1. GENERAL GUIDELINES
Watchtower, the official Jehovah’s Witnesses’ journal, understands that the law of God forbids or rejects without any doubt the whole blood transfusion, and its four main components (plasma, erythrocytes, leukocytes and platelets).
However, there are many products, derivatives or techniques that are not rejected or banned. This means they are allowed. Some of the “smaller fractions” are not rejected. It is also allowed the use of some techniques of autotransfusion, as normovolemic hemodilution and blood salvage.
Since Watchtower guidelines leave the conscience of every Jehovah’s Witness decision on many issues, the individual patient will be asked about each of the points that they personally accept or reject.
The following are guidelines, and what modern medicine offers as an alternative.
2. ALLOWED AND REJECTED DERIVATIVES
- Whole blood
- Plasma: it consists the 55% of blood volume. 90% of plasma is water. 7% is albumin, immunoglobulins, fibrinogen and other fractions in the clotting process. The remaining 3% are nutrients and metabolic products. These fractions, separately, are accepted by most Jehovah’s Witnesses, but together (plasma) are rejected product.
- Leukocytes (white blood cells): These components are present in its greater proportion in transplanted organs and milk (both maternal milk and cow milk), where it is accepted.
- Erythrocytes (red blood cells): Present in the “packed red blood cells.” These cells constitute 40% of blood volume. They contain haemoglobin (97% of red cell volume), which is the oxygen-carrying protein. Products containing free haemoglobin are accepted.
- Platelets: constitute only 0’17% of blood volume.
- Albumin (supported since 1981) and rHuEPO (stimulating protein formation of red blood cells).
- Immunoglobulins and vaccines or serums (1974).
- Antithrombin III.
- Coagulation factors and cryoprecipitate.
- Artificial blood (HemoPure®, PolyHeme®): They are called “oxygen-carrying solutions”. These new oxygen-carrying solutions are accepted, although they derive from animal blood. They are still not allowed by Spanish law, as they are in the experimental period.
3. ALLOWED AND REJECTED TECHNIQUES
These are mainly those that involve blood storage, i.e. predeposit technique. However, it accepts the components, the products of the processing of blood, which are stored later.
- Acute normovolemic hemodilution (ANH) (Watchtower June 15, 1995)
- Intraoperative Recovery (Cell Saver)
- Postoperative recovery (autotransfusion drains)
Medicine uses the term “autologous” to refer to these techniques. Watchtower says in its edition of March 1, 1989 that the ANH and intraoperative recovery (AIT with Cell Saver) are acceptable to most Jehovah’s Witnesses. Postoperative recovery with autotransfusion drainage system is similar to that of hemodilution and therefore is accepted.
Conditions for applying these techniques
Follow the recommendations WATCHTOWER
The patient must accept the technical limitations, conditions and risks. This involves the signing of a special informed consent, in which each point is specified.
The summary is that any autotransfusion technique must, to be acceptable, involve the complete absence of disconnection between the circuit or system through which the blood and the patient, i.e., there must be permanent connection between the autotransfusion system and the system patient’s circulatory system.
4. OTHER INFORMATION OF YOUR INTEREST
Possible measures to supplement the no-transfusion
- Fluid: Crystalloid and colloid. These prevent hypovolemia, ie the lack of intravascular volume, but not carrying oxygen, with the risk of ischemia (lack of oxygen to the tissues). The patients with circulatory problems, irrigation deficit, angina pectoris, history of heart attack or stroke, and chronic lung problems, among others, can see their lives seriously threatened by ischemia subsequent to haemorrhage. The oxygen-carrying solutions are still in experimental stage and are currently not legally accepted.
- Drugs for the correction and prevention of anaemia: There are drugs that stimulate the formation of red blood cells (rHuEPO) and platelets (IL-11). Iron is easy to administer orally or intramuscularly. Intravenous iron (Venofer®) can be used in extreme cases.
- Drugs that cause vasoconstriction (but favour ischemia – lack of oxygen in some tissues) and that promote coagulation (but also may promote thrombosis and possible pulmonary embolism).
- Biological adhesives: fibrin sealants (Tissucol) and platelet sealants (it requires the removal of platelets from the patient’s blood. This technique is not always accepted). They do not produce immediate or perfect closure of bleeding vessels, but help the physiological process of haemostasis.
- Bleeding in surgical techniques: endoscopic techniques, minimally invasive surgery and microsurgery. They do not guarantee the non-bleeding, but generally have lower probabilities of bleeding.
- Equipment and surgical supplies: electrocautery, bipolar coagulator, ultrasonic aspirator CUSA Ligasure® sealing, endoclips, Spongostan®, Tissucol®, Surgicel®. These help to avoid the opening of the blood vessel, and the closure of the already open, but have a limit of vessel size and raw surface.
Specific risk of the strategy of non-transfusion
It is estimated that non-transfusion strategy adds a mortality risk of 0.5-1.5% to the patient’s own (The American Journal of Medicine, February 1993). This means that for every 100 patients undergoing bloodless surgery strictly, there is one that dies needlessly.
This figure is well above the surgical-anaesthetic risk without the restriction of blood. According to recent statistics (Anaesthesia, 56 (12): 1141-1153) in 10,000 anaesthetics:
- There are 8.8 cases of perioperative death
- There are 0.5 cases of perioperative coma
- There are 1.4 deaths associated with anaesthesia
That is, if the possibility of death or coma is 0.5-8.8 per 10,000 operations, the strategy of non-transfusion-risk places this 50-150/10.000 interventions. This means that the risk is 20-100 times higher.
These statistics have been made in different years, and therefore medical technology may have improved this situation. However, we have not found in medical literature most recent statistics in terms of morbidity and mortality associated with strict non-transfusion strategy.
Specific risk of transfusion
These have been described in the summary of bloodless surgery program.
The doctor is your ally in the fight against the disease. No doctor would carry out a transfusion if it is not necessary, nor prescribe medication or recommend surgery.
Blood and its derivatives are not free of risk. But for the patient who really needs a blood transfusion, the risk of transfusion-associated diseases is much less than the risk of dying or falling more severely ill without the transfusion.
Specific measures regarding autotransfusion
- Take oral iron Ferro-Gradumet 1 tablet every 12 hours fasting (before breakfast and before supper).
- If Hb <14g/dL or Hct <42%, which is the administration of rHuEPO. The guidelines will be established in conjunction with the Hematology Department.
- If possible, obtain platelet concentrate for the preparation of platelet glue
- Intraoperative acute intraoperative hemodilution (ANH)
- Intraoperative Recovery (AIT)
- In future, application of platelet glue if required
- Preventing drainage
- If drainage is needed, apply drainage autotransfusion.