“Bloodless” Neurosurgery Among Jehovah's Witnesses: A Comparison with Matched Concurrent Controls

Background

Jehovah's Witnesses (JW) are a Christian faith with >1 million members in the United States who do not accept autologous blood transfusions. The optimal management of these patients undergoing neurosurgical procedures is not well defined. Here, we examined the feasibility and safety of JW undergoing neurosurgery in a blood management program.

Study Design and Methods

Sixty-eight JW patients including 23 men and 45 women (mean age 53 ± 12 years) who underwent a variety of cranial (n = 19) and spinal (n = 49) neurosurgical procedures during a 5-year period were identified retrospectively and their hospital charts, anesthetic records, and operative reports reviewed. A concurrent cohort of sex-, age-, and procedure-matched non-JW controls also was identified.

Results

Among JW patients, a cell-saving system was used in 27 cases, with blood retransfused in 13 cases. Lactated Ringers solution was used extensively intraoperatively; albumin was given to 15 patients. The median decrease in hemoglobin was 2.1 g/dL. One patient had a postoperative hemoglobin value <7 g/dL. One patient returned to the operating room to revise a lumbar pedicle screw, and one patient had postoperative seizures. No cardiopulmonary complications, sepsis, pneumonia, or wound infection were observed. Compared with the matched control group, similar outcome results were observed. Blood loss and operative time also were similar in JW patients and controls.

Conclusions

Neurosurgical procedures in Jehovah's Witnesses are feasible, safe, and have similar outcomes to patients willing to accept transfusion when managed within a multidisciplinary blood-management program.

Introduction

Transfusion practices have changed since the Transfusion Requirements in Critical Care trial in 1999¹ and today a restrictive blood transfusion strategy (hemoglobin [Hgb] ∼7 g/dL) is preferred in general critical care and many surgical patients without serious cardiac disease.2, 3, 4 In part, this has led to the development of “blood management” and the successful application of transfusion-free management even of gastrointestinal bleeding⁵; however, the optimal Hgb and transfusion trigger for neurosurgical patients are still being elucidated, and there is great variance in how these patients are transfused.6, 7, 8, 9, 10 This applies to both patients admitted to the intensive care unit or who undergo elective surgery. In addition, it appears that results from general critical care or other surgical disciplines may not apply to neurosurgical disorders.¹¹

The Jehovah's Witnesses (JW), a religious group of >7 million people in more than 200 countries, including >1 million in the United States, teach its followers to not accept autologous blood transfusions. This creates potential medical, surgical, and ethical challenges for these patients and caregivers. In particular, the choice not to receive a transfusion poses difficulty for the patient, anesthesiologist, and surgeon when deciding on the surgical treatment of any disease. The unique challenges for JW patients are described mainly in cardiothoracic surgery but also in otolaryngology, obstetrics, orthopedic, bariatric, and plastic surgery. In general these clinical series suggest that elective surgery without transfusion, including high-risk procedures such as open-heart surgery12, 13, 14, 15, 16, 17, 18, 19, 20 and liver transplantation,21, 22 can be carried out with similar results to those patients who accept transfusions11, 23, 24, 25, 26, 27, 28, 29 when a multidisciplinary blood management approach is used. Furthermore, the refusal to accept transfusion does not appear to increase the risk for surgical complications or long-term mortality; however, emergency surgery or acute blood loss may be associated with increased morbidity and mortality among JWs,³⁰ and up to one-third of the patients with a postoperative Hgb <6 g/dL may die.³¹

There is a paucity of information on transfusion practices during neurosurgery and in particular among JW patients who undergo cranial or spinal procedures.32, 33, 34, 35, 36 We therefore undertook this observational study to compare JW patients with matched non-JW control patients who underwent elective neurosurgery. We hypothesized that surgery in neurosurgical patients who refuse allogenic transfusion is feasible and as safe as in patients who accept transfusion.