With the obvious challenges of managing major blood loss in patients who refuse blood transfusions, clinicians in Melbourne have sought to learn lessons from their treatment of trauma patients who are Jehovah’s Witnesses.

In a review of patients in the Alfred Trauma Registry, they identified 34 who identified as Jehovah’s Witnesses, of whom half had major trauma.

Anaemia was a clinical problem for 38% of patients, with haemoglobin levels reaching a nadir of 69.7g/L on average five days after admission.

The review found that a wide variety of strategies  – including tranexamic acid, iron and EPO  – were used to minimise blood loss, but many patients did not receive all possible treatments.

The conclusions they drew from the review were:

• Haemoglobin concentrations reached a nadir around four days after injury, and some clinicians may not be aware that delayed response to blood treatment may leave patients at risk of anaemia complications for a longer time than usual.
• Use of blood loss minimising techniques was not optimal for many patients who refuse blood products. Only one third had mention of careful or minimised phlebotomy techniques and PPIs were not used for one in three patients, leaving them at risk of GI blood loss.
• Pulmonary and cardiac optimisation was underused in the preoperative period, with none of the patients having haemodilution, autotransfusion, ECMO or deliberate hypotension/hypothermia.
• Only one third of patients received EPO, even though it appears a logical choice for injured patients who have an impaired EPO response to anaemia.
• Jehovah’s Witness’s may have been assumed to be refusers of all blood products, when in fact many accepted products such as platelets, red cells, FFP and cryoprecipitate
• Haemoglobin-based oxygen carriers such as Sanguinate are potentially lifesaving in  patients for whom blood products are not an option, but only two patients received them as part of clinical trials.

The authors of the review said it appeared some clinicians may not have been aware of all the possible treatment techniques for people who refuse blood products. Given the complex clinical, legal and ethical issues involved in blood refusal, they suggested that a resource centre of the possible options would help clinicians  facing this difficult situation.

Reporting their findings in Vox Sanguinis, they said most major trauma centres would face at least one such case a year and the review showed that the mortality rate was 9%, they added.