Managing Shock in a Jehovah's Witness

Dr. Janel Desalvo presented a case of a 3-year-old Jehovah’s witness, transferred to OHSU for management shock secondary to a necrotic uterine mass complicated by AKI, severe anion gap metabolic acidosis and DIC. This was an interesting case that generated robust discussion regarding the management of shock in patients who cannot receive blood products due to religious or other reasons. Dr. Mandy VanSandt from the department of pathology and Drs. Joe Shatzel and Sven Olson from the department of Hematology were in attendance and provided valuable insight into the management of acute anemia in Jehovah’s witnesses.

Take Home Points

1) Identify patient preferences. It ideal to have detailed discussion regarding transfusion practices with a JW prior to acute need (though this is not always possible). If no documentation exists and the patient is unable to communicate, clinicians should proceed with urgent transfusion in the event of severe symptomatic anemia.

2) Avoidance of anemia with presurgical planning and preoperative optimization is key.

3) Most Jehovah’s Witnesses will not accept whole blood, RBCs, platelets, plasma, or autologous blood transfusions.

4) Jehovah’s Witnesses may accept minor fractions. These include: Albumin, clotting factor concentrates, cryoprecipitate, IVIG, and artificial oxygen carriers (ie HemaPure). HemaPure is not FDA approved and only available via compassionate use exemption for patients with life threatening anemia. Notify blood bank early if you anticipate needing Hemapure. Hemapure is a bridge therapy that is unlikely to be of significant benefit if the underlying etiology cannot be corrected.

5) Manage acute blood loss in this population by achieving source control (if possible), limiting further losses (through judicious blood draws and use of pediatric tubes), administering acceptable fractions to correct coagulopathy along with iron, B12 and EPO to improve RBC production.

6) Patient blood management team (available via smart web at OHSU), hematology, hospital liaison committee (which include JW Elder), patient advocate and ethics team are available resources to provide support to you and your patients.

JW management.JPG

Reference

For those interested in learning further please reference the following review article write by Dr. Shatzel et al from the Journal of Hematology on Treatment of Individuals who cannot receive blood products for religious or other reasons.

https://www.ncbi.nlm.nih.gov/pubmed/28815690