Trip Answers

Question answered:14/05/07 Warning! this question is over two years old.

GPNotebook gives the following reference values for haemoglobin (in the general population):

 

• “haemoglobin
o male 13.5-18.0 g/dl
o female 11.5-16.0 g/dl” [1]

 

We searched the NLH Specialist Library for Surgery, Theatres and Anaesthesia, TRIP and Medline databases but found no guidelines documenting an optimum haemoglobin level for Jehovah Witnesses undergoing hip replacement or elective surgery in general.

 

However, several studies do report associated haemoglobin levels and mortality and morbidity rates in Jehovah Witnesses who declined RBC transfusions.

 

Carson et al found:

 

“RESULTS: Of 2083 eligible patients, 300 had postoperative Hb counts of 8 g per dL or less. The study population was predominantly female (70.3%) with a mean age of 57 years (SD, +/- 17.7). In patients with a postoperative Hb level of 7.1 to 8.0, 0 died (upper 95% CI, 3.7%), and 9.4 percent (95% CI, 4.4-17.0%) had a morbid event. In patients with a postoperative Hb level of 4.1 to 5.0, 34.4 percent (95% CI, 18.6-53.2%) died and 57.7 percent (95% CI, 36.9-76.6%) had a morbid event or died. After adjusting for age, cardiovascular disease, and Acute Physiology and Chronic Health Evaluation II score, the odds of death in patients with a postoperative Hb level of < or = 8 g per dL increased 2.5 times (95% CI, 1.9-3.2) for each gram decrease in Hb level. CONCLUSIONS: The risk of death was low in patients with postoperative Hb levels of 7.1 to 8.0 g per dL, although morbidity occurred in 9.4 percent. As postoperative blood counts fall the risk of mortality and/or morbidity rises and becomes extremely high below 5 to 6 g per dL.” [2]

 

In 2000 Majeski presented the findings of surgery on 132 Jehovah Witnesses patients:

 

“The series includes general surgical procedures in children and adults. Also, vascular surgical procedures in adults are reported. Thirty-one procedures were of significant magnitude to possibly require a blood transfusion. No patient in this series received a blood transfusion. No patient was refused an indicated surgical procedure. Fourteen complications incurred in this series which included one death. The age range of patients in this surgical series was 9 months to 91 years. There was no difference in the male to female ratio. The spectrum of cases reported represents the entire range of procedures seen in general and vascular surgical practices. CONCLUSIONS: The surgical care of Jehovah's Witnesses has become less of an operative risk over the last decade. There are now significant alternatives to the transfusion of blood, such as erythropoietin, iron dextran, aprotinin and Fluosol-DA 20%.... Technological surgical developments and advances, such as the cell saver, argon beam coagulator, acute limited normovolemic hemodilution, autologous whole plasma fibrin gel, and controlled hypotensive anesthesia during anesthesia have contributed substantially to a reduction in the operative loss of blood.

 

The time honored rule of hemoglobin of 10 g/dl and a hematocrit of 30% should not require strict adherence in the postoperative care of most patients. The acceptance of a lower transfusion trigger point of hematocrit of 22% and a hemoglobin of 7 g/dl can significantly reduce transfusion requirements without an increase in morbidity…” [3]

Cothren et al presented a case report on large volume polymerized haemoglobin solution in a Jehovah's Witness following abruptio placentae. In discussion, the author notes:

 

“Although case reports of patients surviving with Hb levels less than 5 g dL 1 exist, …the reported mortality in a large cohort study of Jehovah's Witnesses requiring surgery is 65% for Hb < 3 g dL 1 and 100% for Hb < 2 g dL 1 …” [4]

 

However, a report by the Royal College of Obstetricians and Gynaecologists states:

 

“Major blood loss is most commonly encountered in trauma, surgery (eg cardiovascular and malignant conditions) and obstetric problems. Perioperative mortality increases if bleeding is in excess of 500ml regardless of the preoperative haemoglobin level. Clotting abnormalities are usually encountered when the blood loss exceeds the patient’s circulating volume.” [5]

 

References
1. GPNotebook. Reference range for haemoglobin. (http://www.gpnotebook.co.uk/simplepage.cfm?ID=1067057222)
2. Carson JL, Noveck H, Berlin JA et al. Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion. Transfusion. 2002 Jul;42(7):812-8. (http://www.hubmed.org/display.cgi?uids=12375651).
3. Majeski J. Advances in general and vascular surgical care of Jehovah's Witnesses. Int Surg. 2000 Jul-Sep;85(3):257-65. (http://www.hubmed.org/display.cgi?uids=11325007)
4. Cothren CC, Moore EE and Long JS et al. Large volume polymerized haemoglobin solution in a Jehovah's Witness following abruptio placentae. Transfus Med. 2004 Jun;14(3):241-6. (http://www.blackwell-synergy.com/doi/abs/10.1111/j.0958-7578.2004.00502.x). Please note an ATHENS account is required to access the full text of this article.
5. Royal College of Obstetricians and Gynaecologists. Code of Practice for the Management of Jehovah Witnesses. 2007. (http://www.rcog.org.uk/resources/public/doc/draft_blood_transfusion_obstetrics_gt49.doc

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