The values, beliefs and practices of all patients should be respected.
However, a frank, confidential discussion about the potential risks of their decision and the alternatives to transfusion should take place.
A discussion with each patient regarding what they will and will not accept should take place.
Nearly all Jehovah’s Witnesses refuse transfusion of whole blood (including autologous blood) and primary blood components.
Many JW accept derivatives of blood components (e.g. IVIG, albumin, factor concentrates etc.).
JW usually do not object to intraoperative cell salvage, normovolaemic haemodilution, cardiac bypass or haemodilution.
Recombinant products (e.g. erythropoietin) and pharamacological agents (e.g. tranexamic acid) are usually acceptable.
Advance Decision Documents must be filled out, signed, witnessed and respected at all times.
The ADD must specify exactly which blood components and autologous procedures are and are not acceptable to the patient.
The ADD is only valid in life-threatening situations if it explicitly contains a statement saying that it applies even if the patient’s life is at risk.
A copy of the ADD must be placed in the clinical record.
The patient should retain a copy of the ADD and carry it with them.
It is the patient’s responsibility to inform the hospital of the existence of an ADD.
This may be revoked by the patient at any time whilst he/she retains mental capacity.
Hence, all patients should be given the chance to consent to / refuse blood products, ADD non-withstanding.
ADDs are not valid if:
The patient has previously withdrawn it.
The patient has, under an LPA, conferred authority on a donee to consent to or refuse treatment to which the ADD relates.
Has done anything else clearly inconsistent with the ADD.
Any circumstances specified in the ADD are absent.
The treatment specified is not specifically covered in the ADD.
No one can give consent on behalf of a patient with mental capacity.
In emergencies, where no Advance Decision Document exists, transfusions must be given where life-saving.
Where parents or legal guardians of minors object to essential blood transfusion, a Specific Order Issue can be rapidly obtained from a court.
All hospitals should have policies that describe how to do this, 24/7 and without delay.
If a life-saving transfusion is required and there is no time to apply to the court, the transfusion should be given. This decision should be undertaken by two consultants who are fully informed of the situation and aware of any alternatives to blood transfusion.
Failure to transfuse in a life-or-death situation where the failure leads to death of the child may result in criminal prosecution.
Children aged 16 or older can legally consent to medical treatment.
A child who is under 16 can give consent if they are deemed to be Fraser/Gillick competent.
However, children under 16 who are Gillick competent cannot refuse treatment. If a Gillick competent child refuses blood products but their parents / legal guardians consent to it, the acceptance of the parents / guardians overrides the child’s refusal.
If both refuse, then a court order may be necessary.
Where appropriate, the patient and clinical team may find it helpful to contact the local Hospital Liaison Committee for Jehovah’s Witnesses.
Alternatives to Blood Transfusion
Predeposit autologous donation (PAD) and transfusion
Collection and reinfusion of a patient’s own blood
Most healthy adults can donate up to 3 units of red cells prior to surgery (storage-life 35 days at 4°C).
Iron supplements (if iron deficient) +/- erythropoietin may allow more donations prior to a procedure.
Autologous donations must take place in a licensed blood establishment.
All donations must be processed and tested in the same way as normal donor blood, and are subject to the same requirements for traceability.
Autologous donations are clearly identified and kept separate from allogeneic donations.
Informed consent must be taken for PAD:
Same as for normal blood donation.
Possibility of deferral (if there is a health risk to the patient as a donor or a recipient).
Serious cardiac disease.
Active infection.
Autologous components may not suffice for the intended transfusion requirements.
If not used, the component will be discarded and will not be transfused to other patients.
Candidates for autologous blood include:
Patients with alloantibodies where allogeneic blood may be in short supply.
Patients with rare blood groups (e.g. Bombay).
Patients whose mental health may be put at risk using allogeneic blood.
Children with scoliosis.
Patients who refuse allogeneic blood donations, but consent to PAD.
PAD should only be offered when the admission and surgery date is guaranteed, and the surgery is expected to require blood transfusion.
Sufficient time pre-operatively must be allowed to enable optimal collection and processing of blood.
There must be sufficient time between the last donation and surgery to allow the patient to make full circulatory and volaemic recovery (72 hours).
Candidates for PAD:
Must be judged by a physician to be able to tolerate repeated loss of a predetermined volume of blood (usually no more than 10% of their estimated blood volume).
Should be considered for erythropoietin and iron supplementation.
Must have an acceptable Hb prior to PAD:
Men: Hb 11-14.5
Women: Hb 13-14.5
Must have a clear reason for preferring PAD to allogeneic blood.
Intra-operative cell salvage (ICS)
The collection and reinfusion of blood spilled during surgery.
Results in 20% reduction in donor blood exposure (average saving of 0.7 units per patient).
Process
Blood is aspirated and mixed with an anticoagulant through an “aspiration and anticoagulation” line.
The aspirated blood drains into a collection reservoir, which contains a filter to remove clots and other gross particulate matter.
The blood is centrifuged, retaining the RBC component and forcing out the lighter components into a waste line. As the RBC component is contained, the Hct of the reservoir increases.
Some systems contain optical sensors to detect optimal target Hct.
When the target Hct is reached, the machine enters the washing stage.
Normal saline is pumped into the spinning centrifuge system to displace the remaining waste products.
The end-product of washed, packed RBCs suspended in normal saline is pumped into a bag ready for reinfusion.
Indications for ICS
Surgery where the anticipated blood loss is >20% of a patient’s blood volume.
Surgery where patients have risk factors for bleeding or low pre-operative haemoglobin levels.
Patients who refuse blood.
Patients with rare blood groups or multiple alloantibodies where provision of donor blood is challenging.
Major joint replacement, spinal surgery.
Aortic aneurysm surgery.
Traumatic liver / spleen injuries.
Cardiac surgery.
Benign urological surgery.
Antepartum or postpartum haemorrhage.
Major haemorrhage.
Contraindications to ICS
Bowel contents in the surgical field.
Infected surgical fields.
Other contaminants or unlicensed medicines in the surgical field (e.g. orthopaedic cement, iodine, topical clotting agents)
Sickle cell disease (high %HbS in reinfused products).
Patients with heparin-induced thrombocytopaenia if heparin is used as an anticoagulant in the ICS system.
Gastric / pancreatic secretions.
Relative: patients with malignancies (risk of reinfusion of malignant cells). If ICS is to be used, reinfusion should be done using a leucodepletion filter to minimise the risk of reinfusion of malignant cells.
Acceptable to most JW.
Post-operative cell salvage
Mostly used in orthopaedic procedures.
Blood is collected from drains, washed and reinfused.
Used when expected blood loss is between 500-1000ml.
Collection of salvaged blood must be completed within the manufacturer’s specified time (usually six hours).
Acceptable to most JW.
Acute normovolaemic haemodilution
Several units of blood are collected into standard blood donation packs immediately before surgery.
Patient’s blood volume is maintained via simultaneous crystalloid or colloid infusion.
Blood is stored in OT at room temperature and reinfused at the end of surgery.
Most-often used in cardiac bypass (theoretical infusion of “fresh whole blood” containing platelets and clotting factors).
Hazards:
Fluid overload
Cardiac ischaemia
Wrong blood into patient errors
Most effective as blood conservation in surgery with major blood loss.
However, systematic reviews have shown no significant reduction in exposure to donor transfusions, and safety remains unclear.
Tranexamic acid
Anti-fibrinolytic which inhibits conversion of plasminogen to plasmin by binding to lysine receptor sites on plasminogen.
Plasmin is responsible for the degradation of fibrin: with less plasmin available, there is less fibrinolysis.
TXA reduces the risk of requiring a blood transfusion (by 30%) and the need for further intervention due to rebleeding.
TXA is proven in major trauma (CRASH-2) and post-partum haemorrhage (WOMAN); a trial in major GI bleeding (HALT-IT) is ongoign.
It is usually given as an intravenous bolus followed by an infusion.
Meta-analyses have shown no significant increase in thromboembolic risk.
Erythropoeitin
May be used prior to major orthopaedic surgery in adults
Can be considered off-label in patients who refuse blood donation who are likely to bleed during surgery
Hb > 12 and Hct > 35% should not be exceeded due to thromboembolic complications.
There are also rare cases of EPO complicated by PRCA.
Other pharmacological measures:
Aprotinin: only recommended in very high risk bleeding (may have increased overall mortality compared to other fibrinolytics, increased renal failure and thromboembolic events).
Tissue sealants can reduce surgical bleeding and should be used.
Use of rFVIIa for non-haemophilia-associated bleeding is not recommended due to lack of evidence regarding efficacy and safety risks.
Desmopressin may be of advantage in uraemic platelet dysfunction.
Surgical Considerations
The consultant surgeon and anaesthetist should decide if they will accept the patient on the patient’s terms. If not, they should refer the patient to someone who will.
Patients should be seen early, ideally 6 weeks prior to surgery.
FBC and haematinics should be checked.
Haematinic deficiency must be corrected.
Antithrombotics and anticoagulation should be discontinued prior to surgery.
Risk-benefit discussion with patient.
Alternatives to blood transfusion above should be discussed.
Erythropoietin may be considered for pre-operative optimisation of haemoglobin:
Hb <13g/dL.
Undergoing procedure with risk of significant blood loss.
Haematinic deficiency must be corrected before initiating EPO therapy.
The first dose should be given 3/52 before surgery, and the last dose the day of surgery.
If a sufficient response is seen after the second or third dose, then subsequent doses should be omitted.
Patients on EPO must be prescribed oral iron concurrently to avoid iron deficient developing.
EPO must be stopped if Hb >15g/dL, caution is advised in patients >70.
EPO is relatively contraindicated in uncontrolled hypertension, severe peripheral arterial, carotid, coronary or cerebrovascular disease (increased thrombotic risk), patients with an MI or CVA within the last month, unstable angina, or a previous history of thrombosis.
Possible dose schedules:
600units/kg once a week for three weeks prior to surgery and on the day of surgery.
300units/kg daily for 15 days starting 10 days before surgery (for orthopaedic surgery, British National Formulary).
FBC should be checked weekly on EPO therapy.
Intra-operatively, use cell salvage if the patient consents to it.
Surgical techniques which minimise blood loss should be used.
Blood sampling must be minimised insofar as is possible.
Post-operative anaemia should be corrected with iron supplementation.
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