The refusal of a Jehovah’s witness patient to undergo blood transfusion constitutes an important ethical and legal problem. The need to adopt a life saving therapeutic measure clashes with the patient’s right to choose based on one’s system of values and religious beliefs. In the context of critical and perioperative medicine difficulties are increased by acute and unpredictable events that require a prompt intervention and hinder the adoption of measures made to optimize the patient’s ability to face acute massive blood loss.
Our patient was severely chronically ill when he came to our attention. For the discussed matter, it is particularly interesting to examine his preexisting state of chronic anemia
, which was one of the reasons that prevented the surgical team to correct electively his inguinal hernia in the first place. Both hepatic cirrhosis and alcohol abuse, even if the latter was not present since a couple of years in our patient (the patient quit drinking when he became a Jehovah Witness), are known causes of chronic anemia, with several mechanisms [11
]. Dilutional pseudoanemia
characterizes advanced liver disease [13
]; moreover unapparent bleeding from several causes (portal or alcoholic gastropathy, hemorrhoids) can lead to profound anemization [14
]. Compromised synthesis Vitamin K dependent coagulation factors (II,VII,IX,X), as well as alterations in number and function of platelets, are other known predisposing cause to chronic bleeding in these patients [14
Several indications are reported in the literature to reduce the need of transfusion, especially in the context of election surgery with moderate to high hemorrhage risk [15
]. A painstaking pre-operative assessment of the patient is essential, and ought to be carried out at least 4-8 weeks before surgery. Identifying the causes of a potential anemia allows to institute appropriate therapy, if there is proven iron deficiency, it must be corrected [16
], by giving oral or intravenous iron. The administration of B12 vitamin and folic acid are described as definitely effective therapies in the case of documented deficit, or potentially useful in the context of a multimodal approach to erythropoietic support. Usage of erythropoietin is recommended in patients for whom iron deficiency anemia has been ruled out, several studies have highlighted its effectiveness in reducing the use of transfusions in different types of surgery [17
]. In selected cases it was possible to manage Jehovah’s witness patients without resorting to transfusions for major surgery operations with high hemorrhagic risk [20
]. Suspension or correction of anticoagulant therapies, the correction of potential deficiencies in coagulation factors, the administration of procoagulant (such as tranexamic acid) [21
] agents all represent additional viable strategies, the application of which has to be contextualized in the individual patient based on the entity of hemorrhagic and thrombotic
risk. In our case, these strategies were not taken into account before surgery, as massive blood loss was totally unexpected.
In the case of the patient undergoing urgent surgery, most of these measures cannot be applied. In this case the management of severe acute intraoperative bleeding, in itself a dramatic event even when all available resources can be drawn upon, becomes especially complex. In this context it is necessary to intervene on all factors conditioning the supply of oxygen to tissues in order to compensate, as much as possible, the severe reduction in hemoglobin. It is only possible to act on cardiac output by administering fluids, crystalloids and colloids, and inotropic and vasopressor drugs, therefore enhancing the compensation mechanisms that are naturally activated in the healthy subject to ensure continuous perfusion and tissue oxygenation.
The case we described allows for highlighting of part of these issues. In our patient surgery was an emergency procedure and therefore had to be carried out urgently. The patient had presented chronic anemia likely due to his basal pathology
and previous alcohol abuse. This basal condition was made much worse when unexpected and massive acute intra-operative bleeding did occur. Support of cardiovascular function obtained with fluidotherapy and vasopressors
, the optimization of respiratory exchanges and the unloading of work of breath determined by mechanical ventilation, allowed in the acute situation to keep the patient alive while waiting for erythropoietic support therapies to increase emoglobin levels. One possible advantage was that since his anemia was chronic, the patient was well adapted to it. Of course it is possible that on the long term, the anemia might have had a negative impact on the tissues repair mechanisms, thus causing further complications, which eventually proved irreversible. Anyway, it is possible to obtain a good outcome for a surgical wound even with very low hematocrit values given that a good perfusion is warranted [23
], so in the last decades always more restrictive transfusion strategies were adopted. Several authors evaluated the correlation between anemia and wound healing, with conflicting results [24
]. Minimal hemoglobin level that definitely compromises the process of wound healing is not clear. In animals, the effect of acute intraoperative anemia seems to determine an unfavourable outcome [27
]. Even if our patient had other risk factors for a compromised healing (particularly hepatic failure), we think that prolonged extreme anemia in the postoperative period may have played an important role in his outcome.