Severe anemia in Jehovah's Witness patients
Jehovah's Witness paients traditionally refuse allogenic blood and whole blood products.
- This includes: RBCs, plasma, platelets, white cells) 
- HOWEVER, they are able to choose to accept BLOOD COMPONENT FRACTIONS (includes recombinant factor VII, PCC), though this decision may still vary per individual. 
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:
- 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.  It's worth carefully discussing the risks/benefits with the patient (without visitors present), especially if the need is truly critical.
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.
- Early surgical or hemostatic control
- Tranexamic Acid administration for major trauma < 3 hrs
- Prothrombin complex concentrates
- Recombinant factor VIIa
- Autotransfusion (ie Cell Saver, CATS, or Fresenius cell salvage)
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
Epoetin Alfa (Epogen)
- Dose: 40,000 units IV daily until hemoglobin > 7g/dL then 40,000 units per week
- Onset of Action: 3 days
- Patients must have sufficient iron supplementation or max erythropoesis will not occur
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
- Iron supplementation to keep serum iron 100-400mg/dl
- IV iron sucrose 100mg daily for 10 days
- 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
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
- 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.
- 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
- Dosing: 1 unit (225 mL) administered IV over 4 hours if bleeding
- If patient develops hypertension slow infusion rate
- Gannon CJ, Napolitano LM. Severe anemia after gastrointestinal hemorrhage in a Jehovah’s Witness: new treatment strategies. Crit Care Med 2002;30:1893-5.
- Gyamfi C, Berkowitz RL. Responses by pregnant Jehovah's Witnesses on health care proxies. Obstet Gynecol. 2004;104(3):541-4.
- Waters J, Potter, P. Cell Salvage in the Jehovah’s Witness Patient. Anesth Analg. 2000 Jan;90(1):229-30. Full Text
- Lundby C, Olsen NV. Effects of recombinant human erythropoietin in normal humans. J Physiol 2011;589(Patient 6):1265- 71.
- 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.
- Barsun A et al. Reducing postburn injury anemia in a Jehovah’s Witness patient. J Burn Care Res 2014;35:e258-61.
- ClinicalTrials.gov. Expanded access study of HBOC-201 (Hemopure) for the treatment of life-threatening anemia. 2014. [http:// clinicaltrials.gov/ct2/show/NCT01881503]