Specific Challenges In Cardiac Surgery Surgery in Jehovahs Witnesses

Patients who are Jehovah's Witnesses have certain religious requirements during cardiac surgery, although interpretation and practice varies. All these patients are likely to refuse transfusion of blood or blood products that are non-autologous. Some patients will accept autologous blood that has been stored. Other patients insist that all the blood to be transfused should remain in a circuit connected directly to them. Informed consent as to what is acceptable and what the risks are is of particular importance.

Patients can be started on iron supplements and recombinant ery-thropoetin injections before the operation, to increase the haemat-ocrit. All medications that can increase perioperative bleeding should be withdrawn. During the operation, use of meticulous technique and attention towards haemostasis is vital. Antifibrinolytic medications like aprotinin and tranexamic acid can be used even before the sternotomy is performed.

The use of the cell-saver is important for these patients. A greater degree of haemodilution can be accepted to minimise blood injury and blood loss. Post-CPB heparin reversal is delayed until the surgical haemostasis has been confidently secured. At the end of the procedure, the haemofilter is used to remove the excessive volume of the fluid. The remaining red cell mass can be transfused while still in the circulation. Postoperatively, low haemoglobin is often accepted, and after the patient has started enteral feeds, iron and erythropoetin injections can be resumed. In a situation where the surgeon will be operating on a child whose parents are Jehovah's Witnesses and the child cannot yet sign his/her own consent for operation, the parents' wishes are carefully noted. It is of interest to note the attitude of different legislatures around the world, when surgeons have disregarded the wishes of the parents. These decisions are best made preopera-tively, and surgeons undertaking such work should understand their local situation.

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