Introduction

Jehovah Witness (JW) patients present a unique challenge to anesthesiologists during cardiovascular surgery, since they refuse the use of allogeneic blood or blood-derived products.  However, they do accept other methods that still adhere to their religious principles, such as autotransfusion.  Techniques using autologous blood should maintain physical continuity of blood with the patients at all times, requiring specific modifications of standard intraoperative equipment. may be employed.   This report describes 5 JW patients who successfully underwent major cardiovascular surgery and outlines the blood conservation techniques.

Case Report

Patient 1:       37 years, female, ascending/transverse aortic aneurysm.
Patient 2:       46 years, male, ascending aortic aneurysm.
Patient 3:       55 years, male, ascending aortic aneurysm.
Patient 4:       48 years, male, thoracic aortic aneurysm.
Patient 5:       65 years, male, Type 1 thoracoabdominal aortic aneurysm.

Monitoring during anesthesia and surgery included electrocardiogram (ECG), radial arterial line, transesophageal echocardiography (TEE) and oximetric pulmonary artery catheter for all patients.  Bicaval-femoral cardiopulmonary bypass (CPB) and profound hypothermic circulatory arrest were used for patients 1-3, while left atriofemoral bypass was used for patient 5.

Blood Conservation Strategy

* Preoperative erythropoetin, iron sulfate, folate.

* Meticulous surgical technique.

* Aprotinin
Patients 1-3:    2 million units loading dose, 2 million units pump prime, 500,000 units/hr infusion.
Patients 4, 5:  1 million units loading dose, 250,000 units/hr  infusion.

* Whole Blood Sequestration
Gravity-based sequestration of whole blood into bags containing CPD anticoagulant.  Performed in conjunction with normovolemic or hypovolemic hemodilution), hespan, crystalloid, neosynephrine infusion) - guided by hemodynamic variables and SvO2 (>45%). TEE used to monitor preload and wall motion.

* Autotransfusion device
In patients 4 and 5, blood within the aneurysm (after surgical incision) aspirated and returned unwashed to the patient.

* Return of sequestered blood delayed until aneurysm repair complete, heparin reversed and surgical hemostasis achieved.

* Maintenance of in-line circuitry for all autologous blood tubing to maintain a continuous unbroken circuit.

* Minimization of blood wastage - use of blood for only essential laboratory tests.  

Results

Efficiency of sequestration/blood conservation
 

Patient	Pre-op Hb	Sequestration Volume	Post-op Hb
1	9.2 g/dl	500 ml (2 blood bags)	7.6 g/dl
2	14.6 g/dl	900 ml (3 blood bags)	11.3 g/dl
3	13.3 g/dl	900 ml (3 blood bags)	7.5 g/dl
4	12.9 g/dl	900 ml (3 blood bags)	10.7 g/dl
5	14.0 g/dl	1500 ml (5 blood bags)	11.7 g/dl

Discussion

JW patients can survive major cardiovascular surgery without the use of allogeneic blood products when a blood conservation strategy is coordinated [1].  The anesthesiologist plays a major role in these efforts. Blood sequestration provides fresh whole blood containing coagulation factors and platelets, which are invaluable following CPB and aortic unclamping.  Blood substitutes (Hb derivatives, fluorocarbons - currently in development) will enable sequestration of greater quantities of autologous blood.  The advent of "bloodless surgery" program worldwide will foster more clinical research in the future.

References

1. Svennson LG, Jianping S, Nadolny E, Kimmel W.  Prospective evaluation of minimal blood use for ascending aorta and aortic arch operations.  Annals of Thoracic Surgery, Volume 59, pages 1501-1508, 1995.