Jehovah’s Witnesses and Transfusion in
OB/Peds: A Hematologist’s Perspective
Presented by:
Dr. Lynn Boshkov, MD
Prof of Pathology, Medicine & Pediatrics
Director Hemostasis & Thrombosis
Assoc. Director Transfusion Medicine
Oregon Health & Science University, Portland, OR
Voice: 503-494-7610
e-mail: boshkovl@ohsu.edu
At: OB / Peds Grand Rounds, Tuality Healthcare Hillsboro, OR July 8, 2011
Revised version: CNM Grand Rounds, OHSU,
Tues March 10, 2015, 07:30-08:30
Disclosures:
None
Jehovah’s Witness Patients:
• General principles to follow in working
with JW patients
•
What’s Acceptable?
•
The Pediatric Patient of JW Parents
•
How Low Can You Go?
•
Cases Illustrating Options in the
Adult Ob Gyn Setting
Jehovah’s Witness Patients: General
Suggestions for Health Care Providers
• Work in partnership with the patient & JW
community; act as patient’s advocate.
• Know & explore the acceptability of the full
range of non-blood therapeutic options with
the patient--and use them!!
• Act pre-emptively if possible
•
Realize physiological tolerance of anemia is
generally greater than you may think
Jehovah’s Witnesses: What’s Acceptable?
• Religious objection to the use of many blood
products
•
Acceptability of blood products:
Unacceptable: Whole blood and its
primary components:
RBCs, platelets, plasma, WBCs
Possibly acceptable (individual
conscience): Plasma derivatives: cryoprecipitate, albumin, fibrin glue, factor
concentrates, IVIG, (Hb-based O2 carriers)
UNACCEPTABLE
Whole Blood
450 ml
Primary Components
Plasma (~250 ml)
spin
Platelets
WBCs
RBCs (~200 ml)
MAY be acceptable: “MATTERS OF CONSCIENCE”
Plasma derivatives
“fractions”
Hb-based O2 carriers
(experimental)
Plasma Derivatives = “Matters of Conscience”
spin
Cryoprecipitate
~10 ml
Plasma
~250 ml, 4o C
Fibrin glue
(~1/2 the VWF,
FVIII and fibrinogen
in original plasma)
Physical and/or
chemical separation (s)
2000 - 20,000
donors
Plasma pools
+ thrombin
Albumin
Clotting Proteins
Ex. Prothrombin Complex
Concentrates =PCCs=
Factors II, VII,IX, X
Ex. FVIII, FIX-from plasma
IVIG; RhIg
Many others
• Acceptability of transfusion -sparing
interventions:
• Unacceptable: Autologous predonation
• Conditionally acceptable (with certain
devices/techniques only--blood must
remain in unbroken circuit with body) :
Isovolemic hemodilution, some perioperative
salvage devices
• Almost always acceptable: Epo
• Always acceptable (no issues): darbe
(albumin free), G-CSF, TPO-mimetics, ddAVP,
antifibrinolytics, recombinant factors, rVIIa
“Tips” on explaining “fractions” and transfusion
alternatives :
•
Ask if the patient has an “Advance Directive”—
there is a special section of this dealing with “fractions”
•
Use a special “Refusal Form” to help guide discussion
between you and the patient (OHSU = possible prototype)
•
Usually if one “fraction” is acceptable, all are
•
Erythropoietin = “matter of conscience” (stabilized
with traces of albumin); darbepoietin = no issues
(albumin free)
“Tips” on explaining “fractions” and transfusion
alternatives :
2
It may be helpful to emphasize:
• Plasma’s role as a general carrier (sugars, waste
products, clotting factors, etc)
• The fact that clotting proteins are made in the
liver and traffic normally across the placenta whereas
•
cellular blood elements (RBCs, platelets, WBCs ) are
made in the bone marrow and don’t
That although neither platelets nor plasma are acceptable
to Witnesses that:
•
•
•
•
cryoprecipitate can help platelets work better
PCC s + cryo can supply many clotting
factors (every factor in clotting cascade except V and XI)
fibrin glue can help make local clots
albumin can help blood stay in the vessels
Additional Management “Tips”:
•
The “fractions”/transfusion alternatives discussion
is useful and should be done:
• I have seen all named fractions contribute to
saving lives
• The therapeutic relationship is served
•
Don’t be shy about asking for advice elsewhere—
call me, call Dr David Rozencrantz at Legacy
•
Ask if the patient has a specially trained Hospital
Liaison Elder working with them—these individuals
are often knowledgeable and compassionate and can
help both the patient and the treating MD
OHSU BLOOD REFUSAL FORM
Transfusion of Minors poses medical legal issues
BUT…Court Orders are NOT often necessary at OHSU:
Re: Care of the Child of JW Parents re: Blood Refusal:
The same principles apply as before….
1.
Work in partnership with the patient & JW community;
act as patient’s advocate—Hospital Liaison Elder
involvement in the case and with the treating MD is
very reassuring to the family
2.
Know & explore the acceptability of the full range of
“matters of conscience” and non-blood therapeutic
options with the patient and the family--and use them!!
ex. cryoppt vs platelet txn in severe thrombocytopenia;
romiplostim to increase platelet counts
3.
Act pre-emptively if possible
ex. IV iron and epo to treat anemia pre-op in patients
coming to major surgery—and accelerate Hb recovery
post-op (Note: darbe not approved in peds)
ex. Iron, epo, folate, B12, Vit K routinely as appropriate
Note: Pre-op epo: 300-500 U/kg /wk—takes 2-3 weeks to
get meaningful increase in Hb
Post-op epo: 300-500 U/kg/d SQ--works less well
due to antagonism by inflammatory mediators
4. Realize physiological tolerance of anemia is generally
greater than you may think
Ref: LaCrox J et al Transfusion strategies for patients
in pediatric ICUs NEJM 2007; 356: 1609-1619—
Hbs 7-9 vs 10-12
usually OK in peds
5. Make the family aware of the legal
obligation of the MD to transfuse a minor to
prevent death or serious harm.
Note: If the family has truly seen you work to avoid transfusion
of their child; and if you have worked with a JW Liaison elder;
and if you have communicated clearly with them why you think
the situation has become life threatening; and if you have
avoided getting a court order for the now-necessary
transfusion—or worked to get the court order limited to
transfusion only—then you have done all you could—and they
know it and are often grateful to you—esp after the emotionally
charged moment of the transfusion has passed
Note: I often sit with the family during the transfusion and talk
with them and the patient; I give sedatives as appropriate and
cover the blood bag with a pillowcase and the IV tubing with foil
For a fuller discussion of “Care of the Child
Refusing Blood Products” see Chapt 449 in
Textbook of Pediatrics, 2nd ed, 2012
OK, now back to adults and anemia
tolerance……..
Hb/ Hct: How Low Can You Go?
• Normal Hb: ~12-16 g/dl; Hct ~36-56
• Response to anemia:
• Cardiac: HR, coronary vasodilatation,
 as decompensate: shift to anaerobic
metab; blood from subendo  epicardium
• Peripheral tissues:  blood flow
thru vascular beds;  O2 extraction (if
possible); recruit more capillaries
•  RBC 2,3 DPG: facilitates off-loading
O2 to tissues
• Animal studies: lower limit tolerance:
• Normal CV system: Hb ~3-5 g/dl
• Coronary stenosis: Hb ~7-10 g/dl
• Human perisurgical morbidity/mortality:
Post-Op Hb
30d in hospital mortality 30d morbidity/mortality
Normal
CV disease Normal
CV disease
1.1-2.0
100 %
100 %
100 %
100 %
2.1-3.0
52.6 %
60 %
88.9 %
100 %
3.1-4.0
10.0 %
62.5 %
42.9 %
80.0 %
4.4-5.0
20.0 %
58.3 %
50.0 %
75.0 %
5.1-6.0
7.5 %
14.3 %
23.5 %
40.0 %
6.1-7.0
11.4 %
0%
22.5 %
20.0 %
7.1-8.0
0%
0%
9.8 %
7.1 %
 Tolerance to anemia is determined by
multiple factors including:




Chronicity of development
Underlying cardiovascular status
Age
O2 demands
 One size does not necessarily fit all…
And now on to some
Ob/Gyn patient
cases….