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Invited Commentary
Aug 13/27, 2012

Severe Blood ConservationComment on “Outcome of Patients Who Refuse Transfusion After Cardiac Surgery”

Author Affiliations

Author Affiliation: Department of Surgery, University of Kentucky Chandler Medical Center, A301 Kentucky Clinic, Lexington.

Arch Intern Med. 2012;172(15):1160-1161. doi:10.1001/archinternmed.2012.2458

The article by Pattakos and coauthors1 analyzes outcomes in Jehovah's Witness patients (Witnesses) who do not receive blood transfusion during cardiac operations. They use careful matching statistics to compare Witnesses with a matched group of non-Witnesses who received transfusion. They conclude that no long-term harm accrues to Witnesses as a result of extreme blood conservation interventions.

Witnesses believe that the Bible prohibits ingesting blood and that Christians should therefore not accept blood transfusions or donate or store their own blood for transfusion.2 Members of the religion who voluntarily accept a transfusion are regarded as having disassociated themselves from the religion by abandoning its doctrines and are subsequently shunned by members of the organization.

Witnesses are taught that the use of fractions, such as albumin, immunoglobulins, and hemophiliac preparations, are not prohibited, and accepting these blood fractions is a matter of personal choice (Table). Although accepted by most Witnesses, a few do not endorse this doctrine, and this group adamantly refuses any blood component or fraction.

Table. Permitted Procedures and Products in Jehovah's Witnesses Undergoing Cardiac Operations
Table. Permitted Procedures and Products in Jehovah's Witnesses Undergoing Cardiac Operations
Table. Permitted Procedures and Products in Jehovah's Witnesses Undergoing Cardiac Operations

Surgeons who operate on Witnesses need to understand the nuances of Witnesses' beliefs and use any or all of the interventions listed in the Table if accepted by Witnesses. Witnesses contemplating cardiac operations need to have a specific and individual discussion about surgical options. Few publications that report outcomes of cardiac operations in Witnesses give a complete description of the alternative blood fractions or the blood salvage interventions used in the Witnesses. The article by Pattakos et al1 is no exception. This is an important deficit because there are many options that may or may not be used in Witnesses, with varying hemostatic effects. Because all Witnesses in the study underwent operation at a single institution, protocols for blood conservation may have been standardized.

The authors looked at intermediate to long-term outcomes in Witnesses. This feature separates this study from other similar publications regarding Witnesses. Determinants of long-term outcome after cardiac operations are not necessarily intuitive. Management of cardiovascular risk factors (especially lipid-lowering methods), use of arterial conduits, left ventricular dysfunction, extent of coronary disease, and age are among the determinants of long-term survival in cardiac surgical patients.47 Increasing observational evidence suggests that there are short-term and possibly intermediate to long-term harms from receipt of blood transfusions during surgery.8,9 How receipt of blood harms patients is an area of intense study. Blood transfusion is immunomodulatory, risks disease transmission, and can cause circulatory overload. These factors and others might be expected to reduce short-term survival, but no clear mechanism exists to explain any decrease in long-term survival. More important, the authors did not find any adverse long-term outcomes in patients who received blood transfusions compared with Witnesses who did not receive transfusions. Their results cast doubt on observational data, suggesting that perioperative blood transfusion decreases longer-term survival.

An important limitation of the study is that Witnesses who undergo cardiac surgery are likely a healthier subgroup of Witnesses because those who are believed by their surgeons to require blood transfusion to survive cardiac surgery presumably never go to the operating room. However, the finding that the Witnesses who did not receive transfusions did at least as well as, if not better than, those who received a transfusion raises questions about whether more patients might benefit from surgical strategies that minimize transfusion of blood products.

The findings of this analysis by Pattakos and colleagues add to the increasing data that suggest that more conservative use of blood transfusions would be in our patients' interest, in both Witnesses and non-Witnesses.

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Article Information

Correspondence: Dr Ferraris, Department of Surgery, University of Kentucky Chandler Medical Center, A301 Kentucky Clinic, 740 S Limestone, Lexington, KY 40536 (ferraris@earthlink.net).

Published Online: July 2, 2012. doi:10.1001/archinternmed.2012.2458

Financial Disclosure: None reported.

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