Severe anemia in Jehovah's Witness patients: Difference between revisions

 
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==Background==
==Background==
Jehovah's Witness patients refuse allogenic blood and blood products.  The major clinical complication due to their religious beliefs is life threatening bleeding.  Multiple options exist to temporize and treat bleeding, which include:<ref>Gannon CJ, Napolitano LM. Severe anemia after gastrointestinal hemorrhage in a Jehovah’s Witness: new treatment strategies. Crit Care Med 2002;30:1893-5.</ref>
Jehovah's Witness paients traditionally refuse allogenic blood and whole blood products.   
*Erythropoesis stimulation
*This includes:  RBCs, plasma, platelets, white cells) <ref>https://www.jw.org/en/jehovahs-witnesses/faq/jehovahs-witnesses-why-no-blood-transfusions/</ref>
*HOWEVER, they are able to choose to accept BLOOD COMPONENT FRACTIONS (includes recombinant factor VII, PCC), though this decision may still vary per individual. <ref>https://wol.jw.org/en/wol/d/r1/lp-e/2004448#h=4</ref>
 
This can make cases of life threatening bleeding difficult to addressHowever, multiple options exist to temporize and treat bleeding which are acceptable to Jehovah's Witness patients. These include:<ref>Gannon CJ, Napolitano LM. Severe anemia after gastrointestinal hemorrhage in a Jehovah’s Witness: new treatment strategies. Crit Care Med 2002;30:1893-5.</ref>
*Erythropoesis stimulation
*Iron supplementation
*Iron supplementation
*Oxygen carriers
*Oxygen carriers
*Whole blood conservation
*Whole blood conservation
The use of advanced treatments are generally reserved for patients with severe anemia < 7g/dL
 
It is important to note that individual Jehovah's Witnesses may not strictly adhere to this doctrine; up to 49% of Jehovah's Witness patients in one study would be willing to accept blood products in certain circumstances. <ref>Gyamfi C, Berkowitz RL. Responses by pregnant Jehovah's Witnesses on health care proxies. Obstet Gynecol. 2004;104(3):541-4.</ref> It's worth carefully discussing the risks/benefits with the patient (without visitors present), especially if the need is truly critical.
 
==Control Bleeding==
==Control Bleeding==
Early control of bleeding and coordination with the family or patient is the only means of managing an severely bleeding Jehovah's Witness patient.  Most patients will accept autotransfusion.<ref>Waters J, Potter, P. Cell Salvage in the Jehovah’s Witness Patient. Anesth Analg. 2000 Jan;90(1):229-30. [http://journals.lww.com/anesthesia-analgesia/Fulltext/2000/01000/Cell_Salvage_in_the_Jehovah_s_Witness_Patient.53.aspx Full Text]</ref>
Early control of bleeding and coordination with the family or patient is the only means of managing an severely bleeding Jehovah's Witness patient.  Most patients will accept autotransfusion.<ref>Waters J, Potter, P. Cell Salvage in the Jehovah’s Witness Patient. Anesth Analg. 2000 Jan;90(1):229-30. [http://journals.lww.com/anesthesia-analgesia/Fulltext/2000/01000/Cell_Salvage_in_the_Jehovah_s_Witness_Patient.53.aspx Full Text]</ref>
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==Erythropoesis Stimulation==
==Erythropoesis Stimulation==
High dose epoetin have a multimodal mechanism of action that includes  an increase in reticulocyte count, decrease in plasma volume and increase in Hb levels<ref>Lundby C, Olsen NV. Effects of recombinant human erythropoietin in normal humans. J Physiol 2011;589(Pt 6):1265- 71.</ref>
High dose epoetin has a multimodal mechanism of action that includes  an increase in reticulocyte count, decrease in plasma volume and increase in hemoglobin levels<ref>Lundby C, Olsen NV. Effects of recombinant human erythropoietin in normal humans. J Physiol 2011;589(Patient 6):1265- 71.</ref>


===Epoetin alfa (Epogen)===
===Epoetin Alfa (Epogen)===
*Dose: 40,000 unites IV daily until Hb > 7g/dL then 40,000 units per week<ref name="JW">Posluszny JA Jr, Napolitano LM. How do we treat life-threatening anemia in a Jehovah's Witness patient? Transfusion. 2014;54(12):3026-3034. doi:10.1111/trf.12888.</ref>
*Dose: 40,000 units IV daily until hemoglobin > 7g/dL then 40,000 units per week<ref name="JW">Posluszny JA Jr, Napolitano LM. How do we treat life-threatening anemia in a Jehovah's Witness patient? Transfusion. 2014;54(12):3026-3034. doi:10.1111/trf.12888.</ref>
*Onset of Action: 3 days
*Onset of Action: 3 days
*Patients must have sufficient iron supplementation or max erythropoesis will not occur
*Patients must have sufficient iron supplementation or max erythropoesis will not occur
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==Iron Supplementation==
==Iron Supplementation==
Supplementation will allow for full RBC production but will not correct anemia immediately. Most useful for preparing for scheduled surgical procedures or in burn patients<ref>Barsun A et al. Reducing postburn injury anemia in a Jehovah’s Witness patient. J Burn Care Res 2014;35:e258-61.</ref>
Supplementation will allow for full RBC production but will not correct anemia immediately. Most useful for preparing for scheduled surgical procedures or in burn patients<ref>Barsun A et al. Reducing postburn injury anemia in a Jehovah’s Witness patient. J Burn Care Res 2014;35:e258-61.</ref>
*IV iron sucrose 100 mg daily for 10 days<ref name="JW"></ref>
*Iron supplementation to keep serum iron 100-400mg/dl
*IV iron sucrose 100mg daily for 10 days<ref name="JW"></ref>
**For first dose, test dose 25mg slow push over 15 min
**Wait 2 hrs, if no anaphylactoid reaction, give rest of 75mg
*Oral [[Iron Supplementation]] afterwards
*Oral [[Iron Supplementation]] afterwards
==Vitamin Supplementation==
==Vitamin Supplementation==
Should be provided to all patients
Should be provided to all patients
*Vitamin C: 500 mg TID( q24hrs daily in renal failure)
*Vitamin C: 500mg TID( q24hrs daily in renal failure)
*Folate: 1 mg PO or IV daily (q24hrs)
*[[Folate]]: 1mg PO or IV daily (q24hrs)
*Vitamin B12 multivitamin PO or IV
*[[Vitamin B12]] multivitamin PO or IV


==Decrease phelbotomy==
==Decrease Phlebotomy==
*Use pediatric tubes for blood draws and limit daily volume to 1mL
*Use pediatric tubes for blood draws and limit daily volume to 1mL


==Hb-based oxygen carriers (Hemapure)==
==hemoglobin-Based Oxygen Carriers (Hemapure)==
Hemapure require individual patient IRB and institutional FDA approval and is experimental. Hemopure is approved in South Africa and Russia and is a purifiec acellular bovine Hb in lactated ringer's solution<ref>ClinicalTrials.gov. Expanded access study of HBOC-201
In the US, Hemapure requires individual patient IRB and institutional FDA approval and is experimental.  
*May be able to use this on a US patient by requesting "Expanded Access/Compassionate Care" protocol from FDA (see:  https://www.fda.gov/NewsEvents/PublicHealthFocus/ExpandedAccessCompassionateUse/)
 
Hemopure is approved in South Africa and Russia and is a purifiec acellular bovine hemoglobin in lactated ringer's solution<ref>ClinicalTrials.gov. Expanded access study of HBOC-201
(Hemopure) for the treatment of life-threatening anemia. 2014. [http:// clinicaltrials.gov/ct2/show/NCT01881503]</ref>
(Hemopure) for the treatment of life-threatening anemia. 2014. [http:// clinicaltrials.gov/ct2/show/NCT01881503]</ref>
*Dosing: 1 unit (225 mL) administered IV over 4 hours if bleeding
*Dosing: 1 unit (225 mL) administered IV over 4 hours if bleeding
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==External Links==
==External Links==


==References==
==References==

Latest revision as of 14:26, 25 March 2018

Background

Jehovah's Witness paients traditionally refuse allogenic blood and whole blood products.

  • This includes: RBCs, plasma, platelets, white cells) [1]
  • HOWEVER, they are able to choose to accept BLOOD COMPONENT FRACTIONS (includes recombinant factor VII, PCC), though this decision may still vary per individual. [2]

This can make cases of life threatening bleeding difficult to address. However, multiple options exist to temporize and treat bleeding which are acceptable to Jehovah's Witness patients. These include:[3]

  • Erythropoesis stimulation
  • Iron supplementation
  • Oxygen carriers
  • Whole blood conservation

It is important to note that individual Jehovah's Witnesses may not strictly adhere to this doctrine; up to 49% of Jehovah's Witness patients in one study would be willing to accept blood products in certain circumstances. [4] It's worth carefully discussing the risks/benefits with the patient (without visitors present), especially if the need is truly critical.

Control Bleeding

Early control of bleeding and coordination with the family or patient is the only means of managing an severely bleeding Jehovah's Witness patient. Most patients will accept autotransfusion.[5]

Erythropoesis Stimulation

High dose epoetin has a multimodal mechanism of action that includes an increase in reticulocyte count, decrease in plasma volume and increase in hemoglobin levels[6]

Epoetin Alfa (Epogen)

  • Dose: 40,000 units IV daily until hemoglobin > 7g/dL then 40,000 units per week[7]
  • Onset of Action: 3 days
  • Patients must have sufficient iron supplementation or max erythropoesis will not occur

Iron Supplementation

Supplementation will allow for full RBC production but will not correct anemia immediately. Most useful for preparing for scheduled surgical procedures or in burn patients[8]

  • Iron supplementation to keep serum iron 100-400mg/dl
  • IV iron sucrose 100mg daily for 10 days[7]
    • For first dose, test dose 25mg slow push over 15 min
    • Wait 2 hrs, if no anaphylactoid reaction, give rest of 75mg
  • Oral Iron Supplementation afterwards

Vitamin Supplementation

Should be provided to all patients

  • Vitamin C: 500mg TID( q24hrs daily in renal failure)
  • Folate: 1mg PO or IV daily (q24hrs)
  • Vitamin B12 multivitamin PO or IV

Decrease Phlebotomy

  • Use pediatric tubes for blood draws and limit daily volume to 1mL

hemoglobin-Based Oxygen Carriers (Hemapure)

In the US, Hemapure requires individual patient IRB and institutional FDA approval and is experimental.

Hemopure is approved in South Africa and Russia and is a purifiec acellular bovine hemoglobin in lactated ringer's solution[9]

  • Dosing: 1 unit (225 mL) administered IV over 4 hours if bleeding
    • If patient develops hypertension slow infusion rate

See Also

External Links

References

  1. https://www.jw.org/en/jehovahs-witnesses/faq/jehovahs-witnesses-why-no-blood-transfusions/
  2. https://wol.jw.org/en/wol/d/r1/lp-e/2004448#h=4
  3. Gannon CJ, Napolitano LM. Severe anemia after gastrointestinal hemorrhage in a Jehovah’s Witness: new treatment strategies. Crit Care Med 2002;30:1893-5.
  4. Gyamfi C, Berkowitz RL. Responses by pregnant Jehovah's Witnesses on health care proxies. Obstet Gynecol. 2004;104(3):541-4.
  5. Waters J, Potter, P. Cell Salvage in the Jehovah’s Witness Patient. Anesth Analg. 2000 Jan;90(1):229-30. Full Text
  6. Lundby C, Olsen NV. Effects of recombinant human erythropoietin in normal humans. J Physiol 2011;589(Patient 6):1265- 71.
  7. 7.0 7.1 Posluszny JA Jr, Napolitano LM. How do we treat life-threatening anemia in a Jehovah's Witness patient? Transfusion. 2014;54(12):3026-3034. doi:10.1111/trf.12888.
  8. Barsun A et al. Reducing postburn injury anemia in a Jehovah’s Witness patient. J Burn Care Res 2014;35:e258-61.
  9. ClinicalTrials.gov. Expanded access study of HBOC-201 (Hemopure) for the treatment of life-threatening anemia. 2014. [http:// clinicaltrials.gov/ct2/show/NCT01881503]