It begins with "bloodless surgery"..... again this term, didnt we learn that it was rather "transfusion-less" surgery and that the term is false?
This is an internationl site of neurochirurgy. http://neuros.net/en/jehova_witnesses/ with a complete strategy for encountering JW patients. Background is a good communication between HLC and the neurosurgeon-community.
I looked if Hemosep was mentioned, but I found only Hemopur, obvioully once supported by HLC and the document should be updated because it is not up to date .
The latest sentence in section JW-strategies is almost true, because Watchtower changes its position according to the market.
"Special alternatives are offered on a separate document that describes each of the strategies, processes and products or components and allowed according to the latest data available from the Watch Tower."
Shock... they are playing with lifes!!!
Were the surgeons of Eloise in Canada allowed at all to receive the latest available data from the Watch Tower if the HLC didnt allow access to her room? It turned around her LIFE, and these guys ..snafued it.
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Supported Products
- Albumin (supported since 1981) and rHuEPO (stimulating protein formation of red blood cells).
- Immunoglobulins and vaccines or serums (1974).
- Antithrombin III.
- Coagulation factors and cryoprecipitate.
- Artificial blood (HemoPure®, PolyHeme®): They are called “oxygen-carrying solutions”. These new oxygen-carrying solutions are accepted, although they derive from animal blood. They are still not allowed by Spanish law, as they are in the experimental period.
http://neuros.net/en/jehova_witnesses/
Who do you think gives surgeons such clear instructions how to treat a J.W.?
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JEHOVA WITNESSES
1. GENERAL GUIDELINES
Watchtower, the official Jehovah’s Witnesses’ journal, understands that the law of God forbids or rejects without any doubt the whole blood transfusion, and its four main components (plasma, erythrocytes, leukocytes and platelets).
However, there are many products, derivatives or techniques that are not rejected or banned. This means they are allowed. Some of the “smaller fractions” are not rejected. It is also allowed the use of some techniques of autotransfusion, as normovolemic hemodilution and blood salvage.
Since Watchtower guidelines leave the conscience of every Jehovah’s Witness decision on many issues, the individual patient will be asked about each of the points that they personally accept or reject.
The following are guidelines, and what modern medicine offers as an alternative.
2. ALLOWED AND REJECTED DERIVATIVES
Rejected products
Whole blood
Plasma: it consists the 55% of blood volume. 90% of plasma is water. 7% is albumin, immunoglobulins, fibrinogen and other fractions in the clotting process. The remaining 3% are nutrients and metabolic products. These fractions, separately, are accepted by most Jehovah’s Witnesses, but together (plasma) are rejected product.
Leukocytes (white blood cells): These components are present in its greater proportion in transplanted organs and milk (both maternal milk and cow milk), where it is accepted.
Erythrocytes (red blood cells): Present in the “packed red blood cells.” These cells constitute 40% of blood volume. They contain haemoglobin (97% of red cell volume), which is the oxygen-carrying protein. Products containing free haemoglobin are accepted.
Platelets: constitute only 0’17% of blood volume.
Supported Products
Albumin (supported since 1981) and rHuEPO (stimulating protein formation of red blood cells).
Immunoglobulins and vaccines or serums (1974).
Antithrombin III.
Coagulation factors and cryoprecipitate.
Artificial blood (HemoPure®, PolyHeme®): They are called “oxygen-carrying solutions”. These new oxygen-carrying solutions are accepted, although they derive from animal blood. They are still not allowed by Spanish law, as they are in the experimental period.
3. ALLOWED AND REJECTED TECHNIQUES
Rejected Techniques
These are mainly those that involve blood storage, i.e. predeposit technique. However, it accepts the components, the products of the processing of blood, which are stored later.
Permitted techniques
Acute normovolemic hemodilution (ANH) (Watchtower June 15, 1995)
Intraoperative Recovery (Cell Saver)
Postoperative recovery (autotransfusion drains)
Medicine uses the term “autologous” to refer to these techniques. Watchtower says in its edition of March 1, 1989 that the ANH and intraoperative recovery (AIT with Cell Saver) are acceptable to most Jehovah’s Witnesses. Postoperative recovery with autotransfusion drainage system is similar to that of hemodilution and therefore is accepted.
Conditions for applying these techniques
Follow the recommendations WATCHTOWER
The patient must accept the technical limitations, conditions and risks. This involves the signing of a special informed consent, in which each point is specified.
WATCHTOWER Recommendations
The summary is that any autotransfusion technique must, to be acceptable, involve the complete absence of disconnection between the circuit or system through which the blood and the patient, i.e., there must be permanent connection between the autotransfusion system and the system patient’s circulatory system.
4. OTHER INFORMATION OF YOUR INTEREST
Possible measures to supplement the no-transfusion
Fluid: Crystalloid and colloid. These prevent hypovolemia, ie the lack of intravascular volume, but not carrying oxygen, with the risk of ischemia (lack of oxygen to the tissues). The patients with circulatory problems, irrigation deficit, angina pectoris, history of heart attack or stroke, and chronic lung problems, among others, can see their lives seriously threatened by ischemia subsequent to haemorrhage. The oxygen-carrying solutions are still in experimental stage and are currently not legally accepted.
Drugs for the correction and prevention of anaemia: There are drugs that stimulate the formation of red blood cells (rHuEPO) and platelets (IL-11). Iron is easy to administer orally or intramuscularly. Intravenous iron (Venofer®) can be used in extreme cases.
Drugs that cause vasoconstriction (but favour ischemia – lack of oxygen in some tissues) and that promote coagulation (but also may promote thrombosis and possible pulmonary embolism).
Biological adhesives: fibrin sealants (Tissucol) and platelet sealants (it requires the removal of platelets from the patient’s blood. This technique is not always accepted). They do not produce immediate or perfect closure of bleeding vessels, but help the physiological process of haemostasis.
Bleeding in surgical techniques: endoscopic techniques, minimally invasive surgery and microsurgery. They do not guarantee the non-bleeding, but generally have lower probabilities of bleeding.
Equipment and surgical supplies: electrocautery, bipolar coagulator, ultrasonic aspirator CUSA Ligasure® sealing, endoclips, Spongostan®, Tissucol®, Surgicel®. These help to avoid the opening of the blood vessel, and the closure of the already open, but have a limit of vessel size and raw surface.
Specific risk of the strategy of non-transfusion
It is estimated that non-transfusion strategy adds a mortality risk of 0.5-1.5% to the patient’s own (The American Journal of Medicine, February 1993). This means that for every 100 patients undergoing bloodless surgery strictly, there is one that dies needlessly.
This figure is well above the surgical-anaesthetic risk without the restriction of blood. According to recent statistics (Anaesthesia, 56 (12): 1141-1153) in 10,000 anaesthetics:
There are 8.8 cases of perioperative death
There are 0.5 cases of perioperative coma
There are 1.4 deaths associated with anaesthesia
That is, if the possibility of death or coma is 0.5-8.8 per 10,000 operations, the strategy of non-transfusion-risk places this 50-150/10.000 interventions. This means that the risk is 20-100 times higher.
These statistics have been made in different years, and therefore medical technology may have improved this situation. However, we have not found in medical literature most recent statistics in terms of morbidity and mortality associated with strict non-transfusion strategy.
Specific risk of transfusion
These have been described in the summary of bloodless surgery program.
Medical Problems
The doctor is your ally in the fight against the disease. No doctor would carry out a transfusion if it is not necessary, nor prescribe medication or recommend surgery.
Blood and its derivatives are not free of risk. But for the patient who really needs a blood transfusion, the risk of transfusion-associated diseases is much less than the risk of dying or falling more severely ill without the transfusion.
Specific measures regarding autotransfusion
Preoperative:
Take oral iron Ferro-Gradumet 1 tablet every 12 hours fasting (before breakfast and before supper).
If Hb <14g/dL or Hct <42%, which is the administration of rHuEPO. The guidelines will be established in conjunction with the Hematology Department.
If possible, obtain platelet concentrate for the preparation of platelet glue
Intraoperative:
Intraoperative acute intraoperative hemodilution (ANH)
Intraoperative Recovery (AIT)
In future, application of platelet glue if required
Postoperative:
Preventing drainage
If drainage is needed, apply drainage autotransfusion.
How can I get assistance?
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MEDICAL CONDITIONS
BLOODLESS MEDICINE AND SURGERY: SOME OF THE METHODS
1. GENERAL CONCEPTS
INTRODUCTION
Although blood transfusion can be done today with high security, is not without risks, the main one being transmission of infectious diseases (AIDS, hepatitis B and C, syphilis). It is also well known the shortage of treatment resources (allogeneic blood in blood banks). That is why in recent yearsautotransfusion programs and measures to reduce intra and postoperative bleeding have been developed.
In the Hospital 9 de Octubre we have established a comprehensive bloodless surgery program (CSS program) whose main objective is to avoid allogeneic blood transfusion, using all means, resources and personnel which modern medicine puts at our disposal.
MAIN OBJECTIVES OF THE PROGRAM CSS
- Reduce the possibility of intra and postoperative complications related to blood transfusion (blood infections, transfusion reactions, alloimmunization, etc.)
- Minimising the demand for blood from the blood bank, reserving it for cases that require it (oncology, critical emergencies, etc.).
- Promote appropriate care to patients who for religious or other not wish to be transfused with allogeneic blood (Jehovah’s Witnesses).
- Provide high-quality care.
LINES OF ACTION
There are several measures which, toghether, reduce the need for transfusion.
- Optimum preparation of the patient to obtain adequate amounts of haemoglobin and red blood cells. During the preoperative visit iron treatment is prescribed until the day of surgery.
- Reduced bleeding: bleeding in surgical techniques (endoscopic techniques, minimally invasive surgery, microsurgery). Equipment and surgical devices (electrocautery, bipolar coagulator, ultrasonic aspirator, heat sealing, endoclips, Spongostan, Tissucol, Surgicel). Pharmacological measures to reduce blood loss (hypotension, etc).
- Autotransfusion Program: these are procedures for the extraction and storage of blood or blood components to a donor-patient for subsequent transfusion to the same person at the time of need.
Autotransfusion programs
Types of Autologous
- Predeposit (preoperative autologous, or autologous blood predeposit)
- Normovolemic hemodilution (Acute normovolemic hemodilution or ANH)
- Recovery of blood (Blood savage)
- Intraoperative recovery
- Postoperative recovery
The Haematology Department is responsible for the procedure predeposit. The other techniques are developed in the operating room and are the responsibility of the Department of Anaesthesiology and the various surgical services.
Advantages of Autotransfusion
- Eliminates the risk of transfusion reactions.
- Eliminates the risk of transmission of infectious diseases.
- Eliminates the risk of alloimmunization to red cells, white, platelets and plasma proteins.
- Eliminates the risk of graft versus host disease.
- Useful in patients with multiple alloantibodies or rare blood groups.
- Lowers the number of postoperative infections.
- Meets the need of blood in some Jehovah’s Witnesses.
- Hemodilution improves oxygenation of the tissues by reducing blood viscosity.
- Reduce the demands on the blood supply in times of shortage.
- Psychological effect of patient participation in treatment.
Disadvantages of autologous transfusion
- Requires expert preparation of the specialists involved directly in the performance of each technique.
- Each technique requires particular equipment, which is not present on a regular basis in all hospitals.
2. Predeposit
Predeposit consists of the collection of one or more units of blood in the patient candidate for surgery in the weeks leading up to it, if there are no contraindications to doing so. If the patient’s hemoglobin is low, we will evaluate the possible use of erythropoietin (rHuEPO), a substance that stimulates the formation of blood.
These blood units are stored as predeposit in the Blood Bank properly identified. If the patient-donor needs a transfusion during or after surgery, he receives his own blood, donated previously.
3. Acute normovolemic hemodilution
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| Diagram of acute normovolemic hemodilution | Normovolemic hemodilution before the start of surgery |
This consists of obtaining in the operating room, just before surgery, a blood volume,compensated by adequate infusion of a given volume of fluid. The anaesthesiologist removes a number of bags of whole blood (between 1 and 4) which are available to be reinfused when the patient needs it.
As a result, the patient’s blood is diluted, so that the net amount of haemoglobin lost during surgery is minor. At the end of surgery, when surgical bleeding has been controlled the blood obtained at the beginning of surgery is again reinfused.
The fact that the vast majority of patients are candidates for ANH, low cost and the requirement of little manipulation technique, make the ANH technique is very affordable and practical.
4. RECOVERY OF BLOOD
| It consists of the recovery of blood lost in surgery (in the surgical field and drains). Two methods allow the recovery of cells on the intra and postoperative period: - Intraoperative recovery (IAT or Intraoperative Auto-Transfusion). It is recognized as the standard method of intraoperative autotransfusion, particularly very useful in surgery intraoperative bleeding (eg, total hip, lumbosacral arthrodesis).
- Postoperative recovery (PAT or Postoperative Auto-Transfusion)
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| Diagram of intraoperative recovery of blood | |
INTRAOPERATIVE autologous transfusion (IAT)
It consists of collection of blood from the operative field, which is aspirated and led into a reservoir. Under standard conditions the red cells are separated, washed hemoconcentrated and stored in a bag, ready to be reinfused to the patient.
The procedure requires special apparatus. The Surgical Area in Hospital 9 de Octubre is equipped with a modern Cell Saver-5, which allows not only the recovery of red cells, but also, in specific cases, other blood components, using specialized equipment to do so.
The procedure is performed by the anaesthesiologist responsible for the patient. Since there is no connection at all times between the surgical fields – vacuum – recovery – blood bag – Infusion System – patient, there is no possibility of error as to confusion of identities between the patient and their bags of packed red blood cells.
RECOVERY OF BLOOD WITH DRAINS (autologous postoperative)
It consists of the collection of blood lost through drains in the early hours after surgery. The procedure requires a special drainage bag known as autotransfusion. The blood recovered, in bags, passes through special filters in order to be reinfused later. This technique allows the recovery of whole blood.
5. PREPARATION OF PATIENTS FOR TECHNICAL intraoperative and postoperative autotransfusion
These procedures are more effective the higher the baseline haemoglobin. Ideally, haemoglobin at baseline (before surgery) should be above and not exceeding 12g/dL 17g/dL. To support the achievement of this haemoglobin, we recommend prophylactic oral iron intake in all patients.
In special cases (anaemia) may also consider the administration of erythropoietin (rHuEPO), a substance that stimulates the formation of blood cells, thereby increasing the net amount of haemoglobin.
In the case of predeposit the criteria for drug administration will be individualized for each patient and the decision will be taken by the haematologist who performed the extractions.
Jehovah’s Witnesses Strategies
Surgical techniques to reduce bleeding, the optimal patient preparation, intraoperative hemodilution (ANH) and intraoperative recovery are accepted by the criteria of Watch Tower. It may also be eligible postoperative recovery. The predeposit is not admissible in any case.
Intraoperative ANH and recovery are acceptable to most Jehovah’s Witnesses, subject to compliance with the recommendations of Atalaya and the patient’s request.
Special alternatives are offered on a separate document that describes each of the strategies, processes and products or components and allowed according to the latest data available from the Watch Tower.
How can I get assistance?
