Correspondence
Blood Substitute and Erythropoietin Therapy in a Severely Injured Jehovah's Witness
N Engl J Med 2002; 346:1097-1098April 4, 2002
- Article
To the Editor:
Since a 1945 church decision, Jehovah's Witnesses have refused blood transfusions, even in cases of life-threatening hemorrhage. As a result, physicians need to be aware of alternative therapeutic options for Jehovah's Witnesses.
A 44-year-old Jehovah's Witness was injured in a motor vehicle collision. She sustained a temporal subarachnoid hemorrhage; an orbital tripod fracture; facial lacerations, which were closed urgently for hemostasis; bilateral pulmonary contusions; three rib fractures; and a grade 1 splenic laceration. She was hemodynamically stable, and the initial hemoglobin level was 11 g per deciliter. When the hemoglobin level fell to 5.4 g per deciliter, the family and church elders agreed to the use of erythropoietin and PolyHeme, a polymerized hemoglobin-based blood substitute derived from outdated human red cells (Northfield Laboratories, Evanston, Ill.).1 The patient's own hemoglobin level fell to 3.2 g per deciliter three days after the injury (Figure 1Figure 1
Values for Total, Native, and PolyHeme Hemoglobin during the First Six Days after Injury.). A total of five PolyHeme units (500 ml per unit, containing 50 g of hemoglobin) were transfused. These transfusions maintained the plasma hemoglobin level at 6 g per deciliter or higher. Erythropoietin (600 units per kilogram of body weight) was administered 24 and 48 hours after the injury, with 300 units per kilogram given on days 3, 4, and 5. Blood loss was diminished by hormonally suppressing the patient's menstrual cycle and limiting phlebotomy with the use of pediatric-size tubes. The patient received enteral and intramuscular iron, supplemental ascorbic acid, and parenteral nutrition. She was discharged home, after surgical repair of her orbital fracture, on day 19 after the injury, with a hemoglobin level of 9.8 g per deciliter.Few patients can survive a hemoglobin level of less than 5 g per deciliter without transfusion.2,3 Blood substitutes are an attractive alternative to standard blood transfusion for Jehovah's Witnesses.1,4,5 Blood substitutes provide adequate oxygen-carrying capacity and can act as a bridge until bone marrow production compensates for the loss of red cells. Exogenous erythropoietin stimulates red-cell production. Although the optimal dose of erythropoietin in a critically ill patient remains to be established, our empirically chosen high dose was associated with a rapid response. Combination therapy with erythropoietin and PolyHeme may be particularly useful in the case of a critically ill Jehovah's Witness.
5 ReferencesClay Cothren, M.D.
Ernest E. Moore, M.D.
Patrick J. Offner, M.D.
James B. Haenel, R.R.T.
Jeffrey L. Johnson, M.D.
Denver Health Medical Center, Denver, CO 80204
ernest.moore@dhha. org 1
Gould SA ,Moore EE ,Hoyt DB , et al. The first randomized trial of human polymerized hemoglobin as a blood substitute in acute trauma and emergent surgery. J Am Coll Surg 1998;187:113-122
CrossRef | Web of Science | Medline2
Brimacombe J ,Skippen P ,Talbutt P . Acute anemia to a haemoglobin of 4 g.l-1 with survival. Anaesth Intensive Care 1991;19:581-583
Web of Science | Medline3
Kale PB ,Sklar GE ,Wesolowicz LA ,DiLisio RE . Fluosol: therapeutic failure in severe anemia. Ann Pharmacother 1993;27:1452-1454
Web of Science | Medline4
Gould S ,Sehgal L ,Sehgal H ,Toyooka E ,Moss G . Clinical experience with human polymerized hemoglobin. Transfusion 1993;33:Suppl:60S-60S abstract.
Web of Science5
Johnson JL ,Moore EE ,Offner PJ ,Haenel JB ,Hides GA ,Tamura DY . Resuscitation of the injured patient with polymerized stroma-free hemoglobin does not produce systemic or pulmonary hypertension. Am J Surg 1998;176:612-617
CrossRef | Web of Science | Medline
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Khashayar Vaziri, Jason C. Roland, Linda L. Robinson, H David Reines, Samir M. Fakhry. (2009) Extreme Anemia in an Injured Jehovahʼs Witness: A Test of Our Understanding of the Physiology of Severe Anemia and the Threshold for Blood Transfusion. The Journal of Trauma: Injury, Infection, and Critical Care 67:1, E11-E13
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Ernest E. Moore, Jeffrey L. Johnson, Frederick A. Moore, Hunter B. Moore. (2009) The USA Multicenter Prehosptial Hemoglobin-based Oxygen Carrier Resuscitation Trial: Scientific Rationale, Study Design, and Results. Critical Care Clinics 25:2, 325-356
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Amanda M Ball, P. Shane Winstead. (2008) Recombinant Human Erythropoietin Therapy in Critically Ill Jehovah's Witnesses. Pharmacotherapy 28:11, 1383-1390
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Genève Allison, Colin Feeney. (2004) Successful Use of a Polymerized Hemoglobin Blood Substitute in a Critically Anemic Jehovahʼs Witness. Southern Medical Journal 97:12, 1257-1258
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(2002) Combined Blood Substitute and Erythropoietin Therapy in a Severely Injured Jehovah's Witness. New England Journal of Medicine 347:9, 696-697
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