dr. Mrs. Minnu M. Panditrao explains the problems faced by anesthesiologists in anesthetising the Jehowah's Witness patients because of their beliefs. Ina ddition she also discribes various strategies of Blood conservation.

1. JEHOVAH’S WITNESSES
AND
BLOOD CONSERVATION
STRATEGIES
Dr. Mrs. Minnu M. Panditrao
Consultant
Department of Anesthesiology
Rand memorial; Hospital
Freeport, Grand Bahama
The Bahamas

2. Formerly:
Professor
Department of Anaesthesiology and critical care
Padmashree Dr. D. Y. Patil Medical College
Pimpri Pune.

3. Introduction
• Millenarian restorationist Christian denomination
• Follow New World Translation of Holy Scriptures
• Started in 1870’s as Bible Study Group in USA
• IN 1931 adopted the name “Jehovah’s Witnesses”
• Presently >7 million are living all over the world
• en.wikipedia.org/wiki/Jehova’s_witnesses-

4. Introduction– Beliefs
• Door to door preaching ( Watchtower & Awake )
• Do not celebrate
• Consider secular society – morally corrupt
• Do not work in military services
• Do not take un necessary risks with life
• Do not kill/hurt animals for sport
• Consider abortion and ART as wrong
• Refuse transfusion of blood & its main components-
consider it violation of “God’s Law”
( Acts 15: 19-21 and Genesis 9: 3-4 )

7. Introduction
• Pose problems to treating doctors
• Were mostly refused treatment due to their
adamant stand against blood transfusion
• Nowadays trends are changing
• They carry signed cards/ directives refusing
B.T. and absolving doctors of any liability

11. Introduction
• Do not accept—
- whole blood
- red blood cells
- white blood cell
- platelets
- plasma

12. Introduction
• May accept fractions :
- haemoglobin
- albumin
- immunoglobulins
- interferons
- cryoprecipitate etc.

13. Introduction
May accept treatments:
• Haemodialysis
• Plasmaphresis
• Heart lung bypass circulation
• Cell salvage & reinfusion

14. BLOOD CONSERVATION STRATEGIES
 Very important to reduce blood loss to
minimize the need for transfusion
 Team work
 Multimodal approach, combinations work
synergistically

15. Blood Conservation Strategies in
Surgical Patient
• Preparation of the patients prior to
anticipated blood loss helps them to tolerate
the blood loss to a greater extent

16. Pre-operative Preparation
Identification of factors that increase need for
Blood Transfusion
• Pre operative anaemia
• Coagulopathies
• Malignancy
• Renal failure
• Cardiac/vascular diseases
• Nature of surgical procedure

17. Pre-operative Preparation
Optimization of Haemoglobin Level
• Hb < 10 gm% - Inv. & Tt anaemia, iron, vitamins
& erythropoitin (weekly s/c injs)
• Hb 10-13 gm% - oral iron, vitamin, erythropoitin
• Hb 13-15 gm% - oral iron, vitamin supplements
• Hb > 15 gm% - adequate red cell mass, low risk
• www.uwoanesthesa.ca/ac-perioperative.hmtl-

18. Pre-operative Preparation
• Screening and Optimization of Coagulation
Profile
• Restricted Blood Sampling

19. Planning of Surgical/Anaesthetic
Procedure
• Minimally Invasive Surgical Procedure
• Extended Surgical Team
• Use of Regional Anaesthesia
• www.transfusionontario.org/media

20. Intra-Operative Blood Conservation
Intervention By Anaesthesiologist
• Acute Normovolemic Hemodilution
• Haemostatic Agents
• Positioning of the Patient
• Hypotensive Anaesthesia
• Maintenance of Normothermia
• Optimum oxygenation & 02 delivery
• Minimising 02 demand

21. Acute Normovolemic Hemodilution
• Whole Blood is withdrawn from patient just
before the surgery.
• It is replaced with a Crystalloid solution.
• Blood is re-infused during and after surgery.
• There is reduced loss of Red Blood Cells.
• Reduces need for Allogenic Blood Transfusion.

22. Hemostatic Agents
• Anti-Fibrinolytic Agents
• Desmopressin
• Recombinant Factor VIIa (rFVIIa)
• Somatostatin, conjugated oestrogens
• www.cmaj.ca/cgi/content/full/

23. Anti-Fibrinolytic Agents
Act against breakdown of clot.
Aprotinin –
• Decreases the affinity of serine proteases.
• Attenuates the inflammatory responses.
• Decreases fibrinolysis.
• Increases thrombin generation.
• Dose: 1-2 million kIU IV
250, 000 -500,000 kIU/hr
• A/E- hypersensitivity, heart failure, stroke, renal
dysfunction.

24. Anti-fibrinolytic Agents
Lysine Analogues -- inhibit plasminogen by binding to lysine
binding sites, inhibit deleter. effects of plasmin on platelets
• Tranexamic Acid:
Dose 10 mg/kg IV,
1 mg/kg/hr
• EACA:
Dose 100-150 mg/kg IV,
25 mg/kg/hr
• A/E- GI upset, thrombosis.

25. Desmopressin (DDAVP)
• Synthetic analogue of Arginine Vasopressin
• Induces release of stored Factor VIII and von
Willebrand’s Factor from endothelial cells
• Increases the platelet adhesiveness
• Prevents/controls bleeding in
haemophilics, plalelet dysfunction
• Dose: 0.3 µg/kg IV/SC/Intranasal

26. Recombinant Factor VIIa
• Vitamin K dependant glycoprotein
• Helps in controlling bleeding in patients with
liver disease, factor VII deficiency,
hemophiliacs, congenital platelet dysfunction,
traumatic/surgical hemorrhage not
responding to routine treatment

27. Mechanism of Action
• Binds to tissue factor → Activation of Factor X on
platelet surface (F Xa).
• Factor Xa + Va → Prothrombin Complex →
Thrombin Formation
• Dose: 15-180 µg/kg IV
Plasma level: 50 nM/l – good for partial thrombin
release
Plasma level: 100-150 nM/l – full activation of
thrombin (Thrombin Burst)

28. Intra-Operative Blood Conservation
• Positioning of Patient -
• Making Surgical Part higher than level of heart
reduces the blood loss.
• Hypotensive Anaesthesia –
• Systolic BP: 80 – 90 mm Hg
• Mean Arterial Pressure: 50 – 60 mm Hg
• Maintenance of Normothermia –
• Better tissue Perfusion
• Prevents Acidosis, Vasoparalysis, Coagulation
Failure

29. Intra-Operative Blood Conservation
• Optimum oxygenation & 02 delivery
higher FiO2 in anaemic patients
prevention of hypovolemia,vasocontriction
• Minimising 02 demand
controlled hypothermia (where appropriate)
sedation, analgesia, muscle relaxation,
mechanical ventilation

30. Surgical Techniques to Reduce Blood Loss
• Use of Tourniquet
• Meticulous Hemostasis
• Minimally Invasive Surgery
• Laparoscopic/ Endoscopic Surgery
• Arterial Embolization
• Adrenaline Infiltration at Incision Site

31. Surgical Devices to Reduce Blood Loss
• Use of Electrocautry/ Electrosurgery
• Argon Beam Coagulation
• Laser Surgery
• Stereotactic Laser Surgery
• Gamma Knife Radiosurgery
• Ultrasonic Scalpel
• Microwave Coagulation Scalpel

32. Topical Agents To Control Bleeding
• Topical application of Vasoconstrictors
• Surgical Adhesives-
• Fibrin Glue
• Platelet Gel
• Tissue Sealants
• Topical Packs, Sponges, Meshes, Tinctures and
Special Dressings that promote Coagulation

33. Other Allogenic BT Alternatives
• Intra-operative Cell Salvage
• Blood Substitutes
• Modified Hemoglobin
• PerFluroCarbons

34. Intra-Operative Cell Salvage
• Shed Blood during Surgery/ Post-op period is
collected, filtered and transferred in a anti-
coagulant containing reservoir.
• It is re-infused with or without processing.
• Processing-
• Centrifugally washed to remove debris and
contaminants
• Ultrafilteration, hemoconcentration
• Indications-
• Cardiothoracic, Vascular and major Orthopedic
procedures, ruptured Ectopic pregnancy

35. Intra-Operative Cell Salvage
• Advantages
• Decreased risk of Blood-borne Infections
• Decreased Transfusion Reactions
• Safe in Rare Blood Groups, Multiple Antibodies
• No Immune Suppression
• Disadvantages
• More Expensive
• Increased Staff Training
• Risk of Bacterial Contamination

36. Blood Substitutes
• These are Artificial Oxygen Carriers
• Can Be used as alternatives to allogenic blood
in acute blood loss, or in critically ill patients
• These are
• Modified Hemoglobins
• PerFluroCarbons

37. Modified Hemoglobins
• These are either recombinant or derived from
outdated RBCs (human or bovine)
• Advantages
• No need of cross-matching
• Long shelf life
• Can be stored at room temperature
• Decreased risk of disease transmission

38. Modified Hemoglobins
• Disadvantages
• Short half-life after administration (24-48 hrs)
• Increased Vascular tone and BP
• Renal toxic effects
• Interference with lab Hb measurements
• E.g.
• Polyheme- From Human RBCs
• Hemopure- From Bovine RBCs
• Safety and Efficacy not yet established.

39. PerFluroCarbons
• Trade Names- Oxygent, Oxycyte
• Have the capacity to carry Oxygen and CO2 at a rate
twice that of Hemoglobin
• Advantages-
• Long Shelf Life
• No risk of Transmission of Blood-borne Diseases
• Disadvantage
• Acute Lung Injury if used over long period as higher
concentration of Oxygen required
• Safety and Efficacy needs further research investigation

40. PerFluroCarbons
Oxygent Oxycyte

41. Blood Conservation Strategies in
Critically Ill Patients
• Proper Diagnosis and Treatment of Causative
Factors of Anemia/ Blood Loss
• Reducing Blood Loss associated with diagnostic
testing
• Use of smaller volume collection tubes
• Elimination of discarding of blood during collection
from indwelling catheter
• Use of bedside microanalysis
• Automated Closed Arterial Systems
• Bedside monitoring of SPO2 , ETCO2
• Restricted Blood Sampling Frequency

42. Restricted Blood Transfusion Triggers
• Hemoglobin threshold of 7 gm% is safe and
appropriate
• Allowable blood loss
V = EBV x (Hct1- Hctf)/Hctav

43. • Use of erythropoietin, hematinics and
nutritional support
• Use of hemostatic agents
• Review of use of anti-coagulant/ anti-platelet
agents
• Prompt correction of coagulopathies
• Optimization of Oxygenation O2 delivery/demand
• Use of artificial Oxygen carriers
• Use of Hyperbaric Oxygen

44. Summarizing
• Jehovah’s witnesses are a sect of Christians
who have an aversion for blood/components
• Blood conservation is essential in Jehovah’s
witnesses
• Multimodal approach
• Team work
• Combination of strategies act synergistically

45. Conclusion
• No patient should be denied medical
treatment because of their religious beliefs
• Blood conservation is practical
• Should be extended to all the patients
because blood is a precious commodity
& is not without thorns !