We read with interest the experience of El Azab et al. of providing a cardiac surgery service to Jehovah’s Witness patients [1]. We agree that patients who refuse allogeneic blood products present both moral and ethical challenges, especially in cardiac surgery where significant blood loss and the use of allogeneic blood product transfusion are common. We noted that the pre-operative haemoglobin concentrations were very similar in both groups, despite 3 weeks of treatment with erythropoietin, and the number of patients in the control group who received blood product transfusion was very high. We work in a busy cardiothoracic centre with a blood product transfusion rate of 20 - 25% compared to 65% in the control group in the article. We also feel that the postoperative haemoglobin concentrations would have been interesting, but this information was not provided.
Cell salvage and autologous transfusion is an important component of blood conservation, but this was not part of this hospital’s protocol for managing Jehovah’s Witness patients. Cell salvage is usually acceptable to Jehovah’s Witnesses, but consent needs to be obtained on an individual basis. The 2009 Association of Anaesthetists of Great Britain and Ireland guidelines recommend the use of cell salvage in cases where patients have objections to receiving allogeneic blood product transfusions [2].
In cardiac surgery, cell salvage may be used both intra- and postoperatively. The benefits of intra-operative cell salvage are the salvage of blood before and after cardiopulmonary bypass, and the reduction of the volume of cardiotomy blood that is returned to the patient. The re-infusion of cardiotomy blood has been implicated with the development of a coagulopathy and increased blood loss [3], an increased incidence of postoperative neurocognitive dysfunction [4], and the development of the systemic inflammatory response syndrome [5]. Blood may also be salvaged postoperatively from surgical drains. we feel that cell salvage is an essential component of blood conservation and should be used in all Jehovah's witness patients who consent to its use.
Competing interests
No external funding and no conflicts of interest declared
A. Ashworth
A. Roscoe
University Hospital of South Manchester
Manchester, UK.
E-mail: alandashworth@hotmail.com
References
1. El Azab SR, Vrakking R, Verhage G and Rosseel MJ. Safety of cardiac surgery without bloodtransfusion: a retrospetive study in Jehovah’s Witness patients. Anaesthesia2010; 65: 348-52.
2. The Association of Anaesthetists of Great Britain andIreland (AAGBI) Safety Guideline – Blood transfusion and the anaesthetist:Intra-operative cell salvage. http://aagbi.org/publications/guidelines/docs/cell%20_salvage_2009_amended.pdf.2009 (accessed 03/04/10).
3. Djaiani G, Fedorko L, Borger M, et al. Continuous-flowcell saver reduces cognitive decline in elderly patients after coronary bypasssurgery. Circulation 2007; 116:1888-95.
4. Gu YJ, Vermeijden WJ, de Vries AJ, Hagenaars JAM,Graaff R, van Oeveren W. Influenceof mechanical cell salvage on red blood cell aggregation, deformability, and2,3-Diphosphoglycerate in patients undergoing cardiac surgery withcardiopulmonary bypass. Annals of Thoracic Surgery 2008; 86: 1570-5.
5. Takayama H, Soltow L, Aldea GS. Differential expression in markers forthrombin, platelet activation, and inflammation in cell saver versus systemicblood in patients undergoing on-pump coronary artery bypass graft surgery. Journalof Cardiothoracic and Vascular Anesthesia 2007; 21: 519-23.