The Bleeding Jehovah s Witness: A Nightmare Scenario? David Smith, Bristol Hospital Liaison Committee for Jehovah s Witnesses SW RTC: Bleeding in the Medical Patient - 21 February 2018
Jehovah s Witnesses ~ Putting them in context Circa 1:300 of your patients
Why Witnesses decline blood The Scriptures (Acts 15): Abstain from... blood... If you keep free from these things you will be doing right. RCS Caring for Patients who Refuse Blood (2016): JWs appreciate high-quality care. They value life and want to do whatever is reasonable and compatible with their beliefs to prolong it.
NO 1. Whole Blood 2.RBCs 3. Platelets 4. Plasma (FFP, Octaplas, Lyoplas) 5. WBCs 6. PAD Check 1. Autologous procedures eg Cell Salvage 2. Fractions eg Fibrinogen and other factor concentrates, Albumin, PCC, Cryoprecipitate 3. Transplants No other limitations. Key modalities include: Antifibrinolytics Meticulous Haemostasis Oral & IV Iron Non-blood haemostats, eg Celox Minimal sampling ESAs YES Recombinants
Communicating Choices: Key Documents & Wristband 3/19/2018
460 and 461 patients in the two groups Hb levels at admission: 95g/L No Transfusion 6 week survival Re Bleeding Adverse Events 45 day Mortality 90g/L trigger 15% 91% 16% 48% 9% 70g/L trigger 51% 95% 10% 40% 5%
OVERVIEW FOR THE BLEEDING JW MEDICAL PATIENT No unique procedures or medications so speed and a multimodal approach are crucial 1. Address anaemia even if moderate 2. Identify source of bleeding 3. Treat bleeding & clotting disorders 4. Lower than normal threshold for surgery 1. IV Vit K for severe bleeding 2. Prompt TXA 3. Early or pre-emptive ESAs & iron 4. All surgical & anaesthetic techniques 5. Interventional radiology
How to proceed: UGIB Care Pathway at UHB 3/19/2018
JW with Severe Anaemia: Hb < 70g/L Initiate Anaemia Protocol: EPO: 40k units daily until Hb > 70 g/l, then 40k units weekly. Iron: 100mg IV iron daily for10 days minimum and then consider conversion to oral. Vitamin C, Folate & Vitamin B12 For multiple scenarios including burn injury, GI haemorrhage, trauma, chemotherapy and THA: A multimodal approach is required. enhance endogenous erythropoiesis, reduce blood loss, increase oxygen delivery and reduce oxygen consumption, and avoid hemodilution and iatrogenic anemia. Monitor Hb etc daily with blood gas (0.3ml) Control bleeding; correct coagulopathy Reduce oxygen consumption Supplemental oxygen Avoid haemodilution How do we treat life-threatening anemia in a Jehovah s Witness patient? Posluszny and Napolitano Transfusion 2014;54:3026-34
OPERATIVE TECHNIQUES TO MINIMISE BLOOD LOSS Caring for Patients who Refuse Blood, RCS 2016 Techniques to minimize blood loss Anaesthetic Autologous Coagulation stimulants Haemostatic aids Laparoscopic instead of open surgery; interventional radiology; staged procedures; vasoconstrictors, tourniquet & clamps to stem blood flow Controlled hypotension; regional anaesthesia Cell salvage*; ANH* Tranexamic Acid; Recombinant clotting factors VIIa*, VIII, IX; Desmopressin Diathermy; harmonic scalpels; radiofrequency ablation
GI Bleed Treatment Options INTRAVENOUS IRON: TATM 12 (2012) 122-9 INTERVENTIONAL RADIOLOGY: WJ RADIOL 6 (2014) 4:82 Interventional radiology becomes vital in patients whose GIB remains resistant to medical and endoscopic treatment. Radiology offers diagnostic imaging studies and endovascular therapeutic interventions that can be performed promptly and effectively with successful outcomes.
Acute upper gastrointestinal bleeding in over 16s NICE Clinical guideline [CG141] Published date: June 2012 Last updated: August 2016 o (Introduction) Acute upper gastrointestinal bleeding has a 10% hospital mortality rate. Elderly patients and people with chronic medical diseases have a higher risk of death. o 1.2.2 Base decisions on blood transfusion on the full clinical picture, recognising that over-transfusion may be as damaging as under-transfusion. o 1.2.7 Do not use factor Vlla except when all other methods have failed. o 1.4.7 (Key Priority) Offer interventional radiology to unstable patients who re-bleed after endoscopic treatment. o 1.5.5 Offer endoscopic injection of N-butyl-2-cyanoacrylate to patients with UGI bleeding from gastric varices.
Intensive Care Recommendations from Caring for Patients who Refuse Blood, RCS 2016 [E3] 1. Monitor and minimise postop blood loss 2. Monitor and avoid sepsis. 3. Minimise number/volume of blood samples (can be >70ml/day in ICU AJCC, 2013) 4. Ensure staff are aware of the refusal of blood to ensure extra monitoring. 5. Consider postoperative EPO and/or Iron/B12. 6. Consider postop blood salvage from drains.
Multi-Modal Management: Hepatic Bleed in 75 year old o 2am admission to A&E with major bleed from hepatic artery - Hb 55g/L. o TXA, Darbepoetin & IV Iron administered per Trust Policy for JWs. o Open repair would likely have increased blood loss and risk of mortality hence case referred for interventional radiology o TAE (Transcatheter Arterial Embolization) carried out at 7am bleeding arrested o 2pm: No hepatic artery bleeding: Hb > 70g/L o Patient discharged day 3 with Hb > 100g/L
o More open to having earlier discussions to allow our patients a better say and understanding about their end-of-life wishes o The majority of doctors would not like their lives prolonged if the likely risks and burdens of treatment would outweigh the expected benefits. 3/19/2018
How Far for JWs?? We do not believe that extraordinary, complicated, distressing or costly measures must be taken to sustain a dying person. The consensus may be that those measures would merely prolong the dying process and/or leave the patient with no meaningful life. JWs: Our Views on Healthcare, 2017
In Conclusion: What s Different for Jehovah s Witnesses? o No Blood = firm expectation not simply nice if possible. o Prompt & clear identification of what is acceptable for each patient is vital and must be communicated at handovers. o Clinical toolkit is almost always standard PBM, but often will need to be applied earlier, more aggressively and with multidisciplinary input. o Impact is attritional. o Witnesses (have) driven many workers to find alternative strategies for avoiding bleeding and treating it. These have proved successful, and are now not limited to Jehovah s Witnesses, for which wider society owes them a debt of gratitude. Prof Martin Elliott, GOSH; Gresham lecture 2017
And finally. 3/19/2018