title: How good patient blood management leads to excellent outcomes in Jehovah's witness patients undergoing cardiac surgery.
abstract: OBJECTIVE
  The refusal of blood products makes open-heart surgery in Jehovah's witnesses (JW) an ethical challenge. We demonstrate how patient blood management strategies lead to excellent surgical outcomes.
  
  
  METHODS
  From 2003 to 2008, 16 JW underwent cardiac surgery at our institution. Only senior surgeons performed coronary revascularization (n=6), valve (n=6), combined (n=1) and aortic surgery (n=3) of which two patients presented with acute type-A dissection. Off-pump surgery remained the method of choice for patients requiring a bypass procedure (n=5). Preoperative hematocrit (Hk) and hemoglobin (Hb) were 42.8±4.7% and 14.5±2 g/dl. In three patients with an Hb<12 g/dl, preoperative hematological stimulating treatment was implemented.
  
  
  RESULTS
  All patients survived, no major complications occurred and no blood transfusion was administered. The Cell Saver® system (transfused volume: 474±101 ml) and synthetic plasma substitutes [Ringer's Lactate: 873±367 ml and hydroxyethyl starch (HES) 6%: 700±388 ml] were used routinely as well as hemostaticas, such as bone wax, and fibrin glue. The decrease of Hk and Hb appeared to be the lowest after off-pump surgery when compared to all other procedures requiring cardiopulmonary bypass (CPB) (25±9% vs. 33±6%; P=0.01 and 22±9% vs. 31±6%; P=0.04). Similarly, the decrease of platelets was significantly lower (20±12% vs. 43±14%; P=0.01). In the follow-up period (52±34 months), one patient died due to a non-cardiac reason, whereas all others were alive, in good clinical condition and did not have major adverse cardiac events (MACE) or recurrent symptoms requiring re-intervention.
  
  
  CONCLUSIONS
  Patient blood management leads to excellent short- and long-term outcomes in JW. Combined efforts in regard to preoperative hematological parameter optimization, effective volume management and meticulous surgical techniques make this possible but raise the cautionary note why this is only possible in JW patients.
authors.affiliation: Clinic for Cardiovascular Surgery, Institute of Anaesthesiology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland. maximilian.emmert@usz.ch
authors.forename: Maximilian Y
authors.initials: MY
authors.lastname: Emmert
authors.forename: Sacha P
authors.initials: SP
authors.lastname: Salzberg
authors.forename: Oliver M
authors.initials: OM
authors.lastname: Theusinger
authors.forename: Christian
authors.initials: C
authors.lastname: Felix
authors.forename: Andre
authors.initials: A
authors.lastname: Plass
authors.forename: Simon P
authors.initials: SP
authors.lastname: Hoerstrup
authors.forename: Volkmar
authors.initials: V
authors.lastname: Falk
authors.forename: Juerg
authors.initials: J
authors.lastname: Gruenenfelder
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical / Q000517:prevention & control; D001803:Blood Transfusion / Q000941:ethics; D006348:Cardiac Surgical Procedures / Q000379:methods* / Q000401:mortality; D016208:Databases, Factual; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D005500:Follow-Up Studies; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D033221:Jehovah's Witnesses; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods; D011300:Preoperative Care / Q000379:methods; D012068:Religion and Medicine; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D016896:Treatment Outcome; D016312:Treatment Refusal