Surgery, Blood Transfusion and the Jehovah's Witness Patient
By: John Freedman, MD FRCPC, Professor Emeritus, Medicine, University of Toronto, St Michael's Hospital
For Jehovah’s Witness (JW) the ban on allogeneic blood has been official church doctrine since 1945, and whole blood, red cells, white cells, platelets and plasma are unacceptable to Jehovah’s Witnesses; this is non-negotiable. More recently, this has been modified and currently allows transfusion of ‘minor fractions of blood’ based on individual preference. Bloodless surgery and medicine (Patient Blood Management; PBM) has rapidly evolved over the past few decades. Starting in 1962, Ott and Cooley performed >500 open-heart surgeries on JW patients without use of blood transfusions. PBM continues to improve with new clinical, surgical, and pharmacologic strategies and offers an organized approach to surgery designed to minimize blood loss and to avoid transfusion. These multimodal protocols should be developed by a multidisciplinary team of anesthesiologists, critical care specialists, surgeons, internists, transfusionists, hematologists and bioethicists.
Elective surgery needs to be well planned. Both surgeon and anesthetist must meet with the patient to discuss the planned surgical procedure and its associated risks. In an open, non-judgmental fashion they must ascertain exactly what is acceptable to the individual patient. JW patients are generally very well informed and discussion and conclusions should be documented and witnessed. The patient should be encouraged to have a family member or their religious advisor present during this discussion if they wish. Each hospital will have access to a representative from the religion through the local JW hospital liaison committee. Ideally, 4-6 weeks is needed to allow optimization of the patient’s hemoglobin (Hb), if required, and for thorough discussion and planning e.g. are there alternatives to surgery or can the procedure be performed in stages or by a minimal access technique?
The preoperative process begins with a thorough history and a detailed physical examination. Preoperative counseling with informed consent is of paramount importance and patients are asked to clearly document which, if any, minor or major fractions of blood they would accept, as well as which bloodless-related preoperative, intraoperative, and postoperative measures they will accept. During the preoperative management, Hb levels should be optimized, and efforts should be made to correctly diagnose and treat any existing anemia. Since preoperative Hb is an important predictor of the need for transfusion one should ensure that these patients start with an adequate Hb. At referral the Hb, ferritin, B12 and folate levels should be checked. The results will determine which patients will benefit from a course of iron or erythropoietin (EPO). If time is short or oral iron therapy is ineffective or not tolerated then intravenous iron may be used. Patients may require both EPO and iron. EPO is expensive and has potential side effects including hypertension and thrombosis which may limit its use in patients over 70 years. It may not be acceptable to all JWs since some preparations contain a small amount of albumin. Also at this planning stage, drugs associated with increased bleeding should be stopped if possible prior to surgery; these include aspirin, NSAIDs and anticoagulants. Blood draws should be minimized and use of pediatric tubes for blood draws may be appropriate, especially if a large number of laboratory tests are being performed.
Intraoperative management of the JW patient is complex and requires a high level of technical skill and excellent communication between the surgical and anesthesia teams. Surgical approaches that reduce blood loss, such as handling tissue gently, recognizing potential sources of bleeding and rapidly controlling unexpected hemorrhage, are essential. Patient positioning should maximize access to the surgical field from multiple approaches. Administration of the antifibrinolytic agent, tranexamic acid, can be very useful in reducing blood loss and reducing transfusion in many types of surgery, particularly in cardiac and orthopedic surgery – regimens include intravenous and topical administration. Other techniques may include acute normovolemic hemodilution (ANH) and intraoperative autologous transfusion which may be acceptable to some JWs when performed in a closed system without blood storage; because these interventions are not accepted by all patients, they should be specifically addressed in the advanced directive form.
Postoperative measures include tolerance of anemia and minimization of blood draws — lower transfusion thresholds have become acceptable in recent years. Patients should be monitored closely for bleeding and adequate oxygenation. If acute postoperative bleeding is suspected, the surgeon should consider reoperation promptly. Postoperatively, judicious use of intravenous iron and EPO may be considered.
Many factors may influence individual patient responses on the advanced directive form. The individual freedom that the JW church provides JW patients in accepting or rejecting minor blood fractions or modern interventions allows for patients to incorporate their own values and the advice of their own support network in the decision-making process. The technical language of an advanced directive may be difficult for some individuals to comprehend, which could lead to inaccurate documentation of a patient’s wishes. Thus, patients should be counseled by physicians and/or trained professionals that are thoroughly familiar with the field of PBM. The counselor must understand both the options presented in the advanced directive and the patient’s beliefs. An attending or resident physician not thoroughly familiar or up to date with PBM techniques may not be able to take such vagaries into account when counseling patients. Treating patients who place restrictions on our medical practice which may ultimately result in morbidity or mortality can raise complex issues of a moral and ethical nature and may be a very stressful experience for all involved, particularly if things do not go well. Nonetheless, we must care for all patients, including JWs, in a professional, non-judgmental and confidential manner. We must work on the presumption that every adult patient has the capacity to make decisions about their care and to decide whether they refuse or agree to any treatment.
Transfusion Medicine Quality Improvement Baseline Survey
By: Troy Thompson, MLT BAHSc (Hons), ORBCoN Regional Manager, Central Region
“The continuous journey has to start somewhere!”
The Ontario Transfusion Quality Improvement Plan (OTQIP) committee conducted a survey in January 2017 to gather baseline data from hospitals on Transfusion Medicine quality improvement (QI) initiatives. As quality improvement is a continuous journey, each hospital may be at various points in the quality improvement spectrum. This article will highlight the QIP survey and the participating hospital’s QI activity.
In total, 50 hospital sites participated in the survey, with 31 (62%) sites answering that they have established and implemented transfusion guidelines for blood and blood product utilization. Of the 50 sites, red blood cell (RBC), platelet and plasma guidelines were implemented at 28 (56%), 24 (48%), and 22 (44%) sites respectively while 26 (52%) sites had implemented guidelines for prothrombin complex concentrates (a provision for PCC utilization) and 18 (36%) sites had implemented IVIG guidelines as per the Ministry of Health mandate for IVIG use in Ontario. Transfusion guidelines were approved by a hospital Medical Advisory Committee (MAC) at 29 (94%) sites which may help to support their consistent use. Implementing guidelines is a good place to start when attempting to reduce inappropriate transfusions; 6 (19%) sites answered that the guidelines are followed for “every transfusion order” and 16 (52%) sites answered that guidelines are followed for “most transfusion orders.” The implementation of transfusion order sets (electronic or other) is another strategy that may help in standardizing transfusion practice and 24 (48%) sites answered that they have implemented transfusion order sets. The prospective screening of transfusion orders by a Medical Laboratory Technologist is also an effective way to “curb” inappropriate utilization and 21 (42%) hospitals indicated that they had a prospective screening process in place. This strategy requires much more effort to implement but in combination with consistent medical back-up can be very successful in standardizing transfusion practices. Of those sites that utilize prospective screening, it occurs for “every” or “most transfusion orders” at 10 (48%) sites while 5 (24%) sites screen specific products/components and 6 (29%) sites will screen further if the transfusion order seems questionable.
In order to gauge quality improvement success, quality metrics should be measured and 35 (70%) sites indicated that they are measuring quality metrics. Many sites are collecting the percent of transfusions that occur in patients with pre-transfusion hemoglobins less than 80g/L and the percent of transfusions that are ordered as single RBC unit transfusions. These two metrics were also selected by the OTQIP committee and an electronic platform is available for hospitals to enter and track these data. http://etools.transfusionontario.org/. (Please contact ORBCoN if you do not have an account set up). All Ontario hospitals with transfusion services are encouraged to report in this tool because it provides hospitals with individual progress reports to share with their internal quality and transfusion committees and ORBCoN can generate combined data reports to monitor progress at a provincial level.
Quality improvement initiatives in Transfusion Medicine continue to increase and the reduction of unnecessary tests/procedures such as transfusion is a key component for patient safety as highlighted in the Choosing Wisely Canada campaign. Momentum in Transfusion Medicine QI is gaining and it is important to measure your progress as you work towards your goals. No matter what stage you are at in the QI journey, the journey starts with you, so check out the Ontario Transfusion Quality Improvement Plan at www.transfusionontario.org and make your QI goals today!
“Practice the philosophy of continued improvement; get a little bit better every single day.” Author unknown
Question submitted in response to June 2017 Newsletter article titled "How do we interpret the 60 minute rule" Authored and Responded By: Yulia Lin, MD, FRCPC, Transfusion Medicine Specialist, Sunnybrook Health Sciences Centre
1. The study was performed on RBCs, but the standard is for all blood components. Is there no need to do studies on other blood components before generalizing the standard to include all components (i.e. plasma)?
The study was specifically performed for RBCs. Practically speaking and in my personal opinion, I don’t see much of an issue with the 60 minute rule being extended because:
2. You mentioned a little section about blood products can also be returned to useable inventory provided they have not been outside of a controlled environment for more than the time recommended by the manufacturer. The standard (14.6.2) says the product must be maintained within the “parameters” described in the product monograph. I’m thinking parameters probably also includes temperature as well. As in, if a vial of WinRho was issued out of the lab and came back greater than 8 degrees, it cannot be returned to useable inventory. Your thoughts?
Interesting that you comment on the blood products – that specific section was actually added in conjunction with ORBCON. The parameters would also include temperature. For certain products, we have sought additional information from the manufacturers (outside of the product monograph) on product stability so that has helped us extend some products even longer.