Trasplante de hígado sin transfusión de sangre permite que testigo

Transcription

Trasplante de hígado sin transfusión de sangre
permite que testigo de Jehová reciba el órgano
Martes 23 de Noviembre de 2010
Fuente :La Segunda Online
Paciente de 54 años fue sometido a intervención quirúrgica sin incorporar sangre ajena a su
organismo, lo que está prohibido en su religión, y hoy se recupera en su hogar. Había sido
desahuciado.
Tres años debieron pasar antes de que Luis Salas Sepúlveda pudiera recibir el órgano que le devolvió la
vitalidad a su cuerpo cansado y enfermo. Una cirrosis hepática provocada por una esteatohepatitis no
alcohólica diagnosticada hace tres años lo mantenía postrado y sin esperanzas de recuperación. Sólo el
reemplazo de su hígado le daría una oportunidad de sobrevida.
Así fue como la madrugada de viernes 22 de octubre Luis Salas fue intervenido quirúrgicamente por el
equipo médico encabezado por el Dr. Juan Carlos Díaz, cirujano jefe de la Unidad de Trasplantes del
Hospital Clínico Universidad de Chile, e integrado también por el Dr. Jaime Castillo y el Dr. Gonzalo
Cardemil, jefe del Programa de Cirugía sin Transfusión de Sangre del HCUCH, un programa pionero
que ha permitido a pacientes Testigos de Jehová acceder a medicina de excelencia, con total respeto a
sus creencias.
Este es el segundo caso de trasplante hepático realizado mediante prescindencia de sangre en el país,
una proeza de la medicina moderna, si se considera que en Chillán, su ciudad de origen, Luis Salas
había sido desahuciado.
“Vimos a todos los gastroenterólogos de allá y ninguno nos dio esperanzas de vida. Llegábamos
llorando a la casa después de ver a los médicos, hasta que un día mi jefe en la empresa donde trabajo
me dijo: ‘tú te vas a Santiago para que te mejores’”.
Producto de la cirrosis el hígado queda dañado para siempre, forma cicatrices y deja de funcionar
correctamente. “Era como un higo seco, como una hoja seca”, recuerda Luis. Hoy disfruta de la
vitalidad que un donante anónimo le entregó. A él y a Jehová le agradece, como también al equipo
médico del Hospital Clínico Universidad de Chile que respetó su opción y su creencia.
“Estoy muy agradecido del doctor Juan Carlos Díaz, que fue como un padre; al Dr. Cardemil, que
confió plenamente en mi y que me derivó al Dr. (Danny) Oksenberg, un hepatólogo de excepción, que
me cuidó y que me mantuvo estos tres años hasta la operación”, dice al recordar el tránsito desde su
anterior estado de postración a esta nueva etapa en su vida.
“Hoy siento que Jehová me ha dado una nueva oportunidad, para servir más plenamente y mejor a mi
familia y a los demás. Tengo nuevas metas espirituales, deseos de establecerme en Santiago y volver a
trabajar en la empresa que me ayudó a estar aquí”, explica, mientras se prepara para tocar su armónica
nuevamente, algo que hace unos días era impensado.
Martes 23 de Noviembre de 2010
Fuente :La Segunda Online
Paciente de 54 años fue sometido a intervención quirúrgica sin incorporar sangre ajena a su organismo,
lo que está prohibido en su religión, y hoy se recupera en su hogar. Había sido desahuciado.
Tres años debieron pasar antes de que Luis Salas Sepúlveda pudiera recibir el órgano que le devolvió
la vitalidad a su cuerpo cansado y enfermo. Una cirrosis hepática provocada por una esteatohepatitis no
alcohólica diagnosticada hace tres años lo mantenía postrado y sin esperanzas de recuperación. Sólo el
reemplazo de su hígado le daría una oportunidad de sobrevida.
Así fue como la madrugada de viernes 22 de octubre Luis Salas fue intervenido quirúrgicamente por el
equipo médico encabezado por el Dr. Juan Carlos Díaz, cirujano jefe de la Unidad de Trasplantes del
Hospital Clínico Universidad de Chile, e integrado también por el Dr. Jaime Castillo y el Dr. Gonzalo
Cardemil, jefe del Programa de Cirugía sin Transfusión de Sangre del HCUCH, un programa pionero
que ha permitido a pacientes Testigos de Jehová acceder a medicina de excelencia, con total respeto a
sus creencias.
Este es el segundo caso de trasplante hepático realizado mediante prescindencia de sangre en el país,
una proeza de la medicina moderna, si se considera que en Chillán, su ciudad de origen, Luis Salas
había sido desahuciado.
“Vimos a todos los gastroenterólogos de allá y ninguno nos dio esperanzas de vida. Llegábamos
llorando a la casa después de ver a los médicos, hasta que un día mi jefe en la empresa donde
trabajo me dijo: ‘tú te vas a Santiago para que te mejores’”.
Producto de la cirrosis el hígado queda dañado para siempre, forma cicatrices y deja de funcionar
correctamente. “Era como un higo seco, como una hoja seca”, recuerda Luis. Hoy disfruta de la
vitalidad que un donante anónimo le entregó. A él y a Jehová le agradece, como también al equipo
médico del Hospital Clínico Universidad de Chile que respetó su opción y su creencia.
“Estoy muy agradecido del doctor Juan Carlos Díaz, que fue como un padre; al Dr. Cardemil, que
confió plenamente en mi y que me derivó al Dr. (Danny) Oksenberg, un hepatólogo de excepción, que
me cuidó y que me mantuvo estos tres años hasta la operación”, dice al recordar el tránsito desde su
anterior estado de postración a esta nueva etapa en su vida.
“Hoy siento que Jehová me ha dado una nueva oportunidad, para servir más plenamente y mejor a mi
familia y a los demás. Tengo nuevas metas espirituales, deseos de establecerme en Santiago y volver a
trabajar en la empresa que me ayudó a estar aquí”, explica, mientras se prepara para tocar su armónica
nuevamente, algo que hace unos días era impensado.
Documento descargado de http://www.revespcardiol.org el 18/08/2010. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
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COMUNICACIÓN BREVE
Cirugía cardiaca en testigos de Jehová. Experiencia
en Santander
José M. Bernal, Sara Naranjo, Manuel Trugeda, Aurelio Sarralde, Carmen Diago y José M. Revuelta
Cirugía Cardiovascular. Hospital Universitario Marqués de Valdecilla. Universidad de Cantabria.
Santander. España.
Los testigos de Jehová constituyen una población de
difícil tratamiento para las intervenciones de cirugía cardiaca. Entre 1998 y 2004, todos los pacientes testigos de
Jehová con indicación de cirugía cardiaca (n = 10) fueron
intervenidos por un mismo equipo. El descenso medio del
hematocrito fue, durante la circulación extracorpórea, del
30%, durante el postoperatorio, del 35% y en el alta, del
22%. Un paciente precisó una reintervención precoz por
sangrado importante de origen esternal. Todos los pacientes fueron dados de alta y durante el seguimiento un
enfermo falleció de causa respiratoria.
Las medidas para disminuir y recuperar la pérdida de
sangre permiten realizar intervenciones de riesgo hemorrágico en pacientes testigos de Jehová.
Palabras clave: Cirugía cardiaca. Cirugía sin transfusión.
testigos de Jehová.
Cardiac Surgery in Jehovah’s Witnesses.
Experience in Santander, Spain
As patients who are Jehovah’s Witnesses are against
blood transfusion, they are difficult to manage when a
cardiac intervention is required. Between 1998 and 2004,
all Jehovah’s Witness patients with an indication for
cardiac surgery (n=10) were operated on by the same
multidisciplinary team. The mean fall in hematocrit was
30% during cardiopulmonary bypass, 35% during the
postoperative period, and 22% at discharge. One patient
required cardiac re-exploration because of sternal
bleeding. All patients survived operation and were
discharged. At follow-up, 1 patient died due to respiratory
failure. Technological developments that reduce bleeding
and enable lost blood to be recovered have made it
possible to perform operations involving a risk of
hemorrhage in Jehovah’s Witnesses.
Key words: Cardiac surgery. Bloodless surgery. Jehovah’s
Witnesses.
Full English text available from: www.revespcardiol.org
INTRODUCCIÓN
Los testigos de Jehová suponen un desafío para la
medicina en general y para la cirugía en particular.
Sus fuertes convicciones religiosas y su forma de
interpretar ciertos pasajes bíblicos (Génesis 9: 2-4,
Hechos de los Apóstoles 15: 28,29) les lleva a rechazar, por prohibición divina, cualquier tipo de transfusión. La población de testigos de Jehová en España es
de 125.000, de los cuales 1.000 viven en Cantabria. El
desafío se produce por el choque entre 2 conciencias:
la deontológica del médico que lucha para preservar
la vida en grave peligro y la religiosa del paciente.
Recientemente, se han instaurado programas quirúrgicos mayores denominados cirugía sin sangre. Estos
programas, además del enorme beneficio que representa para los pacientes y para la sociedad, permiten
ofrecer al testigo de Jehová la posibilidad de intervención, respetando sus convicciones, con unos riesgos
disminuidos.
MÉTODOS
Correspondencia: Dr. J.M. Bernal.
Cirugía Cardiovascular. Hospital Universitario Marqués de Valdecilla.
Avda. Marqués de Valdecilla, s/n. 39008 Santander. España.
Correo electrónico: [email protected]
Recibido el 21 de marzo de 2005.
Aceptado para su publicación el 18 de octubre de 2005.
Entre 1998 y 2004, 10 pacientes testigos de Jehová
fueron intervenidos de cirugía cardiaca en nuestro centro. En este tiempo, ningún paciente fue rechazado por
su negativa a recibir transfusiones de sangre. Por una
parte, los pacientes firmaron un consentimiento informado elaborado por el comité deontológico del hospiRev Esp Cardiol. 2006;59(5):507-9
507
ABREVIATURAS
ARA II: antagonistas de l
de la angiotensina II.
EC: enfermedad coronari
DM: diabetes mellitus.
HTA: hipertensión arteria
IAM: infarto agudo de m
IECA: inhibidores del en
de la angiotensina.
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Bernal JM et al. Cirugía cardiaca en testigos de Jehová
tal que incluía una aclaración sobre su condición religiosa, su negativa a las transfusiones de sangre o derivados y su aceptación de las posibles repercusiones
que podrían producirse, incluso el riesgo de perder la
vida. Por otra parte, los profesionales que participaron
en las mencionadas intervenciones (anestesia, cirugía
y cuidados postoperatorios) se comprometieron a respetar la voluntad del paciente. Tanto la anestesia como
la intervención quirúrgica y los cuidados intensivos
postoperatorios estuvieron a cargo del mismo equipo
de profesionales.
El grupo está formado por 5 varones y 5 mujeres
con una edad media de 59,8 ± 6,5 años. La indicación
quirúrgica fue una valvulopatía en 6 pacientes, una enfermedad coronaria en 3 y ambas en uno. Nueve pacientes se encontraban en clase funcional III según la
NYHA y uno en clase IV. Tanto el hemograma como
los estudios de coagulación estaban en los rangos de la
normalidad 24 h antes de la intervención. Todos los
pacientes recibieron aprotinina (Traxylol®) en dosis de
500.000 unidades en la inducción anestésica y
1.500.000 unidades en el cebado de la bomba de circulación extracorpórea. Nueve pacientes fueron intervenidos con circulación extracorpórea (CEC) y uno sin
CEC. Se realizaron 2 procedimientos de revascularización miocárdica coronaria con CEC y uno sin CEC, un
recambio valvular aórtico y doble pontaje coronario en
uno, un recambio valvular aórtico en 2, un recambio
valvular mitral en 2, recambio valvular mitral y anuloplastia tricúspide en uno y doble recambio valvular
mitral y aórtico en uno.
RESULTADOS
El tiempo medio de bypass cardiopulmonar fue de
94,6 ± 28,1 min y el de isquemia miocárdica de 66,1 ±
20,8 min. El ahorro de sangre se realizó con la disminución de las pérdidas de sangre y la recuperación del
máximo posible de sangre perdida. Se realizó una hemostasia exquisita, extremando las medidas habituales. Se emplearon gasas hemostásicas tipo Surgicel® y
todas las cardiotomías fueron aseguradas con colas
biológicas con Tissucol® administrado en aerosol. Se
utilizó el recuperador de células con reinfusión continua Haemonetis®. De los 10 pacientes intervenidos
quirúrgicamente, sólo se reinfundió la sangre recuperada en 3 casos (sangre recuperada: 137, 400 y 510
ml). El sangrado registrado a través de los drenajes torácicos fue de 532 ± 239 ml, con un rango entre 200 y
950 ml. Entre las complicaciones postoperatorias inmediatas destaca una reintervención precoz por sangrado postoperatorio de origen esternal y una reintervención tardía por dehiscencia esternal. De los 10
pacientes intervenidos, se indicó suplemento con hierro por vía oral en 6 y suplemento de ácido fólico en
uno. El tiempo medio de ingreso hospitalario fue de
13,2 ± 5,4 días. En cuanto a la evolución del hemogra508
Rev Esp Cardiol. 2006;59(5):507-9
TABLA 1. Evolución del hematocrito
Pre-IQ
Hematocrito,
media ± DE (%)
Descenso
Rango
CEC
Post-IQ
Alta
40,2 ± 4,6 28,1 ± 3,9 26,2 ± 5,2 31,3 ± 3,4
30,1%
34,6%
22,1%
35-46%
18-35%
21-42%
26-39%
CEC: circulación extracorpórea; IQ: intervención quirúrgica; Post-IQ: valor
más bajo después de la intervención.
ma durante toda la estancia hospitalaria, se muestra en
la tabla 1.
Durante el seguimiento (entre 1 y 6 años; media, 3,3
años) un paciente falleció por insuficiencia respiratoria
terminal y un paciente tuvo que ser reoperado a los 8
meses por una pericarditis constrictiva. Los 9 pacientes
supervivientes han seguido una evolución favorable.
DISCUSIÓN
Probablemente sean los testigos de Jehová la comunidad que más ha contribuido a concienciar a los profesionales de la necesidad de ahorrar al máximo las
necesidades de sangre en los procedimientos quirúrgicos mayores, como la cirugía cardiaca con circulación
extracorpórea. Ya en 1977, el grupo de Cooley1 publicó su experiencia en cirugía cardiaca en testigos de Jehová y mostró que, aunque algunos pacientes fallecían
por falta de transfusión, el riesgo global no estaba gravemente elevado. En España, la primera experiencia
quirúrgica con pacientes de esta comunidad pertenece
a Iglesias et al en 19812. Otro estudio realizado en España evalúa la evolución del hemograma tras la cirugía
cardiaca con CEC sin transfusión de sangre y se ha observado que en las intervenciones no complicadas, el
descenso máximo del hematocrito es de un 33%, cifra
que se obtiene durante la CEC y al cuarto día postoperatorio3. En nuestra experiencia, el valor más bajo de
hematocrito se obtuvo durante la CEC en un paciente
valvular (18,2%), cuyo valor en el momento del alta
era del 26,4%, lo cual significa una disminución del
33%. Otro aspecto que se debe tener en cuenta es el
momento hematológico (valor del hemograma) a partir
del cual se indica la transfusión y que, sin duda, tiene
un componente subjetivo que depende del criterio
científico del médico responsable.
Por otra parte, la pérdida global de sangre se puede
atenuar mediante dos acciones. En primer lugar es necesario evitar o disminuir el sangrado. En cirugía cardiaca con CEC, la introducción de la aprotinina ha
ocasionado una muy importante reducción de las pérdidas hemáticas perioperatorias y postoperatorias, al
igual que el ácido tranexámico. La preparación preoperatoria incluye la utilización preoperatoria de ácido
fólico, hierro y de la eritropoyetina recombinante. El
sangrado postoperatorio intratable puede tratarse con
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Bernal JM et al. Cirugía cardiaca en testigos de Jehová
la reciente utilización del factor VIIa recombinante,
con el cual se han obtenido buenos resultados4. La técnica quirúrgica también influye en el sangrado, ya que
las incisiones en el corazón son susceptibles de pérdidas hemáticas. En este sentido, los hemostásicos tópicos y los adhesivos tisulares constituyen excelentes recursos para controlar y minimizar el sangrado por las
heridas quirúrgicas. Tecnológicamente también son de
gran ayuda para este objetivo los nuevos sistemas de
hemostasia quirúrgica que utilizan pulsos de vapor, ultrasonidos (bisturí armónico) o rayo argón. La segunda
vía de acción es la recuperación y reutilización de la
sangre perdida. En este sentido, los testigos de Jehová
sólo admiten la sangre que no ha llegado a estar almacenada, por lo que los recuperadores de células que aspiran la sangre que se pierde, la limpian, la centrifugan
y la reperfunden son, sin duda, excelentes aliados.
Otra línea de investigación en fase experimental está
en los sustitutos sintéticos de la sangre como los perfluorocarbonos, la hemoglobina recombinante o los
transportadores de oxígeno.
Según datos procedentes de esta comunidad religiosa, la población de testigos de Jehová en España es de
125.000 en el año 2005. Por otra parte, el número de
procedimientos quirúrgicos cardiacos con CEC y revascularizaciones miocárdicas sin CEC en España es
de 427 intervenciones por millón de habitantes y año.
Teniendo en cuenta estas cifras, es previsible que las
necesidades de intervenciones cardiacas de la población de testigos de Jehová sea de alrededor de 50 pacientes/año, cifra en absoluto irrelevante. En particular, en nuestra área de referencia, con una población
estimada de 500.000 habitantes para Cantabria y 1.000
testigos de Jehová, podemos afirmar que ningún paciente perteneciente a esta comunidad, con indicación
quirúrgica de cirugía cardiaca, ha sido rechazado por
su negativa a recibir transfusiones de sangre, por lo
que aunque esta experiencia de 10 pacientes es pequeña, es representativa de las necesidades quirúrgicas de
esta comunidad. En la actualidad, la revascularización
miocárdica con el corazón latiendo y la cirugía endoscópica permiten el tratamiento quirúrgico de la enfermedad coronaria con un notable ahorro en la pérdida
de sangre que beneficia enormemente a esta compleja
población5, y además, el riesgo general y particular es
predecible con las escalas de riesgo6,7. Los testigos de
Jehová y la cirugía cardiaca mantienen una relación
muy intensa de la que probablemente ambos han salido beneficiados8.
BIBLIOGRAFÍA
1. Ott DA, Cooley DA. Cardiovascular surgery in Jehovah’s witness.
Report of 542 operations without blood transfusion. JAMA. 1977;
238:1256-8.
2. Iglesias A, De la Llana R, Larrea JI, Núñez L, Gil Aguado M. Cirugía cardíaca con circulación extracorpórea en testigos de Jehová.
Rev Esp Cardiol. 1981;34:367-70.
3. Arís A, Padró JM, Bonnin JO, Caralps JM. Prediction of hematocrit changes in open-heart surgery without blood transfusion. J
Cardiovasc Surg. 1984;25:545-8.
4. Herman GD, Hendriks MD, Joost MAA, van der Maaten MD, Joost de wolf MD, Tjalling W, et al. An effective treatment of severe
intractable bleeding after valve repair by one single dose of activated recombinant factor VII. Anesth Analg. 2001;93:287-9.
5. Cuenca JJ, Herrera JM, Rodríguez MA, Campos V, Valle JV, Juffé
A. Revascularización arterial completa con ambas arterias mamarias
sin circulación extracorpórea. Rev Esp Cardiol. 2000;53:632-41.
6. Álvarez M, Colmenero M, Martín P, Prades I, Moreno E, González-Molina M, et al. ¿Se puede identificar mediante el EuroSCORE
a los pacientes con mortalidad mínima en cirugía cardíaca? Rev
Esp Cardiol. 2003;56:682-6.
7. Cortina JM. Scores de gravedad y complejidad en cirugía cardíaca.
Usos y limitaciones. Rev Esp Cardiol. 2005;58:473-6.
8. Holt RL, Martín TD, Hess PJ, Beaver TM, Klodell CT. Jehovah’s
witnesses requiring complex urgent cardiothoracic surgery. Ann
Thorac Surg. 2004;78:695-7.
Rev Esp Cardiol. 2006;59(5):507-9
509
8
V I DA
R E F OR M A - Sábado 7 de Octubre del 2006
Cuentan médicos con más de 30 procedimientos alternativos
Aceptan no transfundir
a testigos de Jehová
d Logran convencer
a 2 mil especialistas
para practicar ‘cirugías
sin sangre’
ASÍ LO DIJO
A todos los pacientes
los operamos como si fueran
testigos de Jehová: procuramos el mínimo sangrado posible, recuperamos la sangre
que se llega a perder y usamos medicamentos que ayudan a que el paciente sangre
menos”.
Georgina Montalvo
La sangre resultó ser motivo de coincidencia entre ciencia y religión. Para
los médicos es un tejido “único e insustituible” y para los testigos de Jehová, según lo que Dios dijo a Noé,
es “especial”.
Esto ha servido para que la medicina desarrolle y practique procedimientos quirúrgicos que evitan al
máximo la pérdida de sangre, y para
que los testigos defiendan su postura
de no aceptar ser transfundidos.
“El paciente testigo de Jehová
busca curarse, cree en la ciencia, pero de los miles de tratamientos que
hay es uno el que no quiere, y existen
alternativas que hacen prescindible la
transfusión”, señala Gamaliel Camarillo, director de Información Pública de la asociación religiosa La Torre
del Vigía (testigos de Jehová).
“No buscamos entrar en controversia con los médicos, si uno de ellos
no acepta atender a un testigo, pedimos que nos dé oportunidad de
llevarlo con otro que sí quiera”, comenta Dervis Alfonso Estrada, asesor médico de Servicios de Información sobre Hospitales.
Cuando la transfusión es inevitable, los testigos cuentan con una Exoneración médica por anticipado, que
establece: “Exonero de responsabilidad a los médicos, anestesiólogos
y al hospital y su personal por cualquier daño que resulte de mi negativa a aceptar sangre, a pesar del cuidado competente que en otro sentido se me dé”.
Aléjese del
cansancio
profesional
Quien lo padece tiene la sensación de
que el trabajo lo está consumiendo
como si fuera un papel al que le han
prendido fuego, de ahí la denominación en inglés que dan al síndrome de
agotamiento profesional: burn out.
Se trata de un estado donde las
exigencias de la vida profesional
provocan estrés intenso, que no desaparece cuando la situación que lo
desata termina, sino se acumula, explica Jorge Álvarez, profesor de la Facultad de Psicología de la UNAM.
Médicos, profesores, psicólogos,
enfermeras, rescatistas y todos los
profesionales cuyo trabajo implica
atender a otras personas son los más
susceptibles de desarrollarlo.
“Casi a todas las personas que
atienden a damnificados de desastres naturales les afecta porque sienten que su trabajo nunca va a acabar y
que lo que hacen no es suficiente para que la situación llegue a la calma”,
agrega Álvarez, también especialista
en primeros auxilios psicológicos.
Sin embargo, directivos y ejecutivos de empresas, corredores de bolsa
y contadores, entre otros, que tienen
una alta responsabilidad en la toma
de decisiones, también están expuestos, agrega Juan Manuel Rocha, autor del artículo Síndrome de Burn Out,
¿El Médico de Urgencias Incansable?,
publicado en la Revista Mexicana de
Medicina de Urgencias.
Staff
Jefe de Cirugía de Corazón del Hospital
General La Raza
ASÍ LO DIJO
Los testigos de Jehová han hecho una aportación importante a la ciencia
médica por hacer reflexionar al gremio médico de que
se debe ahorrar la sangre y
no usarla de manera deliberada”.
QUÉ LO DESATA
Ángel Herrera Gómez
David Oziel
Jefe de Cirugía del Incan
ASÍ LO DIJO
Un procedimiento
anestésico correcto permite
aplicar todos los procedimientos para ahorrar sangre,
así es que sí podemos ayudar a los testigos de Jehová
respetando su postura religiosa”.
Isidro Martínez del Valle
Anestesiólogo y profesor
de Farmacología
Miguel Á. Tovar
En 1991, los testigos de Jehová crearon Comités de Enlace con los Hospitales, que se encargan de proveer a
los pacientes los datos de especialistas dispuestos a tratar sin sangre y a
difundir entre los médicos las opciones que existen para evitar la transfusión, explica Alfonso Estrada.
Existen 75 comités con los que
trabajan 950 voluntarios en el País,
y según Estrada, son alrededor de 2
mil médicos los que están dispuestos
a atender a los pacientes sin recurrir
a la transfusión si lo requieren.
Ángel Herrera Gómez, jefe de Cirugía del Instituto Nacional de Cancerología (Incan); Moisés Calderón
Abbo, jefe de Cirugía de Corazón en
el Hospital General La Raza, e Isidro
Martínez del Valle, anestesiólogo y
profesor de Farmacología en la Escuela Nacional de Enfermería y Obstetricia son algunos de los que han
aceptado atender a los testigos respetando su postura, y quienes están
convencidos de que las técnicas que
emplean con ellos debieran utilizarse con todos los pacientes para evitar
los riesgos de una transfusión.
“Los testigos ni son necios ni son
fanáticos, tienen una postura ante
la vida”, comenta Herrera Gómez,
quien hace más de 15 años formó un
equipo de anestesiólogos y cirujanos que practican los procedimientos quirúrgicos sin sangre.
“Desde la aparición de esta organización religiosa en mi vida profesional, me interesé por conocer más
acerca de los procedimientos sin sangre”, señala Martínez del Valle, quien
forma parte del grupo creado por el
cirujano del Incan.
Para Calderón Abbo practicar cirugías sin sangre ha sido un procedimiento “de rutina”, pues él hizo la especialidad de cirugía del corazón en
el Texas Heart Institute, en Houston,
donde se realizó la primera cirugía de
corazón en el mundo a un paciente
testigo de Jehová sin transfundirlo.
“Al regresar a México me di cuenta de que aunque el 85 por ciento de
las operaciones se hace sin transfundir al paciente, los médicos piden a
los testigos que los exoneren de cualquier responsabilidad”, asegura.
Esa actitud, coinciden los médicos, debe evitarse ante los avances.
“Una transfusión no es un procedimiento inocuo, existe el riesgo de
transmitir virus, bacterias y parásitos,
o desarrollar alergias que alteran la
función renal y pulmonar”, señala.
Pero, como en México el procedimiento “de rutina” es la transfusión,
poco se recurre a otras técnicas.
Las críticas constantes del jefe o
los colegas motivan la aparición del
“burn out”.
Georgina Montalvo
Moisés Calderón Abbo
LABOR DE CONVENCIMIENTO
d
Un ambiente donde el desempeño
personal está bajo la mirada crítica
de otros colegas, no saber cuál va a
ser el resultado del trabajo, sobrecarga de tareas y no contar con la infraestructura y las herramientas necesarias para un buen desempeño son
factores que hacen latente la aparición del síndrome.
El cansancio y el estrés manifestado en malestares corporales (dolor
de cabeza, cardiopatías, hipertensión)
y pensamientos negativos también influyen en su desarrollo.
Pensar reiteradamente “algo malo va a suceder”, no convivir con la
familia y amigos, tener miedo de ir
al trabajo o enojarse de manera desproporcionada son signos de que el
síndrome está acechando, advierte
Rocha.
La familia del afectado generalmente es la primera en notar que algo no está bien, pero como mecanismo de defensa y negación, el enfermo
decide seguir trabajando para ocultar
su malestar; entonces, los compañeros de trabajo y las personas a las que
atiende son las víctimas de su mal estado de ánimo.
APÁGUELO
Si cree que está en esta situación, los
expertos recomiendan hablar de inmediato con sus familiares o compañeros de trabajo para comunicarles
cómo se siente y por qué.
Como es un síndrome que se
gesta en un largo periodo, la recuperación también puede llevar tiempo porque el reto, después de aceptar
que se padece, es aprender a manejar
el estrés y definir, en términos reales,
qué es lo que espera de su desempeño profesional.
En casos extremos, donde se llega a la depresión, será necesario pedir ayuda a algún psicólogo.
Asociación Mexicana para la Ayuda
Mental en Crisis
www.amamecrisis.com.mx
LAS ALTERNATIVAS
Cirujanos, anestesiólogos y enfermeras que buscan que los pacientes pierdan la mínima cantidad de sangre en
el quirófano tienen por lo menos 30
opciones para lograrlo.
Según la cirugía, pueden usar
instrumentos que, al mismo tiempo,
cortan, coagulan y cauterizan vasos
sanguíneos; cubrir los órganos sangrantes con una gasa que desprende
sustancias capaces de detener la hemorragia o conectar al paciente a un
aparato que recupera la sangre perdida, la limpia y se la regresa.
Incluso para casos de emergencia, en los que se pierde mucha sangre rápidamente, existen sustancias
que sustituyen el volumen sanguíneo
perdido para permitir que la sangre
que queda optimice sus funciones y
no deje de llegar a órganos vitales, como el cerebro y el corazón.
Cirujanos de México, Alemania,
Bélgica, Estados Unidos, Francia, Inglaterra y Suiza han asegurado la eficacia y seguridad de estas técnicas.
Servicios de Información sobre Hospitales para los testigos de Jehová
Correo: [email protected]
Conoce otros testimonios de
médicos a nivel internacional
video
La Biblia dice
Los testigos de Jehová encuentran en la Biblia más de 500 referencias para no aceptar la transfusión. Noé recibió el mensaje de
Dios de que la sangre (de hombres o animales) es sagrada.
La cita en la que más se basan es del libro Hechos 15:28-29:
“Pues ha parecido bien al Espíritu
Santo y a nosotros no imponeros
otra carga fuera de éstas, que son
indispensables: que os abstengáis
de las carnes consagradas a los
ídolos, de la sangre, de lo estrangulado y de la fornicación (...)”.
“Asumimos que la transfusión
es como si comiéramos sangre”,
señala Gamaliel Camarillo, director de Información Pública.
Incluso no aceptan por separado los componentes principales de la sangre: glóbulos rojos o
blancos, plaquetas y plasma; respecto a las fracciones que se obtienen de éstos, queda en el testigo la decisión de aceptarlas o no.
Para evitar
que llegue
Además de que el “burn out”
es tratable, existen maneras de
prevenirlo:
d Duerma por lo menos 6 horas al día
d No anule su tiempo libre
d Tome vacaciones de manera regular
d Emplee el humor en el trabajo
d Comparta sus sentimientos sobre el
trabajo con sus colegas
Técnicas de Conservación Sanguínea
y Medicina Sin Sangre en UCI
Gabriel E. Pedraza, MD
Director, Adult Critical Care Service
Bronson Methodist Hospital
l uso de transfusiones en UCI es objeto de
continua controversia. En este trabajo describo
nuestra posición, las observaciones y evidencias
en que se basa nuestra apreciación sobre las
transfusiones. También relataré el caso de algunos
pacientes que nos ayudan a conocer más sobre este
problema.
Se efectuó una secuestrectomía, dejando la paciente
laparostomizada. Durante las siguientes cuatro semanas
se hicieron cinco desbridamientos pancreáticos
adicionales en el pabellón y se transfundieron siete
unidades adicionales de glóbulos rojos. Su hemoglobina
durante aquel tiempo oscilaba entre 6 y 7 g/dl.
Alrededor de 6 semanas después de su hospitalización,
pudimos sacarla de la ventilación mecánica. Después
de otras 6 semanas, para un total de 12 semanas en la
UCI, se le dio de alta ella con una hemoglobina de 7,4
g/dl. Durante todo el período relatado y que se prolongó
por 3 meses, fue transfundida con 10 unidades de
sangre. Su hemoglobina nunca fue superior a 8 g/dl
durante su estadía en la UCI. Durante los últimos años
hemos tenido 5 casos de pancreatitis severas con
puntajes APACHE muy altos, en el rango de 20-30.
Los valores menores de hemoglobina eran de
aproximadamente 6,5 g/dl, el rango era de 5,0 - 7,0
g/dl. En el momento del alta, los valores eran similares.
El número total de unidades de GRs transfundidos a
estos pacientes era: 10 en la primera paciente, 3, 2, y
2 y uno no transfundido pues era Testigo de
Jehová. Todos ellos evolucionaron con SDRA.
Una mujer de 31 años de edad se presentó con
pancreatitis aguda, con antecedentes de ingesta
alcohólica. Los exámenes de laboratorio mostraron
valores muy anormales de amilasa, lipasa y
triglicéridos, su hemoglobina era 18,8 g/dl y su
hematocrito 52,4%, reflejando una severa pérdida
de volumen. La TAC mostró pancreatitis edematosa
difusa, y la paciente fue ingresada en la UCI para
observación.
Tres días después ella desarrolló delirium, y un SDRA
(Síndrome de Distrés Respiratorio Agudo). Requirió
oxígeno a 100% con un PEEP de 20 cm. A la semana
de evolución su hemoglobina cayó a 8,2 g/dl y su
hematocrito a 23,2%, con un nivel de ácido láctico
de 1,8. En ese momento comenzamos terapia con
eritropoyetina. Continuó con SDRA por unos diez
días más. Logramos bajar la concentración de oxígeno
a 50% con un PEEP de 16, la hemoglobina siguió
bajando hasta 6,8 g/dl con un hematocrito de 19,4%,
para caer luego a 6,1 g/dl con un hematocrito de
18,5%. Decidimos transfundirla.
Hay personas que preguntan ¿por qué se hace esto?
¿se justifica mantener hemoglobinas tan bajas en una
patología agresiva que tiene una mortalidad muy
alta? Ninguno de estos pacientes murió durante su
estadía en la UCI.
Señalaré algunos datos cuantitativos sobre
transfusiones en EEUU durante el último año y sobre
manejo de anemia en la UCI. Se colectaron 14 millones
de unidades de sangre y se transfundieron 12 millones
de unidades en más de 3 millones de pacientes. La
mayoría de la sangre transfundida se utiliza en el
marco perioperatorio. En la UCI más del 50% de los
A las dos semanas de evolución la paciente continuaba
muy grave. Su presión intra-abdominal había subido
a 25 y requirió una exploración quirúrgica. En ese
momento su hemoglobina estaba en 6,3 g/dl y su
hematocrito en 19%, y se transfundió con 2 unidades
de GR.
24
pacientes tienen anemia. Anticipamos escasez de
sangre porque la población se está envejeciendo y el
número de donaciones va en mengua. Una unidad
de sangre puede costar entre US$ 200 y US$ 1.000,
probablemente alrededor de US$ 400 por unidad si
se incluye todos los gastos asociados.
aceptan. Hay reacciones hemolíticas agudas y tardías.
Algunos médicos están al tanto de la inmunomodulación. En términos de los efectos inmunológicos
con la sangre transfundida, hay una amplia gama de
reacciones que ocurren en las células T y los receptores
de citokinas. Entre otros, un aumento en su número,
modoficaciones en la hemólisis mediada por células,
etc. Todos estos son efectos demostrados in vitro y
en algunos casos en vivo en pacientes transfundidos.
Incidencia de transfusión en la UCI
Jeff Groeger1 del Sloan-Kettering demostró en su
estudio que todos los días se transfunden
aproximadamente al 14% de los pacientes en UCI.
Littenberg2 demostró en un estudio de 1995 que en
cualquier estadía en UCI había una probabilidad de
50% de recibir una transfusión. El estudio de Corwin3
en 1995 reveló que cualquier paciente que tenía una
estadía en UCI de más de una semana tenía una
probabilidad de 85% a ser transfundido, a un
promedio de 9,5 unidades/paciente, que es un número
muy alto. La mayoría de estos pacientes recibían de
2-3 unidades/semana. La flebotomía era responsable
de un 49% de las transfusiones. No hubo una
indicación clara de transfusión en el 29% de los
pacientes y en aproximadamente un tercio de los
pacientes no hubo ninguna indicación en absoluto.
Un hematocrito bajo de <25% solo contribuyó en
un 19% a la indicación de transfusión.
La inmunosupresión mediada por leucocitos, o las
citokinas de ellos, en sangre alogénica de donantes
puede producir algunos efectos potencialmente
beneficiosos. Hay un estudio que demuestra que los
pacientes receptores de un trasplante renal tienen
mejores resultados cuando reciben más sangre. Y hay
un estudio que muestra que cuando se transfunde a
pacientes con la enfermedad de Crohn, éstos
experimentan una leve mejora.
Hay datos recientes que muestran un riesgo
aumentado de infección. También hay datos que
examinan el aumento de perjuicio post-transfusión
o fallo de múltiples órganos. Algunos datos
presentados por Robert Taylor4 muestran que hay un
impacto en la tasa de infecciones nosocomiales en
pacientes transfundidos versus los no-transfundidos.
También hay un aumento en mortalidad en pacientes
transfundidos versus los no-transfundidos.
La mayoría de transfusiones en la UCI no se asocian
con pérdidas agudas de sangre. Estas ocurren en el
pabellón y antes del ingreso en la UCI, aunque sí
ocurren algunas hemorragias gastrointestinales. Sin
embargo, existe una necesidad transfusional bastante
constante de entre 2-4 unidades por semana.
Otro efecto adverso “aceptado” es la sobrecarga de
volumen, que algunos médicos pasan por alto.
Aproximadamente el 10% de los pacientes que reciben
transfusiones de sangre experimentarán edema
pulmonar, lo que podría ser desastroso para alguien
que esté enfermo de gravedad. Hay un síndrome que
ha sido descrito, daño pulmonar agudo relacionado
con transfusiones, conocido por su sigla en inglés
TRALI, que en muchos casos no es diagnosticado.
Una paciente con sangrado post-parto en nuestra
UCI recibió 4 unidades de sangre. Menos de 6 horas
después de recibir la sangre se presentó SDRA y la
paciente requirió oxígeno a 100%. Después insertamos
un catéter y encontramos que su presión pulmonar
era normal. Sospechamos el síndrome TRALI. En
aquel momento la mayoría de los doctores creían que
la razón que se presentó SDRA, o lo que ellos llamaron
edema pulmonar, era que había recibido 4 unidades
La paciente del primer caso estuvo en la UCI por
aproximadamente 12 semanas. Considerando 3-4
unidades de sangre por semana, esta paciente
probablemente habría recibido en la mayoría de las
instituciones entre 36 y 48 unidades de sangre.
Nosotros la manejamos con 10.
Efectos adversos de las transfusiones
Todos mencionan las infecciones y efectivamente
existe contaminación viral y bacteriana. Las personas
están conscientes de estos riesgos y los aceptan, o por
lo menos los médicos que indican transfusiones los
25
de sangre, 3 ó 4 litros de cristaloides y 1 litro de
coloides. Pero una persona de solo 32 años de edad
con un corazón en muy buenas condiciones debería
haber tolerado aquella cantidad. Ya que el catéter
mostraba que la presión de oclusión de la arteria
coronaria era de 15, esto realmente era un caso de
daño pulmonar agudo relacionado con la transfusión.
mayoría de los pacientes críticamente enfermos con
enfermedad cardíaca, con la excepción de pacientes
con infarto agudo del miocardio y angina no estable”.
Hay dos ensayos recientes que estudian las
transfusiones de sangre en la UCI3,6, el ensayo ABC
que incluyó más de 3.500 pacientes de la Europa
Occidental, y el ensayo CRIT. El estudio
Caracterización de Anemia Adquirida en la UCI de
Howard Corwin con casi 5.000 pacientes en 213
hospitales encontró que solo el 19% de los hospitales,
menos de uno en cinco, tenían un protocolo
institucional para las transfusiones. El valor más
común de hemoglobina pre-transfusión para
pacientes en UCI fue alrededor de 8 g/dl, y el mismo
valor para pacientes con enfermedad cardiovascular
era alrededor de 10 g/dl. Cuando se interroga a los
intensivistas, ellos dicen, “Ya no transfundimos.
Dejamos que la hemoglobina baje hasta 7, a veces
hasta 6. Nosotros no creemos en las transfusiones.”
Pero los datos muestran lo contrario y todavía están
transfundiendo a los pacientes con hemoglobinas de
8, 9 ó 10. De modo que es obvio que todavía no
hemos cambiado nuestro manejo de transfusiones
sanguíneas en la UCI.
Razones para transfundir: realidad y mito
Existe la impresión generalizada entre los médicos que
la anemia complica otras enfermedades. Los nefrólogos
estiman que si alguien tiene anemia, la condición de
sus riñones se agravará, y los neurólogos que la condición
del cerebro del paciente se agravará. Otros, creen que
una transfusión mejorará los síntomas y que si el
paciente está en la unidad de cuidados intensivos, es
porque es enfermo y que sus síntomas mejorarán si se
le da sangre. Desde el punto de vista del intensivista,
mejorará la entrega de oxígeno, lo cual mejorará el
consumo de oxígeno, lo cual mejora la función de los
órganos. Estas son las razones por las cuales los médicos
creen que las transfusiones de sangre son beneficiosas.
El estudio de Hébert5 de 1999 siguió a dos grupos
de pacientes, uno con una estrategia liberal de
transfusión y el otro con una estrategia restrictiva.
Las transfusiones de sangre en el grupo restrictivo
fueron 2,6 unidades versus 5,6 en el grupo liberal.
El 33% del grupo restrictivo no recibió ninguna
transfusión. Todos los resultados favorecían la
estrategia restrictiva: menos mortalidad a los 30 días,
menos mortalidad hospitalaria, menos mortalidad
en UCI, y una tendencia hacia menos fallo de los
órganos. Estos resultados apuntan a un cambio mayor
del paradigma en la opinión generalizada del necesario
beneficio de la sangre para el paciente críticamente
enfermo.
Según los resultados del ensayo CRIT, la mayoría de
los pacientes tenían anemia el segundo día después
de ingresar en la UCI. El 44% de los pacientes
recibieron una transfusión durante su estadía. El
número promedio era de 5 unidades de transfusiones
administradas. También en estos casos, la hemoglobina
pre-transfusión era de 8,6 y la edad promedio de los
glóbulos rojos transfundidos era de 21,3 días.
Las cifras nos indican que los pacientes que pasaron
más tiempo en la UCI tenían mas transfusiones, los
que recibieron más transfusiones estuvieron más
tiempo en ventilación mecánica, más tiempo en la
UCI y más tiempo en el hospital. Pero pacientes que
tuvieron una hemoglobina más baja también
estuvieron más tiempo con ventilación mecánica,
más tiempo en la UCI y más tiempo en el hospital,
lo que también es importante.
En un análisis de sub-grupos se demostró que si el
paciente era menos grave y tenía menos edad,
específicamente si tenía menos que 55 años de edad
y un número APACHE 20, una transfusión empeoraba
su condición. La mortalidad de pacientes con
enfermedad cardíaca era igual en ambos grupos. El
análisis indicó que aún en la presencia de enfermedad
cardíaca “una estrategia restrictiva de transfusión de
glóbulos rojos generalmente parecía segura en la
Eficiencia de la sangre homóloga
¿Cuál es el efecto de la sangre almacenada? En el
26
glóbulo rojo de ésta hay niveles bajos de 2,3 DPG,
provocando una gran avidez de la Hb por el oxígeno
disminuyendo la entrega de éste a las células. Además
condiciona un descenso de ATP en los glóbulos rojos,
que lleva a una pérdida de lípidos de la membrana,
convirtiendo la forma de disco del glóbulo rojo en
esfera, lo cual es menos eficiente para el transporte
de oxígeno en la microvasculatura. Esto también hace
que los glóbulos sean menos flexibles y que sobrevivan
menos tiempo.
Existen entre 6 y 8 estudios sobre terapia orientada a
una meta en términos de transfusiones y entrega de
oxígeno. Estos muestran que aumentar el aporte de
oxígeno por transfusión no disminuye la tasa de
mortalidad, de modo que no hay ventaja en intentar
lograr una terapia orientada a esta meta. Gramm y
Smith8 en 1996 examinaron la importancia crítica de
la administración aislada de glóbulos rojos en pacientes
que están críticamente enfermos. Era un estudio
prospectivo con 19 pacientes, y salvo la infusión de
hemoglobina, toda la terapia era igual. No hubo cambio
en la entrega de oxígeno ni en el consumo de oxígeno.
Cambió el pulso cardíaco, lo que era de esperar sin
embargo, no hubo cambio en el consumo de O2.
Paul Marik7 publicó un estudio en 1993 que mostró
el efecto de las transfusiones de GR sobre el consumo
de oxígeno por el sistema gastrointestinal y el resto
del organismo en 23 pacientes con sepsis y ventilación
mecánica. No encontró aumento en el consumo
sistémico de oxígeno medido por calorimetría
indirecta hasta 6 horas post-transfusión. La gasometría
mostró que cuando la sangre transfundida era fresca,
había una mejora en el pH, con un descenso en el
lactato, pero si la sangre tenía unos 14 ó 15 días de
almacenada, estos parámetros incluso empeoraban.
De modo que a medida que la sangre envejece,
empeoran la microcirculación, la entrega y el consumo
de oxígeno.
En 1993 en Critical Care Med, Lorente y Landin9
examinaron el efecto de transfusiones en el transporte
de oxígeno. Hubo 16 pacientes admitidos en UCI
con sepsis, hemoglobina <10 g/dl, que fueron
randomizados a grupos de Dobutamina y de Glóbulos
Rojos. Encontraron un aumento en entrega y consumo
de oxígeno en respuesta a la Dobutamina, pero no
hubo cambio en VO2 después de una transfusión de
sangre. Estudio tras estudio demuestra que no estamos
realmente mejorando el consumo de oxígeno con
sangre transfundida.
Los estudios de los glóbulos rojos almacenados
muestran que la coagulación de la sangre disminuye
después de 2 semanas de almacenamiento. Las
alteraciones en la forma de los GRs comenzaron a
manifestarse también en ese momento y continuaron
agravándose en el tiempo. De modo que mientras
más tiempo se almacena la sangre, menos efectiva
será en aportar oxígeno a los tejidos en caso de ser
transfundida.
Un estudio publicado en el 2000, efectuado en ratas,
comparando resucitación con Ringer Lactato vs GR
y Ringer Lactato mostró que la presión era un poco
más baja en el grupo con Lactato de Ringer que en
el grupo que recibió GRs lavados, probablemente
por los efectos de coloide de los glóbulos rojos. La
entrega de oxígeno también era más bajo en el grupo
de Lactato de Ringer que en el grupo de GRs lavados,
que es lo que indicarían nuestros cálculos: si el nivel
de hemoglobina es más bajo, la entrega de oxígeno
también será más baja. Pero lo que es interesante es
que el control de laboratorio medido a nivel de
diferentes órganos no mostró diferencias entre ellos.
En términos de función de órganos, no hubo ninguna
diferencia entre el grupo de GRs y el grupo de Lactato
de Ringer, lo que significa que el transfundir GRs
no mejoró la respuesta inflamatoria ni la función
orgánica de estas ratas.
Conocemos bien cómo se relaciona el consumo y el
transporte de oxígeno, y sabemos que aquel se mantiene
por medio de un aumento de la salida cardíaca en la
presencia de anemia. Hay una redistribución del flujo
de la sangre y hay mayor extracción del oxígeno. Hay
algunos cambios en la afinidad por el oxígeno, y hay
reclutamiento capilar. Estas son algunas de las
compensaciones para la anemia que permiten mantener
la eficiencia en la oxigenación. Pero puede ser que la
sangre transfundida no pueda entregar el oxígeno del
modo normal, especialmente, como hemos visto, con
sangre más vieja.
Mi segundo informe de caso es de una paciente
testigo de Jehová de 67 años de edad con múltiples
27
problemas médicos. Ingresó en otro hospital con
dolor abdominal, distensión, fiebre y una
hemoglobina de 7,5 g/dl y una hernia estrangulada
y perforada. En el postoperatorio la paciente
desarrolló shock séptico severo que requirió altas
dosis de vasopresores.
extrema, empeorando la hipoxia a medida que aumenta
la producción local. Cuando transfundimos sangre hay
cierto nivel de hemoglobina libre en la sangre
almacenada, la cual puede fijarse al óxido nítrico,
empeorando potencialmente la micro-circulación.
El estudio con microfotografías de un hígado después
de sufrir shock causado por endotoxinas nos muestra
una destrucción completa de los vasos capilares y
pequeñas venas, con pequeños micro-trombos. Es
fácil imaginar lo que pasará si el endotelio está muy
enfermo y la microvasculatura también y se transfunde
sangre con glóbulos rojos menos flexibles. El glóbulo
rojo tiene que deformarse para pasar por los vasos
capilares. El tamaño promedio del glóbulo rojo es de
aproximadamente 7 micrones y el tamaño promedio
del vaso capilar es de aproximadamente 3 micrones.
De modo que si estamos administrando sangre que
consiste de glóbulos rojos poco flexibles, se puede
entender por qué en muchas situaciones las personas
empeoran cuando reciben transfusiones10.
Evolucionó con niveles altos de ac láctico y un pH
de 7 y una hemoglobina de 4,8. Se continuó el soporte
y dos días después su pH empezó a subir, el lactato
a caer con hemoglobina estable. Probablemente la
mayoría de los médicos, frente a una situación así,
dirían que la razón que ella tenía hiperlactaticemia
(mayor de 5,9, probablemente más cerca de 10) era
que había una baja entrega de oxígeno. La única
manera de mejorar esta hiperlactaticemia es mejorar
la entrega de oxígeno, y la manera más fácil de hacer
esto es dar sangre. En esta situación demostramos
que sin sangre, la paciente mejoró.
También, atendimos otra paciente Testigo de Jehová
con hemorragia postoperatoria. Presentaba una
hemoglobina cercana a 2, acidosis metabólica severa
con hiperlactaticemia. Esencialmente se manejó con
vasopresores, obviamente no la transfundimos. La
mayoría enfrentados a un paciente con un lactato de
7 y una hemoglobina de 2, dirían que la razón que
el paciente tiene hiperlactaticemia era la misma que
en la paciente anterior y nuevamente se demuestra
que un buen manejo es suficiente.
Otro estudio realizado por Zallen11 y publicado en
Shock comparó plasma fresco con plasma almacenado
incubados con glóbulos rojos almacenados en términos
de activación de IL-8. Había una tremenda diferencia
en la producción de IL-8 cuando se comparaba plasma
incubado con glóbulos de 8 días de vida con plasma
que contenía glóbulos de 42 días de vida. Parece que
el día 14 ó 15 es el punto crítico, lo cual es consecuente
con los datos de Marik7 que mostraron que los
glóbulos se hicieron un poco más peligrosos
después de 14 días de almacenamiento.
La sepsis provoca muchos efectos en la microvasculatura y en los glóbulos rojos. Hay una alteración en
el flujo/resistencia. Sabemos que se generan citokines
(IL-1, TNF, etc.) Los glóbulos rojos endógenos
también pueden perder flexibilidad, lo cual lleva a
la formación de un “lodo” de agregados de glóbulos
rojos/glóbulos blancos en la microvasculatura. Muchos
de estos pacientes tendrán DIC con micro-trombos,
todo lo cual contribuye a una disminución del flujo
microvascular y de la perfusión de los tejidos.
Se acepta cada vez más que la sangre es un agente
inflamatorio, hay datos que apoyan esto y que es posible
que la transfusión de GRs represente un insulto evitable.
Si nuestros pacientes ya sufren de inflamación, tienen
sepsis y SIRS, una transfusión puede de hecho empeorar
las cosas. Esto está avalado por los trabajos en que se
incuba plasma con glóbulos rojos jóvenes y viejos
observando apoptosis de neutrófilos12. Encontraron
que la apoptosis de PMN se demoró con glóbulos más
viejos, lo que podría llevar a mayores efectos de
inflamación13,14.
Sabemos que el óxido nítrico es un potente vasodilator
endógeno pero tiene aproximadamente 8.000 veces
mayor afinidad por la hemoglobina que lo que ésta
tiene por el oxígeno. Se fija a la molécula de
hemoglobina y, ya que la hemoglobina libre no puede
regular el óxido nítrico, esto resulta en vasoconstricción
En un trabajo realizado por Moore15 en 1997 se
estudió la transfusión sanguínea como un factor de
28
riesgo para fallo de múltiples órganos después de
sufrir lesiones. Hubo 513 pacientes consecutivos con
una calificación de severidad de lesión >15. Examinó
la relación de transfusión de sangre, otros índices de
shock y otros resultados con fallo de múltiples órganos.
Lo que encontró era una relación casi directa: mientras
más unidades de sangre había recibido el paciente,
mayor la incidencia de fallo de múltiples órganos. El
número de pacientes era aproximadamente igual en
las distintas condiciones, sin embargo, mientras más
unidades había recibido el paciente, más alto el
número de calificación de la lesión16.
En nuestra institución tenemos equipo de minimuestreo con que podemos hacer muchos exámenes con
un volumen de muestra muy pequeño. No sacamos
2 ó 3 cc, sino solamente 90-120 microlitros de sangre.
Hay ciertos sistemas avanzados disponibles que
devuelven el espacio muerto al paciente. Se saca la
muestra, y la porción no utilizada se devuelve de
manera segura al paciente. Reduzca el número de
catéteres. Si usted tiene buen control de su Unidad
de Cuidados Intensivos, estos no son problemáticos.
Pero hay muchas UCIs en que las enfermeras sacan
sangre solamente porque es fácil hacerlo. Además, se
deben eliminar las órdenes fijas para exámenes y los
exámenes sin orden médica. Nosotros no tenemos un
protocolo de órdenes fijos. En muchas UCIs es una
práctica común que los residentes escriban órdenes
para exámenes de CDC, LT, sedimentos S y H, lactato,
gases sanguíneos, revisen el nivel de hemoglobina
cada 4 horas. Recibimos a pacientes que han sido
transferidos de otras instituciones donde el paciente
ha estado internado por 2 ó 3 días, y el paciente ingresa con hemoglobinas que se han tomado cada 2
ó 3 horas. ¿Cuál es la necesidad de aquello? Tenemos
que eliminar “órdenes preestablecidas” de exámenes
de sangre y limitar la cantidad de exámenes de sangre
para todo paciente, no solamente en pacientes Testigos
de Jehová. Se puede tolerar la anemia. Y definitivamente se debe utilizar eritropoyetina humana recombinante (rHuEPO).
¿Cuándo transfundimos?
Los gatillos “clásicos” de transfusión utilizan o la
hemoglobina o el hematocrito y cuando se llega
al umbral, transfundimos. La regla “10/30” provino
de un estudio realizado en perros, y también
apareció en el estudio de Adams y Lundy que se
publicó en Surgical, Gynecological and Obstetrics
Journal en 1942. Es increíble que en la actualidad
todavía hay médicos que siguen la regla “10/30”
basada en un artículo publicado por un anestesista
en 1942 que decía que esta era la concentración
óptima de la hemoglobina para entrar en el
pabellón. Hay enormes lagunas en nuestro
c o n o c i m i e n t o , q u e e s p e r a m o s m e j o r a r.
Normalmente no hay ninguna razón identificable
para la transfusión. Pero la mayoría actúa con la
premisa “en caso de duda, transfundamos”.
Si realmente es necesario medir la hemoglobina,
tenemos el Hemocore, que solo necesita una gota de
sangre, es mejor hacerlo de esta manera que extraer
3 ó 4 cc de sangre.
Los nuevos umbrales de transfusión dependerán de la
experiencia del intensivista. He tenido la buena fortuna
de poder atender a la comunidad de testigos de Jehová.
En atenderlos a ellos he ganado una enorme cantidad
de experiencia y conocimiento. Es verdaderamente
asombrosa la tolerancia a la anemia. Lo que intentamos
hacer es no solo atender a nuestros pacientes testigos
de Jehová, sino utilizar nuestra experiencia y
conocimiento para tratar a todos nuestros pacientes.
Como se podía ver en la presentación del primer caso,
tratamos de limitar la cantidad de transfusiones de
sangre en pacientes que no son Testigos. Hemos
mejorado nuestro entendimiento de la anemia. Nuestros
pacientes de UCI raramente sangrarán, por lo cual
nuestro rol es minimizar pérdidas y prevenir sangrados
como los gastrointestinales.
Sabemos que los niveles endógenos de EPO no están
apropiadamente elevados en el paciente críticamente
enfermo en la UCI. Buenos estudios muestran que
hay una respuesta definitivamente pobre a la anemia
en el paciente críticamente enfermo. En parte esto
se puede deber al aumento en la producción de
citokinas (IL-1, TNF), lo cual puede ser responsable
por la respuesta disminuida. Además hay un
metabolismo y disponibilidad anormales del hierro.
La Eritropoyetina es un fármaco muy bueno. Es fácil
de administrar. Es segura. Muchos estudios, entre
los cuales están los estudios de Corwin17, y otro de
San Diego, que muestran que la eritropoyetina es
29
eficaz en elevar los niveles de hemoglobina y en
reducir el número de transfusiones de sangre alogénica
en la UCI. Requiere una dosificación adecuada y
administración de hierro. Todavía faltan muchos
datos para determinar cuál es la dosis óptima de EPO.
Actualmente, lo que nosotros estamos haciendo es
administrar 40.000 UI/semana a cualquier paciente
en la UCI con una hemoglobina de 8. Cualquier
paciente que tiene una hemoglobina inferior a 8
recibirá, dependiendo de la situación, hasta 20.000
UI/día, especialmente si son testigos de Jehová y su
hemoglobina es muy baja. Con todo paciente que
ingresa con una enfermedad severa, como por ejemplo
pancreatitis necrótica, y de quién se sabe que estará
en la UCI por 2 ó 3 semanas, hemos empezado terapia
con EPO tempranamente, aunque su hemoglobina
esté superior a 10, pues sabemos que en una semana
estará en 6 ó 7. Obviamente no hacemos aquello con
todos los pacientes, pero sí con los que creemos que
van a permanecer en la UCI por un período
prolongado18.
tienen miedo de utilizarlo. Básicamente lo
utilizamos con todos nuestros pacientes porque,
como ustedes saben, la ruta enteral posiblemente
no sea una buena manera de entregar hierro a un
paciente que esté críticamente enfermo, porque
posiblemente no sea absorbido. Esencialmente
siempre utilizamos hierro parenteral en pacientes
que padecen de anemia.
Lo más importante en el manejo en la UCI es
mantener la perfusión y la euvolemia. No tiene
ninguna utilidad tener una hemoglobina de 4,5 si
falta volumen. Es mejor que el paciente tenga una
hemoglobina de 3 con una buena perfusión. Es
conveniente minimizar el consumo de oxígeno, la
sedación es muy importante. Rara vez utilizamos
un bloqueador neuromuscular. Incidentalmente,
creo que la mayoría de las personas que están en
la UCI tienen una sedación inadecuada y un
deficiente manejo del ventilador en términos de
sincronía del paciente-ventilador, de modo que
una vez que estén sedados apropiadamente y bien
ventilados evolucionan bien. La entrega de oxígeno
y la perfusión son claves. La recomendación es
minimizar la pérdida iatrogénica de sangre y
utilizar EPO. Evite umbrales estándares de
transfusión, administre la sangre sobre la base de
una unidad a la vez. Considere todas las variables
importantes antes de transfundir: nivel de
hematocrito, condición, co-morbididad, y evalúe
la rapidez y la cantidad de pérdida de sangre.
Hay muchas ventajas en la rHuEPO sobre la
transfusión. Estimula la producción de la
hemoglobina nativa del paciente versus sangre
alogénica. Es medicina basada en evidencia. Mejora
la entrega de oxígeno. Mejora la microcirculación,
porque no se están utilizando glóbulos viejos. No
hay inmunomodulación con sus propias células. Se
conserva un recurso escaso. No es que nunca
transfundimos a un paciente. Pacientes que necesitan
transfundirse deben ser transfundidos. Aunque la
EPO es algo costosa, las transfusiones de sangre
también pueden salir caras, porque hay muchos
costos asociados que a menudo no se toman en
cuenta como el tiempo de hospitalización y otros
similares. De modo que la pregunta es, ¿puede
esperar su paciente?
Resumen
Los riesgos de la sangre alogénica van mucho más
allá de la infección. Es un recurso escaso. Es una
práctica no bien definida. Es difícil de aplicar y definir
normas universalmente aceptadas. Y hay que reevaluar
el equilibrio de demanda y suministro de oxígeno.
Como se menciona en el New Zealand Journal of
Surgery, “una transfusión sanguínea es como un
matrimonio. No debe emprenderse con liviandad,
imprudencia o frivolidad, ni más frecuentemente de
lo que es absolutamente necesario”20.
De EPO generalmente utilizamos: 300 unidades/kg
(20.000 unidades) por 5 días y entonces según
necesidad, o 600 unidades/kg (40.000 unidades)
/semana. Y es muy importante administrar hierro,
ácido fólico y vitamina C19.
En nuestra institución hemos adquirido una vasta
experiencia con hierro parenteral. Sé que no se
utiliza en muchos hospitales, y que muchos médicos
Referencias: Página 52 en sección español
30
Jueves 20 de Agosto de 2009
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Salta
pa_model7
Pertenecen a la religión de los Testigos de Jehová
En Salta, 3.700 personas no aceptan transfusión de
sangre
Firman un documento para impedirla y se basan en razones religiosas fundadas en
la Biblia.Hubo casos en centros asistenciales públicos y privados. En algunos, los
médicos tuvieron que recurrir a la Justicia.
Jueves 20 de Agosto de 2009 Salta Adrián Quiroga El Tribuno
TESTIGOS LEONARDO GUERRERO (IZQUIERDA) JUNTO A SERGIO
RAPETTI CUENTAN LAS EXPERIENCIAS DE LAS CONGREGACIONES.
En la provincia de Salta hay 3.700 Testigos de Jehová, organizados en 44
congregaciones, que no aceptan transfusiones de sangre aunque sus vidas corran
peligro. Las razones son religiosas fundadas en la Biblia.
El superintendente de una de ellas y coordinador del comité de enlace con los
hospitales, Leonardo Julio Guerrero, de 63 años, informó que desde 1996 fueron
transfundidos 7 niños en centros asistenciales públicos y privados y que dos
fallecieron.
"No les colocaron sangre por mala voluntad de los médicos, sino por la gravedad de
los casos. Por lo general los profesionales de Salta respetan nuestra decisión, pero lo
hacen muchas veces por temor, por urgencia y porque algunos no conocen el uso de
las alternativas", destacó Guerrero en una entrevista con El Tribuno.
Los Testigos no aceptan transfusiones de sangre completa, glóbulos rojos, blancos,
plaquetas o plasma bajo ningún concepto, aunque el personal médico las crea
necesarias para salvarles la vida. También se niegan a que les extraigan sangre para
almacenarla y transfundirla posteriormente.
Lo dejan establecido con la firma de un documento con directivas anticipadas y la
designación de un representante para la atención médica que decida por ellos en
caso de hallarse incapacitados.
BEBE TRATADO CON ALTERNATIVAS NO SANGUÍNEAS
Otro recordado caso de hijos de matrimonios que tienen esa religión sucedió el 17 de
septiembre de 1998 en el Hospital de Niños de esta ciudad.
"En ese momento el pequeño tenía diez meses y sufría una anemia. Sin embargo no
recibió sangre porque les entregamos hierro, ácido fólico y eritropoyetina. Le
suministraron los fármacos y se recuperó sin inconvenientes", remarcó Guerrero.
El superintendente de una de las congregaciones destacó que tienen muy buena
relación con los médicos salteños y que mantuvieron charlas y les entregaron
documentación y material bibliográfico a 392 que trabajan en establecimientos
públicos y privados, con las alternativas para evitar las transfusiones. De ellos 123
trabajan en el hospital San Bernardo.
"Nosotros estamos a favor de la vida. Cada miembro de las congregaciones decide
por sí mismo. Nadie está obligado ante situaciones extremas. Se trata de su relación
con Dios y de obedecer o no el principio bíblico de no comer sangre", dijo Guerrero.
En diálogo con este medio y acompañado por Sergio Eduardo Rapetti, de 41 años,
quien es un "anciano" de la congregación y miembro de noticias en la provincia de
Salta, Guerrero comentó que fue sometido a dos operaciones en clínicas privadas de
esta ciudad y que no recibió transfusión de sangre.
"Me intervinieron en la próstata y por una hernia y los médicos utilizaron fármacos
que les suministramos", recordó.
"Las alternativas son seguras, sencillas y eficaces", destacó Guerrero.
Por otra parte, Rapetti informó que en esta ciudad hay 25 congregaciones de
Testigos de Jehová, que están integradas por 2.000 personas, y que en el interior de
la provincia existen 19 conformadas por 1.700 miembros.
Expansores
Los pacientes Testigos de Jehová aceptan expansores del volumen sanguíneo no
hemáticos.
Sostienen que lo correcto son las alternativas médicas a la transfusión de sangre que
comprenden el uso sistemático de estrategias clínicas adecuadas para el tratamiento
de la hemorragia y de la anemia.
Las prácticas combinan fármacos, equipos y técnicas médicas y quirúrgicas con el
fin de reducir o evitar la pérdida de sangre y acelerar su producción. Las denominan
medicina y cirugía sin sangre, o de ahorro de sangre.
Los Testigos sostienen que la vida es sagrada, que por ello debe hacerse todo
esfuerzo razonable y humano por mantenerla y prolongarla.
Notas Relacionadas



Los fundamentos de la negativa
“Si es necesario, recurrimos a la Justicia”
El fallo de una jueza
Pertenecen a la religión de los Testigos de Jehová
En Salta, 3.700 personas no aceptan transfusión de sangre
Firman un documento para impedirla y se basan en razones religiosas fundadas en la
Biblia.Hubo casos en centros asistenciales públicos y privados. En algunos, los médicos
tuvieron que recurrir a la Justicia.


Los fundamentos de la negativa
“Si es necesario, recurrimos a la Justicia”
El hombre de la operación de corazón
participó de una reunión religiosa
15 March 2011
Asombrosa recuperación del Testigo de Jehová.
De vuelta al ruedo. Tras su operación, Jorge Antelaf volvió a su fe.
Para algunos fue sorprendente. Es que después de ser reoperado del corazón hace dos
semanas sin recibir donaciones de sangre, Jorge Antelaf, participó de una asamblea de
testigos de Jehová en Puerto Madryn el fin de semana.
El caso fue publicado en exclusiva por Jornada y generó repercusión en el ambiente
local. El practicante fue intervenido en el Instituto Cardiovascular “Pueblo de Luis” y la
operación se extendió por 5 horas. Médicos formados en la Fundación Favaloro fueron
quienes realizaron la cirugía. “Es increíble la recuperación que tuvo Jorge,” destacó uno
de los allegados a la familia.
Antelaf fue operado por primera vez en 1993 en Buenos Aires. En aquella oportunidad
los médicos que participaron de aquella intervención le anticiparon que en 20 años
debería ingresar al quirófano nuevamente. Y así lo hizo. El testigo de Jehová fue
reoperado, pero sin dadores de sangre, ya que su religión no se lo permite. Tras 5 horas
en la sala, el hombre salió airoso de una nueva cirugía a corazón abierto.
Antelaf, después de una semana de recuperación, volvió a la iglesia. Y en compañía de
su esposa Cristina, le rezó a Díos.
http://www.diariojornada.com.ar/10817/Pol%C3%ADtica/El_hombre_de_la_operacion
_de_corazon_participo_de_una_reunion_religiosa_
Operación a corazón abierto sin dadores
de sangre
15 March 2011
Se trata de un paciente que, por cuestiones religiosas, no recibe transfusiones. Fue en
febrero pasado. Nunca se había hecho algo similar en la ciudad. La práctica quirúrgica
la realizó un equipo de la Fundación Favaloro.
Después del quirófano. Antelaf y Cristina, en una sala común, tras cinco horas de una
operación compleja.
Cuando la ciencia es bien aplicada, se pueden salvar vidas. Y pasó en Trelew. Jorge
Antelaf es testigo de Jehová y en su religión están prohibidas las transfusiones de
sangre. Pero la tecnología más avanzada terminó superando los principios bíblicos. Es
que esa persona pudo operarse del corazón sin recibir dadores y gracias a una pequeña
válvula disfruta con su familia de los placeres cotidianos.
Antelaf entró al quirófano el 27 de febrero. Un equipo de especialistas, formado en la
Fundación Favaloro, lo recibió. Y durante 5 horas el practicante estuvo en las manos de
los profesionales, aunque con la fe puesta en Dios. Su familia siguió segundo a segundo
la operación y cuando alrededor de las 15.15 uno de los cardiólogos se acercó a ellos y
le dijo, “la operación fue un éxito, el paciente está bien”, se fundieron en un abrazo.
Es la primera vez que sea realiza esta práctica de corazón abierto sin dadores en Trelew
y en un paciente que ya fue operado hace 20 años de lo mismo. Según describió
Marcelo Nahin, médico que operó a Antelaf, “fue una operación riesgosa porque esta
persona ya fue operada de lo mismo hace 20 años, o sea, se trató de una reoperación”,
que implica un doble compromiso. El lugar de emociones fue el centro de
cardiovascular “Pueblo de Luis”.
“Este caso es una reoperación cardíaca, o sea, no es una cirugía cardíaca de primera vez.
Es un hombre que se operó exactamente hace 20 años en el sanatorio Güemes de la
Ciudad de Buenos Aires. Aquella vez se le puso una válvula cardíaca mecánica. Esa
válvula le duró 20 años”, por eso “hubo necesidad de cambiarla” ya que “empezó a
fallar”, explicó Nahin sobre la práctica. En esta línea agregó: “Él tenía una válvula
mecánica monodisco, que se dejó de usar, pero hace 20 años era la que estaba en el
mercado. La que se puso ahora es bi-disco, porque tiene dos discos, son dos las puertitas
que abren” y permiten el flujo de sangre.
“Las reoperaciones cardíacas tienen mayor complejidad, mayor grado de
complicaciones y sangrado que aquellas que se hacen por primera vez. En este caso se
dio la particularidad que hicimos la reoperación en un paciente que no puede recibir
transfusiones de sangre porque es testigo de Jehová”, explicó el profesional.
Y consideró que se trata “del primer testigo de Jehová que operamos en Trelew respecto
a cirugía cardíaca. Creemos que es también en la Patagonia”. En este marco, el médico
comparó que cuando se trabaja en “un paciente sometido a cirugía por primera vez,
pedimos de entre 10 a 12 dadores de sangre. Acá no sólo fue de segunda vez y que
sangra muchísimo, sino que los dadores fueron cero”.
Con Antelaf, explicó Nahin, “se trajo un recuperador celular, save cell, que sería como
guarda de las células que es un aparato que recupera algunos glóbulos rojos del campo
quirúrgico y eso se puede volver a transfundir. Se vuelve a utilizar la sangre del
paciente”, clarificó.
El método
Más allá de que no hubo transfusión de sangre, todo el éxito pasa por el cambio de
métodos. Se reemplazaron válvulas. “La válvula monodisco que sacamos produce
mucho torbellino en la sangre porque tiene un sólo disco. Y produce el crecimiento del
tejido Pannus que fue el que la obstruyó. Las válvulas biliflet, al tener mayor apertura,
tienen mejor performance hemodinámica y no genera ese crecimiento del tejido”,
detalló el profesional.
“La reoperación cardíaca –comentó el médico- tiene mucho mayor riesgo porque
después de la primera cirugía el corazón se pega al hueso, y en la segunda hay que abrir
el hueso nuevamente con una cierra especial. En la primera cirugía se usa una cierra de
corte directo donde en 10 segundo el hueso se abre. Para esta cirugía, como el corazón
está pegado a la cara posterior del hueso esternón, se usa una cierra oscilante, que es
muy parecida a las que se usan para retirar yesos; pero para que pase esta cierra se tarda
más o menos entre 30 o 40 minutos. Supongamos, si la cierra toca el corazón que está
pegado debajo del hueso, se termina la cirugía. Por eso hay que ser delicado y
detallista”.
En cuanto al proceso de recuperación, “las primeras 48 horas son críticas y un alta
estándar en la cirugía cardíaca es a los 7 días”, precisó el médico. La operación cuesta
aproximadamente 35 mil pesos “sin contar el recuperador de sangre”, comentó Nahin.
que tiene un valor aparte.
http://www.diariojornada.com.ar/10695/Pol%C3%ADtica/Trelew_operacion_a_corazon
_abierto_sin_dadores_de_sangre
Los testigos de Jehová y las transfusiones de sangre.
Los testigos de Jehová amamos la vida y acudimos a los médicos para cuidar nuestra
salud. No creemos en la curación por fe. En el primer siglo, el apóstol cristiano Pablo indicó que
los dones sobrenaturales ‘serían eliminados’. (1 Corintios 13:8.). Por lo tanto los Testigos
aceptamos todo tratamiento médico disponible para sostener la vida, incluso los que
involucran transfusiones de hierro endovenoso, eritropoyetina, etc., entre otros recursos médicos.
La postura de los Testigos sobre abstenernos de sangre es básicamente bíblica.
Acatamos la decisión clara del concilio cristiano que se celebró en Jerusalén en el primer siglo, a
saber, de “abstenerse [...] de sangre, de animales estrangulados y de uniones ilegales. Haréis
bien en guardaros de todo eso”. (Hechos 15:29, Nueva Biblia Española [católica].).
Los métodos alternativos no sanguíneos ha dado muy buenos resultados a miles de
pacientes testigos de Jehová, al grado que muchos médicos en el mundo se suman día tras día en
la postura de evitar las transfusiones de sangre. Esta actitud también la aceptan personas que no
practican las creencias de los Testigos.
Algunos casos tratados con alternativas no sanguíneas en Argentina:

Paciente: Marianella, edad 7 años, atendida en Hospital Garraham. Diagnóstico: MALFORMACIONES
VASCULARES. Estas malformaciones afectaron diferentes partes de su cuerpo, principalmente el aparato
digestivo, donde se producían ampollas sangrantes que la llevaba a constantes estados anémicos. El cuerpo
médico hizo consultas con hospitales de España, EE.UU. y México, la respuesta fue que no se había hallado
una solución a la patología. A pesar de tal pronóstico, la Jefa de Endoscopía ideó un sistema denominado
“por ataduras”, lo que consistía en efectuarle varias operaciones endoscópicas desde la tráquea hasta el
cólon. En el tratamiento, se utilizó ácido tranexámico, eritropoyetina hierro sacarato, Se usaron también
técnicas como el Recuperador Celular tipo Cell Saber y Hemodilución Normovolemica Aguda.
Actualmente Marianella cuenta con 18 años y aún continúa con tratamientos y controles.

Paciente: Camila, edad 8 años, Diagnóstico: OPERACIÓN DE CORAZÓN: Cierre de DAP HMD
(cateterismo). Fue atendida en Setiembre de 2012 en el Hospital Garraham. La operación se realizó con
éxito con estrategias no sanguíneas.

Paciente: Jorge, edad 14 años. Diagnostico: TUMOR CEREBRAL (Fibro Angiona de Cabun
Nasofaringeo), fue atendido por el equipo de Otorrinolaringología del Hospital Garraham. El equipo médico
consideró que se trataba de una operación de alto riesgo, pero se efectuó todo con éxito y sin utilizar sangre.
Respecto a los recursos no sanguíneos, El Dr. Jorge Trainini, director del Hospital
Presidente Perón de Avellaneda, Bs. As. comentó: “Ante el desafío de no transfundir
descubrimos que los pacientes que no transfundíamos estaban mucho mejor. En nuestra
especialidad –cirugía cardiovascular- se suele usar mucha sangre, pero nosotros decidimos
hacer al revés: no transfundir a ninguno, sea o no testigo de Jehová. Incorporamos mucha
tecnología para usar la misma sangre del paciente, al punto que hoy es muy raro que en
nuestro servicio se transfunda. Depende de la filosofía con que encare el arte médico y de
alejarse de la medicina de mercado”. La Dra. Mabel Maschio, coordinadora del Plan Nacional
de Sangre comentó: “Lejos de ser Negativo, el mensaje de los Testigos de Jehová ayudó a
realizar importantes protocolos de investigación que permiten disminuir el umbral de
transfusiones para todo paciente.” (cita en bastardillas de la revista Viva, negritas nuestras).
Algunos ejemplos de técnicas médicas y quirúrgicas sin sangre:
Fluidos: Para mantener el volumen sanguíneo y evitar un choque hipovolémico, se usan la
solución de lactato de Ringer, el dextrán, el almidón hidroxietílico y otros productos. Algunos
fluidos en fase de experimentación transportan oxígeno.
Fármacos: Hay proteínas creadas mediante ingeniería genética que estimulan la producción de
glóbulos rojos (eritropoyetina), plaquetas (interleuquina 11) y diversos glóbulos blancos (GMCSF, G-CSF). Otros medicamentos reducen significativamente la pérdida de sangre durante las
intervenciones quirúrgicas (aprotinina, antifibrinolíticos) o contribuyen a aminorar las
hemorragias agudas (desmopresina).
Adhesivos biológicos: Se aplican directamente apósitos de colágeno y celulosa para detener las
hemorragias. Las colas y selladores de fibrina pueden taponar las punciones o cubrir amplias
zonas de tejidos sangrantes.
Máquinas de recuperación de sangre: Estas máquinas recuperan la sangre derramada durante
una intervención quirúrgica o un trauma, que luego es filtrada y reinfundida al paciente en un
circuito cerrado. En casos extremos, pueden recuperarse litros de sangre con este sistema.
Técnicas quirúrgicas: La buena planificación, que incluye consultar a especialistas con
experiencia, ayuda al equipo quirúrgico a evitar complicaciones. Es vital actuar rápido para
detener el sangrado. Las demoras mayores de veinticuatro horas pueden incrementar
significativamente la mortalidad. La reducción de las grandes operaciones a varias menores
aminora la pérdida total de sangre.
Instrumentos quirúrgicos: Algunos cortan y sellan simultáneamente los vasos sanguíneos.
Otros sellan la hemorragia en amplias zonas de tejido. Hay instrumentos laparoscópicos o de
carácter mínimamente invasivo que permiten operar sin las pérdidas de sangre ocasionadas por
las grandes incisiones.
En resumen, los Testigos de Jehová nos abstenemos de las transfusiones de sangre en
obediencia a un mandato cristiano y bíblico, el cual ya nos referimos arriba, pero, a consecuencia
de tal postura esto nos ha ayudado a mantener una buena salud, en vista de los consabidos efectos
negativos de las transfusiones sanguíneas.
"Albarracini Nieves, Jorge Washinton si medidas precautorias
S.C. A. 523, L. XLVIII.
s U P l' e m a
COI'
t e:
- 1-
La Cámara Nacional de Apelaciones en lo Civil, Sala A, revocó la decisión de la anterior instancia que autorizaba a realizar al Sr. Pablo Albarracini Ottonelli
una transfusión de sangre y denegó la medida cautelar solicitada en tal sentido por su
progenitor (v. fs. 21/22 y 89/91)
Contra dicha decisión, la actora dedujo recurso extraordinario tederal,
que fue replicado, denegado en lo relativo a la tacha de arbitrariedad y concedido por la
cuestión federal fundada en el artículo 14 de la ley nO 48 (fs. 98/115, 194/213 y
214/215).
- IIEntiendo que en este caso se trae a discusión, por un lado, una restricción
al derecho a disponer del propio cuerpo y a la libertad religiosa del señor Albarracini
Ottonelli, y, por el otro, la preservación de la vida y la salud (v. arts. 14, 19,33 y 75,
inciso 22, de la Constitución Nacional y previsiones internacionales concordantes).
En tales condiciones existe, sin duda, una cuestión federal en los términos del altículo 14 de la ley nO 48 (Fallos: 319:1363; entre otros). Y sin perjuicio del
cauce conferido por la Cámara Civil al recurso, según se detalló supra, lo cierto es que
también, y porque en estos términos debería plantearse el debate, V.E. se encuentra
habilitada a tratar las cuestiones vinculadas con la alegación de arbitrariedad.
-1-
-IlI-
El artículo II de la ley 26.529, transcripto por la a qua, establece que
"Toda persona capaz mayor de edad puede disponer directivas anticipadas sobre su salud, pudiendo consentir o rechazar determinados tratamientos médicos, preventivos o
paliativos, y decisiones relativas a su salud. Las directivas deberán ser aceptadas por el
médico a cargo, salvo las que impliquen desarrollar prácticas eutanásicas, las que se'
tendrán como inexistentes".
A fojas 117 obran "las directivas anticipadas" suscriptas por Pablo Albarracini Ottonelli, en donde expresa que es testigo de Jehová y que no acepta transfusiones de sangre completa, glóbulos rojos, glóbulos blancos, plaquetas o plasma bajo
ningún concepto, aunque el personal médico las crea necesarias para salvarle la vida.
Siendo éste el presupuesto necesario para la aplicación del artículo II
citado, la Cámara Civil entendió que otorga plenos efectos jurídicos a pa¡1ir de la sanción de la ley citada y que estas directivas deben ser respetadas dando prioridad a la
voluntad del paciente fundada en su derecho a la autodeterminación, sus creencias religiosas y su dignidad, aun cuando en este caso -sostiene el tribunal- las manifestaciones
del padre del paciente vuelve relativo este "testamento vital" con base en "su relación
oscilante en la práctica de su creencia religiosa". Y agrega en este sentido que no se
advierte que haya transcurrido un largo lapso desde que se celebrara este acto -marzo de
2008, conforme fs. 4 y 63 vta.- por lo que no hay ningún elemento que lleve a la alzada
a considerar "que pudo haber mediado algún cambio en la idea religiosa del paciente",
porque de haber existido intención de modificarlo lo hubiera revocado.
-2-
"Albarracini Nieves, Jorge Washinton si medidas precautorias
S.C. A. 523, L. XLVIII.
Sin desconocer que hubo una manifestación expresa y teniendo en cuenta
que ésta es fruto de una convicción religiosa, lo cierto es que, en este trance, resultaría
relevante oír los pareceres de sus seres queridos. Pero hete aquí que, por un lado, la
cónyuge y las personas a quienes el interesado designó como
rep~esentantes
en esta si-
tuación, y por el otro, el padre del paciente, se arrogan la interpretación de la voluntad
del nombrado, incapaz de expresarse, trasuntando exigencias contradictorias: unas rechazando la transfusión y otro demandándola.
Esta inceltidumbre sobre la voluntad del paciente impide situar el caso
en el supuesto del altículo II de la ley 26.529, que la exige como presupuesto básico.
Desde otro punto de vista y puesto que no sabemos cuál es actualmente
su voluntad ante una situación de vida o muelte como la que está atravesando, resulta
"
relevante que los médicos intenten salvarle la vida aun por medio de la técnica en debate. Porque más allá de la prohibición religiosa, lo cierto es que se trata de una intervención menor y que de por sí no parece indicar una crueldad terapéutica. Y además, puesto
que el Estado asume la responsabilidad de intentar salvar su vida, queda desplazada, en
su inconsciencia, su propia responsabilidad ante el credo al que dijo pertenecer.
Por lo demás, esta solución se compadece con los protocolos médicos
internacionales en la materia y, sobre todo, con lo que establecen las normas superiores.
Porque cabe recordar que V.E. ha declarado que el derecho a la vida es el
primer derecho de la persona humana, que resulta reconocido y garantizado por la Constitución Nacional, por lo que es de la mayor importancia advertir la especial perspectiva
de este derecho (Fallos: 310: 112), pues el primer deber del juez es preservar la vida (Fallos: 324:51, voto del juez Nazareno).
-3-
y siguiendo la postura adoptada por la jurisprudencia norteamericana, el
Estado retiene cuatro intereses fundamentales respecto de las decisiones médicas que
deben adoptarse en estas situaciones, a saber: 1) la preservación de la vida; 2) la prevención del suicidio; 3) la protección de terceras personas inocentes; y 4) el mantener la
integridad ética de la profesión médica (Satz v. Perlmutter, 362 So. 2d 160, Fla. Dis!.
el. App.,
1978, entre otros).
Pues bien, dentro de la premura ínsita a lo extremo de la situación, es de
mi opinión que V.E. puede ordenar la práctica médica tendiente a salvaguardar la vida
de Albarracini Ottonelli, en la medida en que el informe médico aún .pendiente, lo indique .como indispensable.
Buenos Aires, l° deju!lio de 2012.
LUIS SAMJ;I,CO GON1ALEl \'If¡nCfILP¡
A.
523.
XLVIII
Albarracini
Nieves,
Jorge washington
sI
medidas
precautorias.
Buenos Aires,)- cJ..e JUh{-.D k 2-D-!2..
vistos
los autos:
"Albarracini Nieves,
Jorge Washington si
medidas precautorias".
Considerando:
1°)
nes
en
lo
tancia,
Que
Civil,
denegó
la
al
la
revocar
rracini
el
la Cámara Nacional
de Apelacio
pronunciamiento de
primera
medida precautoria
hington Albarracini
los médicos
Sala A de
Nieves
tratantes de
Ottonelli
a
los
solicitada por
efectos
de
que
se
ins
Jorge
Was
autorizase
a
su hijo mayor de edad Pablo Jorge Alba
-internado
en
la
Clínica
Bazterrica
de
esta
Ciudad Autónoma de Buenos Aires- a efectuarle una transfusión de
sangre
que resultaba necesaria para
2°)
blo
un
Jorge
Que
según
Albarracini
hematoma
surge
Ottonelli
de
una herida de
un
de
robo.
En
la
causa,
se
tancias
tico
de
reservado,
médicos
que
la
citada
de
2012).
lo
pertenece
obra una
con
asisten
al
Que
culto
anterioridad
a
y
al
lesión
arma de- fuego
actualidad,
en el
han
dado
inguinal
como
según
surge
destacado
la
necesidad
"Testigos
(conf.
corresponde
de
Jehová",
efectuada por él
su hospitalización-
el
lB
de
de
las
cons
con pronós
de
informe
que
con
intensiva y
señalar
y
Pa
secundario,
crítico,
terapia
estado
autos,
consecuencia de
de
su
de
citado nosocomio
área
asimismo,
declaración
constancias
encuentra en estado
internado
transfusión
3°)
la
las
ingresó
intraparenquimatoso
con motivo
intento
de
su restablecimiento.
que
en
los
efectuarle
30
el
el
mayo
paciente
expediente
marzo de
certificada por
de
200B
escribano
piiblico,
en
la
que
manifiesta
dicha pertenencia
y que
por
tal
motivo no acepta transfusiones de sangre.
4°)
las
Que
presentes
diciones
c6nyuge
de
habida
actuaciones,
expresarse
de
invocando
de
voluntad y
solicitando
5 0)
contraban
su
a
el
ley
26.529
entendido
en
impide
el
dada
en
giosas
su
soporte
caso
el
y
padre
su
no
se
-derecho
habia
situaci6n
en el
por
que
en
a
la
un
dejado
como
la
documento
que
que
que expresamente
aunque
-que
los
libertad
peligrase
seglin el
medicos-
de
de
se
daba
se
ne
su vida.
art.
11
de
resguardaban
autodeterminaci6n,
autorreferentes,
excepcional
ex
la
citada
sin
que
norma
se
que
eutanasicas.
ende,
derecho
una
deconductas
derechos
paciente
sangre
de
Carnevale,
libertad religiosa y de
expediente
aceptadas
supuesto
el
respetadas
su
el
directivas
constitucional
For
ser
de
dichas
ser
las practicas
debian
el
con
dicha decisi6n.
planteada
en
en
la mencionada expresi6n
cuesti6n
a
iniciarse
planteo efectuado por
la
transfusiones
que
Eliana
los
anticipadas"
debian
como
Romina
enumerar
que
de
encontraba
de
relaci6n
obrar
se
opuso al
respete
seiia16
en
"directivas
principio
diera
al
sostuvo
misma,
se
momento
no
autonomia individual,
voluntad
recibir
en
alzada
generado,
Asimismo,
la
la
se
despues
salud,
conciencia-,
cuenta de
si
al
la existencia de
involucrados
vida yala
gaba
Que
que
paciente
Fablo Albarracini,
progenitor
habia
el
por
el
presada
cuenta de
a
dignidad,
llevaban
a
quo
consider6
priorizando
la
y
a
la
que
voluntad
autodeterminaci6n,
que
las
tales
del
sus
manifestaciones
considerar
que
pudiese
directivas
paciente
creencias
fun
reli
rea1izadas
haber
por
mediado
A.
523.
XLVIII
Albarracini Nieves,
Jorge washington s/
medidas
precautorias.
one g9'tktkq/_t-
_
algUn cambio en la idea religiosa de Pablo,
tido
intenci6n
qUe" hubiese
de
modificar
revocado
la
el
pues de haber exis
testamento vital,
voluntad
expresada
en
lo
el
16gico
era
instrumento
analizado.
6")
Que
las
resoluciones
p:t:ecautorias no autorizan el
nario
cias
ya
que
no
definitivas
embargo,
(Fallos:
se
refieren
a
medidas
otorgamiento del
recurso extraordi
principio,el
de
en
300:1036;
earaeter
308:2006,
entre
senten
otros).
Sin
cabe hacer excepci6n a dicha regla en 'los casos en que,
como en autos,
o
revisten,
que
lo resuelto cause un agravio que,
circunstancias de hecho,
pueda ser de
tardia,
por sumagnitud
insuficiente o
imposible ieparaci6n ulterior, pues ella acuerda al decis6rio el
earaeter de definitivo a los efectos de la apelaci6n'eJttraordi
naria del
308:90;
art.
14
314:1202
de
y
la ley 48
323:2790).
(conf.
Fallos:
Asimismo,
el
rio resulta admisible en la medida queel
nado
la,inteligencia de
ha
sida
3"
de
contraria alderecho
la ley 48).
7";
esta Corte
publicado
te
_-.
-
',;
las
en Fallos:
afectado por
....•
Que
remi ten a
neg6. a' recibir
"
clausulas
, . ..,,_
....
,-c
yontrarias. a
..
profesaba.
316:
fundado
en
298:409;
recurso
300:1036;
8°)
examine
Que
presenta
sin
perjuicio
de
particularidades
lo
que
expresado,
en
alguna
el
caso
medida
lo
sub
dis
tinguen del precedente mencionado y que requieren las
siguientes
precisiones:
la
Bazterrica
festar
a
primero,
en
los
que
estado
de
médicos
tar conforme
las
a
firmó
blancos,
sonal
médico
albergar
por
dudas
dado
a
su
notarial
de
en
la
el
causa
de
certificación
Acta n°
cuestionamientos
FO
eran
de
que
el
(conforme
De
18
o
a
acep
de
marzo
aceptar
glóbulos
aunque
el
per
la vida".
del
Natalio
permitan
sena
de puno y letra
R.
de
que
documento
firmado
surge
no
rojos,
elementos
digitales
formulados
mani
terapias
manifestó
formal
público
el
concepto
existen
original
372).
clínica
pudo
las
en
glóbulos
ningún
no
no
dispuesto
para salvarme
impresiones
372
que
estaba
cual
la validez
escribano
e
el
bajo
lo
a
culto.
completa,
plasma
respecto
firmas
12,
en
crea necesarias
Que
ante
procedió
los
sangre
o
su
que
constancia
que obra en autos
Pablo,
tos n°
de
las
hay
de
por
ingresó
cuales
biológicos
documento
plaquetas
gO)
lado,
que
un
"transfusiones
o
médicos
creencias
Segundo,
2008,
inconsciencia
profesionales
procedimientos
de
Pablo Albarracín
Strusberg
la
que
certificación
Libro de
requerimien
esta manera quedan despejados
en este punto por el
actor
en
el
recurso extraordinario.
10)
que
el
Que
paciente
no
al
existen
momento
pruebas
de
expresar
considerado
la trascendencia y las
tampoco
hay para
las
presiones
de
considerar
terceros
o
de
claras
que
dicha
y
convincentes
voluntad
consecuencias de
que
la
esa voluntad
opción
no
de
haya
su decisión;
fue viciada por
efectuada
haya
sido
A.
523.
XLVIII
Albarracini Nieves,
Jorge Washington sl
medidas
precautorias.
g9'<k rkk aak/ l
_
/
adoptada con otra intenci6n gue
Ia de profesar el
de,
no existen razones para dudar de gue el
bl0
ha manifestado
su negativa
con discernimiento,
11)
por
posterioridad
a
abandonado
culto
mente
tipo
Ia
en
de
de
de
menos
presumir
para
gue
no
contrario,
de
su mismo
monio
se
realiz6 en el
12)
actual
Ia
diciembre
de
Ia
de
esfera
Ia
de
de
cual
Pa
formulado
alega
documento,
regresar
10
a
su
este
gue
hijo
"y
asi
podria
propio
y
se
generar
suficiente
Reino
de
algiin
tiempo de
como
de
de
Ia
para
sus
demanda,
encuentra
segUn resulta
Sa16n del
habria
argumento generico y
escrito
Pabl0
con
sucesiva
del mantenimiento en el
este
gue
causa,
los
Testigos
dudas
sobre
aI
creen
el
casado
ca
actor
con
una
el
matri
de
Jehovâ
2011.
dado
expresi6n
corresponde
fue
habido una modificaci6n en
el
credo,
recurrente
fundamento
actualidad
Que
cini,
tiene
en
mujer
de
dicho
luego
hubiese
gue
2
transfundido
el
Sin embargo,
reconoce
el
de
respecto
Pabl0.
en
parte
oportunidades",
precisiones
aI
otra
firma
incertidumbre
rente
cias;
Ia
distintas
decisi6n
ser
acto por el
Por en
intenci6n y libertad.
Que
el
a
culto.
gue
de
no
existen
voluntad
examinar
si
realizada
esta
libertad personal
decisi6n
gue
por
se
establece
Ia
validez
Pabl0 Albarra
encuadra
Ia
dentro
Constituci6n
Nacional.
13)
rresponde
libertad
el
recordar
individual
articul0
hombres
Que
gue
19
de
gue
ante
un
gue
una
en
Ia
caso
de
las
Ia
gue
gravedad
premisas
Constituci6n
consagra
ningUn modo
de
"Las
ofendan
aI
del
presente
fundamentales
Nacional
acciones
orden y
a
se
co
de
Ia
encuentra
en
privadas
Ia moral
de
los
publi-
ca,
ni perjudiquen a un tercero,
exentas de
Que,
tal
Belluscio y Petracchi
ha
dej ado
Fundamental
este
ca
o
puede
de
de
su
rechos
c.
otorga
de
el
individuo un ambito
de
sin
citado
autonomia
las
S.
al
19,
las
acciones,
hechos
y
significa
gor,
el
derecho
de
como
se
en
a
la
salud
la
que,
la
la vida privada
sus
destinadas
familiares
a
de
los
la
y
estan
para
la
0
fisica
difundidas,
autorizados
para
ni
(Fallos:
sino
de
ello
en
y
s610
suma,
las
formas
al
propio
los
extraños
la
a otros
areas
de
habitos
En
ri
esfera
aspec
las personas
violar
sin
seña16
ambito
y,
imagen y nadie puede
una persona
Indalia
intimidad.
no
de
econ6mica,
cuenta
por
acer
la divulga
reservadas
divulgaci6n
cual
violen
un
fisica
Ley
Estado
individuo,
en
amistad,
ser
no
situaci6n
familiar y de
de
el
del
sentimientos,
comprende
la
parte
Cor
la
fundamentales
un
mental
potencial
0
en
ilegitima
privacidad
corporal
libertad
juridicamente
comunidad
0
de
perjuicios"
teniendo
y
19
por
y
era
familiares,
datos
real
circulo
integridad
daños
jueces
esta
"Ponzetti de Balbin,
protege
la
art.
decisiones
intimos
la personalidad espirituaı
vidad no
de
el
si
conocimiento
un peligro
domestica,
tos
0
por
cuyo
dichas
resolver que
relaciones
aceptadas
alguna
constituida por
religiosas,
individuo
A.
" ...
creencias
vida
decisiones
caso
datos
las
de
tanto
en el
ciertos
individual
costumbres,
en
Asi,
art.
las
interferencia
tribunal,
de
establecido
los
"Bahamondez",
el
Atlantida
pUlılica
la disidencia de
citada causa
libremente
terceros.
el
la
record6
que
particulares,
306,1892)
que
en
al
adoptar
Editorial
ci6n
como
claramente
persona,
los
y
la autoridad de los magistrados".
14)
te
estan s610 reservadas a Dios,
tales
inmiscuir
de
su acti
su
consentimiento
y
s610
por
ley
0 el
podrä
A.
523.
XLVIII
Albarracini Nieves,
Jorge Waahington sl medidas
precautorias.
\
justificarse
la intromisi6n,
rior en resguardo de
siempre que medie un interes
la libertad de los
otros,
supe
la defensa de
sociedad,
las buenas costumbres o la persecuci6n del crimen
(voto
la
mayoria,
XXXVI
"vazquez
de
V.356.
1aci6n.
bre
19
de
s/incidente
2003,
de
Que
a
todos
su
disponer
ra
de
validamente
oponerse
los
io
a
todo
limites de
les
es
propio.
la base
de
de
su pertenencia,
de
despliega
su
cuerpo
con
tituciona1
(Fallos:
que
sobre
al
acciones
De
la
consagra
316:479
16)
en
este
que
el
presente
tales
caso,
se
art.
"Bahamondez"
Que
a
o
se
de
voto
principios
en
e1
de
vida
que
de
1a
los
"e1
art.
la
cual
cuerpo,
ordenado
la
de
de
con
obrar
reaccionar
por
u
enervar
trata del
sefior
reconocido
declaraci6n
que
con
La estructura
sus
por
el
hombre,
las
cuales
y
libertad
se
Constituci6n
Dres.
de
Fayt
forman
la
cons
Naciona1"
y Barra) .
particular
encuentran
que
expresa
1a prerrogativa
resultan
se
segun
un bien
dada
fundamenta
de
que
tentativa
la
esta
traves
19
septiem
facultad
la
caso,
por
modo,
de
ape
individuo una esfe
esta
consecuencia,
garantizado
causa
de
su propio
Ha
conlleva
En el
constitucional
libertad.
infraestructura
en
de
la Constituci6n Nacional.
la norma
su vida
obrar
caci6n
de
y
dicho
al
y
posibilidad
esa prerrogativa.
como
tancial
voluntad;
prop6sito,
19
atribuir
impedimentos
propio
art.
su
30
prerrogativa
cuanto
su
el
ha
obrar,
a
tiene
se
su
a
la
... "
Maqueda).
caso
una
en
incidente
sentencia de1
Dr.
ese
sl
de
de
de
en
actos,
sujeta
libre
citado
Evelin Karina
hombres
sus
sobre
sefiorio
tambien
de1 voto de1
los
propia vida,
8°;
ape1aci6n",
tambien
de
vivencia humana
Ferra,
de
24
15)
concede
pueden
cons.
consid.
la
apli
comprometidos,
precisamente,
1as
dad espiritua1
e1
creencias
re1igiosas,
Y
es
con
afirmar que
1a posibi1idad de
especifico,
0 de
hace
cientes
a
1a
sustento
aceptar
tienen
derecho
a
hacer
opciones
a1
idea
1ey
26.529
zar
determinadas
expresi6n de
otorgar
11
sibi1idad de
diendo
tas
10
que
se
tendran como
en
derecho
y
medico,
aun
1as
0
rechazar
un tratamiento
2
Que
tratamien
que
acuerdo
con
10s pa
sus
pro
e1
por
e1
derecho
pasarse
persona
1egis1ador
a
aceptar
medicos
por
capaz
y decisiones
aceptadas
a1to
mayor
anticipadas
determinados
desarro11ar
ser respetada.
0
en
1a
recha
"con
0
sin
esta
1ey
e).
puede
toda
ser
la
Corte
sentido
capacidad
cuando
su
11evar10s
razones
inc.
no
es posib1e
que
de
sobre
su
edad
por e1
a
medico
practicas
su
a
po
sa1ud,
tratamientos
re1ativas
1a
pu
medicos,
sa1ud.
cargo,
eutanasicas,
Es
sa1
1as
que
ha
re
inexistentes.
este
1a
de
procedimientos
rechazar
imp1iquen
17)
si
0
a
receptada
directivas
deberan
1as
cordado
que
aun cuando parezcan irraciona1es
paciente
0 pa1iativos,
vo
sa1ud 0
demas,
disponer
directivas
su
(art.
reconoce
consentir
preventivos
a1
sido
terapias
causa"
Por
art.
ha
en
en e110s
y que esa 1ibre e1ecci6n debe
Esta
su
0
persona1i
mencionadas
autodeterminaci6n y autonomia persona1;
imprudentes,
en
1a
se1eccionar una forma a1ternativa de
pios va10res 0 puntos de vista,
o
sa1ud,
y fisica y 1a integridad corpora1,
citado precedente.
to
1a
para
que
de
Europea
"prima
decidir
rechazo
pueda
de
Derechos
facie,
si
cada
acepta
causar
a una muerte prematura.
e1
rechazo
son
Humanos
adu1to
0
no
danos
Mas
raciona1es
e1
tratamiento
permanentes
aun,
0
tiene
no
a
importa
irraciona1es,
A.
523.
XLVIII
Albarracini
Nieves,
Jorge Washington al
medidaa
precautorias.
desconocidas
Moscow
fusal
O
aiin
and others
of
de
ella
tomar
en
la
Que,
las
que
cabe
ficada
tad,
Que,
782
re
T.
Adult:
que
Re
la
adul
conciernen
en
relevante
sea
que
le
limitada
piiblico
individual
of
(Court of Appeal) .
validamente
interes
In
witnesses
libertad de una persona
circunstancias
de
que
adulta a un
conformidad
no
judicial
que
tratamiento
y
no
con
resultar1a
la decisi6n del
discernimiento
a
fundamentales
derecho
resoluci6n
cuando
Jehova's
aquellos
en
iinica
claramente
no
a
juego
forma
y
de
aparecen
caso.
concluir
una
persona
al
la
ser
algiin
interes,
19)
dos,
puede
en el
configuradas
of
referencia
cierto,
decisiones
exista
dicho
en
(Case
weekly Law Report
por
restricci6n
tutelar
no
3
directamente,
casos
que
v Russia,
Treatment,
18)
ta
inexistentes"
los
principios
constitucionalmente
autorizara
sanitario
a
directamente
justi
someter
en contra de
individuo hubiera
afectara
enuncia
sido
a
una
su volun
dada con ple
derechos
de
terce-
ros.
As1,
moral
piiblica,
mientras
o
a
los
con
la
a
lo
pautas
Dra.
mejor
del
Highton de
Una
art.
19
de
proteger1a
la
el
a
resulten
obrar
persona
derechos
cluso piiblicos pertenecen
aunque
una
no
ajenos,
ofenda
sus
al
orden,
comportamientos
su privacidad,
y hay que
molestos
terceros
colectivo
para
(Fallos:
a
328:2966,
la
in
respetarlos
o
desentonen
disidencia
de
convertir
al
No1asco) .
conclusi6n
Carta
fuero
Magna
contraria
en
1ntimo de
una
la
significaria
mera
f6rmula
conciencia
o
vac1a,
aquellas
que
s610
conductas
de
tan
escasa
el
mundo
importancia
exterior
que
(Fallos:
no
tuvieran repercusi6n alguna en
316:479,
disidencia de
los
Dres.
Be
lluscio y Petracchi) .
Tal
base de
sea,
tal norma
la
actos
incoacta
nan ... n
juez
segun
autos
medico
de
indiquen
anterior,
que
bertad personal
informe
admisible
ello,
del
en
p.
la
elemental
valores
personal,
de
fundados
la
en
que
voto
al
no
de
lo
etica
la
o
la
que
libre,
determi
concurrente
un
del
a
no existi6
justificara
la
constancias
tratamiento
encuadra en algunas
mencionadas
--conforme
que
existir
recibir
religiosas,
excepcionales
que
voluntad
cit.,
negativa
concluir
la
la libertad moderna,
la
los
que
1941).
creencias
relevante
precisamente,
realicen
Balbinn,
precedentemente--
publico
Por
se
consecuencia,
sus
cabe
y
exigencia
de
19,
en
circunstancias
arrollados
teres
Que,
a
es
sujeto
consid.
contrario
las
rando
que
conciencia
meri tos
del
desconoce,
la base misma de
cual
nponzetti
Petracchi,
vista
la
de
creencia
20)
en
de
la
dignos
(caso
de
n ... es
autonomia
convicci6n
los
punto
los
en
el
conside
principios
en el
cas o
des
algun
restricci6n en
la
in
li
nombrado.
oido
del
Cuerpo
el
recurso
el
senor
Medico
Procurador
Forense,
extraordinario
-//-
se
General
y
decIara
interpuesto y
se
agregado
el
formalmente
confirma
el
A.
523.
XLVIII
Albarracini
Nieves,
Jorge washington
sl
medidas
precautorias.
-ff-pronunciamiento
la
naturaleza
de
apelado.
las
Costas
cuestiones
por
SU
orden
planteadas.
en
Notifiquese
vuelvase.
'/
ENRIQUE S PETRACCH\
JUAN CARLOS MAQUEDA
VO-I/-
atenci6n
y
a
de
А.
523.
ХLVІІІ
Albarracini
Nieves,
Jorge
Washington
аl
medidas
precautorias.
-//-ТО DEL SENOR MINISTRO DOCTOR DON CARLOS S.
FAYT
Considerando:
Que
remitir а
de
10s
go,
а
10s
Fayt
ехсерсібп
considerando
13
Que
persona
efectos
fundamentos
jueces
еоп
10s
humana
у
10
es
por
asi,
porque
-re1acionados
sefiorio de1 hombre
tidad,
honor,
чuе,
еп
cuanto
pi1b1ica,
пі
рrоtессібп
autoridad
su
ta1es
еп
perjudiquen
constituciona1
de
10s
еоп
а
caso
саЬе
316:479,
voto
Fa110s
sustancia1mente
e1
i11timo
un
derechos
su
у
tanto
ana1o
parrafo
по
su vida,
sus
de1
a1
gozan
cuerpo,
de
1a
la
сот
su iden
trascendentes,
orden,
а
de
mas
а
de
dignidad-
creencias
ofendan
19
у
su
11ega -inc1uso(art.
esencia1es
1ibertad
tercero,
чuе
magistrados
10s
sobre
intimidad
у
еп
presente
reso1utiva.
prenden a1
su
e1
de
resu1tar
manifestado
1a parte
e110
reso1ver
de1 precedente
у Barra,
de
de
1a
1a
amp1ia
eximir10s
Сопstіtuсібп
moral
de
la
Nacio
na1) .
Por
ma1mente
e11o,
admisib1e
sentencia.
1as
oido e1
Costas
cuestiones
el
por
sefior Procurador Genera1,
se
recurso
se
su
orden
extraordinario
еп
debatidas.
аtепсібп
,
а
у
la
VO-//-
for
confirma
la
naturaleza
de
oportunamente,
vase.
cдR1.0S S. FAYr
dec1ara
devue1-
A.
523.
XLVIII
Albarracini
Nieves,
Jorge
Washington
s/
medidas
precautorias.
-//-TO DEL SENOR MINISTRO DOCTOR DON ENRIQUE SANTIAGO PETRACCHI
Considerando:
1 0)
ci6n
de1
cando
11i,
vs
SU
Sr.
Jorge
solicita
autorice
de1
a
anticipadas
y
de
g16bu1os
para
medica",
Sr.
Pab10
terminos
de
10s
NO ACEPTO
aunque
arts.
Que
de
fs.
paciente
se
4/6,
de
medico
antes
citada,
encuentra en
discernimiento",
admitir
1ugar
e1
recurso
234
inc.
en aque1.
"Direc
para
1a
segiin
e1
pUb1ica,
manifiesta:
de
sangre
0
1as
"Soy
comp1eta,
p1asma,
crea
instancia
bajo
necesarias
(fs.
1a autenticidad de
con e1
a
y
que
origina1) .
condiciones
hizo
232
de
C1inica
titu1ado
p1aquetas
1a decisi6n de primera
1a base
1a
invo
Ottone
representante
TRANSFUSIONES
(destacado en e1
en
sangre
Ottone11i
persona1
quien,
"efectos
hijo
escribano
b1ancos,
e1
a
documento
A1barracini
presenta
A1barracini
mi
un
1a
Nieves,
JOrge
de
de
por
con
urgente
obra un
designaci6n
1a vida"
mentaci6n de
4/6
g16bu1os
concepto,
bien parti6
p1eno
y
rojos,
sa1varme
fs.
Jorge
Jehova
"no
de
certificado
Pab10
3°)
si
A1barracini
tratantes
10s
inician
a rea1izar una transfusi6n de
a
testigo
ningiin
en
se
precautoria
medicos
Que
e1
padre
medida
CABA,
CPCC" ,
atenci6n
cua1
de
10s
de
actuaciones
Washington
una
2°}
tivas
1as
condici6n
Bazterrica
1°
Que
de
21/22),
1a
docu
fundamento de que
tomar decisiones
1a medida
solicitada por
e1
con
su
padre.
4°}
Pab10
na1
de
Que
ante
Jorge A1barracini
Ape1aciones
en
Ottone11i,
10
Civi1,
interpuesto
1a
Sa1a A de
revoc6
1a
por
1a
1a
esposa
de
Camara Nacio
reso1uci6n de
primera
instancia,
por
"primar
decisión
las
el
la
considerar,
directivas
principio
religiosa... "
adoptada por
anticipadas,
de
5')
Que
contra
Nieves
96/115),
fue
en
raigambre
da,
la
a
sultan
el
jueces
mitir
salud,
a
6')
Que
la
se
que
debia
Ottonelli
en
encuentran fundadas
en
libertad de
decisión
en
las
y
el
Sr.
conciencia
por
juego
el
a
quo
cuestiones
análogas
Fallos
que
a
como
y
Petracchi),
a
cuyos
502
(fs.
214/215)
derecho
a
eon
de
la
vi
examine
re
conciencia.
el
debatidas
479,
Washington
personalisimos
el
suscita
las
316:
(fs.
"derechos
tales
Jorge
extraordinario
recurso
libertad religiosa y de
"Bahamondez",
sub
y
resueltas
(disidencia
términos
en
de
los
corresponde
re
en razón de brevedad.
ello,
traordinario
atencién
y,
esa
constitucional",
Belluscio
Por
se
cuales
concedido
están
sustancialmente
casa
Pablo Albarracini
interpuso
bien
que
clara
cuestiones,
89/92).
Albarracini
fundamento
las
otras
autodeterminación y de
(fs.
que
entre
a
y
se
declara
se
confirma
la naturaleza
oportunamente,
formalmente
de
la
procedente
sentencia.
las
Costas
cuestiones
el
por
debatidas.
recurso
su
orden
ex
en
Notifique
devuélvase.
ENRIQUE S PETRACCHI
ES CaPIA FIEL
Poder Judicial de la Nación
TEXTO COMPLETO:
Suprema Corte:
—I—
La Cámara Nacional de Apelaciones en lo Civil, Sala A, revocó la decisión de la anterior
instancia que autorizaba a realizar al Sr. Pablo Albarracini Ottonelli una transfusión de
sangre y denegó la medida cautelar solicitada en tal sentido por su progenitor (v. fs. 21/22 y
89/91)
Contra dicha decisión, la actora dedujo recurso extraordinario federal, que fue replicado,
denegado en lo relativo a la tacha de arbitrariedad y concedido por la cuestión federal
fundada en el artículo 14 de la ley n° 48 (fs. 98/115, 194/213 y 214/215).
— II —
Entiendo que en este caso se trae a discusión, por un lado, una restricción al derecho a
disponer del propio cuerpo y a la libertad religiosa del señor Albarracini Ottonelli, y, por el
otro, la preservación de la vida y la salud (v. arts. 14, 19, 33 y 75, inciso 22, de la
Constitución Nacional y previsiones internacionales concordantes).
En tales condiciones existe, sin duda, una cuestión federal en los términos del artículo 14
de la ley n° 48 (Fallos: 319:1363; entre otros). Y sin perjuicio del cauce conferido por la
Cámara Civil al recurso, según se detalló supra, lo cierto es que también, y porque en estos
términos debería plantearse el debate, V.E. se encuentra habilitada a tratar las cuestiones
vinculadas con la alegación de arbitrariedad.
— III —
El artículo II de la ley 26.529, transcripto por la a quo, establece que “Toda persona capaz
mayor de edad puede disponer directivas anticipadas sobre su salud, pudiendo consentir o
rechazar determinados tratamientos médicos, preventivos o paliativos, y decisiones
relativas a su salud. Las directivas deberán ser aceptadas por el médico a cargo, salvo las
que impliquen desarrollar prácticas eutanásicas, las que se tendrán como inexistentes”.
A fojas 117 obran “las directivas anticipadas” suscriptas por Pablo Albarracini Ottonelli, en
donde expresa que es testigo de Jehová y que no acepta transfusiones de sangre completa,
glóbulos rojos, glóbulos blancos, plaquetas o plasma bajo ningún concepto, aunque el
personal médico las crea necesarias para salvarle la vida.
Siendo éste el presupuesto necesario para la aplicación del artículo 11 citado, la Cámara
Civil entendió que otorga plenos efectos jurídicos a partir de la sanción de la ley citada y
que estas directivas deben ser respetadas dando prioridad a la voluntad del paciente
fundada en su derecho a la autodeterminación, sus creencias religiosas y su dignidad, aun
cuando en este caso —sostiene el tribunal— las manifestaciones del padre del paciente
vuelve relativo este “testamento vital” con base en “su relación oscilante en la práctica de
su creencia religiosa”. Y agrega en este sentido que no se advierte que haya transcurrido un
largo lapso desde que se celebrara este acto —marzo de 2008, conforme fs. 4 y 63 vta.—
por lo que no hay ningún elemento que lleve a la alzada a considerar “que pudo haber
mediado algún cambio en la idea religiosa del paciente”, porque de haber existido
intención de modificarlo lo hubiera revocado.
Sin desconocer que hubo una manifestación expresa y teniendo en cuenta que ésta es fruto
de una convicción religiosa, lo cierto es que, en este trance, resultaría relevante oír los
pareceres de sus seres queridos. Pero hete aquí que, por un lado, la cónyuge y las personas a
quienes el interesado designó como representantes en esta situación, y por el otro, el padre
del paciente, se arrogan la interpretación de la voluntad del nombrado, incapaz de
expresarse, trasuntando exigencias contradictorias: unas rechazando la transfusión y otro
demandándola.
Esta incertidumbre sobre la voluntad del paciente impide situar el caso en el supuesto del
artículo 11 de la ley 26.529, que la exige como presupuesto básico.
Desde otro punto de vista y puesto que no sabemos cuál es actualmente su voluntad ante
una situación de vida o muerte como la que está atravesando, resulta relevante que los
médicos intenten salvarle la vida aun por medio de la técnica en debate. Porque más allá de
la prohibición religiosa, lo cierto es que se trata de una intervención menor y que de por sí
no parece indicar una crueldad terapéutica. Y además, puesto que el Estado asume la
responsabilidad de intentar salvar su vida, queda desplazada, en su inconsciencia, su propia
responsabilidad ante el credo al que dijo pertenecer.
Por lo demás, esta solución se compadece con los protocolos médicos internacionales en la
materia y, sobre todo, con lo que establecen las normas superiores.
Porque cabe recordar que V.E. ha declarado que el derecho a la vida es el primer derecho
de la persona humana, que resulta reconocido y garantizado por la Constitución Nacional,
por lo que es de la mayor importancia advertir la especial perspectiva de este derecho
(Fallos: 310:112), pues el primer deber del juez es preservar la vida (Fallos: 324:51, voto
del juez Nazareno).
Y siguiendo la postura adoptada por la jurisprudencia norteamericana, el Estado retiene
cuatro intereses fundamentales respecto de las decisiones médicas que deben adoptarse en
estas situaciones, a saber 1) la preservación de la vida; 2) la prevención del suicidio; 3) la
protección de terceras personas inocentes; y 4) el mantener la integridad ética de la
profesión médica (Satz v. Perlmutter, 362 So. 2d 160, Fla. Dist. Ct. App., 1978, entre
otros).
Pues bien, dentro de la premura ínsita a lo extremo de la situación, es de mi opinión que
V.E. puede ordenar la práctica médica tendiente a salvaguardar la vida de Albarracini
Ottonelli, en la medida en que el informe médico aún pendiente, lo indique como
indispensable. — Buenos Aires, 1° de junio de 2012. — Luis Santiago González Warcalde.
A. 523. XLVIII
Albarracini Nieves, Jorge Washington s/medidas precautorias.
Buenos Aires, 1° de junio de 2012.
Vistos los autos: “Albarracini Nieves, Jorge Washington s/ medidas precautorias”.
Considerando:
1°) Que la Sala A de la Cámara Nacional de Apelaciones en lo Civil, al revocar el
pronunciamiento de primera instancia, denegó la medida precautoria solicitada por Jorge
Washington Albarracini Nieves a los efectos de que se autorizase a los médicos tratantes de
su hijo mayor de edad Pablo Jorge Albarracini Ottonelli —internado en la Clínica
Bazterrica de esta Ciudad Autónoma de Buenos Aires— a efectuarle una transfusión de
sangre que resultaba necesaria para su restablecimiento.
2°) Que según surge de las constancias de autos, Pablo Jorge Albarracini Ottonelli ingresó
al citado nosocomio con un hematoma intraparenquimatoso y lesión inguinal secundario,
con motivo de una herida de arma de fuego como consecuencia de un intento de robo. En
la actualidad, según surge de las constancias de la causa, se encuentra en estado crítico, con
pronóstico reservado, internado en el área de terapia intensiva y los médicos que lo asisten
han destacado la necesidad de efectuarle la citada transfusión dado su estado (conf. informe
30 de mayo de 2012).
3°) Que asimismo, corresponde señalar que el paciente pertenece al culto “Testigos de
Jehová”, y que en el expediente obra una declaración efectuada por él el 18 de marzo de
2008 —con anterioridad a su hospitalización— certificada por escribano público, en la que
manifiesta dicha pertenencia y que por tal motivo no acepta transfusiones de sangre.
4°) Que habida cuenta de que al momento de iniciarse las presentes actuaciones, el
paciente no se encontraba en condiciones de expresarse por sí misma, Romina Eliana
Carnevale, cónyuge de Pablo Albarracini, se opuso al planteo efectuado por el progenitor
invocando la existencia de la mencionada expresión de voluntad y solicitando se respete
dicha decisión.
5°) Que después de enumerar los derechos que se encontraban involucrados en la cuestión
planteada —derecho a la vida y a la salud, autonomía individual, libertad religiosa y de
conciencia—, la alzada señaló que el paciente había dejado expresada su voluntad en
relación a una situación como la que se había generado, al obrar en el expediente un
documento que daba cuenta de “directivas anticipadas” en el que expresamente se negaba a
recibir transfusiones de sangre aunque peligrase su vida. Asimismo, sostuvo que dichas
directivas —que según el art. 11 de la ley 26.529 debían ser aceptadas por los médicos—
resguardaban el principio constitucional de libertad de autodeterminación, entendido como
soporte de conductas autorreferentes, sin que se diera en el caso el supuesto excepcional de
la citada norma que impide las prácticas eutanásicas.
Por ende, el a quo consideró que tales directivas debían ser respetadas priorizando la
voluntad del paciente fundada en su derecho a la autodeterminación, sus creencias
religiosas y su dignidad, y que las manifestaciones realizadas por su padre no llevaban a
considerar que pudiese haber mediado algún cambio en la idea religiosa de Pablo, pues de
haber existido intención de modificar el testamento vital, lo lógico era que hubiese
revocado la voluntad expresada en el instrumento analizado.
6°) Que las resoluciones que se refieren a medidas precautorias no autorizan el
otorgamiento del recurso extraordinario ya que no revisten, en principio, el carácter de
sentencias definitivas (Fallos: 300:1036; 308:2006, entre otros). Sin embargo, cabe hacer
excepción a dicha regla en los casos en que, como en autos, lo resuelto cause un agravio
que, por su magnitud o circunstancias de hecho, pueda ser de tardía, insuficiente o
imposible reparación ulterior, pues ello acuerda al decisorio el carácter de definitivo a los
efectos de la apelación extraordinaria del art. 14 de la ley 48 (conf. Fallos: 298:409;
300:1036; 308:90; 314:1202 y 323:2790). Asimismo, el recurso extraordinario resulta
admisible en la medida que el recurrente ha cuestionado la inteligencia de cláusulas
constitucionales y la decisión ha sido contraria al derecho fundado en aquellas (art. 14, inc.
3° de la ley 48).
7°) Que las cuestiones que llegan a conocimiento de esta Corte remiten a aquellas que
dieron origen al precedente publicado en Fallos: 316:479 (“Bahamondez”) (LA LEY, 1993D, 130) en el que un paciente afectado por una hemorragia digestiva, con anemia y melena
se negó a recibir transfusiones de sangre por considerar que eran contrarias a las creencia
del culto “Testigos de Jehová” que profesaba.
8°) Que sin perjuicio de lo expresado, el caso sub examine presenta particularidades que en
alguna medida lo distinguen del precedente mencionado y que requieren las siguientes
precisiones: primero, que Pablo Albarracini ingresó a la clínica Bazterrica en estado de
inconsciencia por lo que no pudo manifestar a los profesionales médicos cuales eran las
terapias o procedimientos médicos o biológicos que estaba dispuesto a aceptar conforme a
las creencias de su culto.
Segundo, que hay constancia de que en el 18 de marzo de 2008, firmó un documento en el
cual manifestó no aceptar “transfusiones de sangre completa, glóbulos rojos, glóbulos
blancos, plaquetas o plasma bajo ningún concepto aunque el personal médico las crea
necesarias para salvarme la vida”.
9°) Que en la causa no existen elementos que permitan albergar dudas respecto de la
validez formal del documento señalado, dado que obra en autos el original firmado de puño
y letra por Pablo, ante el escribano público N. R. S. que procedió a su certificación
(conforme surge de la certificación notarial de firmas e impresiones digitales Libro de
requerimientos n° 12, Acta n° 372 F° 372). De esta manera quedan despejados los
cuestionamientos formulados en este punto por el actor en el recurso extraordinario.
10) Que no existen pruebas claras y convincentes de que el paciente al momento de
expresar dicha voluntad no haya considerado la trascendencia y las consecuencias de su
decisión; tampoco las hay para considerar que esa voluntad fue viciada por presiones de
terceros o de que la opción efectuada haya sido adoptada con otra intención que la de
profesar el culto. Por ende, no existen razones para dudar de que el acto por el cual Pablo
ha manifestado su negativa a ser transfundido fue formulado con discernimiento, intención
y libertad.
11) Que por otra parte el recurrente alega que con posterioridad a la firma de dicho
documento, su hijo habría abandonado el culto para luego regresar a éste “y así
sucesivamente en distintas oportunidades”, lo que podría generar algún tipo de
incertidumbre respecto del mantenimiento en el tiempo de la decisión de Pablo. Sin
embargo, este argumento genérico y carente de precisiones no tiene fundamento suficiente
como para al menos presumir que hubiese habido una modificación en sus creencias; al
contrario, en el propio escrito de demanda, el actor reconoce que en la actualidad Pablo se
encuentra casado con una mujer de su mismo credo, y según resulta de la causa, el
matrimonio se realizó en el Salón del Reino de los Testigos de Jehová el 2 de diciembre de
2011.
12) Que dado que no existen dudas sobre la validez actual de la expresión de voluntad
realizada por Pablo Albarracini, corresponde examinar si esta decisión se encuadra dentro
de la esfera de libertad personal que establece la Constitución Nacional.
13) Que ante un caso de la gravedad del presente corresponde recordar que una de las
premisas fundamentales de la libertad individual en la Constitución Nacional se encuentra
en el artículo 19 que consagra que “Las acciones privadas de los hombres que de ningún
modo ofendan al orden y a la moral pública, ni perjudiquen a un tercero, están sólo
reservadas a Dios, y exentas de la autoridad de los magistrados”.
14) Que, tal como recordó la disidencia de los jueces Belluscio y Petracchi en la citada
causa “Bahamondez”, esta Corte ha dejado claramente establecido que el art. 19 de la Ley
Fundamental otorga al individuo un ámbito de libertad en el cual éste puede adoptar
libremente las decisiones fundamentales acerca de su persona, sin interferencia alguna por
parte del Estado o de los particulares, en tanto dichas decisiones no violen derechos de
terceros. Así, en el caso “Ponzetti de Balbín, Indalia c. Editorial Atlántida S. A. s/daños y
perjuicios” (Fallos: 306:1892) (LA LEY, 1986-C, 411) el tribunal, al resolver que era
ilegítima la divulgación pública de ciertos datos íntimos de un individuo, señaló que el
citado art. 19: “… protege jurídicamente un ámbito de autonomía individual constituida por
los sentimientos, hábitos y costumbres, las relaciones familiares, la situación económica,
las creencias religiosas, la salud mental y física y, en suma, las acciones, hechos o datos
que, teniendo en cuenta las formas de vida aceptadas por la comunidad están reservadas al
propio individuo y cuyo conocimiento y divulgación por los extraños significa un peligro
real o potencial para la intimidad. En rigor, el derecho a la privacidad comprende no sólo la
esfera doméstica, el círculo familiar y de amistad, sino a otros aspectos de la personalidad
espiritual o física de las personas tales como la integridad corporal o la imagen y nadie
puede inmiscuirse en la vida privada de una persona ni violar áreas de su actividad no
destinadas a ser difundidas, sin su consentimiento o el de sus familiares autorizados para
ello y sólo por ley podrá justificarse la intromisión, siempre que medie un interés superior
en resguardo de la libertad de los otros, la defensa de la sociedad, las buenas costumbres o
la persecución del crimen..,” (voto de la mayoría, consid. 8°; también citado en la causa
V.356. XXXVI “Vázquez Ferrá, Evelin Karina s/ incidente de apelación. s/incidente de
apelación”, sentencia del 30 de septiembre de 2003, cons. 24 del voto del Dr. Maqueda) LA
LEY, 2003-F, 437.
15) Que también en ese caso se ha dicho que “el art. 19 concede a todos los hombres una
prerrogativa según la cual pueden disponer de sus actos, de su obrar, de su propio cuerpo,
de su propia vida, de cuanto les es propio. Ha ordenado la convivencia humana sobre la
base de atribuir al individuo una esfera de señorío sujeta a su voluntad; y esta facultad de
obrar válidamente libre de impedimentos conlleva la de reaccionar u oponerse a todo
propósito, posibilidad o tentativa por enervar los límites de esa prerrogativa. En el caso, se
trata del señorío a su propio cuerpo y en consecuencia, de un bien reconocido como de su
pertenencia, garantizado por la declaración que contiene el art. 19 de la Constitución
Nacional.La estructura sustancial de la norma constitucional está dada por el hombre, que
despliega su vida en acciones a través de las cuales se expresa su obrar con libertad. De
este modo, vida y libertad forman la infraestructura sobre la que se fundamenta la
prerrogativa constitucional que consagra el art. 19 de la Constitución Nacional” (Fallos:
316:479 “Bahamondez” voto de los Dres. Fayt y Barra).
16) Que tales principios resultan de particular aplicación al presente caso, en el que se
encuentran comprometidos, precisamente, las creencias religiosas, la salud, la personalidad
espiritual y física y la integridad corporal, mencionadas en el citado precedente. Y es con
sustento en ellos que es posible afirmar que la posibilidad de aceptar o rechazar un
tratamiento especifico, o de seleccionar una forma alternativa de tratamiento hace a la
autodeterminación y autonomía personal; que los pacientes tienen derecho a hacer
opciones de acuerdo con sus propios valores o puntos de vista, aun cuando parezcan
irracionales o imprudentes, y que esa libre elección debe ser respetada.
Esta idea ha sido receptada por el legislador en la ley 26.529 al otorgar al paciente el
derecho a aceptar o rechazar determinadas terapias o procedimientos médicos “con o sin
expresión de causa” (art. 2 inc. e).
Por lo demás, no puede pasarse por alto que esta ley en su art. 11 reconoce a toda persona
capaz mayor de edad la posibilidad de disponer directivas anticipadas sobre su salud,
pudiendo consentir o rechazar determinados tratamientos médicos, preventivos o
paliativos, y decisiones relativas a su salud. Estas directivas deberán ser aceptadas por el
médico a cargo, salvo las que impliquen desarrollar prácticas eutanásicas, las que se
tendrán como inexistentes.
17) Que la Corte Europea de Derechos Humanos ha recordado en este sentido que “prima
facie, cada adulto tiene el derecho y la capacidad de decidir si acepta o no tratamiento
médico, aun cuando su rechazo pueda causar daños permanentes a su salud o llevarlos a
una muerte prematura. Más aun, no importa si las razones para el rechazo son racionales o
irracionales, desconocidas o aún inexistentes” (Case of Jehova’s witnesses of Moscow and
others v Russia, en referencia a In re T. Adult: Refusal of Treatment, 3 Weekly Law Report
782 (Court of Appeal).
18) Que, por cierto, la libertad de una persona adulta de tomar las decisiones
fundamentales que le conciernen a ella directamente, puede ser válidamente limitada en
aquellos casos en que exista algún interés público relevante en juego y que la restricción al
derecho individual sea la única forma de tutelar dicho interés, circunstancias que
claramente no aparecen configuradas en el caso.
19) Que, de conformidad con los principios enunciados, cabe concluir que no resultaría
constitucionalmente justificada una resolución judicial que autorizara a someter a una
persona adulta a un tratamiento sanitario en contra de su voluntad, cuando la decisión del
individuo hubiera sido dada con pleno discernimiento y no afectara directamente derechos
de terceros.
Así, mientras una persona no ofenda al orden, a la moral pública, o a los derechos ajenos,
sus comportamientos incluso públicos pertenecen a su privacidad, y hay que respetarlos
aunque a lo mejor resulten molestos para terceros o desentonen con pautas del obrar
colectivo (Fallos: 328:2966, disidencia de la Dra. Highton de Nolasco).
Una conclusión contraria significaría convertir al art. 19 de la Carta Magna en una mera
fórmula vacía, que sólo protegería el fuero íntimo de la conciencia o aquellas conductas de
tan escasa importancia que no tuvieran repercusión alguna en el mundo exterior (Fallos:
316:479, disidencia de los Dres. Belluscio y Petracchi).
Tal punto de vista desconoce, precisamente, que la base de tal norma “…es la base misma
de la libertad moderna, o sea, la autonomía de la conciencia y la voluntad personal, la
convicción según la cual es exigencia elemental de la ética que los actos dignos de méritos
se realicen fundados en la libre, incoacta creencia del sujeto en los valores que lo
determinan…” (caso “Ponzetti de Balbín”, cit., voto concurrente del juez Petracchi, consid.
19, p. 1941).
20) Que, en consecuencia, al no existir constancias en autos que indiquen que la negativa
de recibir un tratamiento médico contrario a sus creencias religiosas, encuadra en algunas
de las circunstancias excepcionales mencionadas en el considerando anterior, cabe concluir
—-conforme a los principios desarrollados precedentemente— que no existió en el caso
algún interés público relevante que justificara la restricción en la libertad personal del
nombrado.
Por ello, oído el señor Procurador General y agregado el informe del Cuerpo Médico
Forense, se declara formalmente admisible el recurso extraordinario interpuesto y se
confirma el pronunciamiento apelado. Costas por su orden en atención a la naturaleza de
las cuestiones planteadas. Notifíquese y devuélvase. — Elena I. Highton de Nolasco. —
Carlos S. Fayt (según su voto). — Enrique Santiago Petracchi (según su voto). —Juan
Carlos Maqueda.
Voto del señor ministro doctor don Carlos S. Fayt.
Considerando:
Que a los efectos de resolver el presente caso cabe remitir a los fundamentos del
precedente de Fallos 316:479, voto de los jueces Fayt y Barra, por resultar sustancialmente
análogo, con excepción de lo manifestado en el último párrafo del considerando 13 y la
parte resolutiva.
Que ello es así, porque los derechos esenciales de la persona humana —relacionados con
su libertad y dignidad— comprenden al señorío del hombre sobre su vida, su cuerpo, su
identidad, su honor, su intimidad y sus creencias trascendentes, que, en cuanto tales y en
tanto no ofendan al orden, a la moral pública, ni perjudiquen a un tercero, gozan de la más
amplia protección constitucional que llega —incluso— a eximirlos de la autoridad de los
magistrados (art. 19 de la Constitución Nacional).
Por ello, oído el señor Procurador General, se declara formalmente admisible el recurso
extraordinario y se confirma la sentencia. Costas por su orden en atención a la naturaleza
de las cuestiones debatidas. Notifíquese y, oportunamente, devuélvase. — Carlos S. Fayt.
Voto del señor ministro doctor don Enrique Santiago Petracchi:
Considerando:
1°) Que las actuaciones se inician con la presentación del Sr. Jorge Washington Albarracini
Nieves, quien, invocando su condición de padre de Pablo Jorge Albarracini Ottonelli,
solicita una medida precautoria urgente a “efectos de que VS autorice a los médicos
tratantes de mi hijo en la Clínica Bazterrica de CABA, en los términos de los arts. 232 y
234 inc. 1° del CPCC”, a realizar una transfusión de sangre en aquél.
2°) Que a fs. 4/6 obra un documento titulado “Directivas anticipadas y designación de un
representante para la atención médica”, certificado por escribano pública, según el cual el
Sr. Pablo Jorge Albarracini Ottonelli manifiesta: “Soy testigo de Jehová y NO ACEPTO
TRANSFUSIONES de sangre completa, glóbulos rojos, glóbulos blancos, plaquetas o
plasma, bajo ningún concepto, aunque el personal médico las crea necesarias para salvarme
la vida” (destacado en el original).
3°) Que la decisión de primera instancia (fs. 21/22), si bien partió de la base de admitir la
autenticidad de la documentación de fs. 4/6, antes citada, con el fundamento de que el
paciente “no se encuentra en condiciones de tomar decisiones con pleno discernimiento”,
hizo lugar a la medida solicitada por su padre.
4°) Que ante el recurso interpuesto por la esposa de Pablo Jorge Albarracini Ottonelli, la
Sala A de la Cámara Nacionalde Apelaciones en lo Civil, revocó la resolución de primera
instancia, por considerar, entre otras cuestiones, que debía “primar la decisión adoptada por
Pablo Albarracini Ottonelli en las directivas anticipadas, las cuales se encuentran fundadas
en el principio de autodeterminación y de libertad de conciencia y (fs. 89/92).
5°) Que contra esa decisión el Sr. Jorge Washington Albarracini Nieves interpuso recurso
extraordinario (fs. 96/115), que fue bien concedido por el a quo (fs. 214/215) con
fundamento en que están en juego “derechos personalísimos de clara raigambre
constitucional”, tales como el derecho a la vida, a la salud, a la libertad religiosa y de
conciencia.
6°) Que las cuestiones que suscita el sub examine resultan sustancialmente análogas a las
debatidas y resueltas en el caso “Bahamondez”, Fallos 316: 479, 502 (disidencia de los
jueces Belluscio y Petracchi), a cuyos términos corresponde remitir en razón de brevedad.
Por ello, se declara formalmente procedente el recurso extraordinario y se confirma la
sentencia. Costas por su orden en atención a la naturaleza de las cuestiones debatidas.
Notifíquese y, oportunamente, devuélvase. — Enrique Santiago Petracchi.
Original Article
European Journal of Trauma and Emergency Surgery
Optimizing Outcomes in the Jehovah’s Witness
Following Trauma: Special Management
Concerns for a Unique Population
Chrysanthos Georgiou, Kenji Inaba, Joseph DuBose, Pedro G.R. Teixeira,
Pantelis Hadjizacharia, Ali Salim, Carlos Brown, Peter Rhee, Demetrios Demetriades1
Abstract
Background: The objective of this study was to describe the management of the Jehovah’s Witness (JW)
in an intensely active level I trauma center and review
the modern therapeutic options available for the
trauma care of these patients.
Study design: A retrospective review of injured JWs
admitted to a busy trauma center over a 13-year period
was conducted.
Results: Over the study period, 143 JWs were identified. Among these, 15.4% (22/143) overall and 32.3%
(10/31) requiring surgical intensive care unit (SICU)
admission accepted transfusion. Overall, 56.6% of JWs
(81/143) required operation and 21.7% (31/143) were
admitted to the SICU with a complication rate of 4.2%
(6/143) and a mortality of 1.4% (2/143). One patient of
the 31 patients that were admitted to the SICU received 10 ml of blood with subsequent discontinuation of the transfusion and was excluded from
analysis. Of the 30 JWs admitted to the SICU, 20
(66.7%) did not receive transfusion and demonstrated
mean admission and nadir hemoglobin (Hb) levels of
12.7 (±2.5) and 9.1 (±3.0) mg/dl, respectively. Ten patients accepted transfusion. This group had longer
mean SICU stays (23.3 vs. 5.5 days) but similar mortality (10%, 1/10 vs. 5%, 1/20) compared to non-transfused counterparts. Only one complication (1/20, 5%)
was observed in the JWs who were not transfused,
compared to a 40% (4/10) complication rate in those
accepting transfusion.
Conclusion: Although our experience was limited,
we found no significant difference in the mortality
or morbidity between JW patients who received or
1
abstained from transfusion following major trauma.
We should keep in mind that the population was
small, in order to extract safe conclusions regarding
whether we should transfuse or not transfuse trauma
patients. We can, however, see interesting insights on
the value of trauma resuscitation.
Key Words
Injury Æ Wounds and injuries Æ Trauma Æ Outcome
assessment Æ Jehovah’s Witnesses Æ
Hemoglobin Æ Blood transfusion
Eur J Trauma Emerg Surg 2009;35:383–8
DOI 10.1007/s00068-009-8246-6
Introduction
There are almost six million Jehovah’s Witnesses (JWs)
worldwide, with more than a million residing in the
United States [1]. JWs share a belief system that prohibits the receipt of blood or blood products, including
whole blood, packed red blood cells, white blood cells,
plasma, and platelets. Other components, such as immune globulins, albumin, erythropoietin, and clotting
factors, are, however, more commonly considered to be
acceptable for use [1]. In the setting of major trauma
and hemorrhage, health care providers must reconcile
the need to respect the rights of the patient to refuse
potentially life-sustaining treatment with their own
scientific and ethical desire to do what they have been
trained to do – give blood to the symptomatic bleeding
patient. Aggressive management approaches and protocols for this special population can serve to minimize
Division of Trauma Surgery and Surgical Critical Care, Department
of Surgery, USC + LAC Medical Center, University of Southern
California, Los Angeles, CA, USA.
Received: December 19, 2008; revision accepted: May 8, 2009;
Published Online: July 9, 2009
Eur J Trauma Emerg Surg 2009 Æ No. 4 URBAN & VOGEL
383
Review Article
The Journal of TRAUMA威 Injury, Infection, and Critical Care
The Contemporary Approach to the Care of Jehovah’s
Witnesses
Duncan B. Hughes, MD, Brant W. Ullery, MD, and Philip S. Barie, MD, MBA, FCCM, FACS
Background: Jehovah’s Witnesses
are widely known for their prohibition on
the acceptance of blood transfusion. Such
refusal serves as a potential obstacle to
optimal therapeutic intervention among
critically injured Jehovah’s Witnesses. As
such, care of these patients requires an aggressive and multidisciplinary approach to
therapy.
Methods: A review of the pertinent
English language literature.
Results: Jehovah’s Witnesses exercise
the right of any adult with capacity to refuse
medical treatment and often carry advance
directive cards indicating their incontro-
vertible refusal of blood. Despite their belief
regarding transfusion, Jehovah’s Witnesses
do not have a higher mortality rate after
traumatic injury or surgery. Transfusion
requirements are often overestimated. Increased morbidity and mortality is rarely
observed in patients with a hemoglobin
concentration >7 g/dL, and the acute hemoglobin threshold for cardiovascular
collapse may be as low as 3 g/dL to 5 g/dL.
There are many modalities to treat the
Jehovah’s Witness patient with acute
blood loss. Treatment with recombinant
human erythropoietin, albumin, and recombinant activated Factor VIIa have all
been used with success. Autologous autotransfusion and isovolemic hemodilution
can also be used to treat patients who
refuse transfusion. Hemoglobin-based oxygen carriers may play a future role as
intravascular volume expanders in lieu of
transfusion of red blood cell concentrates.
Conclusion: There are many treatment modalities available to assist in the
care of Jehovah’s Witness patients, especially since their beliefs on the intricacies
of the Blood Ban appear to be in flux.
Key Words: Jehovah’s Witness, Transfusion, Trauma, Critical care, Surgery.
J Trauma. 2008;65:237–247.
J
ehovah’s Witnesses trace their origin to a Bible study
group founded in Allegheny, PA in 1869 by Charles
Taze Russell.1,2 The study group engaged in extensive
biblical analysis that led to, in their belief, the detection of
fundamental errors in traditional Christian doctrine, including
those related to common Christian teachings on the nature of
the deity and the immortality of the soul. Indeed, the religious
convictions of this following were based on strict literal
interpretation of the Bible.1,3,4 Russell and his group members,
originally known as Bible Students, believed that disobeying
biblical commands would ultimately forfeit any opportunity
for eternal life. The study group subsequently rejected much
of mainstream Christianity in favor of what they considered
to be a restoration of first-century Christianity. A decade later, in
1879, the first issue of an illustrated religious magazine, later
called The Watchtower, was published and Russell’s study
group sparked the creation of nearly 30 congregations across
seven states.2 Initially known as Zion’s Watch Tower Tract
Submitted for publication November 17, 2007.
Accepted for publication March 24, 2008.
Copyright © 2008 by Lippincott Williams & Wilkins
From the Department of Surgery (D.B.H., B.W.U., P.S.B.), Division of
Critical Care and Trauma, Weill Cornell Medical College, New York, New
York; and Department of Public Health (P.S.B.), Division of Medical Ethics,
Weill Cornell Medical College, New York, New York.
Address for reprints: Philip S. Barie, MD, MBA, Department of Surgery, Weill Cornell Medical College, Payson 713-A, 525 East 68 Street, New
York, NY 10065; email: [email protected].
DOI: 10.1097/TA.0b013e318176cc66
Volume 65 • Number 1
Society, the name Jehovah’s Witnesses (based on Isaiah 43:
10 –12) was not adopted until 1931.
As the most rapidly growing religious group in the western world, Jehovah’s Witnesses represent an international
religious organization comprised of over 6.7 million members worldwide, with more than one million members in the
United States.5,6 Members of the organization believe that
God’s name is Jehovah and that the use of such is necessary
for valid worship.7 Jehovah’s Witnesses are recognized for
their person-to-person ministry and for their involvement
with literacy programs and disaster relief. To be acknowledged as a member, an individual must be approved as a minister and satisfy a minimum monthly time requirement in the
ministry.2 Jehovah’s Witnesses pledge allegiance to God’s
Kingdom, an entity that is viewed as an authentic government
unto itself, and therefore remain neutral politically.8 Members
do not salute flags, join service organizations, enlist in the
military, vote in public elections, or take any interest in civil
government.9,10
THE BLOOD BAN
Because the Watchtower Society, the governing body of
Jehovah’s Witnesses, introduced the blood ban in 1945, Jehovah’s Witnesses have been known widely in the medical
community for their prohibition on the acceptance of blood
transfusion. This position is based on literal interpretation of
passages in the Old Testament that allegedly forbid transfusion, namely Genesis 9:3– 4, Leviticus 17:10 –16, and Acts
15:28 –29. For instance, Jehovah’s Witnesses interpret the
237
following passage to mean that God (Jehovah) has forbidden
them to “eat blood”:
“For it (the blood) is the life of all flesh; the blood of it is
for the life thereof; therefore I say unto the children of Israel,
ye shall eat the blood of no manner of flesh: for the life of all
flesh is the blood thereof. Whoever eateth it shall be cut off”
(Leviticus 17:14).
In an oft-cited The Watchtower article, receiving blood
products intravenously is described to be analogous to literally “eating” blood, or its components therein:
“A patient in hospital may be fed through the mouth,
through the nose or through the veins. When sugar solutions are
given intravenously, it is called intravenous feeding. So the
hospital’s own terminology recognizes as feeding the process
of putting nutrition into one’s system via the veins. Hence the
attendant administering the transfusion is feeding the patient
blood through the veins, and the patient receiving it is eating
through his veins” (The Watchtower 1951;July:415).
The blood ban requires that Jehovah’s Witnesses not
accept transfusion of allogeneic blood components, including
whole blood, red blood cell (RBCs) concentrates, white blood
cells, plasma, and platelets.11–13 Autologous blood must also
be refused if predeposited (e.g., preoperative setting). However, autologous blood can be accepted if it is maintained in
continuous contact with the patient’s blood (e.g., intraoperative autotransfusion with no disruption or interruption of the
tubing circuit). The permissibility of this specific circumstance
allows for intraoperative utilization of isovolemic hemodilution
and intraoperative RBC salvage as feasible methods to ensure
hemodynamic stability, provided that a continuous circuit
from the patient to the intravenous tubing and blood bag is
maintained.14
Jehovah’s Witnesses who consciously accept a blood
transfusion violate the blood ban and were subjected historically to excommunication, or organized communal shunning, under Scriptural doctrine.15 However, the Watchtower
Tract Society issued a directive in 2000 stating that the
organization would no longer excommunicate members who
did not comply with the blood ban.16 The official statement
read: “If a baptized member of the faith willfully and without
regret accepts blood transfusions, he indicates by his own
actions that he no longer wishes to be one of Jehovah’s
Witnesses. The individual revokes his own membership by
his own actions, rather than the congregation initiating this
step.” Issuance of the directive made no change in the end
result given that any individual knowingly accepting allogeneic blood products is still considered to be revoking his
religious affiliation because he or she no longer accepts and
follows a core tenet of the faith.
Members of this faith group think generally that blood
contains one’s moral and physical characteristics, and that
accepting a transfusion will “pollute” oneself with the
world’s ideas, thus losing one’s holiness.12 Furthermore, they
believe that “the time gained on earth from a blood transfu238
sion is inconsequential to the eternal spiritual damnation that
results from it.”15 In fact, the Jehovah’s Witness community
will often send a representative from the religion to “stand
watch” at the hospital bedside to ensure that no transfusions
are administered. There is, however, variability within the religion and not all members approach the Blood Ban equally. For
example, many Jehovah’s Witnesses will accept fractions of
whole blood, such as albumin, recombinant human erythropoietin (rHuEPO), immunoglobulins, and factor concentrates,
whereas others will not. This decision is often left to the
individual member.17 If a Jehovah’s Witness patient requests
to receive a blood transfusion secretly, it is likely that they
will not be discovered by the community, unless they admit
the act to a fellow Jehovah’s Witness. As a result, if a
Jehovah’s Witness patient privately communicates a desire to
receive transfusions, the physician should be reminded that
patient confidentiality is of utmost importance, and that confidentiality is vital to avoiding potential social and religious
repercussions.17
PHYSICIAN-PATIENT RESPONSIBILITY AND
COMMUNICATION
When caring for a Jehovah’s Witness patient, available
hospital resources are a crucial asset to support the patient’s
decision-making process. Many hospitals have an ethics committee available for consultation, and a risk management
group available for legal advice. Often at large medical centers
with blood conservation programs, there are also transfusion
medicine specialists available. In addition, it is possible that
a Jehovah’s Witness patient may be confused or unsure of
their transfusion options, and may not be aware that certain
blood fractions are acceptable to many Jehovah’s Witnesses.
There is often a Hospital Liaison Committee of Jehovah’s
Witnesses available at major medical centers. This group may
address patient questions, and may place inquiring physicians
in contact with other physicians with previous experience in
similar situations (call 718-560-4300 or e-mail [email protected]).18
Management of the Jehovah’s Witness patient may also
pose an ethical dilemma to the supervising physician. In some
circumstances, a physician may not think comfortable accepting a Jehovah’s Witness patient given their treatment limitations. There is an emotional burden endured by a health-care
provider watching a patient die in a “preventable” medical
setting. Physicians should consider these ramifications, and in
nonemergent cases, consider transferring the care of a Jehovah’s Witness patient to another health care provider if he or
she is encumbered personally.19 Such circumstances would
not be considered inappropriate, provided that the transferring physician arranges alternate means of care. Additionally,
it is important for the family members to be informed of the
reason for the transfer, and that the accepting physicians be
made aware of the patient’s medical preferences.18
Whereas Jehovah’s Witnesses frame their objection to
blood transfusion on religious grounds, they secure their
position by highlighting the hazards associated with such
July 2008
Contemporary Approach to Jehovah’s Witnesses
medical intervention. The Watchtower Society warns its
members that transfusions are plagued with near-certain disastrous health consequences, citing a host of risks related to
incompatibility and blood-borne diseases.12 However, the
Society often fails to mention the benefits of transfusion.
Interestingly, and perhaps paradoxically, their faith permits
the consumption of animal meat and wearing of products
made from animal hides. As physicians, we must respect the fact
that some people have beliefs that they deem more important
than their own lives, but this is not say that those beliefs cannot
be questioned, or that patients cannot be encouraged to examine
them for themselves.18
LEGAL PARAMETERS
In 1914, the landmark case of Schloendorff v. Society of
New York Hospital established the right of any adult with
capacity to refuse medical treatment.20 It is now commonplace for adult Jehovah’s Witnesses to exercise this right by
carrying with them a wallet-sized advance directive card
indicating their incontrovertible refusal of blood (Fig. 1). The
blood refusal card informs health care personnel that no blood
is to be given to the individual, under any circumstance,
irrespective of prognosis in the absence of transfusion. This
advance directive should be made known to all health care
Fig. 1. Jehovah’s Witness blood refusal card (from Associated Jehovah’s Witnesses for Reform of Blood: http://www.ajwrb.org/watchtower/
card.shtml).
239
providers at the time of hospitalization, or be executed as
soon as practicable thereafter.
Laws pertaining to a parent’s right to refuse blood transfusion either for themselves or for their children vary according to state. Each state has a mechanism to seek judicial relief
when a parent of a minor child refuses to consent to necessary
treatment of him or herself or of a minor. The courts have
upheld parents’ decisions to refuse blood transfusion for
themselves when the remaining parent, a family member, or
a friend would be able to care for a minor child or children if
the patient died.
The legal power to provide or withhold consent for
medical treatment of children who lack capacity falls under
the umbrella of parental responsibility, except in the setting
of an emergency. A series of court decisions21–23 has clarified
that parents do not have the ability to refuse blood on behalf
of their children when blood product administration is warranted. Such limitation on parental rights is based on three
overarching principles: First, the child’s interests and those
of the state outweigh parental rights to refuse medical
treatment21; second, parental rights do not give parents lifeand-death authority over their children21,22; and third, parents
do not have an absolute right to refuse medical treatment for
their children based on their religious beliefs if that refusal is
regarded as unreasonable.22,23
However, the ability of some adolescents, or so-called
mature minors, to refuse medical treatment is not as clear-cut.
Three United States (IL, TN, and WV) recognized the concept of the mature minor, and adolescents in these states are
granted the same decision-making rights as adults.24 In the
remaining states, adolescents rely on parental decisionmaking, or that of the courts, if necessary.
In the case of an emergency, decision-making for the
patient can be complicated. Blood refusal cards document
informed risks, but do not document that the patient understands the potential benefits. One may argue that a blood
refusal card, therefore, cannot be accepted as signed with
informed consent, unless a thorough conversation transpires
between physician and patient. Whenever possible, physicians should provide the necessary information for an individual to make an informed choice. In the event that such an
opportunity is not possible, or if there is any doubt regarding
the validity of a blood refusal card, physicians should administer blood products in life-threatening situations. Suicide
attempts, severe injuries in minors, or a documented change
in religious faith represent circumstances where blood product administration may be considered.24 In complicated cases
such as these, there is the possibility of legal action taken against
the hospital or health care provider by individuals other than the
patients themselves.18 Although Jehovah’s Witnesses are not
generally litigious, family members, or nonpracticing Jehovah’s
Witnesses may pursue legal action after watching a loved one
die from “nontreatment,” regardless of the patient’s documented
wishes. As the health care provider, in circumstances where
family members do not agree with the patient’s medical deci240
sions, it is important to be aware of the discrepancy and have a
thorough discussion with family members and, if possible, hospital patient representatives.
EARLY RECOGNITION OF RELIGIOUS AFFILIATION
Optimization of patient care for Jehovah’s Witnesses
demands early knowledge of the patient’s religious affiliation. Nelson et al.25 reported a 16-year retrospective review
of traumatically injured Jehovah’s Witnesses at a Level I
trauma center, a group that included 77 patients with 92%
blunt and 8% penetrating injuries. The authors observed an
“unacceptably” high rate of unrecognized Jehovah’s Witness
patients, as the primary physician was aware of patients’
religious affiliations in only 32% of cases. Furthermore, more
than one-half of all patients’ charts in this review lacked any
documentation of the patients’ religious status by any member of the health care team. Transfusion was administered to
only 5% (n ⫽ 4) of Jehovah’s Witness patients; one against
the will of an adult patient with capacity, one to a minor
under a court order, and two in the trauma room before the
patients’ religious status was known. Major changes in therapeutic approach, including early operation, were made in
13% of these patients as a direct result of early determination
of religious affiliation. In response to their findings, Nelson et
al. recommended that the religious organization should provide members with bracelets or necklaces (“medical alert”
style). An additional recommendation was to revise the standard Advanced Trauma Life Support protocol for history
taking to include a specific question pertaining to religious or
personal objections to blood transfusion.
CLINICAL CONSEQUENCE OF TRANSFUSION
REFUSAL
After proper recognition of Jehovah’s Witnesses in the
trauma or critical care setting, the religious beliefs of these
individuals beg the pertinent question of whether practicing
Jehovah’s Witnesses have an increased risk of death after
traumatic injury or surgery. In 2003, Varela et al.26 conducted
a retrospective cohort study of 556 patients comparing the
risks of death after major trauma for Jehovah’s Witnesses and
other religious groups (i.e., Catholics, Baptists, and others).
There was no significant difference in mean injury severity score
identified among religious groups, nor any statistically significant associations between religion and injury severity score.
Significant predictors of mortality were age, systolic blood
pressure upon admission, Glasgow Coma Scale score, and
type of trauma. After controlling for these predictors of mortality, Varela et al., concluded that Jehovah’s Witnesses had
no increased risk of death after major trauma compared with
other religious groups.
Indeed, the consequences of refusing blood transfusion
have been surprisingly anticlimatic, at least for elective surgery. In 1993, Kitchens27 conducted a review of 16 reported
series of Jehovah’s Witness patients who were not given
blood despite undergoing 1,404 surgical procedures that norJuly 2008
mally require blood transfusion. Severe anemia was implicated as the primary cause of death of eight patients (0.6%),
and contributed to the death of 12 additional patients (0.9%).
Given that refusal of transfusion by Jehovah’s Witnesses
increased the overall operative risk by only 0.5% to 1.5%,
Kitchens concluded that such refusal “is not as perilous as
anticipated”. Several other studies have corroborated this
finding in nontrauma settings, citing no difference in operative morbidity or mortality in Jehovah’s Witnesses compared
with non-Jehovah’s Witnesses undergoing cardiac,28 –30
neurologic,31 urologic,32 orthopedic,33,34 and major gynecologic and obstetric surgery,35 even after controlling for preoperative risk factors.
In addition to the apparent lack of mortality benefit
attributable to transfusion, recent data suggest that Jehovah’s
Witnesses may actually benefit with regard to improved clinical
outcomes from the decision to forego transfusion. Vincent et
al.36 led a multicenter prospective observational cross-sectional
study of 3,534 critically ill non-Jehovah’s Witness patients
admitted to 146 western European intensive care units (ICU)
during a 2-week period in 1999. Paradoxically, the study
found that ICU length of stay, organ dysfunction, and overall
mortality (29.0% vs. 14.9%) were significantly higher in
critically ill patients who underwent transfusion compared
with similar nontransfused patients. Kneyber et al.37 reached
similar conclusions in a critically ill pediatric population.
Jehovah’s Witness cite the risk of contagion as a reason for
refusing transfusion, and although very rare, there exists the
transmission of disease through blood transfusion. Transfusion has long been associated with the risk of transmission of
human immunodeficiency virus and hepatitis C, especially
before 1985 when accurate testing was not available. Although the risk of these diseases through transfusion is now
very low, there are new infectious agents that pose a threat to
the safety of blood transfusion. Protozoa (e.g., Plasmodium)
and viruses other than human immunodeficiency virus (e.g.,
West Nile virus, Severe Acute Respiratory Syndrome coronavirus) are of emerging concern, namely because current
testing either does not exist, or may be unreliable.38 There
will always be an infectious risk associated with transfusion,
and any effort to minimize transfusion will also minimize the
risk of transmission of etiologic agents.
Considering the rarity with which Jehovah’s Witnesses
die from severe anemia after major elective surgery27–35 and
that transfusion may actually portend a worse prognosis,36
Carson et al.39 explored the clinical consequences of very low
hemoglobin concentration in individuals who decline blood
transfusion for religious reasons. The retrospective cohort
study included 2,083 patients who underwent surgery and
subsequently had a postoperative hemoglobin concentration
of 8 g/dL or less. After adjusting for age, cardiovascular
disease, and Acute Physiology and Chronic Health Evaluation II score, the odds of death for patients with a postoperative hemoglobin concentration of 8 g/dL or less increased
2.5 times (95% CI, 1.9 –3.2) for each 1 g decrease in hemoVolume 65 • Number 1
globin concentration. However, it was evident that morbidity
and mortality rates dramatically increased only when the
hemoglobin concentration decreased below 5 g/dL (34% vs.
57.7%, respectively).
Many studies have examined the effects of very low
hemoglobin concentrations on circulation and cognitive functioning to analyze the “terminal hemoglobin threshold” in
human beings.40 – 44 In otherwise healthy individuals, the terminal hemoglobin is unknown but appears to be below 5
g/dL, and may even be as low as 3 g/dL.40 – 42 Cognitive
functioning is usually impaired before the effects on global
circulation become apparent.40,43 When hemoglobin concentrations are acutely lowered to 5 g/dL, there is no evidence of
circulatory insufficiency. However, cognitive functioning and
memory begin to decline at hemoglobin concentrations of 6
g/dL and 5 g/dL, respectively.43 These impairments are reversible and resolve with a single transfusion (hemoglobin
concentrations ⬎7 g/dL)43 or supplemental oxygen.44 Of
note, these studies were conducted in healthy individuals, and
there is no accounting for confounding variables (e.g., underlying cardiac disease, medications, sepsis, trauma) that may
alter the hemoglobin concentration threshold in critical care
patients.
The effect of RBC mass on clinical outcome remains
controversial. Nikolsky et al.45 conducted a study of 6,929
consecutive patients who were treated with percutaneous coronary intervention. Of the 6,929 patients, 1,708 (24.6%) had
anemia according to criteria of the World Health Organization (hematocrit ⬍39% for men and ⬍36% for women).
Anemic patients had significantly higher mortality rates during hospitalization and at 1 year (1.9% vs. 12.8%) compared
with those who did not have anemia (0.4% vs. 3.5%). After
adjusting for age, gender, diabetes mellitus, creatinine clearance, and congestive heart failure, low baseline hematocrit
remained a significant predictor of a 1-year increased mortality risk. Conversely, Rao et al.46 analyzed clinical data
from over 24,000 patients hospitalized for acute coronary
syndrome across three large international trials and found
transfusion in patients with higher hematocrit levels to be
associated with increased 30-day mortality. The authors cautioned against the routine use of blood transfusion to maintain
arbitrary hematocrit levels in stable patients given that the
association between transfusion and increased 30-day mortality was observed only in patients with nadir hematocrit
levels above 25%; no such association was observed in patients with nadir hematocrit levels of 25% or less. In addition,
mild degrees of both preoperative anemia and polycythemia
have been associated with an increased risk of 30-day postoperative mortality and cardiac events in noncardiac surgical
patients.47 Blood transfusion has also been shown to be a
significant risk factor for the development of infection in
critically ill patients48 –50 and to increase the occurrence of
postoperative atrial fibrillation after cardiac surgery.51 Thus,
the literature supports the tenets that blood transfusion may
241
Fig. 2. The Watchtower Bible and Tract Society’s current classification of blood products by acceptability.
have risks and benefits, depending on the clinical circumstance and patient demographics.
CONTEMPORARY STRATEGIES IN THE CLINICAL
MANAGEMENT OF JEHOVAH’S WITNESSES
The clinical management of Jehovah’s Witness patients
in a trauma, surgical, or critical care setting requires a high
index of suspicion and an aggressive and multidisciplinary
approach. Immediate intervention (including the decision to
operate early), effective identification of bleeding, minimizing iatrogenic and intraoperative blood loss, enhancing RBC
production, ensuring adequate hemostasis, and maintaining
intravascular volume and are all important strategies to incorporate into the care of a Jehovah’s Witness patient.
The Watchtower recently repeated the long-standing religious position of Jehovah’s Witnesses, stating that the acceptance of allogeneic whole blood and its four primary
components (i.e., RBCs, white blood cells, platelets, and
plasma) violates Jehovah’s law.52 However, the steadfast
views of this religious group appeared to be in flux following
a second article,53 published in the same 2004 edition of The
Watchtower, entitled “Be Guided by the Living God,” which
redefined the guidelines for use of blood products. The article
detailed the rules regarding which blood products are “unacceptable” and which are for the “Christian to decide.” Moreover, the article featured a newly developed chart that clearly
demarcated the acceptability of various blood products, including minor fractions derived from blood (Fig. 2). Potentially acceptable blood fractions include albumin, rHuEPO,
clotting factor concentrates, and oxygen therapeutics. Solid
organ and stem cell transplantation is an additional treatment
modality debated within the Jehovah’s Witness community.
Whereas some accept transplantation as a therapeutic option,
many think that it falls within the guidelines set forth by the
Blood Ban. The following represent key components in the
current management of patients who elect to forego blood
transfusion (Table 1).
Albumin
The use of albumin in the critical care setting remains a
controversial issue. Whereas the properties of albumin portend several potential therapeutic benefits, including maintenance of plasma oncotic pressure, protective effects on the
microcirculation, antioxidant and scavenger activities, and
242
Table 1 Strategies in the Clinical Management of
Jehovah’s Witness Patients
Strategy
Minimize iatrogenic
blood loss
Minimize intraoperative
red blood cell loss
Enhance red blood cell
production
Ensure hemostasis,
prophylactic or
therapeutic
Maintain blood volume
Methods of Achievement
Elimination of unnecessary
phlebotomy
Reduction of test sample volume
Meticulous surgical technique
Isovolemic hemodilution
Hypervolemic hemodilution
Intraoperative blood salvage
“Bloodless” surgery
Recombinant human
erythropoietin (rHuEPO)
Supplemental iron, vitamin B12,
and folate
Early operative intervention
Correction of coagulopathies
Desmopressin
Antifibrinolytic agents
Aprotinin
Recombinant human factor VIIa
Crystalloid solutions
Synthetic colloid solutions
anticoagulant effects, its utility relative to survival benefit has
yet to be demonstrated. Two meta-analyses have broadly
investigated effects of albumin administration in heterogenous populations of critically ill patients.54,55 Neither of these
reports could detect a survival benefit with the use of albumin, with the earlier report54 even noting a 6% increase in
mortality among albumin recipients. Moreover, a recent multicenter, double-blind, randomized, trial56 found no difference in mortality between ICU patients receiving either 4%
albumin or normal saline for fluid resuscitation. The trial concluded that albumin and saline should be considered clinically
equivalent treatments for intravascular volume resuscitation,
albeit in a heterogenous study population, and selection of
resuscitation fluid should be guided by its safety, tolerability,
and cost. Given the paucity of evidence for clinical benefit,
the routine use of albumin, either in critically ill patients at
large or in the consenting Jehovah’s Witness, does not appear
to be economically justifiable at the present time.
Recombinant Human Erythropoietin
Erythropoietin is a hormone produced by the kidneys
that stimulates bone marrow to produce RBCs. The rationale
July 2008
for therapy with rHuEPO, an albumin-containing product,
involves increased erythropoiesis resulting in a higher hemoglobin concentration and the subsequent reduction in the need
for RBC transfusion. Treatment with rHuEPO may be an
option in a Jehovah’s Witness patient, depending on their
individual belief regarding receipt of albumin or albumincontaining products. In addition, RBC production may be
augmented further by supplementary iron, vitamin B12, and
folate therapy, as indicated.
A prospective, randomized, double-blind, placebo-controlled,
multicenter trial conducted by Corwin et al.57 demonstrated
that a weekly dosing schedule of rHuEPO was associated
with an increase in hemoglobin concentration and a corresponding significant reduction in the rate of allogeneic RBC
transfusion. Several studies have investigated the most efficacious dose of rHuEPO. Recently, Georgopoulos et al.58
assessed the efficacy of two rHuEPO dosing schedules (group
A: iron ⫹ rHuEPO 40,000 U weekly; group B: iron ⫹
rHuEPO 40,000 U thrice weekly) compared with controls
(group C: iron saccharate only). The dose-response study
found that the cumulative number of RBC units transfused,
average number of RBC units transfused per patient and per
transfused patient, average volume of RBCs transfused per
day, and percentage of transfused patients were significantly
higher in the control group than in either experimental group.
Although Georgopoulos et al. demonstrated a significant reduction in the need for RBC transfusion with rHuEPO therapy, the magnitude of the reduction did not differ between the
two dosing schedules. However, a dose-dependent response
of hematocrit and hemoglobin concentrations to rHuEPO was
observed, and the administration of rHuEPO to critically ill
patients at a dose of 40,000 U thrice weekly was deemed safe
and efficacious.
Nevertheless, conflicting clinical and biochemical findings suggest that rHuEPO therapy may be ineffective in
critically ill patients, who often have increased concentrations
of endogenous EPO, a finding that challenges the utility of
supplementing EPO stores that are otherwise intact.59,60 In
addition, abnormal iron metabolism in critically ill patients
(i.e., iron deficiency or decreased iron availability secondary
to sequestration) limits optimal erythropoiesis even in the
setting of adequate endogenous and exogenous EPO.61,62
Moreover, critical illness is complicated by a surge of proinflammatory cytokines, which compounds the defective
erythropoiesis via decreasing production and survival of
RBCs, bone marrow suppression, decreased iron availability,
and reduced production of EPO.63
factor VIIa. Initially approved for the treatment of bleeding in
hemophilia patients,64 Recombinant human activated factor
VIIa (NovoSeven, Novo Nordisk Pharmaceuticals, Princeton,
NJ) has received much attention in recent years for its proposed use as an adjuvant therapy in the control of hemorrhage, and thus may serve as a useful clinical tool in the
treatment of Jehovah’s Witness trauma, surgical, or critical
care patients.
Intravenously administered recombinant activated factor
VIIa (rFVIIa) binds to tissue factor at the site of endothelial
injury, thereby triggering a local coagulation process that
begins with the production of thrombin and subsequent platelet activation. The surface of activated platelets serves as a
scaffold for rFVIIa to potentiate the activation of the coagulation cascade, directly or indirectly.65,66 Hemostasis is
achieved upon the generation of additional thrombin, with
stability of clot formation conferred by rFVIIa-mediated activation of thrombin-activated fibrinolysis inhibitor.67
The hemostatic capabilities of rFVIIa have been applied
to trauma patients with massive hemorrhage and coagulopathy since 1999.68 In a double-blind randomized controlled
trial, Boffard et al.69 reported that use of rFVIIa as an adjuvant therapy was associated with a significant decrease in
RBC transfusion requirements in blunt trauma patients surviving 48 hours or more. Similar but less dramatic trends
were observed in cases of penetrating trauma. Two recent
reports from the Australian and New Zealand hemostasis
registry offered similar support for the use of rFVIIa in
trauma.70,71 Whereas trends toward a reduction in mortality
and critical complications have been observed, the only randomized controlled trial to date69 reported no significant
difference in mortality between trauma patients who received
rFVIIa and those who received placebo. A retrospective review of 5,334 combat trauma patients requiring massive transfusion also showed no survival benefit in patients receiving
rFVIIa, independent of timing of rFVIIa administration.72
Nevertheless, early administration of rFVIIa (within 4 hours
of onset) was shown to reduce mortality and improve functional outcome in patients developing acute intracerebral
hemorrhage.73 In addition, one case report describes the successful perioperative use of rFVIIa in a warfarin-anticoagulated
Jehovah’s Witness patient with an acute subdural hematoma
after undergoing surgical evacuation without excessive blood
loss.74 A multicenter, multinational prospective randomized
trial is currently underway to better elucidate the efficacy of
rFVIIa in trauma patients and the optimal timing of therapy
initiation.75
Recombinant Human Activated Factor VIIa
Hemoglobin-Based Oxygen Carriers
Correction of coagulopathies is central to ensure either
prophylactic or therapeutic hemostasis. Given that some Jehovah’s Witnesses may refuse fresh frozen plasma or cryoprecipitate, several alternatives may be used in the setting of
actual or expected hemorrhage, including aprotinin, antifibrinolytics, desmopressin, and recombinant human activated
A primary goal in any trauma or surgical patient is to
maintain adequate intravascular volume. Traditionally, maintenance of blood volume is achieved with crystalloid solutions and blood products. In Jehovah’s Witnesses, however,
allogeneic blood products are not permissible, and crystalloid
may be insufficient by itself to maintain adequate oxygen
243
delivery. As a result, the development of a “perfect” blood
substitute, or synthetic colloid solution, is of great interest.76
Such a product would have definite advantages over human
RBCs, including rapid and widespread availability; fewer
requirements with regard to storage, transport, and compatibility
testing; a longer shelf life; and a more consistent supply. An
ideal substitute would be less antigenic than allogeneic
RBCs, and would have less risk of disease transmission. In
addition, one would have the ability to treat patients who
refuse standard blood transfusions.
Within the classic construct of transfusion medicine, the
general role of blood is to supply oxygen to tissues via
hemoglobin. Accordingly, early attempts in the 1940s to
develop blood substitutes were focused on a simple cell-free
solution of hemoglobin.77 Investigations showed that unmodified cell-free hemoglobin had limitations; namely, its oxygen
affinity was too high for effective tissue oxygenation, its
half-life within the intravascular space was too short to be
useful clinically, and its tendency to dissociate into dimers
caused renal tubular injury.76 Various types of hemoglobin
modification methods (e.g., purification, cross-linkage, polymerization) were developed more recently to overcome these
obstacles.77 Efficiency of cross-linked hemoglobin to transport and unload oxygen was confirmed in a variety of animal
shock models; modified hemoglobin solutions improve tissue
oxygenation at a rate similar to that of infusion of allogeneic
blood products.78
The use of two cross-linked polymers of bovine (Hemopure, Biopure, Cambridge, MA) and human (PolyHeme,
Northfield Laboratories, Evanston, IL) origin are beginning
to be integrated into cardiac and abdominal surgery as well as
trauma care.79 – 82 The intravascular half-life of the polymerized form of bovine hemoglobin solution (PBH) is approximately 24 hours, and its excretion is nonrenal. Administration
of PBH results in vasoconstrictive effects that may also increase systemic and pulmonary vascular resistance, with a
resultant decrease in cardiac index. As such, this product is
recommended to serve as a bridge until either donor blood
becomes available or the patient’s endogenous RBCs undergo
active regeneration.83 The PBH solution is currently undergoing phase III clinical trials as a perioperative alternative to
RBC transfusion in orthopedic surgery in the United States,
the European Union, Canada, and South Africa. Notably,
Hemopure has been approved for human use and commercial
sale in South Africa since April 2001, unique for this product
class. Additionally, the U.S. Naval Medical Research Center
was granted $4 million in Congressional funding for the U.S.
Navy to continue research and development of PBH.84
PolyHeme (PHH) is derived from pyridoxylated polymerized outdated hemoglobin from human blood, with an
intravascular half-life of 24 hours and a shelf life of longer
than 12 months (refrigerated). In a phase II randomized trial
comparing the therapeutic benefit of PHH with that of allogeneic RBCs, PHH reduced the required number of allogeneic RBC transfusions in patients with acute trauma.81,82 No
244
adverse clinical events, including vasoactive properties, were
observed in this trial. Currently, this product is undergoing
phase III studies for the treatment of patients with substantial
acute blood loss.
In general, hemoglobin-based oxygen carriers (HBOCs)
reduce or eliminate the need for allogeneic blood transfusions in patients undergoing orthopedic surgery, elective
abdominal surgery, and coronary artery bypass graft
surgery.76,81,83,85,86 If HBOCs are approved for such use,
Jehovah’s Witnesses may benefit from a rapidly available
universal oxygen-carrying volume expander, and HBOCs
may serve as a bridge in the temporary support of a patient
who will not accept blood products. The major limitation of
HBOCs still relates to their short intravascular half-life,
whereas a transfused RBC can persist in the circulation for
several weeks in a patient with no active bleeding or hemolysis. Given that utilization of an HBOC requires frequent
readministration, they would be costly as a definitive replacement for blood.
Acute Normovolemic Hemodilution
Acute normovolemic hemodilution (ANH), or intraoperative hemodilution, has been advocated as a safe, easy, and
inexpensive method to avoid exposure to allogeneic blood
since the 1970s.87 This blood conservation technique involves withdrawing blood from a patient into standard collection bags before or shortly after induction of anesthesia,
with maintenance of normovolemia using simultaneous infusion of crystalloid or colloid replacement. Circulating blood
volume remains constant given that the reduction in red cell
mass is compensated by the increase in plasma volume, and
the patient’s blood can be reinfused at any time during or
after surgery.
A recent meta-analysis of prospective, randomized controlled studies of ANH determined that this blood conservation
technique decreases the likelihood of exposure to allogeneic
blood and the volume of blood transfused.88 However, heterogeneity exists among study results and the overall benefit
of ANH remains inconclusive at this time. Nevertheless, a
recent review notes that ANH achieves similar outcomes at
lower cost compared with autologous predonation and, if
combined with other pharmacologic strategies, may eliminate
future use of allogeneic blood transfusion entirely for elective
surgery.89 Several other theoretical advantages of ANH have
been described.90 –92 For instance, the circulating blood in
ANH has a lower hematocrit; therefore, blood loss represents
a saving relative to quantitative red cell mass. ANH is also
associated with reduced blood viscosity, thereby reducing
systemic vascular resistance and allowing for an increase in
cardiac output without an increase in myocardial oxygen
consumption. In addition, reinfusion of withdrawn blood exposes patients to a large volume of their own platelets and
coagulation factors, thus preserving the patient’s inherent
coagulation function.
July 2008
Autologous Autotransfusion
In addition to the four primary components of allogeneic
blood, Jehovah’s Witnesses also reject any autologous blood
that has been separated from the body. These prohibitions,
however, do not prevent most Jehovah’s Witnesses from
consenting to the use of blood management techniques and
procedures involving temporary diversion of autologous
blood as long as no allogeneic blood is used (i.e., cardiopulmonary bypass, dialysis, intraoperative blood salvage, and
reinfusion). Although the lay person may not discern a difference between these interventions and autologous blood
that has been separated from the body, Jehovah’s Witnesses
distinguish the acceptability of such therapy on the basis of
whether the diverted blood remains part of the circulatory
system. The majority of Jehovah’s Witnesses, for example,
think that the extracorporeal tubing utilized in cardiopulmonary bypass, dialysis, or cell salvage equipment represents an
extension of their own circulatory system provided that the
tubing remains continuous with the patient’s intravascular
compartment.
The acceptance of autologous donation and retranfusion
technology remains at the discretion of each individual patient. Conventional cell saver autotransfusion is not accepted
by all Jehovah’s Witnesses because the salvaged blood is
processed in batches, thereby interrupting the continuity of
the blood with the body. However, newer modalities permit
continuous processing of salvaged blood, and therefore are
able to achieve an uninterrupted flow of RBCs back to the
patient. Whereas in principle a continuous circuit can be
expensive and require relatively sophisticated equipment, its
use enhances control of sterility and reduces the amount of
allogeneic blood transfusions required by patients.
Transplantation
The use of solid organ and stem cell transplantation
therapy is also debated within the Jehovah’s Witness community. Whereas some consider transplantation to fall under
the guidelines set forth by the Blood Ban, many Jehovah’s
Witnesses will accept these treatment modalities as long as
allogeneic blood components are removed from the process.
The first case of a solid organ transplantation of a Jehovah’s
Witness took place at University of California, Los Angeles
in 1986.93 Since then, numerous other cadaveric and living
donor transplants have been published in this patient population, including liver,94 kidney,95 pancreas,95 and lung.96
Solid organ transplantation often requires a large surgical
dissection and suturing of major vessels. Moreover, patients
requiring liver transplantation are often at a higher risk of
bleeding because of coagulation disturbances resulting from
cirrhosis and portal hypertension, thrombocytopenia, altered
platelet-vessel interaction, low levels of coagulation factors,
and arterial and venous collaterals.97 Consequently, if any
solid organ transplantation is going to be considered in a
Jehovah’s Witness patient that will not accept transfusion,
stringent patient selection and vigilant preoperative, intraoperative, and postoperative blood management is essential for
success in these patients.
Some Jehovah’s Witness patients also accept allogeneic
hematopoietic stem cell transplantation. As with solid organ
transplantation, the stipulation for accepting this treatment is
that it be “bloodless”, or without the transfusion of RBCs,
platelets, or plasma. There is a growing body of literature
supporting the feasibility of “bloodless transplants” in properly selected patients, given that the procedures are performed with meticulous attention to blood conservation and
supportive care. The willingness to accept allogenic hematopoietic stem cells while denying the progeny of those stem
cells is potentially a conflicted argument. The decision to
accept transplantation of any kind is left to the individual
member, and falls in line with the decision of whether or not
to accept albumin, rHuEPO, immunoglobulins, and factor
concentrates. As with whole blood fractions, it is unclear as to
the line that separates acceptable treatments from those that
are against the tenets of the religion. This emphasizes further
that the belief system of Jehovah’s Witnesses is in flux, and
the absolute guidelines for treatment are becoming blurred.
CONCLUSION
Jehovah’s Witnesses represent a unique and sometimes
frustrating challenge to the medical field. As physicians, it is
important to understand the basis for their collective beliefs
and the choices they make in the medical realm. It is equally
important to understand the circumstances in which it may be
appropriate to pursue alternative means of care and that the
need for transfusion is often overestimated. The “terminal
hemoglobin threshold” may be as low as 3 g/dL to 5 g/dL in
some patients, and transfusion alone is not without potential
deleterious physiologic effects. Given the ethical and legal
dimensions associated with the contemporary care of the
Jehovah’s Witness patient, a low threshold is necessary when
deciding when, and if, to utilize available hospital resources.
The belief system of this religious group appears to be in a
state of flux, specifically concerning the Blood Ban and its
application. Effective patient-physician communication is
necessary to elucidate the best avenue of care for all parties
involved.
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247
Recombinant Human Erythropoietin Therapy in
Critically Ill Jehovah’s Witnesses
Amanda M. Ball, Pharm.D., and P. Shane Winstead, Pharm.D.
Blood transfusions and blood products are often given as a life-saving measure
in patients with critical illness. However, some patients, such as Jehovah’s
Witnesses, may refuse their administration due to religious beliefs. Jehovah’s
Witnesses accept most available medical treatments, but not blood
transfusions or blood products due to their religion’s interpretation of several
passages from the Bible. Since recombinant human erythropoietin (rHuEPO)
became available, several cases have been reported in which rHuEPO was
successfully administered to critically ill Jehovah’s Witnesses. Administration
of rHuEPO in combination with other blood conservation techniques has
been shown to increase hemoglobin levels and survival in patients who
experienced trauma, burns, general surgery, or gastrointestinal hemorrhage.
We performed a literature search of the MEDLINE and International
Pharmaceutical Abstracts databases of rHuEPO therapy in the Jehovah’s
Witness population. Fourteen cases were identified in which rHuEPO was
administered to Jehovah’s Witnesses who required the drug for critical care
resuscitation as an alternative to blood products. In each clinical situation,
rHuEPO enhanced erythropoiesis; however, time to the start of treatment,
dosages, route of administration, and treatment duration varied widely.
Supplementation with adjunctive agents, such as iron, folic acid, and vitamin
B12, was also beneficial. Use of rHuEPO in Jehovah’s Witnesses may provide
an alternative to blood transfusions or blood products. Other alternatives,
such as hemoglobin-based oxygen carriers and perfluorocarbons, are also
being explored.
Key Words: erythropoietin, rHuEPO, Epogen, Jehovah’s Witness, hemorrhage.
(Pharmacotherapy 2008;28(11):1383–1390)
OUTLINE
Published Reports of Jehovah’s Witnesses Treated with
Recombinant Human Erythropoietin for Off-Label
Indications
Trauma
Burns
General Surgery
Gastrointestinal Hemorrhage
Adjunctive Therapy with Iron, Folic Acid, and Vitamin B12
Alternative Therapy with Hemoglobin-Based Oxygen
Carriers and Perfluorocarbons
Recommended Use of Recombinant Human
Erythropoietin in Jehovah’s Witnesses
Conclusion
From the Department of Pharmacy, the Hospital of the
University of Pennsylvania, Philadelphia, Pennsylvania (Dr.
Ball); and Pharmacy Services, UK Healthcare, and the
Department of Pharmacy Practice and Science, College of
Pharmacy, University of Kentucky, Lexington, Kentucky
(Dr. Winstead).
Address reprint requests to Amanda M. Ball, Pharm.D.,
Department of Pharmacy, Basement Silverstein, 3400 Spruce
Street, Philadelphia, PA 19104.
Blood transfusions and blood products are
often given as a life-saving measure in patients
with critical illness. However, some patients,
such as Jehovah’s Witnesses, may refuse their
administration due to religious beliefs. Jehovah’s
Witnesses are followers of a Christian religion,
with about 5.5 million practicing members
worldwide. They accept most available medical
1384
PHARMACOTHERAPY Volume 28, Number 11, 2008
treatments, but not blood transfusions or blood
products due to the religion’s interpretation of
several passages from the Bible. United States
courts have consistently supported the adult
patient’s decision to refuse blood on the basis of
religious beliefs.1 Thus, clinicians are obligated
to respect patients’ preferences, and alternatives
to blood transfusions and blood products are
needed.
In Jehovah’s Witnesses, the mainstay of
treatment of hemorrhage is blood conservation,
and a number of techniques are used to minimize
blood loss in this patient population. Techniques
include perioperative blood salvage from
autotransfusion of blood, prevention of intraoperative blood loss through surgical technique,
induced hypotension, and correction of
coagulopathy. Minimizing phlebotomy and
iatrogenic blood loss in intensive care patients is
another important blood conservation technique.
Oxygen demand and consumption can be
minimized through sedation, paralysis, mechanical
ventilation, and possibly hypothermia, along with
maximizing oxygen delivery through administration
of inotropes or using hyperbaric oxygen chambers.2
With use of these blood conservation techniques,
patients have survived with extremely low hemoglobin levels without enhanced erythropoiesis.
In 1989, recombinant human erythropoietin
(rHuEPO) received approval from the United
States Food and Drug Administration for
treatment of anemia associated with chronic renal
failure. The drug is a 165–amino acid glycoprotein
that stimulates red blood cell production in the
same manner as endogenous erythropoietin.
Other treatment indications approved by the
FDA include anemia due to chronic kidney
disease, anemia secondary to zidovudine therapy
in patients with human immunodeficiency virus
infection, anemia secondary to cancer chemotherapy,
and reduction of allogeneic blood transfusions
during surgery. The drug also has been used for
many off-label indications.
Many Jehovah’s Witnesses have accepted
rHuEPO as a treatment option to maintain and
enhance erythropoiesis even though the vial
contains albumin. The drug has been administered
with success in critically ill Jehovah’s Witnesses
for numerous hemorrhagic conditions.
To gain a better understanding of the use of
rHuEPO in Jehovah’s Witnesses who required the
drug for critical care resuscitation as an alternative
to blood products, we conducted a literature
search of the MEDLINE and International
Pharmaceutical Abstracts databases. Search
terms were Jehovah’s Witness and erythropoietin,
epoetin, Epogen, Procrit, and darbepoeitin; only
reports published in English and concerning
adult human patients were identified. The search
yielded 32 articles; however, 18 were excluded
because the patients had been treated with
rHuEPO for FDA-approved indications, such as
oncology and elective surgery, or the patients did
not receive rHuEPO for critical care resuscitation
as an alternative to blood products (e.g., pregnant
women). Thus, 14 case reports were reviewed in
detail. These critically ill Jehovah’s Witnesses
had experienced trauma, burns, general surgery,
or gastrointestinal hemorrhage and were treated
with rHuEPO as a potentially life-sustaining
measure as an alternative to blood transfusions or
products.
Published Reports of Jehovah’s Witnesses
Treated with Recombinant Human
Erythropoietin for Off-Label Indications
Trauma
Prevention and management of hemorrhagic
shock due to traumatic injury without administration of blood and blood products are extremely
difficult and have led to the administration of
rHuEPO with fluids, intravenous iron, and
polymerized blood substitute products. Since
1990, several reports have been published
regarding rHuEPO administration in Jehovah’s
Witnesses with acute traumatic injury.
Successful rHuEPO treatment was described in
a 36-year-old woman who was involved in a
motor vehicle accident and sustained bilateral
hemothoraces, left acetabular fracture, and
several pelvic fractures.3 On day 7 of hospitalization, the patient’s hemoglobin level and
hematocrit had declined to 4.6 g/dl and 14%,
respectively; intravenous rHuEPO was started at
300 units/kg/day for 3 days, followed by 150
units/kg subcutaneously 3 times/week for 14
days. Her hematocrit climbed steadily to almost
40% by day 30, with an absolute change of
greater than 26% with rHuEPO administration.
A 45-year-old woman sustained several
traumatic injuries after a train accident and
required a splenectomy.4 On day 7, the patient
started receiving rHuEPO 36,000 units given
over 1 week (route of administration not
reported). Her hemoglobin level declined to 3.2
g/dl by hospital day 16 (likely due a tracheostomy
performed on day 13). However, by day 44, her
hemoglobin level increased by almost 5 g/dl to
RECOMBINANT HUMAN ERYTHROPOIETIN FOR JEHOVAH’S WITNESSES Ball and Winstead 1385
greater than 8 g/dl.
A 48-year-old man was given intravenous
rHuEPO 4750 units/day (50 units/kg/day)
starting 10 hours after hospital admission
secondary to traumatic injuries sustained in an
airplane crash; his hemoglobin level was 6.8
g/dl. 5 On hospital day 3, due to a continued
decline in his hemoglobin level to 3.0 g/dl, his
daily dose of intravenous rHuEPO was increased
to 28,500 units (300 units/kg). This daily dose
was maintained until day 13, then the frequency
was decreased to every other day for a total of
five doses. The patient was discharged with a
hemoglobin level of 11.3 g/dl on day 54. The
resulting absolute change in hemoglobin level
after rHuEPO therapy was 4.5 g/dl.
Use of an extremely high dose of rHuEPO was
described in a 51-year-old woman involved in a
motor vehicle accident.6 On hospital admission,
the patient’s hematocrit was 12%; treatment with
rHuEPO was started immediately, along with
albumin, cryoprecipitate, vitamin K, and
suppression of menses. The rHuEPO dosage was
20,000 units given intravenously every other day.
When the patient’s hematocrit declined to 7%,
the dosage was increased to 7000 units every 8
hours, and intravenous iron was added. The
patient’s hematocrit increased to 35% (absolute
change of 28%), and she was transferred to a
long-term care facility after 30 days of rHuEPO
treatment. She subsequently died as a result of
her injuries.
The highest weight-based rHuEPO dose
reported was given to a 44-year-old woman who
was involved in a motor vehicle accident and
sustained a temporal subarachnoid hemorrhage,
facial fractures, rib fractures, and a splenic
laceration.7 Treatment with a hemoglobin-based
oxygen carrier and rHuEPO 600 units/kg/day
(route of administration not reported) was started
within 24 hours of the injury and was continued
for 2 days. The dosage was subsequently
decreased to 300 units/kg/day for 3 days. By
hospital day 19, the patient’s hemoglobin
increased from 3.2 to 9.8 g/dl (absolute change of
6.6 g/dl).
A 67-year-old man involved in a motor vehicle
accident started receiving intravenous rHuEPO
48,000 units/day (weight not reported) on
hospital day 2 when his hemoglobin level
decreased to 3 g/dl.2 The patient also received
iron, folic acid, and vitamin B12. In addition,
induced hypothermia, minimization of phlebotomy,
and aggressive fluid resuscitation with hetastarch
and crystalloids were implemented. These
techniques and the use of rHuEPO resulted in an
absolute change in hemoglobin level of 4.9 g/dl,
and at discharge on hospital day 47, the patient’s
hemoglobin level was 7.9 g/dl.
These six cases represent, to our knowledge,
the only current published reports of rHuEPO
use in Jehovah’s Witnesses with traumatic
injuries. Despite the small number of cases, each
patient’s hemoglobin level increased with
rHuEPO therapy. Starting dosages ranged from
50–600 units/kg/day, and all six patients received
iron supplementation. Furthermore, in each
report, intravenous rHuEPO was started during
the initial stages of critical illness and, in some
cases, transitioned to subcutaneous administration.
Intravenous administration may avoid alterations
in absorption and the delay to onset seen with
subcutaneous administration.
The rHuEPO dosage administered in these
Jehovah’s Witnesses with traumatic injury varied
widely. In addition, the time at which rHuEPO
therapy was started also varied, from less than 24
hours to 7 days after the injury. Given the
variation in these reports, the time to start and
the dosage of rHuEPO therapy in patients with
traumatic injury should be individualized and
based on severity of injury and decline in
hemoglobin level.
Burns
Two case reports describe use of rHuEPO in
patients with burns. The first involved a 52-yearold man with 15% burns on his face and hands.8
On admission, the patient’s hemoglobin level and
hematocrit were 15.4 g/dl and 45%, respectively.
However, after grafting the patient’s hands only,
his hemoglobin level decreased significantly, to
8.0 g/dl, and hematocrit decreased to 24%. Blood
loss was anticipated as further grafting procedures
were performed. Administration of rHuEPO was
begun on hospital day 10. Success was achieved
with a dosage of 300 units/kg/day intravenously
for 7 days, followed by 150 units/kg subcutaneously 3 times/week for another 3 weeks. The
patient’s hemoglobin level increased by 3 g/dl.
The second report described a 71-year-old
woman with 18% burns over her total body
surface area. 9 On admission, the patient’s
hemoglobin level and hematocrit were 12 g/dl
and 38%, respectively. By hospital day 14, her
hemoglobin level had declined to 7 g/dl.
Treatment with rHuEPO was begun on hospital
day 15 with a non–weight-based dosage of 4000
units subcutaneously 3 times/week for 19 days.
1386
Several skin grafts were performed, and the
patient’s hemoglobin level at discharge remained
unchanged at 7 g/dl.
In both of these patients with burns, rHuEPO
therapy was successful. However, the dosage and
duration of rHuEPO treatment were extremely
different between the two patients. In addition,
the maximum dose (300 units/kg/day) was still
lower than the doses given to trauma patients.
The first patient with burns experienced benefit
from rHuEPO treatment whereas the second
patient experienced a neutral effect. Of note,
only the first patient received iron supplementation and weight-based rHuEPO dosing.
General Surgery
Use of postoperative rHuEPO in two patients
who had undergone gastrointestinal surgery was
reported in a case series.10 Both were successfully
managed with rHuEPO and adjunctive agents.
The first patient was a 55-year-old woman who
underwent a subtotal colectomy and Brooke’s
ileostomy for ulcerative colitis. Two days after
surgery, her hemoglobin level had decreased from
13.6 to 2.8 g/dl, and treatment was begun with
intravenous rHuEPO 10,000 units/day plus
subcutaneous rHuEPO 10,000 units/day (280
units/kg/day). This dosage was continued until
hospital day 16, when her hemoglobin level had
increased to 4.8 g/dl; her rHuEPO dosage was
then reduced to 10,000 units/day subcutaneously
(140 units/kg/day). At discharge, her hemoglobin
level had increased to 10.4 g/dl. The total
duration of rHuEPO treatment was not provided;
however, it was estimated to be more than 30
days, and the result was an absolute change in
hemoglobin level of 7.6 g/dl.
The second patient was a 43-year-old man who
underwent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy.10
His initial hemoglobin level was 11.1 g/dl;
however, 18 days after surgery, it had decreased
to 4.6 g/dl. Therapy with subcutaneous rHuEPO
5000 units/day (60 units/kg/day) was started. By
day 32 after surgery, the patient’s hemoglobin
level had increased to 6.5 g/dl; the rHuEPO
dosage was reduced to 5000 units 3 times/week.
At hospital discharge, the patient’s hemoglobin
was 10.5 g/dl (absolute change 5.9 g/dl).
This case series described the only two known
reports in which patients were treated with
rHuEPO after undergoing general surgery.
Because only two patients were involved and the
rHuEPO dosages varied widely (60–280 units/
kg/day), one cannot draw conclusions regarding
the most appropriate rHuEPO dosage for this
population. Ultimately, both patients reached
similar hemoglobin level end points (10.4 and
10.5 g/dl) even though therapy was started at
very different times (day 2 vs 18 after surgery).
Gastrointestinal Hemorrhage
The mainstay of treatment for gastrointestinal
hemorrhage involves the repair or resection of
the source of bleeding, administration of proton
pump inhibitors, and blood transfusions as
needed. We identified four reports of Jehovah’s
Witnesses who received rHuEPO for this lifethreatening bleeding. A 66-year-old woman with
four shallow 0.5-cm ulcers in the peripyloric and
bulbar region had a hematocrit of 18%. 11
Although no active bleeding was noted, the
patient’s hematocrit dropped to 14.5% on
hospital day 3. Intravenous rHuEPO 20,000
units/day for 3 days was started, followed by
6500 units every other day. By day 14, her
hematocrit had increased to 27.1% (absolute
change 12.6%).
The second report involved a 63-year-old man
with a duodenal ulcer. 10 On admission, his
hemoglobin level was 4.8 g/dl. On day 15, his
hemoglobin level had further decreased to 4.4
g/dl; he was given rHuEPO 4000 units/day (50
units/kg) subcutaneously, which resulted in a
final hemoglobin level of 6.2 g/dl (absolute
change in hemoglobin level 1.4 g/dl) over the
next 12 days.
In the third report, rHuEPO was administered
to a 50-year-old woman for treatment of
gastrointestinal hemorrhage who had been
receiving rHuEPO 3000 units intravenously 3
times/week for anemia due to chronic kidney
disease.12 Before the gastrointestinal hemorrhage
occurred, the patient’s hematocrit was 33%,
which decreased to 18.4% on admission. When
her hematocrit decreased to 10.4%, her dosage of
subcutaneous rHuEPO was increased to 10,000
units (130 units/kg) 3 times/week and eventually
to 20,000 units (260 units/kg) 3 times/week. The
patient received approximately 1200 units/kg in
week 1, 1670 units/kg in week 2, and 270
units/kg each week thereafter. Her hematocrit
rose from 10.4% to 38.5% (absolute change of
28.1%) during the 4 weeks of the increased
rHuEPO dosage.
The fourth patient was a 50-year-old man with
prepyloric ulcer with stigmata and no active
bleeding; his hemoglobin level on admission was
4.3 g/dl.13 On admission to the intensive care
unit, his hemoglobin had dropped to 3.5 g/dl,
and subcutaneous rHuEPO 20,000 units (250
units/kg) every other day was started. His
condition declined, and ultimately he received 5
units of hemoglobin-based oxygen carriers based
on compassionate administration. On hospital
day 3, his dosage of subcutaneous rHuEPO was
increased to 40,000 units/day (500 units/kg/day).
Over the next 30 days, the patient’s hemoglobin
level increased to a maximum of 7.6 g/dl
(absolute change of 4.1 g/dl) before he died from
sepsis.
These patients with gastrointestinal hemorrhage
had the poorest outcomes compared with the
other critically ill Jehovah’s Witnesses. One died
after receiving both rHuEPO and an hemoglobinbased oxygen carrier; another survived but
remained in a vegetative state. In these reports,
less aggressive dosing strategies were used, and
the subcutaneous route of administration was
used in three of the four patients. Starting
dosages varied from 50 units/kg/day to 250
units/kg every other day; typically, dosages
required upward titration to a maximum of 500
units/kg/day. Furthermore, all patients with
gastrointestinal hemorrhage received rHuEPO
therapy for extended periods to achieve the
desired response; in two, the treatment duration
was 30 days or longer.
Adjunctive Therapy with Iron, Folic Acid, and
Vitamin B12
In most of the case reports, patients received
adjunctive therapies along with rHuEPO to
enhance production of red blood cells. These
therapies included iron, folic acid, and vitamin
B 12 (cyanacobalamin). Iron was the most
commonly used of the three adjuvant therapies.
Iron is used in hemoglobin production, and
hemoglobin response to rHuEPO may be greater
when the two agents are administered concomitantly. During rHuEPO therapy, functional iron
deficiency may be seen, probably due to the
inability to adequately mobilize iron stores
during the period of enhanced erythropoiesis.
The manufacturer recommends that iron stores
be evaluated before rHuEPO is administered,14
but this usually is impractical in urgent situations
as well as in critical illness. The manufacturer
also recommends that all patients receiving
rHuEPO after surgery receive supplementation
with iron, and notes that virtually all patients
receiving rHuEPO eventually require iron
supplementation.14
Folic acid and vitamin B12 are used in purine
and pyrimidine biosynthesis, which ultimately
leads to DNA biosynthesis. When either folic
acid or vitamin B 12 is deficient, synthesis of
proteins and redirection of metabolic pathways
are decreased, which ultimately leads to
ineffective erythropoiesis. It is recommended
that at least 3–5 µg/day of vitamin B12 should be
obtained from meat or dairy products each day.15
Although humans have stores of folic acid, these
are readily used, and humans require 50 µg/day
from their diet. During critical illness, these
dietary needs are generally not met, and
supplementation is required.
Alternative Therapy with Hemoglobin-Based
Oxygen Carriers and Perfluorocarbons
Hemoglobin-based oxygen carriers (e.g.,
PolyHeme; Northfield Laboratories Inc.,
Evanston, IL) as a substitute for red blood cell
transfusions are in clinical development. 16
Although these agents are not currently available
for use in the United States, they may be a viable
treatment alternative in the future for Jehovah’s
Witnesses. These products offer the advantages
of no cross-matching required before transfusion,
longer shelf-life than packed red blood cells
(often > 1 yr), and enhanced oxygen delivery.
Also, the risk of infectious disease transmission is
low, and nonrecombinant products undergo
extensive purification for sterilization.
Potential complications associated with
hemoglobin-based oxygen carriers include
nephrotoxicity from release of free hemoglobin,
hypertension, esophageal dysmotility, and
abdominal discomfort. These products may also
interfere with laboratory testing assays due to
their color. Clinicians should be aware of the
possible interference and work closely with the
clinical laboratory for alternative methods of
laboratory testing if possible.
Perfluorocarbons are another class of agents
developed for use in oxygen delivery. These
agents are made of raw materials and are carbon
based with either fluorine or other halogens.
Perfluorocarbons dissolve oxygen in proportion
to the partial pressure of oxygen. They are not
derived from human or animal blood, crossmatching is not required before transfusion, risk
of infectious disease transmission is low, and
immunogenicity is low. The shelf-life of
perfluorocarbons is up to 2 years, which is longer
than that of packed red blood cells. Potential
1388
Table 1. Summary of Case Reports of Jehovah’s Witnesses Who Received Recombinant Human Erythropoietin Therapy
Start versus End of Therapy
Age (yrs),
Hemoglobin Level
Hematocrit
Therapy Started Treatment
Sex
(g/dl)
(%)
(hospital day)
Duration
Starting Dosage
Trauma
36, F3
4.6 vs NR
14 vs ~40
7
17 days
300 units/kg i.v. q.d.
45, F4
3.2 vs > 8
NR vs NR
7
1 wk
36,000 units over 1 wka
48, M5
6.8 vs 11.3
NR vs NR
1
23 days
4750 units i.v. q.d.
(50 units/kg)
NR vs NR
12 vs 35
1
30 days
20,000 units i.v. q.o.d.
51, F6
44, F7
3.2 vs 9.8
NR vs NR
2
5 days
600 units/kg q.d.a
67, M2
Burns
52, M8
71, F9
General surgery
55, F10
3 vs 7.9
NR vs NR
2
47 days
48,000 units i.v. q.d.
8 vs 11
7 vs 7
24 vs NR
NR vs NR
10
15
4 wks
19 days
300 units/kg i.v. q.d. for 7 days
4000 units s.c. 3 times/wk
2.8 vs 10.4
8 vs 33
2
> 30 days
4.6 vs 10.5
NR vs NR
18
> 2 wks
10,000 units i.v. q.d. +
10,000 units s.c. q.d.
(280 units/kg)
5000 units s.c. q.d.
(60 units/kg)
NR vs NR
14.5 vs 27.1
3
11 days
20,000 units i.v. q.d.
63, M10
4.8 vs 6.2
15 vs 20
15
12 days
50, F12
NR vs NR
10.4 vs 38.5
2
> 30 days
50, M13
3.5 vs 7.6
NR vs NR
1
30 days
4000 units s.c. q.d.
(50 units/kg)
10,000 units s.c. 3 times/wk
(130 units/kg)
20,000 units s.c. q.o.d.
(250 units/kg)
43, M10
Gastrointestinal
hemorrhage
66, F11
NR = not reported.
a
Route of administration not reported.
b
This dosage was given for 10 days, then the frequency was decreased to every other day for 5 doses.
adverse effects are splenomegaly and hepatomegaly,
flu-like symptoms (back pain, malaise, flushing,
fever), and transient thrombocytopenia (on
hospital days 3–4).
Recommended Use of Recombinant Human
Erythropoietin in Jehovah’s Witnesses
Published reports of rHuEPO therapy in
Jehovah’s Witnesses experiencing traumatic
injury, burns, general surgery, or gastrointestinal
hemorrhage are limited to case reports and case
series (Table 1).2–13 Although it is impossible to
recommend a single dosing regimen that is
effective for treatment of hemorrhage in a
Jehovah’s Witness during critical illness, these
case reports illustrate that the drug is effective.
Of note, publication bias occurs for case reports
that are only positive. These cases summarize
the current pertinent medical literature but do
not include any unpublished negative or
untoward effects of rHuEPO.
Potential adverse effects of rHuEPO include
thromboembolic and cardiovascular events,
hypertension, headache, and arthralgias. When
considering treatment with rHuEPO, clinicians
should weigh these potential adverse effects
against the potential benefits.
Furthermore, although case reports provide the
poorest level of evidence from which to draw
conclusions and make recommendations, no
results from randomized controlled trials have
been published regarding rHuEPO therapy for
critically ill Jehovah’s Witnesses. The available
literature demonstrates the variation in the time
of starting rHuEPO therapy, the use of both
intravenous and subcutaneous routes of
administration, the variable and wide range of
doses for starting and continuing rHuEPO
therapy, the variable administration of adjunctive
agents, and the differences in treatment duration.
Proactive, early initiation of rHuEPO therapy
may be required to achieve optimal response in
Jehovah’s Witnesses given that rHuEPO’s effect
Table 1. (continued)
Ending Dosage
150 units/kg s.c. 3 times/wk
Same as starting dosage
28,500 units i.v. q.d.b
(300 units/kg)
7000 units i.v. q8h
300 units/kg q.d.a
Adjunctive Agents
Iron i.m.
Iron, vitamin B12, folic acid
Iron 300 mg i.m. b.i.d.,
vitamin B12 100 µg i.m. q.d.
Iron i.v.
Hemoglobin-based oxygen
carrier p.o., iron i.m.
Iron, vitamin B12, folic acid
150 units/kg s.c. 3 times/wk
Iron 300 mg t.i.d.
None
(140 units/kg)
Iron p.o.
5000 units s.c. 3 times/wk
(60 units/kg)
Iron i.v., vitamin B12,
folic acid
6500 units i.v. q.o.d.
Iron p.o., folic acid,
vitamin B12 s.c.
Iron i.v., vitamin B12,
folic acid
Iron i.v., folic acid
20,000 units s.c. 3 times/wk
(260 units/kg)
(500 units/kg)
Hemoglobin-based oxygen
carrier, iron p.o.
on hemoglobin level is delayed. Furthermore,
combining rHuEPO with adjunctive agents such
as iron, folic acid, and vitamin B 12 may be
required to achieve optimal response. There may
be a theoretical benefit to using the intravenous
route of administration in a few subgroups of
patients, such as patients whose conditions are
hemodynamically unstable or obese critically ill
patients, in whom drug absorption by the
subcutaneous route would be more variable.
Most of the case reports provided the rHuEPO
dosage as weight based (i.e., in units/kilogram).
Evidence is conflicting as to whether this is a
required method of rHuEPO dosing. Although
the original studies evaluating rHuEPO therapy
and hemoglobin response used weight-based
dosing strategies, subsequent studies have relied
on standardized regimens. A weight-based
approach also allows clinicians to gauge the
intensity of the dosing regimen.
The pharmacokinetic properties of rHuEPO
indicate a low volume of distribution (0.042–
0.07 L/kg).17 Therefore, one can estimate that the
drug should stay within the intravascular space
to maintain its effect instead of distributing
widely into tissues and fat. One advantage of
standardized dosing is that waste is minimized.
In addition, several case reports used standardized
dosing. Therefore, it seems reasonable to round
doses to the nearest vial size (i.e., 20,000 units).
Conclusion
The case reports we reviewed demonstrate that
rHuEPO may have a role in the treatment of
critically ill Jehovah’s Witnesses experiencing
trauma, burns, gastrointestinal surgery, or
gastrointestinal hemorrhage as an alternative to
blood product administration. Selection of
dosage and evaluation of adverse events remain
areas for future investigation. Along with
rHuEPO therapy, appropriate supplementation
with iron, folic acid, and vitamin B12 should be
strongly considered in patients with critical
illness.
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recombinant human erythropoietin (r-HuEPO) in a Jehovah’s
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4. Kraus P, Lipman J. Erythropoietin in a patient following
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Witness: case report and discussion. Am J Crit Care
1993;2(3):256–9.
6. Gilcreast DM, Avella P, Camarillo E, Mullane G. Treating
severe anemia in a trauma patient who is a Jehovah’s Witness.
Crit Care Nurse 2001;21(2):69–72, 75–8, 80–2.
7. Cothren C, Moore EE, Offner PJ, Haenel JB, Johnson JL.
Blood substitute and erythropoietin therapy in a severely
injured Jehovah’s Witness. N Engl J Med 2002;346(14):1097–8.
8. Boshkov LK, Tredget EE, Janowska-Wieczorek A.
Recombinant human erythropoietin for a Jehovah’s Witness
with anemia of thermal injury. Am J Hematol 1991;37(1):53–4.
9. Kim D, Slater H, Goldfarb IW, Hammell EJ. Experience with
patients with burns who refuse blood transfusion for religious
reasons. J Burn Care Rehabil 1993;14(5):541–3.
10. Wolff M, Fandrey J, Hirner A, Jelkmann W. Perioperative use
of recombinant human erythropoietin in patients refusing
blood transfusions: pathophysiological considerations based on
5 cases. Eur J Haematol 1997;58(3):154–9.
11. Pousada L, Fiorito J, Smyth C. Erythropoietin and anemia of
gastrointestinal bleeding in a Jehovah’s Witness [letter]. Ann
Intern Med 1990;112(7):552.
12. Walton T, Macon EJ. Erythropoietin use in a Jehovah’s Witness
patient. Ann Pharmacother 2002;36(4):729–30.
13. Gannon CJ, Napolitano LM. Severe anemia after gastrointestinal hemorrhage in a Jehovah’s Witness: new treatment
strategies. Crit Care Med 2002;30(8):1893–5.
14. Amgen Manufacturing Ltd. Epogen (epoetin alfa) package
insert. Thousand Oaks, CA; 2007.
15. DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey
LM, eds. Anemias. Pharmacotherapy: a pathophysiologic
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16. Stollings JL, Oyen LJ. Oxygen therapeutics: oxygen delivery
without blood. Pharmacotherapy 2006;26(10):1453–64.
17. McEvoy GK, ed. Epoetin alfa. In: AHFS drug information 2003.
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Injury, Int. J. Care Injured 40 (2009) 21–27
Contents lists available at ScienceDirect
Injury
journal homepage: www.elsevier.com/locate/injury
Review
The role of erythropoietin in the acute phase of trauma management:
Evidence today
N.K. Kanakaris a, G. Petsatodis b, B. Chalidis a, N. Manidakis a, G. Kontakis c, P.V. Giannoudis a,*
a
Academic Department of Trauma & Orthopaedics, Leeds Teaching Hospitals, Leeds, UK
University Orthopaedic Department, G.H. ‘‘G. Papanikolaou’’, Thessaloniki, Greece
c
Department of Trauma & Orthopaedic Surgery, University of Crete, Greece
b
A R T I C L E I N F O
S U M M A R Y
Article history:
Accepted 5 September 2008
Trauma patients often present in a state of haemorrhagic shock. Blood products remain the gold standard
of resuscitation, but allogeneic blood transfusions (ABTs) are associated with several risks. The
stimulating effect of recombinant-erythropoietin (EPO-A) on erythropoiesis has raised interest in its
administration as an alternative.
The existing evidence on the early use of EPO-A in the acute phase of trauma patients management
consists of only 14 publications. The level of evidence of these studies and the number of treated patients
was not found to be adequate to support its generalised use, despite their favourable results. Its safety
profile, the preliminary proofs of its efficacy, and the additional cyto-protective properties of EPO-A strongly
encourage further controlled studies assessing its use in the acute setting of initial trauma management.
ß 2008 Elsevier Ltd. All rights reserved.
Keywords:
Erythropoietin
EPO
Transfusion alternatives
Trauma
Review
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Trauma in Jehovah’s witnesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hip fracture trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Experimental studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
* Corresponding author at: Academic Unit, Trauma and Orthopaedic Surgery,
Clarendon Wing, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK.
Tel.: +44 113 3922750.
E-mail address: [email protected] (P.V. Giannoudis).
Abbreviations: ABT, allogeneic blood transfusions; BFU-E, burst forming unit
erythrocytes; CFU-E, colony forming units erythrocytes; CFU-GEMM, colony
forming units granulocytes erythrocyte monocyte/macrophage; EPO-A, recombinant human erythropoietin alpha; FDA, food and drug administration; Hb,
haemoglobin; IGF-1, insulin like growth factor-1; MOF, multiple organ failure;
RBC, red blood cells; RCT, randomised controlled trial/s; RDW, red cell distribution
width; rhEPO, recombinant human erythropoietin; rmSCF, recombinant murine
stem cell factor; rmIL-3, recombinant murine interleukin-3; SCF, stem cell factor;
SIRS, systemic inflammatory response syndrome; sTfR, serum transferrin receptor;
TRALI, transfusion related acute lung injury; UI/kg, units international per kilogram
of body weight.
0020–1383/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2008.09.006
21
22
23
23
23
24
24
25
25
25
Introduction
Contemporary trauma is characterised by a continuous rise in
its incidence and diversity. It can be broadly divided into highenergy trauma (i.e. motor vehicle collisions) that represents the
first cause of mortality of the young and active part of the
population), and low energy (i.e. falls) that affects the frail and
rapidly increasing elderly population.82
Despite the evolution in prophylactic measures and the
advances in emergency medicine and acute trauma management,
the morbidity and mortality burden is huge.8,11,69,72 The care of the
trauma patient usually involves major surgery in the first 48 h,
together with the need for blood transfusion due to the initial or
N.K. Kanakaris et al. / Injury, Int. J. Care Injured 40 (2009) 21–27
22
Table 1
Adverse effects and risks of allogenic blood transfusions (ABT).
a/a
ABT Risk
Reported incidence
References
1
2
3
4
5
6
7
8
9
10
11
12
13
Febrile reactions
Urticarial reactions
Transfusion related acute lung injury: TRALI
Haemolytic reaction
Viral hepatitis B
Viral hepatitis C
Human Immunodeficiency Viral infection
Anaphylactic shock
Fatal haemolytic reaction
Bacterial contamination
Human T cell lymphocyte virus I/II
Impairment of microcirculatory flow
Immune suppression: risk for MOF, SIRS
1:17–200
1:33–100
1:2,000–5,000
1:6,000–70,000
1:31,000–250,000
1:103,000–3,100,000
1:420,000
1:500,000
1:600,000
1:100,000–1,000,000
1:1,900,000
N/A
N/A
47,57
31,57
26,95
47,57
20,47,48
20,47,48,76
47,62
47,57
47,93
7,76,94
19,20
21,88
21,61,73,93
ABT, allogenic blood transfusion; MOF, multiple organ failure; N/A, not available; SIRS, systemic inflammatory response syndrome; TRALI, transfusion related acute lung
injury.
intraoperative blood loss and the necessary resuscitation requirements.2,59,75 Haemorrhage is the leading, but not the only, cause of
anaemia in injured patients.66,84 It is correlated with bone, visceral
and soft-tissue damage, with operative interventions, repetitive
excessive blood sampling, gastrointestinal blood loss, and also
impaired post-traumatic bone marrow function, and reduced iron
availability.39 It is constantly reported that over 60% of multiple
trauma patients, and 30–70% of the elderly with a hip fracture are
transfused with allogeneic blood during their hospitalisation.3,33,71
Allogeneic blood transfusions (ABTs) are the gold standard in
the effort to restore the transport of oxygen to the tissues. The
haemoglobin threshold of transfusion ranges between 7 and 10 g/
dl in the literature.36,57,70 However, significant concerns about the
adverse effects of ABT (Table 1) have prompted a review of
transfusion practice and the search for a safer and more
biologically rational treatment of anaemia. Moreover, the number
of units transfused has been shown to be an independent predictor
of worse clinical outcome.21,25,61,63 Furthermore the scarcity of
blood donors, the cost of maintenance of blood banks, and the
increase in demand for blood have all been considerable factors
questioning the current practice.59,77 Another reason for further
studying the alternatives to ABT in the trauma setting is the respect
given to the patients’ autonomy according to certain religious
beliefs against receiving allogeneic biological products.40,91
Several surgical and anaesthetic techniques have been developed to reduce bleeding (endoscopy, laparoscopy, electric scalpel,
minimally invasive osteosynthesis, invasive radiology, hypotensive anaesthesia, intraoperative blood salvage, re-infusion of postoperative drainage). In addition, a number of biological products
that reduce blood loss (aprotinin, antifibrinolytics and desmopressin acetate, factor VIIa), and new drugs that stimulate platelet
production (recombinant IL-11 and recombinant human thrombopoietin) have been all implicated in the quest of minimise the
need for ABT.9,76,85 Recently, blood substitutes have also been
studied in the trauma population such as polymerised human
haemoglobin,35,96 perfluorocarbons,83,89 and finally the stimulation of the endogenous production of red blood cells with
exogenous erythropoietin therapy.
Erythropoietin is a glycoprotein hormone that is secreted
predominantly by renal cortical interstitial cells in response to
tissue hypoxia and decreased red blood cell mass.68 It has a
molecular weight of 30,400 and its responsible gene is located on
chromosome 7. Erythropoietin acts directly on the red blood cell
precursors in the bone marrow, affecting their proliferation,
differentiation and the erythrocyte maturation (Fig. 1). Recently,
additional properties have been elicited. The identification of
erythropoietin receptors and its autocrine/paracrine production in
other organs (brain – astrocytes, neurons, brain capillaries –, spinal
cord, retina and testis), the ability of exogenous EPO-A to cross the
blood–brain barrier under certain circumstances, and the growing
evidence for its neuroprotective and neurotrophic role against
various types of neuronal damage (focal ischaemic stroke,
concussive brain injury, seizures, autoimmune encephalomyelitis,
spinal cord injury) increase the potentials of EPO-A administration.10,12,28,50,98
Recombinant human erythropoietin (rhEPO) has been produced commercially since the mid-1980s by using the ovarian cells
of Chinese hamsters, into which the gene for human erythropoietin
has been inserted.54 It has an identical sequence to endogenous
human erythropoietin and its haematopoietic properties are
indistinguishable. Four types of recombinant human erythropoietin exist: alpha, beta, delta and omega, with different pharmacokinetic and pharmacodynamic properties.86
Recombinant human erythropoietin alpha (EPO-A) has been
used to stimulate erythropoiesis. Usually, 72 h are required for a
significant reticulocyte response in peripheral blood and 10–14
days for an increase in haemoglobin levels. The magnitude of the
erythropoietic stimulation by epoetin alfa has been proven to be
dose dependent, and has been used in either daily dosing schemes
of 300 UI/kg or weekly doses of 600 UI/kg subcutaneously. Since
1989 and its first FDA-approved indication for renal failure
anaemia, it has been used in treating anaemias of various a
etiologies.22,37,56,64 Furthermore, the evidence for its use during
the prolonged hospital stay of the trauma patients, especially in the
intensive care setting, is increasingly supportive.15,16,55,81,93
On the other hand, blood loss or post-injury anaemia at the
acute setting needs a fast intervention in order to avoid
cardiovascular strain and circulatory shock. Thus, EPO-A has not
been tried in initial trauma management, but mostly as a preoperative adjuvant to elective surgery.1,24,46,51,60 The aim of this
study is to comprehensively review the existing evidence for the
use of erythropoietin in the initial stages of trauma management.
Materials and methods
A standard Medline literature search was performed. The
keywords ‘‘erythropoietin’’, ‘‘EPO’’, and ‘‘trauma’’ or ‘‘injury’’ were
used in an OVID search engine query (http://gateway.uk.ovid.com,
accessed last 15-07-08). As exclusion criteria we used studies
referring to elective cases, or to the use of erythropoietin in
intensive care or during prolonged hospital stay of trauma cases, or
for other types of anaemia besides post-traumatic or intraoperative due to bleeding, review articles, letters to the editor, expert
opinion articles, and editorials. Articles’ abstracts were retrieved
23
Figure 1. Erythropoietin interaction on the red blood cell precursors in the bone marrow, affecting their proliferation, differentiation and the erythrocyte maturation.
and evaluated for their suitability for review. When the publications included relevant data from previous studies, the original
studies were also retrieved and used for the present analysis.
Results
The initial PubMed query found 771 publications from 1963 till
2008. After applying the exclusion criteria, and evaluating the
abstracts of 105 publications, 14 original studies met the inclusion
criteria (Table 2). There were 8 studies referring to trauma in
Jehovah’s witnesses,13,18,29,43,49,52,53,92 4 prospective/retrospective
trials focused on hip fractures,27,32,41,74 and 2 experimental in vivo
studies.38,44
literature.13,18,29,43,49,52,53,92 The reported types of trauma were
either blunt or penetrating, and in several cases the severity of
blood loss reached critical levels. Alternatives means of restoring
the lost blood cell volume are limited in these patients, and the
option of EPO-A together with iron supplementation offered
accelerated erythropoiesis and minimised the time period of these
patients being at risk. The administered subcutaneous doses of
EPO-A varied between 300 UI/kg three times per week, or daily for
5 consecutive days, or 50 UI/kg every alternate day in a paediatric
case.18 The positive results of these case reports have been quoted
in the literature by several authors in order to provide arguments
towards an expansion of rhEPO indications in the trauma field,
despite the fact they are just sporadic reports at a minimal
evidence level.
Trauma in Jehovah’s witnesses
Hip fracture trauma
Recombinant human erythropoietin administration in Jehovah’s witnesses refusing blood transfusions has offered a safe and
reliable solution in all the case reports we retrieved in the existing
The combined administration of intravenous iron and
recombinant human erythropoietin (rhEPO or EPO-A) in the
Table 2
Studies referring to the use of erythropoietin in the acute trauma setting.
a/a
Studies
Level of evidence5
Number of cases/controls
Subject
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Jim43
Koestner et al.49
Kraus and Lipman52
Collins and Timberlake13
Victorino and Wisner92
Gilcreast et al.29
Lanthaler et al.53
Digieri18
Goodnough and Merkel32
Schmidt et al.74
Garcia-Erce27
Izuel-Rami et al.41
Hoynck van Papendrecht et al.38
Jones et al.44
IV
IV
IV
IV
IV
IV
IV
IV
III–IV
III–IV
II
III
II
II
1
1
1
1
1
1
1
1
9
4
83
63
15
15
Jehovah’s witness case report
Jehovah’s witness retrospective case series
Hip fractures prospective case series study
Hip fractures prospective case series study
Hip fractures prospective case control study
Hip fractures retrospective case control study
Blood loss in rats experimental in vivo study
Blood loss in mice experimental in vivo study
a
b
c
Control group treated without iron or EPO-A.
Control group treated without any supplement or with only oral iron.
Control group treated with iv and oral iron supplementation.
vs.
vs.
vs.
vs.
41a
196b vs. 68c
30
45
24
acute setting of hip fracture surgery was studied by Goodnough
and Merkel.32 In their case series they included 7 patients
with an intertrochanteric and 2 with a neck of femur fracture,
a median age of 78 years (71–90), a median admission
haematocrit of 35.2% (42.6–41%), and median intraoperative
blood loss of 550 ml (150–1000 ml). They received 150 UI/kg of
subcutaneous EPO-A daily until discharge (median length of stay
was 6 days/range 3–7). The median net calculated increase in
RBC volume after EPO-A administration ranged from 316 to
492 ml (median 398). However, 3 of these 9 patients did not
avoid an ABT. The authors refer to a historic control group of hip
fractures where ABT was used in 61% of the patients, to conclude
in favour of the use of erythropoietin in the hip fracture
population, as it decreased the transfusion incidence by half. The
lack of a proper control group and the small numbers in the
study population certainly limits the strength of evidence of this
particular study, and weakens the strength of the authors’
arguments.
A similar small series of hip fracture patients treated with
rhEPO (150 UI/(kg day) sc plus a single dose of iv iron on the day of
admission) have been reported as preliminary results in a review
article by Schmidt et al. in 1998.74 In a preliminary analysis of these
results the authors reported a steady increase in the reticulocyte
count starting from day 1 to day 5, in 3 out of 4 patients, suggesting
a favourable effect of EPO-A as an early stimulus of erythropoiesis
in hip trauma.
In 2005 a prospective, observational, non-randomised study
was published addressing more systematically the administration
of EPO-A in the same trauma population. Garcia-Erce et al.27
studied the effect of a single subcutaneous dose of 40,000 UI of
EPO-A together with three doses of intravenous iron in
75 osteoporotic hip fracture patients with an admissionHb < 13 g/dl. They compared the ABT incidence and the number
of transfused blood units together with several clinical outcome
measures between this study group and a control group of
similarly injured patients, with comparable demographics and
treatment methods. The transfusion data showed a significant
decrease in the rates of ABT in the EPO-A group that reached
statistical significance, especially in female patients and for
intertrochanteric hip fractures. Moreover, a trend towards fewer
post-operative infections and lower 30-day mortality was
observed at the EPO-A group. The accelerated erythropoiesis of
the EPO-A group was verified through laboratory tests at the 7th
post-surgery day with an increase of the reticulocyte count, serum
transferrin receptors (sTfR), and red cell distribution width
(RDW). The authors found a clear benefit of using rhEPO in order
to reduce the requirements of ABT and the potential adverse
effects of allogeneic transfusions in the specific trauma population of hip fractures.
The same year another publication focused again on hip
fractures and the use of rhEPO.41 The authors studied the
effectiveness of perioperative anaemia treatment with iron or a
combination of EPO-A and iron, on transfusion rates, postoperative haemoglobin levels, post-operative length of stay, and
infection rates. They reviewed retrospectively studied 329 hip
fracture patients of whom the EPO-A group (one subcutaneous
dose of 40,000 UI) consisted of 63 cases. This subgroup of patients
was transfused less than the rest (36.5% vs. 52.0% in the control
group with just oral iron supplementation, and 67.6% in the third
group of both iv and oral iron administration) (p = 0.002). There
were no significant differences in the infection rates and mean
post-operative stay between the subgroups. They argued with
Goodnough and Merkel,32 Schmidt et al.,74 and Garcia-Erce et al.27
in favour of the combined administration of rhEPO with iv iron in
order to minimise ABT.
Experimental studies
The data produced by the in vivo studies was confirmed in two
animal models of acute blood loss. In 1992 Hoynck van
Papendrecht et al.38 investigated the hypothesis that the administration of EPO-A can reduce the need for ABT. They produced a rat
model of a 20% blood loss and tried different schemes of EPO-A
administration starting pre-operatively, or on the day of operation,
with a duration of 5 or 10 days, and compared their results with
controls which did not receive any EPO-A. Their results indicated
that the administration of EPO-A in the acute setting immediately
after surgery provided a stimulus for an increase of Hb levels that
however did not show the marked difference of the subgroup of
early pre-operative EPO-A treatment. The prolonged scheme of
EPO-A treatment also offered minimal benefits that appeared after
the 8th post-operative day. They concluded that the beneficial
effect of EPO-A could be anticipated in elective cases where preoperative administration is feasible but not in the acute setting of
traumatic blood loss.
Jones et al.44 investigated also the effect of recombinant human
erythropoietin (rhEPO) in a mouse model of blood loss (one third of
calculated total blood volume). Three study groups received rhEPO
and the control group only iron supplementation. In addition to
erythropoietin, the authors investigated the effect of two nonerythroid-specific progenitors (recombinant murine stem cell
factor (rmSCF) and recombinant murine interleukin-3 (rmIL-3)).
The administration of rhEPO in the study groups was initiated 4
days after the blood loss in all groups and consisted of 3 daily doses.
The most interesting finding was that the subgroup receiving
rhEPO without any other cytokines had a somewhat reduced
presence of erythroid progenitors compared to the control. This led
the authors to conclude that the response of an individual to the
use of rhEPO in the acute setting of trauma is governed by the
presence of these rhEPO-target cells. In their model the administration of exogenous erythropoietin did not increase further the
numbers of these cells and questioned the rational of supplementing the endogenous erythropoietin secreted after the stimulus of
blood loss with rhEPO.
Discussion
Recombinant human erythropoietin as a blood conservation
agent is well established for use in patients with anaemia of a
chronic nature (chronic renal failure,78 post-radiation or chemotherapy aplastic anaemia56), or preoperative in elective
surgery,23,60 and critically ill patients.14,87 Primarily, the satisfactory safety profile of rhEPO in these clinical settings, and
secondarily, the adverse effects of ABTs have lead to an expansion
of its use.
The reported side effects of EPO-A administration (namely
thromboembolic events 10–16%, hypertension, seizures, influenza-like symptoms, etc.—all <10%) originate mostly from the
large series referring to elective surgery, critically ill, or patients
with chronic anaemia.4,16,67 However, in all of the studies referring
to the use of rhEPO in the specific setting of polytrauma (case
reports of Jehovah’s witnesses), or low energy hip trauma in the
elderly, no major concerns have been raised concerning the safety
of the administration of rhEPO. The dosing schemes used varied
from single doses of 40,000 UI to daily doses of 150 UI/kg or
alternate daily doses of 300 UI/kg. Mostly they were a reflection of
the proven safe doses of EPO-A used in the existing large series of
erythropoietin in different clinical settings.30,90
The efficacy of exogenous erythropoietin is reported as
satisfactory and there appears to be a consensus in the existing
trauma literature that it upregulates erythropoiesis and decreases
the transfusion rates and the amount of blood needed per
patient.34,57 This effect is seen on standard laboratory tests
(reticulocyte cell count) after the 2nd or 3rd day. A few authors
also report a correlation of the administration of EPO-A and the
resulting blood transfusion decrease with significant clinical
outcome parameters such as post-operative infection rates and
30-day mortality.27,41
The supplementary cyto-protective role of EPO-A has been
strongly supported by mainly preclinical studies over the last
decade and this adds to the arguments in favour of its use in injured
patients.12 The results of many animal and a few clinical studies
demonstrate that rhEPO protects the brain, spinal cord, retina,
heart, and kidney from ischaemic and other types of injury.28,45
Mainly its neuroprotective effect has been proven to minimise
tissue necrosis if given in the initial 24 h after blunt brain or spinal
trauma.50,98
The large recent RCT of Corwin et al.,16 which included among
others 793 trauma patients admitted to intensive care units of 115
medical centres, did not find any significant effect of EPO-A
administration on ABT transfusion rates and quantity in comparison to the placebo group. However, the authors reported
statistically significant difference in the raise of Hb levels in the
EPO-A group (1.6 2 g/dl vs. 1.2 1.8 g/dl), a higher incidence of
venous thromboembolism (16.5% vs. 11.5%), and a decrease in the
overall mortality rate (8.5% vs. 11.4%). They explained their surprising
results regarding the effect of EPO-A on ABT transfusions by the low
transfusion threshold (Hb < 8 g/dl) they used and most importantly
the decrease on mortality by the cyto-protective properties of EPO-A.
The existing evidence from rhEPO administration in the acute
setting of the initial management of trauma is nonetheless
insufficient. As recorded in this review, it results from just a few
studies, which are of low level of evidence. Either they are case
reports or small case series, or they are biased due to the lack of
proper randomisation. The shortfall of the published studies is
mentioned in the existing reviews on the subject.34,58,74
The reported advantages of its use at the small subgroup of
injured patients who strongly oppose ABT cannot directly correlate
with the clinical conditions of the vast majority of the trauma
population. It offers a relatively safe alternative, with unproven
efficacy. In injured Jehovah’s witnesses, the supporting evidence
does not reach the contemporary requirements of evidence-based
medicine. A well-designed and conducted multicentre study is
required to provide strong proof of its efficacy in this particular
patient group.40,91
The two quoted experimental studies38,44 raise a significant
concern regarding the rationale of rhEPO in the acute trauma
setting. The basic limitation is the rate and volume of erythropoiesis that is achievable with exogenously administered rhEPO. The
available population of cells expressing erythropoietin receptors
governs the magnitude of the erythropoietic response anticipated
after EPO administration. The cell-targets of EPO are shown in
Fig. 1 and are also affected by cytokines (IL3, SCF, IGF-1) besides
erythropoietin. The burst forming unit erythrocyte (BFU-E) is the
earliest cell of the erythrocyte lineage that can be stimulated by the
erythropoietin (endogenous or exogenous), and can act as a
threshold to the erythropoietic response besides the administration of rhEPO.
The recent addition of the RCT of Corwin et al.16 is a significant
step forward that denotes the importance of conducting welldesigned multicentre trials with clear endpoints. Unfortunately it
was not focused only in trauma and assessed mostly polytrauma
patients who were admitted for over 2 days at an ICU.
Another significant parameter is the cost-effectiveness of EPO-A
in the trauma population. EPO-A is an expensive drug and its use
must be justified by proper health economics analysis. The existing
25
evidence is again drawn from studies referring in other clinical
settings.17,79 The conclusion of these studies is mostly in favour of
the use of EPO-A and one would expect similar positive results in
the acute trauma setting. However, recent studies on critically ill
patients failed to identify statistically significant differences with
direct financial benefits.16,80 A cost of $2154 for five doses of EPO-A
was required to avoid one transfusion. The authors preserved their
reservations over its use, and advocated further research focused
on the potential clinical and financial benefits in the trauma
population.
We expect in the near future the publication of randomised
controlled trials (RCT) evaluating the safety, efficacy, and costeffectiveness of rhEPO in trauma and polytrauma patients. The
necessity of reducing ABT is pressing and stimulates the scientific
community towards transfusion alternatives. Of special interest
will also be the combination of RBC substitutes and rhEPO therapy,
but this should be anticipated in a longer time frame as RBC
substitutes are under investigation in phase III trials.42,65,97
A well designed RCT study5,6 should focus on a certain subgroup
of trauma or polytrauma (e.g. hip fractures, or pelvic fractures);
should include a standardised administration of iv iron and at least
two different dosing schemes of EPO-A (e.g. a single dose of
40,000 UI and 150 UI/(kg day)) initiated on admission; should
exclude patients with a Hb > 13 g/dl, history of clinically evident
venous thromboembolism; should have standardised transfusion
trigger thresholds (e.g. Hb < 8.0 g/dl), and include clinical and
laboratory endpoints (reticulocyte cell count, Hb, time of recovery
of the anaemia, evaluate quality of life and functional recovery of
the patient, complication rates, infection rates, length of hospital
stay, 30-day mortality rate, etc.).
Ideally, these endpoints would be enriched with secondary
endpoints (e.g. cognitive function, extent and outcome of brain or
spinal necrosis, cardiac functional parameters) assessing the
additional cyto-protective effect of EPO-A in blunt head or cardiac
trauma patients. The evaluation of erythropoietin’s safety should
include blood pressure and venous flow objective measurements.
Finally, a power analysis of the necessary study sample in order
to have results which reach statistical significance should be
performed in order to be successful and be completed at a
reasonable time frame.
Conclusion
The existing evidence doesnot support the administration of
recombinant human erythropoietin in trauma patients in the
initial phases of their management. There are indications that it
has a safe profile at the standard doses of elective cases, and is
effective in low energy hip-trauma in the elderly. Well designed
and performed randomised controlled studies are needed to
establish treatment protocols before the administration of this
agent is expanded to clinical practice in acute trauma.
Conflict of interest
None.
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Hematology, June 2006; 11(3): 187–191
The care of a child with multiple trauma and severe anemia
who was a Jehovah’s Witness
LUCIANA ANDREA DIGIERI, IVAN POLLASTRINI PISTELLI, &
CID EDUARDO DE CARVALHO
Intensive Care Unit, Pediatric Department, Faculty of Medical Sciences, Santa Casa de São Paulo, Rua Cesário Mota Júnior,
112—CEP 01221-020, São Paulo, Brazil
Abstract
Jehovah’s Witness followers do not accept blood derived transfusions and available methods for avoiding transfusion have been
used with degrees of success, demonstrating that the probability of death after trauma in these patients may not be significantly
different from religious groups. In this report, we describe the case of a child victim of a multiple trauma with severe anemia
due to blood loss, whose family would not authorize blood transfusion because of their Jehovah’s Witness faith. We discuss the
current indications for restricting transfusion, as well as highlighting new tools that contribute to the success of minimizing
blood loss, thus avoiding transfusion.
Keywords: Blood transfusion, anemia, trauma, Jehovah’s Witness
Introduction
Trauma is among the main causes of morbidity and
mortality in children and adolescents in Brazil and in
the United States, contributing a greater number of
lost life years than those due to oncologic and
cardiovascular diseases added together [1]. Currently,
the risks and complications of blood transfusions are
being studied and new measures to minimize the need
for its use have been developed, in addition to the
respect given to the patients’ autonomy or those
responsible for their religious beliefs.
In this study, we report a case of a child injured by a
car accident causing severe anemia, whose family did
not authorize blood transfusion because they are
Jehovah’s Witnesses, and discuss the current tendency
for restricting transfusion, as well as elucidating new
tools that contribute to the success of minimizing
blood loss, thus avoiding transfusion.
Case report
Six-year-old male child, coming from São Paulo, was
the victim of a motor vehicle accident with transient
loss of consciousness at the site of the injury, was
transferred by the air transportation unit and taken to
the Hospital of the Santa Casa de Misericordia de São
Paulo. During transport, the victim received volume
expansion (20 ml/kg). The patient arrived immobilized, conscious, oriented, pallor 3 þ /4 þ , respiratory rate of 28 breaths per minute, heart rate of 132
beats per minute, blood pressure of 100/60 mmHg,
Glasgow Coma Scale of 15, with scalping, loss of brain
matter, cranial depression, periorbirtal edema on the
right, abrasion wounds on the face, thorax and
abdomen, stable hip, hematoma on the right thigh
with femur fracture, a contusion – laceration wound on
the left thigh and scrotal region and glans penis
hematoma.
Initial laboratory investigation revealed a normal
amylase, hemoglobin (Hb) of 6 g/dl and hematocrit
(Ht) of 18.6%. Volume expansion was repeated using
100 ml/kg of Ringer lactate and the patient was sent
for imaging studies (Computerized tomography of the
cranium, cervical column, thorax, abdomen and
radiography of the entire body), and remained stable
with a heart rate between 88 and 110 bpm, respiratory
Correspondence: L. A. Digieri, Intensive Care Unit, Pediatric Department, Santa Casa de São Paulo, Faculty of Medical Sciences,
Rua Cesário Mota Júnior, 112 –CEP 01221–020– São Paulo, Brazil. Tel: 55 11 5572 2693. Fax: 55 11 55728420. E-mail: [email protected]
ISSN 1024-5332 print/ISSN 1607-8454 online q 2006 Informa UK Ltd.
DOI: 10.1080/10245330600774942
188 L. A. Digieri et al.
rate between 20 and 28 bpm and mean BP between 73
and 83 mmHg. Cranial computed tomography
detected brain swelling and cranial depression; the
other tomography studies did not reveal other lesions.
The radiography study demonstrated a hip fracture
and confirmed right femur fracture, and a contrast
study ruled out urethral lesion.
Despite volume expansion, the patient quickly
developed hemodynamic decompensation, with
tachycardia and hypotension, and was sent to the
surgical department where he received 180 ml/kg of
volume, of both colloid and crystalloid, and underwent surgery for cleaning and suture of the scrotal
wound and laceration on the left thigh; following these
procedures, the neurosurgery team repaired the
cranial wound via a right frontal craniotomy of the
depressed region and anchoring of the dura mater on
the bone border. The plastic surgery team then
undertook débridement of the devitalized necrotic
tissue and carried out a scalp rotation repair, with
approximation of the surgical wound borders. The
orthopedic surgery team finalized the operation with
reduction and external fixation of the right femur
diaphysis fracture through endoscopy.
During surgery the patient maintained a normal HR
and mean blood pressure on the lower normal limit.
Anesthesia was of the duration of 712 h and surgery 7 h.
At the beginning of anesthesia the patient presented
Ht of 18% and the family would not authorize blood
transfusion because their religious faith. Three hours
from the beginning of anesthesia, the patient
presented an Ht of 14.9% and 5 h from the beginning,
an Ht of 12.5%. Blood gas analysis, in series, was done
to verify the intraoperative levels of lactate, and all the
analyses demonstrated slight compensated metabolic
acidosis and slightly elevated lactate (between 1.9 and
3.0). The patient was quickly sent to the Pediatric
ICU where he was sedated and intubated. The patient
presented pallor 4 þ /4 þ , with miosis and normal
pupil reflexes, systolic murmur 2 þ /6 þ present on
all auscultation sites of the precordium, heart rate of
124 bpm, BP of 114 £ 47 mmHg, respiratory rate of
15 bpm, Sat O2 of 98%, filiform peripheral pulses with
slowed capillary perfusion and filling. The patient
presented light metabolic acidosis, 12% Ht, altered
coagulation screen, normal electrolytes and renal
function. Prophylactic antibiotic therapy was started,
as well as vitamin K and erythropoietin therapy
(50 UI/kg, SC) on alternate days and folic acid (5 mg)
on a daily basis. After a few hours the child developed
hypotension, without improvement following volume
expansion (60 ml/kg), receiving dopamine at an initial
dose of 5 mcg/kg/min, and progressively increasing the
dose to 15 mcg/kg/min, establishing hemodynamic
improvement. In the 24 h that followed the introduction of dopamine, another three volume expansions
were necessary using 20 ml/kg of Ringer lactate due to
decreasing BP. Hemodynamic stabilization was only
Figure 1. Chronological evolution of mean blood pressure.
achieved 48 h after surgery (Figure 1), at which time
dopamine infusion was suspended. There was an
increase in the Ht from 12 to 14.9 within the period
of 1 week.
During the postoperative period there was much
discussion among the clinical teams regarding blood
transfusion despite the family’s non-approval, with the
teams in favor of the transfusion arguing that the low
Ht levels could damage the area where the scalp was
repaired, with loss of the graft and possible meningeal
infection. However, the Pediatric ICU team decided
that transfusion could be withheld unless anemia
decompensated with immediate risk to life, respecting
the firm and irrevocable opinion of the family.
On the 4th postoperative day, the child developed a
fever and after 72 h of clinical and laboratory
observation, the antibiotics were changed, and the
child returned to a normal apyretic state in 48 h. One
week after the trauma, the dose of erythropoietin was
increased from 50 to 300 UI/kg on alternating days
and intravenous iron hydroxide was introduced at a
dose of 3 mg/kg/day during 7 days. Approximately 10
days following the accident, the patient had an Hb of
5.0 d/dl and the scalp showed a central point of
necrosis, and again the possibility of transfusion was
discussed. One week later, surgical débridement of the
necrotic tissue was performed. During the 20 days that
the patient stayed at the hospital from the date of the
accident, he received 10 doses of erythropoietin. On
the 20th day the patient the Hb had increased to
10.3 g/dl (Figure 2), at which time erythropoietin
therapy was suspended and a few days later was
discharged from the hospital.
Figure 2. Chronological evolution of Ht.
Severe anemia and Jehovah’s
Two months after the accident the patient returned
to the hospital for orthopedic follow-up and brought
laboratory exams revealing Hb of 12.6 g/dl and Ht
of 39.8%.
Discussion
Jehovah’s Witness, is a religion that has more than 6
million followers worldwide [2], it does not accept
blood transfusions due to beliefs based on biblical
passages, such as “Every moving thing that liveth shall
be meat for you. But flesh with the life thereof, [which
is] the blood thereof, shall ye not eat” (Genesis 9:
3 –4) and “And whatsoever man (there be) of the
house of Israel, or of the strangers that sojourn among
you, that eaten any manner of blood; I will even set my
face against that soul that eateth blood, and will cut
him off from among his people, for the life of the flesh
(is) in the blood” (Leviticus 17:10 –11) [3]. Despite
refusing blood derived products, it is known that the
probability of death after trauma in previously healthy
JW patients is similar to those of other religious
groups, usually due to the extra efforts exerted in care
because of the refusal of blood, permitting critically
lower levels of hemoglobin for longer periods [2].
In general, after bleeding is controlled, the Ht has a
tendency to stabilize within 5 –6 days, increasing
slowly and progressively from this point on [4]. This
observation supports the minimization of transfusion
as it is recognized that the initial low Ht level is
inevitably followed by recovery.
Several publications in the literature describe
different Ht levels for the indication of transfusion,
most of these with hemoglobin under 8.4. Recently,
however, there has been a trend to recommend blood
transfusion from either lower values or only in cases of
hemodynamic instability, rather than using a specific
Ht level as a trigger. Studies have shown that low Ht
levels, such as 20%, are well tolerated in healthy and
hemodynamically stable children [4] and, therefore,
all indications for transfusion should be individually
analyzed in order to assure that they are based on the
clinical observation of the patient, the presence of
eventual hemorrhage and on hemodynamic parameters, rather than the Ht alone.
The duty of the blood bank team, hematologists,
surgeons, anesthesiologists and intensive care doctors
is of fundamental importance for minimizing blood
loss, consequently avoiding transfusions. Several
surgical and anesthetic techniques have been developed to avoid blood loss, such as the development of
approaches that reduce bleeding (endoscopy and
laparoscopy); development of the electric scalpel and
of biological material, such as “fibrin glues”, that
eliminate extensive areas of bleeding; use of new drugs
that stimulate platelet production (recombinant IL-11
and recombinant human thrombopoietin), reduce
blood loss during surgery (aprotinin, afibrinolytics
189
and desmopressin acetate) and help to reduce acute
bleeding (desmopressin and FVIIa); maintain
anesthesia with controlled hypotension during surgery
(in orthopedic patients it may reduce blood loss up to
50%) and avoid hypothermia (which reduces platelet
function and increases bleeding) [5]. However, the
most important advance recognized for blood transfusion prevention is the use of recombinant human
erythropoietin.
Erythropoietin is a glycoprotein that directly acts on
the red blood cell precursors in the bone marrow,
controlling proliferation, differentiation and erythrocyte maturation. The erythropoietin gene is located on
chromosome 7q 11 – 22 and consists of five exons and
four introns. Four types of recombinant human
erythropoietin exist: alpha, beta, delta and omega
and present different pharmacokinetic and pharmacodynamic properties. The administration of recombinant human erythropoietin (alpha) has shown an
increase in reticulocyte count and Ht levels, reducing
the need for transfusion. Administration can be done
subcutaneously, which does not require access and
prolongs the increase of serum erythropoietin,
sustaining the erythropoiesis stimulus, or can be
administered intravenously. The rate of administration can be daily or once, twice or three times a
week, according to the necessity of each patient [6].
In JW patients, erythropoietin has been used
successfully, avoiding transfusions in several surgical
procedures with initial doses of 300 UI/kg, three times
a week; other studies have used erythropoietin doses of
150 UI/kg/week for 3 – 4 weeks, prior to elective
surgeries, such as thoracic, cardiac or orthopedic,
where there can be loss of up to 20% of the total
volume, with results demonstrating up to 50%
reduction in the need for transfusions. Another form
of administration, which is also effective, is with an
initial dose of 300 UI/kg/day during five consecutive
days, followed by alternating days until a 38% Ht level
is achieved. This same study demonstrates a 50%
reduction in the number of transfusions a critical
anemic patient receives, whether from sepsis, blood
loss, reduction in the endogenous erythropoietin
production, functional iron deficiency associated to
the immune system or frequent exam collection,
which are the most important causes of anemia in
these patients [7]. Usually, 72 h are required for a
significant response in the detection of increased
reticulocytes in peripheral blood and 10 – 14 days for
an increase in hemoglobin levels [6].
Erythropoiesis is accelerated with administration of
erythropoietin and may result in the depletion of the
patient iron stock. Therefore, nutritional support and
iron supplements are highly recommended during
therapy and serum iron should be analyzed on a
regular basis [2]. The association of erythropoietin
with intravenous iron reduces erythropoietin doses
and accelerates the correction of anemia [6,8]. Among
190 L. A. Digieri et al.
the possible side effects of erythropoietin use, the
literature cites self-limited cold-like conditions, that
improves within 24 h with treatment of the symptoms;
hypertension and thrombosis associated to the rapid
increases in hemoglobin; anaphylactic reaction,
hyperkalemia and thrombocytosis, which are rarely
reported [6]. Close clinical observation minimizes
such occurrences.
There are various complications that may be
associated to blood transfusion, such as allergic
reaction and risk of death associated to mismatched
transfusion affecting either ABO, rhesus or other
antigen systems. There have also been confirmed
reports of bacterial contamination in platelet concentrates and platelets obtained by apheresis affecting
1:2000 units transfused and, even though the
prevalence of bacterial sepsis associated to transfusion
is unknown, it is estimated that there are 333 – 1000
cases of severe sepsis each year [5]. Furthermore, it is
important to bear in mind the transmission of
infectious viral diseases through contaminated blood.
The rate of HIV transmission is progressively getting
smaller from the education and careful selection of the
donors; associated with the application of new
laboratory tests, such as that which detects the p24
virus antigen and reduces the immune window from
22 to 16 days. This has already become routine in the
US blood banks at a cost of 5$ per unit, preventing
approximately 8 cases of HIV associated to transfusion
per year. The rate of hepatitis C transmission from
blood transfusions still remains much higher than that
of HIV, and has an incidence of 1:103,000, with 85%
of these patients developing chronic hepatitis and 20%
developing cirrhosis, with the high risk of hepatocarcinoma [9].
One of the least considered but significant effects of
transfusion is immunosuppression which also contributes to mortality [7], several studies have
demonstrated that blood transfusions have been
associated to higher incidences of postoperative
infections in several populations [5,7,10], and greater
rates of neoplasia recurrence according to the number
of transfusions done [5,9]. One hypothesis that
reinforces this connection between transfusion and
immunosuppression is the possibility that transfusion
may increase the risk for nosocomial infection and
sepsis. In a study conducted in Europe, Vincent et al.
demonstrated a positive relationship between the
increase in transfusion rate and mortality. Mortality
was roughly two times greater among patients that
received transfusions. After controlling factors such as
disease severity and organic failure, the authors
estimated that blood transfusions increased mortality
in 37%, demonstrating that the mortality rate was
significantly greater in the group that received blood
in comparison to the group that did not [7]. On
average, each unit of transfused blood increased the
risk of nosocomial infection by 50%. Patients that
receive transfusions are 12 times more susceptible to
developing hospital acquired pneumonia [7,11]. Also
favoring this theory, there are studies that demonstrate reduced risks of infection and mortality in
patients who receive filtered blood. The difference in
mortality is mainly due to an increase in the incidence
of multiple organ failure (MOF) or anastomosis
dehiscence in patients that received non-filtered
blood. Other studies demonstrate a significant
increase in MOF in victims of trauma who received
6 or more units of blood, reinforcing the hypothesis
that the white blood cells of the transfused blood
exacerbate an inflammatory response after the trauma
[9]. The use of blood lacking leukocytes may result in
a shorter period of intensive care and less complications, according to several publications [11]. Bilgin
et al. [12] undertook a study comprised of two groups
of patients that underwent cardiovascular surgery,
with one receiving normal blood and the other
receiving blood without leukocytes. It was observed
that the group with leukodepletion has a 4%
reduction in the mortality rate. Cytokines accumulated during blood storage are not removed during
filtration, and therefore reach similar levels in filtered
and non-filtered blood [9].
In studies done in critical ICU patients that
developed acute respiratory distress syndrome
(ARDS) after hospitalization and had analysis to
identify risk factors for its development and subsequent mortality, it was demonstrated that blood
transfusion significantly increases this risk and death
by ARDS, having a dose dependent effect [10].
The risk and adverse effects of blood transfusions
has led to the development of blood substitutes.
Several components are in varying stages of development and testing, but the side effects are still too great,
limiting their use on a routine basis.
Polymerized human hemoglobin is being developed and does not seem to present toxicity
associated to its components. In two published
studies, the patients received up to 6 units of this
polymer (equivalent to 6 units of blood) without
demonstrating fever, renal toxicity, liver dysfunction
or other signs of toxicity. Even though the sample in
these studies is small, if the safety and efficacy of this
polymerized hemoglobin is to be confirmed in more
comprehensive studies, a significant reduction may
occur in conventional blood transfusion, especially
those done electively [9].
Intraoperative hemodilution may be better tolerated than postoperative anemia because of the reduced
need of oxygen during general anesthesia [9]. The
only indication for blood transfusion is in increasing
oxygen supply for the tissues. The normal response to
normovolemic anemia is an increase in cardiac output
and O2 extraction in critical ill patients [9]. The
technical variation and duration of blood storage may
contribute red blood cell deformation, altering O2
Severe anemia and Jehovah’s
availability, and reduces 2,3-diphosphoglycerate
when stored longer than one week, also reducing O2
liberation to the tissues, increasing hemoglobin
affinity for oxygen. Therefore, stored blood may
harm tissue consumption of O2 in critical patients
[7 –9]. Patients who receive erythropoietin need O2
for shorter periods because there is an increase in 2,3diphosphoglycerate in the erythrocytes that shifts the
hemoglobin dissociation curve to the right [8].
It is known that the immunomodulatory effects of
transfusion may not be well tolerated in critical
patient, where sepsis, trauma, pneumonia and
respiratory failure may simulate an initial inflammatory response that is increased by blood derived
products. Furthermore, other risks of transfusion such
as allergic reactions, infection and hemolysis also
increase mortality among patients that receive blood
transfusion. Unfortunately, the individual indications
for transfusions are often not well defined, and are
frequently carried out solely to normalize hemoglobin
rates. It is important to define the risks and benefits of
blood transfusion and, with the development of new
strategies, attempt to avoid unnecessary transfusions
and adopt new strategies, such as erythropoietin and
iron administration.
The experience of the studies done by JW with the
development of alternative forms of treatment in
relation to blood transfusions may many times be
applied without harm and reduce mortality rates. The
goal of this case report is to alert doctors about the
several inherent risks of blood transfusions and
provide alternative tools for treating severe anemia,
especially in critically ill children without using blood
derived products.
Acknowledgements
We are grateful to the Support Center for Scientific
Publications of Santa Casa de São Paulo — Faculty of
Medical Sciences for the editorial assistance.
191
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[1] Robb TV, LaHurd N, Kemp L, Carmel M, Suecoff S, Rubin
DH. Impact of adult trauma center certification on pediatric
emergency visits. J Emerg Nurs 2004;30:413.
[2] Varela JE, Gomez-Marin O, Fleming E, Cohn SM. The risk of
death for Jehovah’s Witnesses after major trauma. J Trauma
2003;54:967–972.
[3] Nelson BS, Heiskell LE, Cemaj S, O’Callaghan TA, Koller
CE. Traumatically injured Jehovah’s Witnesses: A sixteen-year
experience of treatment and transfusion dilemmas at a level I
trauma center. J Trauma 1995;39:681–685.
[4] Shafi S, Gilbert JC, Carden S, Allen JE, Glick PL, Caty MG,
Azizkhan RG. Risk of hemorrhage and appropriate use of
blood transfusions in pediatric blunt splenic injuries. J Trauma
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[5] Shander A. Surgery without blood. Crit Care Med
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[6] Ng T, Marx G, Littlewood T, Macdougall I. Recombinant
erythropoietin in clinical practice. Postgrad Med J
2003;79:367–376.
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A, Meier-Hellmann A, Nollet G, Peres-Bota D. Anemia and
blood transfusion in critically ill patients. JAMA
2002;288:1499–1507.
[8] Silverberg DS, Blum M, Agbaria Z, Deutsch V, Irony M,
Schwartz D, Baruch R, Yachnin T, Steinbruch S, Iaina A. The
effect of i.v. iron alone or in combination with low-dose
erythropoietin in the rapid correction of anemia of chronic
renal failure in the predialysis period. Clin Nephrol
2001;55:212–219.
[9] Caruso LJ, Gabrielli A. Transfusion therapy in the critically ill.
Curr Opin Anaesthesiol 1999;12:149–153.
[10] Jackson WL, Jr, Shorr AF. Blood transfusion and the
development of acute respiratory distress syndrome: More
evidence that blood transfusion in the intensive care unit may
not be benign. Crit Care Med 2005;33:1420–1421.
[11] Shorr AF, Jackson WL. Transfusion practice and nosocomial
infection: Assessing the evidence. Curr Opin Crit Care
2005;11:468–472.
[12] Bilgin YM, van de Watering LM, Eijsman L, Versteegh MI,
Brand R, van Oers MH, Brand A. Double-blind, randomized
controlled trial on the effect of leukocyte-depleted erythrocyte
transfusions in cardiac valve surgery. Circulation 2004;
109:2755–2760.
Journal of Clinical Anesthesia (2008) 20, 538–541
Case report
Management of hemorrhagic shock when blood is
not an option
Colin F. Mackenzie MB ChB, FRCA (Professor) a,b,⁎,
Chet Morrison MD (Assistant Professor)c , Mahmood Jaberi MD (Assistant Professor)d ,
Thomas Genuit MD (Attending Surgeon)e ,
Subishani Katamuluwa BS (Research Assistant)a , Aurelio Rodriguez MD (Professor)f
a
National Study Center for Trauma and Emergency Medical Systems, University of Maryland School of Medicine, Baltimore,
MD 21201, USA
b
Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
c
Department of Surgery, Michigan State University, East Lansing, MI 48824, USA
d
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD 21224, USA
e
Department of Surgery, Sinai Hospital, Baltimore, MD 21215, USA
f
Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, USA
Received 5 June 2007; revised 22 May 2008; accepted 22 May 2008
Keywords:
Blood;
Blood products;
Coagulation;
Hemorrhagic shock;
Jehovah's Witness
patients
Abstract
Objective: To describe an alternative approach to management of severe lifethreatening hemorrhagic
shock and the outcome when blood was not a treatment option.
Design: Case Report of the use of a Hemoglobin Based Oxygen Carrier (HBOC-201)when control of
hemorrhage and intravenous crystalloids were unsuccessful in reversal of hemorrhagic shock and
progressive ischemia.
Setting: Trauma Center.
Patients: Jehovah's Witness.
Outcome: Hospital discharge and 6 month follow-up uneventful.
© 2008 Elsevier Inc. All rights reserved.
1. Case report
A 23 year-old 70.3-kg Jehovah's Witness man was a
pedestrian struck by a car and admitted to the trauma center
at University of Maryland, Baltimore, MD. He complained
of pelvic and abdominal pain and shortness of breath. On
examination, blood pressure (BP) was 118/65 mmHg, heart
⁎ Corresponding author. Department of Anesthesiology, University of
Maryland, Baltimore, MD 21201, USA.
E-mail address: [email protected] (C.F. Mackenzie).
0952-8180/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.jclinane.2008.05.012
rate (HR) was 99 bpm, respiratory rate (RR) was 28 breaths
per minute, and oxygen saturation (SpO2) was 96% on face
mask oxygen. He was noted to have abrasions on his right
flank, abdomen, and thorax with tender abdomen and 2+
hematuria. Radiography showed multiple fractures of the
right ribs, a small left pneumothorax, fractures of the left
iliac wing, left acetabulum, and anterior column, and
separation of the symphysis pubis and both sacroiliac
joints. He had a grade 3 liver laceration involving the
posterior segment of the right hepatic lobe extending into
the right hepatic vein and portal system. Active bleeding
When blood is not an option
539
Fig. 1 All values of red blood cell and plasma (total) Hb (left y-axis [g/dL]) and Hct (right y-axis [%]) throughout hospitalization of a
Jehovah's Witness patient. Arrows = the timing of dosages (Hb [g]) of Hb-based oxygen carrier (HBOC-201; Hemopure; Biopure Corp). Point
1 = Hb and Hct admission values; point 2 = when consent was obtained to administer HBOC-201; point 3 = postadministration values of 150 g
of HBOC-201; point 4 = half-life (19 hrs) of HBOC-201; point 5 = 8 days after first administration of HBOC-201, showing intrinsic increases
in Hb and Hct values.
was noted in the space of Retzius and periurethral region.
There was bleeding from both right and left internal iliac
arteries and his hepatic artery. His admission hemoglobin
(Hb) was 13.4 g/dL and progressively decreased to a nadir
of 4.5 g/dL (Fig. 1, point 1 to point 2). Despite infusion of
2,550 mL of crystalloid, 500 mL of hetastarch, and efforts
to control bleeding, BP values decreased to 84/44 mmHg,
with a HR of 110 bpm for the initial 8 hours. He refused
blood transfusion.
The patient's trachea was intubated, he was sedated, and
his lungs were mechanically ventilated with neuromuscular
block to minimize oxygen consumption, because serum
lactate was increasing despite efforts at fluid resuscitation
(Table 1). A left tube thoracostomy was performed to relieve
the pneumothorax. Ninety minutes after admission, he
underwent angiographic selective gel foam embolization
until hemostasis of the bleeding sites was achieved, in the left
and right internal iliac arteries and their subdivisions, and in
segmental branches of the right hepatic artery. An inferior
vena caval filter was placed. He next underwent percutaneous screw fixation of his sacral disruption, which resulted
in good posterior pelvic alignment. Eight hours after this
minimal blood loss procedure, his Hb was 6.1 g/dL and his
lactate increased from 3.0 to 4.3 mmol/L. The patient was
then begun on a course of vitamin K (10 mg), erythropoietin
(14,000 U/d for 6 days, then 20,000 U on alternate days),
iron supplements (100 mg), and vitamin C (500 mg) to
maximize erythropoiesis.
Because the patient's trachea was intubated, he was
sedated and receiving mechanical ventilation, we obtained
consent from the patient's family to use a nonhuman, Hbbased, acellular oxygen-carrying solution (HBOC-201,
Hemopure; Biopure Corp, Cambridge, MA). Under a Food
and Drug Administration (FDA) compassionate use and
institutional review board–approved protocol, 150 g of
HBOC-201 was administered on hospital day 2. With
HBOC-201 dosing, there was an increase in total Hb (plasma
Hb plus Hb in the red cells) from 4.6 to 7.4 g/dL within 24
hours. At this same time, hematocrit (Hct, %) after HBOC201 infusion decreased from 11.7% to 11.6%, indicating
volume expansion by the cell-free HBOC-201 (Fig. 1, point 2
to point 3). Increased plasma Hb from HBOC-201 augmented
oxygen carriage of the circulating red cells, as judged by the
normalization of serum lactate (Table 1). The half-life of
HBOC-201 is about 19 hours because total Hb decreases from
7.4 to 5.1 g/dL by hospital day 4 (Fig. 1, points 3 to 4). To
maintain efficacy (in this case, Hb concentration), we
Table 1
Serum lactate levels after the patient's admission
Hours after admission
Level (mmol/L)
0
2
7
9
12
17
30
3.0
4.2
4.2
4.3
3.3
2.5
1.9
Total number of hours after admission was 30.
540
administered redosing of 30 g of HBOC-201 on hospital day
5. Total Hb increased from 4.5 to 5.9 g/dL.
On hospital day 8, the patient's trachea was extubated.
Erythropoiesis was stimulated and Hct increased from
14.2% on hospital day 10 to 21.7% (Fig. 1, point 5 onward).
This patient received no blood. His pelvic injuries and
acetabulum were repaired by fluoroscopy-directed placement of percutaneous screws on hospital day 12, when his
Hct was 26%. On the day after surgery, the patient was
discharged home with an Hct value of 25.1% and was
walking on crutches. His follow-up has been uneventful for
more than 6 months, and he has resumed all his preinjury
activities except kick boxing, because of some limitation of
left hip movements.
2. Discussion
The precipitous decrease of Hb and Hct in the hours after
admission to the trauma center, together with his lactate
levels increasing to 4.3 mmol/L despite administration of
fluids and efforts to control hemorrhage, all indicate that this
patient was in uncontrolled hemorrhagic shock. Critical Hb
concentration is about 7 g/dL, below which tissue oxygenation is imperiled [1]. Many different approaches have been
described in the literature to overcome the physiologic deficit
resulting from acute inadequacy of Hb [2] in patients after
trauma. Surgical control of bleeding and blood transfusion
are considered the standards of care. The approach described
in this Jehovah's Witness patient avoided any open surgical
procedure, either for hemorrhage control of his liver and
vascular injuries or orthopedic stabilization of major pelvic
and acetabular fractures. Nonoperative management for liver
injuries is less likely to fail than for splenic or renal injury
[3]. Percutaneous fixation of sacral injuries diminishes
potential blood loss and operative times [4]. Closed
reduction and percutaneous fixation of anterior column [5],
or both anterior and posterior column acetabular fractures,
using cannulated screws and fluoroscopy, reduce blood loss
and operative time. Mean blood loss for these procedures can
be less than 100 mL [6].
A problem associated with erythropoiesis after trauma is
that there is inadequate erythropoietin response [7] because
of release of inflammatory cytokines that down-regulate the
erythropoietin gene, inhibit bone marrow, and alter iron
metabolism [8]. Erythropoietin levels are preserved so that
the persistent anemia associated with injury is related to
failure of the bone marrow to respond to erythropoietin. In
one study of human bone marrow taken from patients after
trauma, addition of exogenous erythropoietin not only
failed to increase hematopoietic progenitor colony counts
but appeared to have a dose-dependent suppressive effect
[7]. These data call into question the benefit of administration of recombinant erythropoietin for trauma patients to
improve hematopoiesis. Even when benefit is shown,
erythropoietin effects take 10 days to three weeks [9,10].
C.F. Mackenzie et al.
However, in this patient, until alternative strategies were
worked out and to obtain FDA compassionate use approval,
erythropoietin was started. One intervention that can
promote a more balanced proinflammatory and antiinflammatory response, and may reduce posttraumatic complications, is hypertonic saline (NaCl) [11]. After a single dose
of 250 mL of 7.5% NaCl and 6% dextran 70, neutrophil
activation was blunted and monocyte redistribution was
altered to minimize the decreased production of myeloid
colony-stimulating cytokines after multiple injuries [11,12],
and proregulatory cytokines were increased. Such an
immunomodulatory response may reduce posttraumatic
complications including multiorgan failure and sepsis.
Use of the nonoperative approach to control bleeding
from the liver and pelvic injuries was an important method
to minimize blood loss. The use of percutaneous screw
fixation to stabilize sacroiliac disruption allowed bleeding
(which would normally be uncontrolled until definitive
reduction of the fracture) to be reduced early in this patient's
care, with minimal blood loss and operative time. Acetabular
fracture repair is usually delayed until the patient is
stabilized; percutaneous repair is used to reduce blood
loss, and it produces a good functional outcome [5]. The
infusions of HBOC-201 enabled Hb concentration to be
maintained and sedation, neuromuscular paralysis, and
intubation to be discontinued. Reports in humans suggest
that HBOC-201 increases serum iron, ferritin, and erythropoietin, and stimulates erythropoiesis, with a resulting
increase in Hct one week later (day 9 in this patient),
which is equivalent to one U of blood transfusion after
HBOC-201 [13]. In addition, an acellular Hb solution can
facilitate microcirculatory oxygen delivery to ischemic
tissue, such as that found in uncontrolled hemorrhagic
shock [14,15], and can maintain life in trauma patients with
cellular Hb values less than three g/dL [16]. Iron, folic acid,
and vitamin B12 should be administered, but it is unclear
whether erythropoietin is beneficial or detrimental. Blood
draws should be minimized. Because reticulocyte counts
require a separate blood draw at our institution, none was
performed. Pediatric-sized blood tubes were used to
minimize the 41 ± 39.7 mL/24-hour volumes usually
drawn in critically ill patients [17]. In view of the potential
benefit of hypertonic saline over other resuscitative solutions
(including blood) in counterbalancing the inflammatory
response and decreasing hemodilution, 7.5% NaCl and 6%
dextran may be helpful for initial resuscitation and should be
considered in patients when blood is not an option. Finally,
once stabilization of the patient has occurred, acute
normovolemic hemodilution [18,19] is a blood-conserving
technique that would be useful if a known high blood loss
procedure (eg, a multilevel spinal stabilization procedure)
had to be undertaken to provide definitive correction of
traumatic injuries. In this patient, hemodilution with HBOC201 would maintain Hb during such surgery until autologous
blood reinfusion. The successful outcome in this patient
shows that hemorrhagic shock can be managed without
When blood is not an option
blood, if expeditious angiographic embolization and percutaneous skeletal fixation procedures are used to control
bleeding, and repeated dosages of Hb solution are provided
until intrinsic Hb increases in about one week.
541
[10]
[11]
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[12]
[1] Intaglietta M. Microcirculatory basis for the design of artificial blood.
Microcirculation 1999;6:247-58.
[2] Gannon CJ, Napolitano LM. Severe anemia after gastrointestinal
hemorrhage in a Jehovah's Witness: new treatment strategies. Crit
Care Med 2002;30:1893-5.
[3] Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D.
Nonoperative treatment of blunt injury to solid abdominal organs: a
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[4] Nork SE, Jones CB, Harding SP, Mirza SK, Routt ML Jr. Percutaneous
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[6] Parker PJ, Copeland C. Percutaneous fluoroscopic screw fixation of
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severe injury in humans. Ann Surg 2003;238:748-53.
[9] Gabriel A, Kozek S, Chiari A, et al. High-dose recombinant
human erythropoietin stimulates reticulocyte production in patients
[13]
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novel hemoglobin based oxygen carrier in normal male and female
subjects. J Lab Clin Med 1995;126:444-51.
Page TC, Light WR, McKay CB, Hellums JD. Oxygen transport by
erythrocyte/hemoglobin solution mixtures in an in vitro capillary as a
model of hemoglobin-based oxygen carrier performance. Microvasc
Res 1998;55:54-64.
York GB, Eggers JS, Smith DL, et al. Low-volume resuscitation with a
polymerized bovine hemoglobin-based oxygen-carrying solution
(HBOC-201) provides adequate tissue oxygenation for survival in a
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Gould SA, Moore EE, Hoyt DB, et al. The life-sustaining capacity of
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Case Reports
Care of the Injured Jehovah’s
Witness Patient: Case Report
and Review of the Literature
Narong Kulvatunyou, MD,* Stephen O. Heard, MD†
Department of Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; and Department of Anesthesiology and Department of Surgery, UMass
Memorial Medical Center, Worcester, MA
Care for the Jehovah’s Witness patient can be a challenge and often a dilemma to clinicians
because of the patient’s religious beliefs and teachings against receiving blood and blood
products, especially in emergency or trauma settings. We present a case of a severely injured
elderly Jehovah’s Witness patient who survived. We also review the literature and offer an
organized approach to care for such patients. © 2004 by Elsevier Inc.
Keywords: Anemia; blood transfusion; erythropoietin; Jehovah’s Witness
patients; trauma.
Introduction
Over one million Jehovah’s Witnesses live in the Unites States.1 Their religious
conviction against receiving blood and blood products can create a difficult
clinical dilemma, particularly in the trauma setting. Improvements in surgical
technique, decreased phlebotomy rates, and use of erythropoietin have allowed
clinicians to perform quite complex surgical procedures such as coronary artery
bypass grafting2 or liver transplantation.3 However, in an acute emergency with
a significant amount of blood loss, awareness and preparation are key elements
to limit further blood loss and improve the chances of patient survival. We
present a case of a severely injured Jehovah’s Witness patient, review the
literature, and offer an organized approach to care for such patients.
*Attending Surgeon and Surgical Intensivist,
Ramathibodi Hospital
†Professor and Chairman of Anesthesiology,
UMass Memorial Medical Center
E-mail: [email protected]
Address correspondence to Dr. Heard at the
Department of Anesthesiology, UMass Memorial Medical Center, 55 Lake Ave. North,
Worcester, MA 01655, USA.
Received for publication August 21, 2003;
revised manuscript accepted for publication
February 2, 2004.
Journal of Clinical Anesthesia 16:548 –553, 2004
© 2004 Elsevier Inc. All rights reserved.
360 Park Avenue, South, New York, NY 10010
Case Reports
A 67-year-old man was an unrestrained driver in a car that hit a tree. He reported
no loss of consciousness and was hemodynamically stable at the scene. He was
admitted to an emergency room at an outside hospital, at which time a
hematocrit (Hct) level of 36.4% was noted. After an episode of hemoglobin
(Hb) desaturation, he was transferred to UMass Memorial Medical Center. In
the Emergency Department of this institution, he became transiently hypotensive (blood pressure 80 mmHg) but responded promptly to an intravenous (IV)
crystalloid bolus. The only active external bleeding source was the nose, which
was easily controlled. The remainder of the work-up revealed right-sided rib
fractures, right anterior chest wall and mediastinal hematomas, left pneumothorax, bilateral pulmonary contusions, and fractures of the left distal humerus and
left distal femur. The admitting Hb level was 9.7 g/dL. Although a left chest tube
0952-8180/04/$–see front matter
doi:10.1016/j.jclinane.2004.02.002
Care of Jehovah’s Witness patients: Kulvatunyou and Heard
Figure 1. Hemoglobin concentration (gm/dL; solid squares)
or reticulocyte count (%, open circles) as a function of
hospital day. E ⫽ doses of erythropoietin (48,000 units);
arrow ⫽ daily doses.
was inserted, the patient’s respiratory status slowly deteriorated, and he required tracheal intubation and mechanical ventilation. Prior to intubation, he stated adamantly
that he did not want to receive any blood or blood
products. His past medical history was significant for a
right hemispheric stroke and a recent open reduction and
internal fixation of a left hip fracture. Because the left
femur fracture involved the femoral plate, operative management was required, and he was taken to the operating
room (OR) for application of an external fixator. His Hct
just prior to transfer to the OR was 22.5%. Fluid intake in
the emergency room was 5500 mL of normal saline and
urine output was 1000 mL. In the OR, 700 mL of lactated
Ringer’s solution was administered and the patient’s urine
output was 130 mL. Blood loss was 200 mL. Postoperatively, he was admitted to the surgical intensive care unit
(ICU) and monitored with a pulmonary artery (PA)
catheter that measured cardiac output (CO) and mixed
venous oxygen saturation (SvO2) continuously. Over the
next 24 hours, he received a total of 7.6 L of crystalloid,
1000 mL of hetastarch, and norepinephrine to maintain
adequate end-organ perfusion. Urine output was 1985 mL.
Pulmonary capillary wedge pressure ranged from 13 to 16
mmHg. Blood urea nitrogen (BUN) and creatinine were
14 mg/dL and 1.0 mg/dL, respectively. To minimize
metabolic demand, mild hypothermia was maintained
(35.5°C), and the patient was heavily sedated and paralyzed. On hospital day #2, his hemodynamic status stabilized and the norepinephrine was discontinued. His Hb
had decreased to 3 g/dL (Figure 1). Therapy with iron,
folate, vitamins B12 and K, and erythropoietin (48,000
units IV daily; Ortho-Biotech, Chapel Hill, NC) was instituted. Blood work was kept to a minimum, with phlebotomy performed every other day and the use of a microcapillary blood gas analyzer (Instrumentation Laboratory,
Lexington, MA), which required less than 0.5 mL of blood
for electrolyte, arterial blood gas (ABG), and Hct analyses.
His arterial oxygen tension (PaO2) was maintained at 150
Figure 2. Oxygen delivery (mL/min 䡠 M2; solid squares) or
consumption (mL/min 䡠 M2; open circles) during the first 8
days of hospitalization.
to 200 mmHg. His cardiac index (CI) was always above 3
L/min 䡠 M2 and SvO2 ranged from 38% to 45% (Figure 2).
Maximal reticulocyte count was 14% (Figure 1). His ICU
course over the next few weeks was complicated by respiratory failure due to his pulmonary contusions and ventilator-associated pneumonia. A percutaneous tracheostomy
was performed and he was transferred to a respiratory ICU
on hospital day #26, and then to a long-term rehabilitation
center on hospital day #47. His discharge Hb level was 7.9
g/dL.
Discussion
The medical literature was reviewed for trauma cases
involving Jehovah’s Witness patients.4-10 Table 1 summarizes these cases and includes severity of injury, lowest Hb
levels reported, and outcome. Only those cases in which
Hb and outcome were documented and no allogeneic
blood or cell saver blood was transfused, are included in
the table. We believe our case represents the most severely
injured Jehovah’s Witness trauma patient with respect to
age, severity of injury (ISS of 29), and Hb level who has
survived. The decrease in Hb in our patient was most likely
a result of bleeding at the sites of the left femur fracture
and rib fractures, epistaxis, pulmonary contusions, and
hemodilution (as a consequence of crystalloid resuscitation). In contrast to our case, Rupp et al.7 and Finfer et al.8
described patients with lower Hb levels and comparable
injury severity who survived; however, those patients were
relatively young. Nelson et al.10 reported their experience
treating 77 Jehovah’s Witness trauma patients, including
children, but they did not provide descriptions of individual patient injury, severity of injury, management, or
outcome.
Several strategies can be utilized to treat the Jehovah’s
Witness patient, including intraoperative blood salvage,
minimizing metabolic demand, maximizing oxygen delivery, reducing iatrogenic blood loss, and increasing red
blood cell production.
J. Clin. Anesth., vol. 16, November 2004
549
Case Reports
Table 1. Summary of Trauma Cases Involving Jehovah’s Witnesses
Age/Injury
1.) 17-year-old male: contact sport with
ruptured spleen4
2.) 47-year-old male: airplane crash with
multiple long bone fracture5
3.) 18-year-old male hemophiliac: motor
vehicle crash with splenic laceration6
4.) 18-year-old male: bicycle - car crash
with multiple lower extremity and
pelvic fractures7
5.) 29-year-old male: motor vehicle
crash with multiple long bone
fractures8
crash with multiple long bone
fractures8
crash with hemothorax and pelvic
fracture9
8.) 44-year-old female: motor vehicle
crash with subarachnoid hemorrhage,
orbital tripod fracture, facial
lacerations, pulmonary contusions, 3
rib fractures, and a grade I splenic
laceration24
9.) 24-year-old male: 30-foot fall from
window with fractures of right frontal
bone, maxilla (Le Fort III),
mandible, ribs (right 3–5), left patella
and right radial head38
10.) 45-year-old female: train crash with
multiple bilateral rib fractures, left
hemopneumothorax, contused left
lung, and ruptured spleen39
11.) 61-year-old male: fell 30 feet at a
construction site with a subdural
hematoma, left subarachnoid
hemorrhage and fractures of the left
scapula, right radius and left ribs40
crash with mesenteric hematoma and
fractures of the pelvis, lumbar spine,
ribs, scapula and elbow40
13.) 43-year-old male: 25-foot fall with
dislocated hip and fractures of the
acetabulum, humerus, and radius40
crash with blunt chest trauma,
multiple extremity fractures, and
head injury10
15.) 26-year-old male: diving accident
with head injury and C-5 fracture
with quadraplegia with subsequent GI
hemorrhage10
16.) 15-year-old male: gunshot wound
to groin with bladder and bowel
injuries10
crash with pulmonary contusions and
left humerus and femur fractures
ISS/RTS
Hb g/dL
ICU LOS (d)
Outcome
N/A
N/A
0
Survived
16
2.6
18
Survived
N/A
N/A
0
Survived
N/A
2.5
N/A
17/7.84
1.6
4
Survived
N/A
0.9
0
Cardiac arrest during surgery
N/A
4.5
N/A
Survived, 42 d hospitalization
N/A
3.2
N/A
Survived, 19 days
hospitalization [blood
substitute given]
N/A
1.8
1
N/A
3.2
N/A
Survived, 24-day
hospitalization.
N/A
5.4
N/A
Survived, 41-day
hospitalization
N/A
4.0
N/A
Survived, 52-day
hospitalization
N/A
5.7
N/A
Survived, 16-day
hospitalization
N/A
6.5
N/A
Death
N/A
5.6
N/A
Survived
N/A
7.9
N/A
Survived
29/7.84
3.0
26
Survived, 41 d hospitalization
Cardiac arrest
Survived, 32-day
hospitalization
ISS ⫽ injury severity score, RTS ⫽ revised trauma score, Hb ⫽ hemoglobin, ICU ⫽ intensive care unit, LOS ⫽ length of stay in days, N/A ⫽ Not
available, GI ⫽ gastrointestinal.
550
Perioperative Blood Salvage
Use of blood salvage techniques may be accepted by some
Witnesses.11 If possible, the use of this modality should be
explored before surgery.12 Likewise, autotransfusion of
blood retrieved from hemothoraces is also possible.13 Most
often, if these techniques are accepted by the patient, a
continuous column of blood must be maintained between
the salvage device and patient.
thermia can have adverse effects on coagulation; thus, the
benefits of reducing metabolic rate must be weighed
against the risk of inducing a coagulopathy and increasing
blood loss.20 Because it is not uncommon for patients to
shiver when hypothermia is being induced, neuromuscular block becomes necessary. Use of neuromuscular block
can reduce metabolic demand, even without hypothermia.
Indeed, some clinicians have reported myocardial ischemia in Jehovah’s Witness patients when paralysis has been
reversed prematurely.19
Prevention of Intraoperative Blood Loss
A variety of interventions can be utilized to minimize
intraoperative blood loss in the OR. Meticulous surgical
technique is mandatory. Acute normovolemic hemodilution may be a valuable means to reduce intraoperative
blood loss.14 However, an adequate beginning Hct level is
required for this technique to be useful and, as mentioned
previously, a continuous column of blood must be maintained between the patient and the storage bag. In our
patient, Hct was too low at the beginning of surgery for
this strategy to be used.
Induced hypotension is another technique by which
blood loss can be reduced intraoperatively.15 However,
this method is often impractical in the trauma patient who
is already unstable or hypovolemic, and perhaps underresuscitated. The possible exception is the hypotensive
patient who has suffered penetrating torso trauma.16 In
such a situation, so-called hypotensive resuscitation (used
until definitive control of bleeding in the OR is achieved)
may improve patient outcome.
Correction of coagulopathies is extremely important
and should be dictated by the appropriate laboratory
studies; however, most Witness patients will not allow the
use of fresh frozen plasma or cryoprecipitate and/or
platelets. Pharmacologic aids such as the serine protease
inhibitor, aprotinin; lysine analogue antifibrinolytics such
as epsilon aminocaproic acid and tranexamic acid;
DDAVP; and recombinant human factor VIIa (rhFactor
VIIa) may be useful in individual cases.17 However, to date,
there have been no controlled trials evaluating the effectiveness of these agents in trauma patients. Nonetheless,
there is evidence suggesting that rhFactor VIIa is useful as
rescue therapy in patients with exsanguinating hemorrhage.18
Minimizing Oxygen Consumption and Demand
Strategies to reduce metabolic demand include sedation,
analgesics, neuromuscular blockade, and hypothermia.19
Mechanical ventilation may be useful to prevent hyperventilation and decrease the work of breathing. Whether
neuromuscular blockers and/or hypothermia should be
used depends on the degree and severity of the physiological insult. The recommended level of hypothermia is 30°
to 32°C because oxygen consumption is reduced by almost
50% at these temperatures, with few cardiac side effects.19
Although the oxyhemoglobin dissociation curve is shifted
to the left with hypothermia, both the solubility of oxygen
in plasma and tissue affinity for oxygen increases. Hypo-
Maximizing Oxygen Delivery
Oxygen delivery is dependent on Hb concentration, Hb
oxygen saturation (SpO2), CI, and, to a lesser extent, the
amount of oxygen that is dissolved in plasma. The clinician should strive for SpO2 of 100% and ensure that
intravascular volume is optimal. If necessary, an inotropic
agent may be used to augment CI once the patient has
been volume resuscitated. Although the contribution of
oxygen that is dissolved in plasma to overall oxygen
delivery is small, increases in oxygen content of slightly
greater than 1 volume percent can be achieved by maintaining high PaO2 levels. For those centers that are
equipped with hyperbaric chambers, significant increases
in oxygen content can be realized with hyperbaric oxygen
therapy.21 Artificial blood substitutes (eg, perfluorocarbons) are still being investigated but promise to be of
great utility in the future treatment of these patients.22,23
Indeed, there are case reports describing the use of
human24 and bovine25 Hb products in Jehovah’s Witness
trauma patients. The use of these products is a matter of
conscience by the Witness.24
Our patient received a significant volume of crystalloid
to maintain intravascular volume. Greater reliance on
colloids for resuscitation in this patient may have allowed
for smaller volumes of resuscitation fluid to be used.
However, large volumes of hetastarch may have adverse
effects on coagulation,26 and the use of albumin may be
associated with a greater decrease in Hb compared with
the use of crystalloid solutions.27 Compared with crystalloid solutions, hypertonic saline solutions (with or without
colloids) achieve an efficiency in plasma volume expansion by a factor of 10.28 Definitive evidence that the use of
hypertonic saline solutions will reduce tranfusion requirements in trauma patients is lacking.
We chose to monitor our patient with a PA catheter
that measures CO and SvO2 continuously. In doing so, we
were able to assess adequacy of oxygen delivery and
estimate oxygen consumption without resorting to phlebotomy. We maintained inspired oxygen concentration
(FIO2) at 0.6, thereby achieving a PaO2 in the range of 150
to 200 mmHg, which represented 10% to 12% of the O2
content. Although the oxygen extraction ratio is normally
12% to 20%, it increased to 65% in our patient, indicating
a reduction in convective oxygen delivery. However, tissue
oxygenation was probably adequate because serial ABGs
failed to show the development of a metabolic acidosis
indicative of anaerobic metabolism.
551
Case Reports
Minimizing Iatrogenic Blood Loss
A number of studies have documented that phlebotomy
can result in a tremendous amount of blood loss in ICU
patients.29,30 Reducing the frequency of testing and the
size of the blood sample tube can reduce iatrogenic blood
loss.31,32 In addition, point-of-care diagnostic technologies
can provide a number of tests that utilize very small
amounts of blood.33 Use of noninvasive and invasive
oximetric techniques can reduce further the need for
blood testing.
In addition to the use of continuous pulse oximetry and
SvO2, we chose to use a whole blood gas analyzer to
measure on a daily basis ABGs, sodium, potassium, ionized
calcium, and glucose. Residual blood in the syringe was
used to measure Hct in a capillary tube. Less than 1 mL of
whole blood was required for these tests.
Enhancing Erythropoiesis
Increased red blood cell production can be accomplished
by administering recombinant human erythropoietin
(Procrit or Epogen) and supplemental iron.19 Koestner et
al.9 first recommended the use of this agent in trauma
patients, and they noted a reticulocyte response varying
from 2% to 17%. Two points of interest need to be
mentioned. First, it is important to keep in mind that
there have been several cases7,19,34-36 in which the authors
did not use synthetic erythropoietin despite Hb values as
low as 1.4 g/dL and their patients still survived. Some
clinicians did not have access to the drug, but the majority
omitted it because their patients were young and erythropoiesis was appropriate. Rupp et al.7 noted a reticulocyte
count of 24% without using erythropoietin. Because our
patient was elderly and his Hb level was 3 g/dL, we chose
to use erythropoietin. The reticulocyte count went from
2% to 14%. Second, the clinician must bear in mind that
erythropoietin contains small amounts of human albumin
(2.5 mg/mL).20,37 Because albumin is a blood product,
the subject may require discussion with the patient or
patient’s family. Most Jehovah’s Witnesses will accept
treatment with erythropoietin.
Conclusion
We present a case of a severely injured Jehovah’s Witness
patient and offer an organized approach to the management of this uniquely ill individual. Hemostasis, minimizing metabolic demand, optimizing oxygen delivery, limitation of iatrogenic blood loss, and use of erythropoietin
are the cornerstones of therapy.
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553

Trasplante de hígado sin transfusión de sangre permite que testigo

Transcription

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