Bloodless surgery and gynecological patients among Jehovah’s Witnesses

Overview Objective: The aim of this research is to present our experiences with the surgical treatment of gynecological patients among Jehovah’s Witnesses. Moreover, the medical, moral, and ethical problems in this regard have been highlighted. Methods: 75 Jehovah’s Witnesses patients were operated on for various benign and malignant gynecological diseases between 2007 and 2018. All of these patients were operated on according to the rules of blood-sparing surgery. Results: The operations were assessed according to the dia­gnosis, mode of surgery, estimated blood loss, and disease outcome. Excessive blood loss did not occur during any of these operations, and the estimated blood loss for the same procedure was 10 to 550 mL. Conclusion: Jehovah’s Witnesses gynecological patients is a group of high-risk patients because they refuse to undergo blood transfusion. Nevertheless, the principles of blood-sparing surgery should be applied to not only Jehovah’s Witnesses patients but also to all patients in general. Even if a blood transfusion is the last resort to solve issues pertaining to excessive blood loss during complicated operations, the said procedure always carries certain risks. Therefore, blood transfusion should be performed only on rare occasions. Jehovah’s Witnesses patients categorically refuse blood transfusion even if it is the only way to save one’s life. Even though the legislation of the Czech Republic deals with this problem, there are other moral and ethical aspects that need to be addressed in this regard. Keywords: bloodless surgery – Gynecologic surgery – Jehovah’s Witnesses – legislation – moral and ethical problems

IRON CORRECTION DURING BLOODLESS SURGERY IN PATIENTS WITH MITRAL HEART DISEASES

Objective. To study the effectiveness of the preoperative combined correction, using hydroxide of iron (III) and stimulation of hematopoiesis with erythropoietin on the postoperative anemia in patients, undergoning bloodless surgery (mitral valvere placement) in conditions of artificialblood circulation. Methods. A single-center prospective non-randomized and retrospective study involving patients (n=80) undergoning the operation for mitral valve disease was carried out. There were 54 men (67.5%) and 26 women (32.5%) with an average age of 52.8±4.9 years (M±σ). The patients were divided into three groups. Group A consisted of patients with normal serum iron levels undergoning of the application of blood component preparations. Group B included patients with normal serum iron levels who were undergoning bloodless surgery. In group C the patients with initially low levels of iron in the blood serum, preoperative correction of the saturating dose iron hydroxide and stimulation with erythropoietin were carried out, and bloodless procedure was applied while the operation. Results. The results of this study show that patients in group A require a sufficiently large volume of donor blood components during surgery. In group B, mitral valve replacement can be performed using bloodless technology without transfusion of donor blood components. Correction of a low preoperative serum iron level in group C increases its preoperative serum iron level by 7.4 times and Hb by 4.4% of the initial haemoglobin values. The level of postoperative anemia in group C (p>0.05) compared with group B (p>0.05) is 8.5% less (p>0.05). Conclusion. Correction of low preoperative iron levels and stimulation of erythropoiesis in patients with mitral heart disease after mitral valve replacement using a bloodless surgery reduces the postoperative anemia level. What this paper adds For the first time the impact of preoperative correction of anemia, using iron (III) hydroxide and stimulation of hematopoiesis, applying erythropoietin in patients undergoning the surgery for mitral valve defect using bloodless technology in conditions of artificial blood circulation (ABC) has been determined.

How to approach orthognathic surgery in patients who refuse blood transfusion

Background Some patients who need surgery refuse a blood transfusion because of their religious beliefs or concerns about blood-borne infections. In recent years, bloodless surgery has been performed successfully in many procedures, and is therefore of increasing interest in orthognathic surgery.Methods Ten Jehovah’s Witnesses who visited our bloodless surgery center for orthognathic surgery participated in this study. To maintain hemoglobin (Hb) levels above 10 g/dL before surgery, recombinant erythropoietin (rEPO) was subcutaneously administered and iron supplements were intravenously administered. During surgery, acute normovolemic hemodilution (ANH) and induced hypotensive anesthesia were used. To elevate the Hb levels to >10 g/dL after surgery, a similar method to the preoperative approach was used.Results The 10 patients comprised three men and seven women. Their average Hb level at the first visit was 11.1 g/dL. With treatment according to our protocol, the average preoperative Hb level rose to 12.01 g/dL, and the average Hb level on postoperative day 1 was 10.01 g/dL. No patients needed a blood transfusion, and all patients were discharged without any complications.Conclusions This study presents a way to manage patients who refuse blood transfusions while undergoing orthognathic surgery. rEPO and iron supplementation were used to maintain Hb levels above 10 g/dL. During surgery, blood loss was minimized by a meticulous procedure and induced hypotensive anesthesia, and intravascular volume was maintained by ANH. Our practical approach to orthognathic surgery for Jehovah’s Witnesses can be applied to the management of all patients who refuse blood transfusions.

Organization, current state and immediate prospects of the problem «bloodless surgery»

The research focus of the publication is the problem of preserving the blood of the operated patient. The variety of blood preservation methods shows the multidisciplinary nature of the problem and the importance of well-coordinated teamwork of busy doctors. For more than 20 years, surgical, anesthetic, transfusion technologies of blood saving have been used mainly in cardiac surgery patients. The use of a complex of blood-saving technologies allows you to reduce the amount of blood loss and the consumption of donor blood components. Over 7 years in cardiac surgery, the number of recipients of donor hemocomponents decreased by 41% (erythrovesue) and 61% (FFP). Autologous plasma is 68-78% of the total volume transfused to cardiac patients. 50% of patients operated on the ascending aorta do not need a blood transfusion. Blood loss during extensive liver resections has decreased three times in 10 years and does not require allogeneic blood transfusions. An adequate multidisciplinary approach to solving the problem of blood conservation can improve the results of surgical treatment of patients.

Bloodless Medicine and Surgery: A Review of Practice and Consideration of Jehova Witnesses

Blood transfusion plays important role in medical and surgical practice and has been employed in varying medical and surgical procedures. An increasing amount of literature concerning blood conservation, restrictive transfusion strategies, pharmacological manipulation of the haemostatic and fibrinolytic systems, minimal invasive surgery, local haemostatic agents and guidelines for blood transfusion, is being published each year. This review aims to summaries the key concepts of bloodless medicine and surgery, offer a practical guide on how to approach such cases and outline currently available approaches to manage anemia or bleeding in patients. The standard practice is to keep vigilance to the possibility of reactionary or secondary haemorrhage. Continued bleeding is aggressively managed by postoperative blood salvage, or surgical intervention to stop haemorrhage. A multidisciplinary effort therefore has to be made through the entire chain, from the outpatient clinic through discharge from the hospital, with the utmost exertion of all team members in which surgeons play a key role and the medical laboratory scientist in the adaptation of bloodless surgery program.