for suspected malignancy in preoperative examinations. It is important from a psychosocial point of view that the fear of cancer and the factors affecting anxiety are determined and necessary interventions are made. Objectives The aim of this study was to determine the level of state anxiety, fear of cancer, and influencing factors in women who had hysterectomies with a risk of cancer in the waiting period for the pathology result. Methods The research data were collected from 109 women who underwent hysterectomy while waiting for the pathology result on the third or fourth postoperative day. Patients completed the Personal Information Form, State-Trait Anxiety Inventory-I, and Cancer Worry Scale. Results Women who underwent hysterectomy with the risk of gynecological cancer had high levels of state anxiety and cancer fear after hysterectomy; type of hysterectomy significantly affected cancer fear (P = .022), and social support (P = .015), type of hysterectomy (P = .024), and family history of cancer (P = .022) significantly affected state anxiety. Conclusion The management of these women’s concerns can be improved if healthcare professionals know more about the factors affecting their state anxiety and fear. Implications for Practice Health professionals witness patients’ most private experiences and play a key role in providing care and support. This study may be foundational in the planning and implementation of nursing interventions to manage causes of anxiety and fear during this waiting period.

Minimally Invasive Approach versus Sternotomy for Cardiac Surgery in Jehovah's Witness Patients

To evaluate the outcomes of minimally invasive cardiac surgery (MICS) compared with the sternotomy approach for Jehovah's Witness (JW) patients who cannot receive blood transfusions DESIGN: This was a retrospective observational study. The study was conducted at a specialized cardiovascular intervention and surgery institute. The study cohort comprised JW patients undergoing cardiac surgery between September 2016 and July 2022. None MEASUREMENTS AND MAIN RESULTS: Patients (n = 63) were divided into MICS (n = 19) and sternotomy (n = 44) groups, and clinical outcomes were analyzed. There was no difference in types of operation except coronary bypass grafting (n = 1 [5.3%] in the MICS group v n = 20 [45.5%] in the sternotomy group; p = 0.005). There were no between-group differences in early mortality and morbidities. Overall survival did not differ significantly during the follow-up period (mean, 43.9 ± 24.4 months). The amount of chest tube drainage was significantly lower in the MICS group on the first postoperative day (mean, 224.0 ± 122.7 mL v 334.0 ± 187.0 mL in the sternotomy group; p = 0.022). The mean hemoglobin level was significantly higher in the MICS group on the day of operation (11.7 ± 1.3 mg/dL v 10.6 ± 2.0 mg/dL in the sternotomy group; p = 0.042) and the first postoperative day (12.3 ± 1.8 mg/dL v 11.2 ± 1.9 mg/dL; p = 0.032). MICS for JW patients showed favorable early outcomes and mid-term survival compared to conventional sternotomy. MICS may be a viable option for JW patients who decline blood transfusions.

Anesthetic Management of a Jehovah's Witness Patient for Coronary Artery Bypass Grafting With Antiphospholipid Antibody Syndrome and Renal Transplant.

Anesthesia for cardiac surgical patients with antiphospholipid antibody syndrome (APLS) presents challenges with monitoring anticoagulation during cardiopulmonary bypass. Additionally, this condition is associated with other autoimmune diseases and comorbidities that need to be considered in caring for these patients, and there is minimal evidence for specific strategies during cardiac surgery. Separately, Jehovah's Witness (JW) patients typically do not consent to receiving blood products, presenting an additional challenge for resuscitation during cardiac surgery and especially in the context of APLS. We present our approach to the anesthetic management of a JW patient with systemic lupus erythematosus (SLE) complicated by APLS, thrombocytopenia, and renal failure with history of renal transplant who presented for coronary artery bypass surgery. Management strategies we recommend include administration of antifibrinolytics after heparinization to mitigate bleeding risk and interdisciplinary management with the perfusion, intensive care, surgical, and nephrology teams.

Bloodless Treatment of Jehovah’s Witness Patients with Lymphoma and Multiple Myeloma

Background/Aims: Jehovah’s Witnesses refuse blood transfusions for religious reasons. Soonchunhyang University Hospital Seoul has operated a bloodless treatment center since 2000, and a database of bloodless treatment patients has been created. This study aimed to analyze the bloodless treatment outcomes of lymphoma and multiple myeloma patients.Methods: We retrospectively analyzed data of patients diagnosed with lymphoma (22 patients) or multiple myeloma (seven patients) who were treated bloodlessly at Soonchunhyang University Hospital Seoul from 2006 to 2021.Results: The 2-year survival rate for lymphoma patients was 66.6%, with 22.7% dying within 6 months of diagnosis. Those who died early (within 6 months) had a median hemoglobin level of 5.5 g/dL and a median platelet count of 50,142/µL. Dyspnea due to anemia was the most common symptom reported by patients at the end of life. Patients with multiple myeloma had a median survival of 60.3 months and a 2-year survival rate of 57.1%. Although three of the seven multiple myeloma patients were eligible for autologous stem cell transplantation, they were treated with chemotherapy only due to limitations of the bloodless treatment. The drug type and intensity were adjusted due to hematological toxicities in 71.4% of multiple myeloma patients.Conclusions: A significant proportion of patients completed their planned course of chemotherapy and achieved long-term survival. The treatments of some patients were adjusted due to the use of bloodless treatment at the initial chemotherapy session, which affected their response to treatment.

Operative Repair of Type A Aortic Dissection in Jehovah’s Witnesses: Insights From a Case Series

BackgroundJehovah’s Witnesses are known to refuse allogeneic blood products. Consequently, many surgeons will decline to perform aortic surgery on this patient group, given their higher risk. We present here a case series describing operative repair of type A aortic dissection without the use of allogeneic blood products. MethodsFrom 2018 to 2021, 6 Jehovah’s Witness patients underwent open repair of type A aortic dissection. We reviewed preoperative characteristics, diagnostic workup, operative technique, and postoperative outcomes. We also looked specifically at use of autologous whole blood, Cell Saver (Haemonetics) transfusion, synthetic clotting factors (recombinant factor VIIa), and albumin and prothrombin complex concentrate when allowed. ResultsModified hemiarch replacement was performed with the branched single-anastomosis frozen elephant trunk repair (B-SAFER) technique in 4 patients; 2 patients received a standard hemiarch replacement. Aortic valve replacement was performed in 2 patients; root replacement was performed in 1 patient. There were no immediate postoperative coronary complications, strokes, or instances of renal failure. Average decrease in hemoglobin concentration after surgery was 2.3 ± 1.5 g/dL (mean ± SD). Thirty-day mortality was 0. Five of 6 patients survived to discharge, and all survivors to discharge were still alive at the time of submission. ConclusionsBloodless aortic dissection repair in these rare patients can be performed safely in specialized centers using the techniques described. Furthermore, we believe that these techniques can be applied to the general population of patients undergoing emergent cardiac operation to avoid allogeneic transfusions.

ThTP3.8 Promoting Awareness and optimizing perioperative management for Jehovah's Witnesses (JW) patients: A Quality Improvement Project (QIP)

Abstract Aims The restriction in using blood products poses a unique challenge to healthcare providers during treatment of JW patients. Current trust guidelines cover the peri-operative aspects of the management. We carried out a QIP to review the awareness amongst clinicians of appropriate guidelines and protocols in managing this cohort of patients. Methods An online survey was sent out to clinicians of all grades within the Trust, asking specific questions related to the use of blood products and alternative options; awareness of protocols including who to contact for advice. Results Our results of 102 responses revealed, 76% clinicians were not familiar with the trust guidelines. There was a wide variation in the knowledge about blood products which could be used and 42% were not aware of acceptable alternative options. 68% were not sure whom to contact for advice in and out of hours. 20% knew how to update an alert on the online medical records to identify patents’ wish of refusal for use of blood products. 94% were unaware of any preoperative and consent checklist for blood products. 50% were aware of checking Advance Directive for Refusal of Treatment (ADRT). Conclusion This QIP highlighted the lacunae in the awareness of trust protocols amongst clinicians of all grades. We aim to provide support and alerts on our Trust Intranet for managing this cohort of patients. Our ultimate goal is to produce a uniform national protocol available to all hospitals in the UK.

Is Head and Neck Free Flap Reconstruction Feasible in Jehovah’s Witness Patients?

Jehovah's Witnesses (JW) population are members of a religious group that refuses blood transfusion. This presents a dilemma for surgical teams when performing major surgical procedures on these patients. This study aimed to assess the safety and feasibility of undergoing microvascular free flaps for maxillofacial reconstruction in JW patients and whether the type of underlying pathology impacts outcomes. This was a multi-institutional retrospective cohort study. The sample consisted of all JW patients who have undergone microvascular free tissue transfer for maxillofacial pathology between January 2016 and January2021. The primary predictor variable was the underlying pathology for which patients underwent head and neck free flap reconstruction; this was benign versus malignant disease. The primary outcome variables were safety, defined as discharge from the hospital with no mortality, and feasibility defined as successful free flap reconstruction. Other variables included age, race, sex, length of surgery, length of hospital stay, and intraoperative use of vasopressors. Data analysis was performed utilizing t-tests for means and χ2 for proportions. Alpha was setat< 0.05. A total of 12 participants from 7 participating sites met the inclusion criteria. There were 9 males and 3 females with a mean age of 58.3±8.3years. There were no deaths in this cohort and all patients were discharged from the hospital. All 12 free flap reconstructions were successful with no incidents of free flap loss; none of the patients received any blood transfusions or any other blood products. Subgroup analysis showed that patients treated for malignant disease versus benign disease had longer operations (11.2±2.9 vs 6.3±0.2hours, P<.01) and a longer hospital length of stay (11.8±4.9 vs 5.3±0.5days, P=.04). Our series supports the safety and feasibility of maxillofacial free flap reconstruction in this challenging subset of patients. Microvascular reconstructive surgeries for malignant diseases often result in longer operative times and hospital stays.

P-018 ABDOMINAL WALL REPAIR IN JEHOVA´S WITNESSES. PRE, INTRA AND POSTOPERATIVE MANAGEMENT

Abstract Aim Abdominal Wall Repair (AWR) is a surgical procedure with a risk of bleeding during and after its performance. Patients who reject blood transfusion require strategies to avoid bleeding or to increase the margin of indication for transfusion. Materials and methods We analyzed the Jehovah's Witnesses patients who underwent AWR in our hospital and the perioperative management aiming to prevent fatal anemia and allow the performance of the surgery in this group of patients. Results We present three Jehovah's Witnesses patients undergoing AWR for multirecurrent midline incisional hernias. All of them attended hematology consultation prior to surgery to improve their situation at the time of surgery. During surgery, hemostatic material was used in areas at risk of subsequent bleeding. All received iron after surgery and, prior to hospital discharge, a dose of erythropoietin if needed. Patient characteristics are presented in the table. No bleeding requiring blood transfusion or other complications occurred. Follow-up in outpatient clinics showed a correct evolution. Conclusions Multidisciplinary care and particular attention to avoid bleeding and improve the condition of patients with refusal of blood transfusion makes complex abdominal wall surgery feasible and safer.

Management strategies for perioperative anaemia in the severely burn-injured Jehovah's Witness patients who decline a blood transfusion: A systematic review with illustrative case reports.

The management of severe burn-injured Jehovah's Witness patients who decline a blood transfusion poses unique challenges. The literature is scant for guiding perioperative anaemia management in these patients. We present a systematic review of this patient group, along with illustrative, consecutive case reports of our experience. A systematic review was performed on Embase, MEDLINE and PubMed databases on articles discussing the treatment of burn-injured Jehovah's Witness patients. Articles were excluded if discussing isolated inhalation injury, or if blood transfusions were permitted. Nine articles including a total of 11 patients revealed consistent themes. A multimodal medical and surgical approach is suggested. Medical strategies are directed at reducing blood loss and optimising haematopoiesis and include rationalising blood collection, reversing coagulopathy, administering tranexamic acid and regular erythropoietin. Surgical strategies include staged aggressive debridement, tumescent adrenaline infiltration and limb tourniquets. We found that the argon beam coagulator was an effective haemostatic adjunct not previously described in literature. Management of anaemia in severely burn-injured Jehovah's Witness patients is challenging. This systematic review presents a summary of strategies directed at minimising blood loss, and optimising haematopoiesis. Careful preoperative planning, meticulous surgical technique, and postoperative physiological support are caveats to success.

Challenges in the care of Ewing’s sarcoma in a Jehovah’s Witness patient

Ewing’s sarcoma is a bone and soft tissue neoplasm, whose management is related to hematological toxicity. This aspect represents a medical and ethical challenge in Jehovah’s Witnesses patients, who, due to their religious beliefs, reject the blood component transfusion, with the risk of discontinuing chemotherapy or using suboptimal doses. We present the case of a 34-year-old Colombian woman, Jehovah’s Witness, diagnosed with Ewing’s sarcoma with clinical stage IIB (T1N0M0) in the left maxillary and mandibular regions, treated with chemotherapy, who presented a hemoglobin nadir of up to 4.5 g/dL, and surgical indication as part of the treatment. In these patients, the transfusion decision has ethical implications that require therapeutic alternatives and a multidisciplinary approach.

Therapeutic modalities in thrombotic thrombocytopenic purpura management among Jehovah’s Witness patients: A review of reported cases

IntroductionDevout members of the Jehovah’s Witness faith flatly refuse transfusions of white blood cells, red blood cells, platelets, and plasma. The latter agent is a mainstay in the treatment of thrombotic thrombocytopenic purpura (TTP). Alternative treatment options for Jehovah’s Witness patients are needed and reviewed herein. MethodsCases of TTP treatment among Jehovah’s Witnesses were obtained from the published literature. Key baseline and clinical data were extracted and summarized. ResultsA total of 13 reports spanning a 23-year period and 15 TTP episodes were identified. Median (IQR) age was 45.5 (29.0–57.5) and 12/13 (93%) patients were female. Neurologic symptoms were present in 7/15 (47%) episodes at presentation. Disease confirmation with ADAMTS13 testing was present in 11/15 (73%) of episodes. Corticosteroids and rituximab were employed in 13/15 (87%) and 12/15 (80%) of cases, respectively, with apheresis-based therapy employed in 9/15 (60%) episodes. For eligible cases, caplacizumab was used in 4/5 (80%) episodes; average time to platelet response was shortest in these cases. Sources of exogenous ADAMTS13 accepted by patients in this series included cryo-poor plasma, FVIII concentrate, and cryoprecipitate. Conclusions: Successful management of TTP within the boundaries of the Jehovah’s Witness faith is possible.

228 - Complete response with bortezomib-dexamethasone and daratumumab in an elderly frail jehovah’s witness patient with high tumor burden light chain multiple myeloma presenting with severe anemia and thrombocytopenia

228 - Complete response with bortezomib-dexamethasone and daratumumab in an elderly frail jehovah’s witness patient with high tumor burden light chain multiple myeloma presenting with severe anemia and thrombocytopenia