This document describes the peri-operative management of a Jehovah's Witness patient requiring an emergency exploratory laparotomy who refused blood transfusion. It presents a case report of a 65-year-old male who underwent surgery under general anesthesia. Special consent was obtained for no blood transfusion. Intraoperatively, blood loss was replaced with crystalloids and the colloid Tetrastarch (Voluven) to maintain cardiovascular stability given the patient's anemia. The patient had an uneventful recovery without blood transfusion, demonstrating that surgery can be safely performed in Jehovah's Witness patients refusing transfusion through careful pre-operative optimization and use of alternatives to blood loss replacement like collo

1. PERI-OPERATIVEPERI-OPERATIVE
MANAGEMENT OF AMANAGEMENT OF A
“JEHOVAH’S WITNESS”“JEHOVAH’S WITNESS”
PATIENT POSTED FOR ANPATIENT POSTED FOR AN
EMERGENCY EXPLORATORYEMERGENCY EXPLORATORY
LAPAROTOMY:LAPAROTOMY:
A CASE REPORT, SERIES ANDA CASE REPORT, SERIES AND
A PROPOSED PROTOCOLA PROPOSED PROTOCOL

2. Dr. M.M. PANDITRAODr. M.M. PANDITRAO
Dr.(Mrs.) M.M. PANDITRAODr.(Mrs.) M.M. PANDITRAO
Dr.(Mrs.) B.B. SHAHDr.(Mrs.) B.B. SHAH
Dr.(Mrs.) M. BANNERJEE*Dr.(Mrs.) M. BANNERJEE*
Dr. S. DASDr. S. DAS
Department of Anaesthesiology & Critical CareDepartment of Anaesthesiology & Critical Care
Padmashree Dr. D. Y. Patil Medical CollegePadmashree Dr. D. Y. Patil Medical College
(Deemed University)(Deemed University)
Pimpri, PunePimpri, Pune

3. INTRODUCTIONINTRODUCTION
The members of “Jehovah’s witness”, a group of
believers in Christianity, who refuse to accept
“BLOOD TRANSFUSION”,
even auto transfusion, blood products and
albumin, pose a special challenge to the
Anaesthesiologists/ Clinicians and are often
turned down by hospitals. The basis of this
belief is according to the dictate given in the
Gospels.
THE BIBLE: NEW TESTAMANT: (Acts:THE BIBLE: NEW TESTAMANT: (Acts:
Chapter 15:verses 28/29)Chapter 15:verses 28/29)

4. 2828"For it seemed good to the Holy"For it seemed good to the Holy
Spirit and to us to lay upon you noSpirit and to us to lay upon you no
greater burden than these essentials:greater burden than these essentials:
2929 that you abstain from thingsthat you abstain from things
sacrificed to idols andsacrificed to idols and from bloodfrom blood andand
from things strangled and fromfrom things strangled and from
fornication; if you keep yourselvesfornication; if you keep yourselves
free from such things, you will dofree from such things, you will do

5. For elective procedure:For elective procedure:
Preventive and precautionary measures-Preventive and precautionary measures-
• Building up of HaemoglobinBuilding up of Haemoglobin
• Use of torniquettesUse of torniquettes
• Better surgical skillsBetter surgical skills
(electro-cautery, managing Haemostasis)(electro-cautery, managing Haemostasis)
• Other alternatives of blood loss:Other alternatives of blood loss:
COLLOIDSCOLLOIDS –– Polygelins, starches orPolygelins, starches or
Dextrans.Dextrans.

6. CASE REPORTCASE REPORT
A 65 year old maleA 65 year old male
Occupation - mechanicOccupation - mechanic
Complaints - distention of abdomen & pain inComplaints - distention of abdomen & pain in
abdomen since 4-5daysabdomen since 4-5days
Past HistoryPast History
Lump in abdomenLump in abdomen
Operated case for the same one month backOperated case for the same one month back

7. Personal historyPersonal history
Appetite -Appetite - decreaseddecreased
Sleep -Sleep - decreaseddecreased
Stool -Stool - not passednot passed
Bladder-Bladder- normalnormal
Family historyFamily history -- Not significantNot significant
Drug historyDrug history -- Not significantNot significant

8. GENERAL EXAMINATIONGENERAL EXAMINATION
Averagely built, cachexic maleAveragely built, cachexic male
AfebrileAfebrile
Pallor ++Pallor ++
Decreased response to oral commandDecreased response to oral command
PulsePulse-98/min-98/min
BP-140/80 mm HgBP-140/80 mm Hg
R/RR/R-24/ min-24/ min
MPC- Grade IIMPC- Grade II

9. SYSTEMIC EXAMINATIONSYSTEMIC EXAMINATION
• CNS-Decreased response to verbal commandsCNS-Decreased response to verbal commands
• Rest Examination was essentially normalRest Examination was essentially normal
PROVISIONAL ΔPROVISIONAL Δ
? Ac.INTESTINAL OBSTRUCTION? Ac.INTESTINAL OBSTRUCTION
SEPTICAEMIASEPTICAEMIA

10. INVESTIGATIONSINVESTIGATIONS
HB -HB - 8 gm%,8 gm%,
TLC - 9900,TLC - 9900,
DLC (%)DLC (%) N-86N-86, L-08, M-03, E-03,, L-08, M-03, E-03,
ESR -ESR - 60 mm/hr60 mm/hr..
BT/CT - 01’30”/05’15” Mins.BT/CT - 01’30”/05’15” Mins.
BSL® - 86mg%,BSL® - 86mg%,
Sr. Cr - 1.4mg%, BUL - 31mg%,Sr. Cr - 1.4mg%, BUL - 31mg%,
Sr. Electrolyte - NaSr. Electrolyte - Na++
-143 meq/lit,-143 meq/lit,
KK++
-- 2.7 meq/lit,2.7 meq/lit,
ClCl--
106 meq/lit106 meq/lit

11. Urine Examination:Urine Examination:
Routine -Routine - Albumin: +3Albumin: +3, Sugar - absent, Sugar - absent
Microscopic - Pus cells 8-10/hpf,Microscopic - Pus cells 8-10/hpf,
Epi.cells 1-2/hpf,Epi.cells 1-2/hpf, RBC 10-12/hpf.RBC 10-12/hpf.
LFTLFT : Sr.Bilirubin (T) 0.5mg%, (Dir)0.1mg%: Sr.Bilirubin (T) 0.5mg%, (Dir)0.1mg%
ALT-30 IU/lit, ALP-47IU/lit.ALT-30 IU/lit, ALP-47IU/lit.
CXRCXR : Normal: Normal
ECGECG : WNL: WNL

12. USG (Abdomen) :USG (Abdomen) :
Multiple retro-peritoneal nodes areMultiple retro-peritoneal nodes are
seenseen
? Lymphomatous in origin? Lymphomatous in origin
Other possibilities -Other possibilities -
? Retro-peritoneal sarcoma/fibrosis? Retro-peritoneal sarcoma/fibrosis
? Metastases/Secondaries? Metastases/Secondaries
Pancreas-NormalPancreas-Normal
Gall bladderGall bladder-Reveals sludge within.-Reveals sludge within.
Both kidneys are minimally swollenBoth kidneys are minimally swollen..

13. ANESTHETIC MANAGEMENTANESTHETIC MANAGEMENT
Patient was taken for surgery under GeneralPatient was taken for surgery under General
Anesthesia , as ASA V (E) at 3.45pm.Anesthesia , as ASA V (E) at 3.45pm.
• Special consent for “No Blood Transfusion”Special consent for “No Blood Transfusion”
• NBMNBM
• Intravenous lines: CVP & a 18G cannula secured.Intravenous lines: CVP & a 18G cannula secured.
• Pulse rate -100/min,Pulse rate -100/min,
• BP - 140/80 mmHgBP - 140/80 mmHg
• Respiratory rate - 20/min.Respiratory rate - 20/min.
• Pre-induction CVPPre-induction CVP - 12 cm of H- 12 cm of H22O,O,
• SpO2= 100%.SpO2= 100%.
• ECG monitoring with standard lead II was startedECG monitoring with standard lead II was started

14. INDUCTION:INDUCTION:
• Pre-oxygenation with 100% oxygen by maskPre-oxygenation with 100% oxygen by mask
for 3 minfor 3 min
• Induced with IV Propofol sleep dose (12 ml.,Induced with IV Propofol sleep dose (12 ml.,
1%) and Succinylcholine 100mg.1%) and Succinylcholine 100mg.
• Sellick’s maneuvereSellick’s maneuvere
• Intubated with ET tube no. 8.5, cuff inflated.Intubated with ET tube no. 8.5, cuff inflated.
Air entry checked, Tube fixed.Air entry checked, Tube fixed.
• N.M.Blockade with AtracuriumN.M.Blockade with Atracurium
• Continuous monitoring of Pulse, BP,SaO2%,Continuous monitoring of Pulse, BP,SaO2%,
ECG, CVP, Urine output and Blood loss.ECG, CVP, Urine output and Blood loss.

15. MAINTANENCEMAINTANENCE::
• Maintained on controlled ventilation on OMaintained on controlled ventilation on O22 + N+ N22OO
(50:50) & Isoflurane- trace conc.(50:50) & Isoflurane- trace conc.
• IV Pentazocine 15 mg and IV Torsemide 5 mgIV Pentazocine 15 mg and IV Torsemide 5 mg
• CVPCVP ≈≈ 12 cm H12 cm H22O maintained upto the resection ofO maintained upto the resection of
obstructed bowel loop, then went down uptoobstructed bowel loop, then went down upto ≈≈ 22
cmHcmH22O. Third space loss ≈ 2000 ml.O. Third space loss ≈ 2000 ml.
• Prophylactically – Tetrastarch- VoluvenProphylactically – Tetrastarch- VoluvenRR
infused,infused,
2packs of 500mi. Given intra-operatively2packs of 500mi. Given intra-operatively
• IV fluids replaced as per NBM and maintenanceIV fluids replaced as per NBM and maintenance

16. REVERSALREVERSAL
• Neostigmine 2.5mg+ Atropine 1.2mgNeostigmine 2.5mg+ Atropine 1.2mg
• Patient extubated after suctioningPatient extubated after suctioning
• Patient was shifted to ICU on oxygenPatient was shifted to ICU on oxygen
through Ventury maskthrough Ventury mask
• In ICU Voluven continued -3In ICU Voluven continued -3rdrd
packpack
• Uneventful course and recovery withinUneventful course and recovery within
a weeka week

17. 4.40 pm4.40 pm 05.0005.00
pmpm
5.305.30
pmpm
6.006.00
pmpm
6.30pm6.30pm 7.007.00
pmpm
7.307.30
pmpm
IVIV
drugdrug
ss
AtracuriAtracuri
umum
AtracuAtracu
riumrium
AtracuAtracu
riumrium
AtracuAtracu
riumrium
AtracurAtracur
iumium
AtracuAtracu
riumrium
PentazoPentazo
cinecine
TorseTorse
midemide
IVIV
infusinfus
ionion
DNSDNS
VoluveVoluve
nn
RLRL
VoluveVoluve
nn
DNSDNS RLRL
VoluveVoluve
nn
DNSDNS
VoluveVoluve
nn
SpOSpO22
100%100% 100%100% 100%100% 100%100% 100%100% 100%100% 100%100%
CVPCVP +12cm+12cm
HH22 OO
+12cm+12cm
HH22 OO
+12cm+12cm
HH22 OO
+12+12
cmcm
HH22 OO
+2cm+2cm
HH22 OO
+2 cm+2 cm
HH22 OO
+4cm+4cm
HH22 OO
BPBP 140/80140/80
mm.Hgmm.Hg
110/70110/70
mmHgmmHg
100/70100/70
mm.mm.
HgHg
100/70100/70
mm.mm.
HgHg
100/70100/70
mmHgmmHg
110/70110/70
mm.mm.
HgHg
130/70130/70
mm.mm.
HgHg
PRPR 100/min100/min 120/mi120/mi 110/mi110/mi 106/mi106/mi 110/mi110/mi 102/mi102/mi 110/mi110/mi

18. DISCUSSIONDISCUSSION
A person who belongs to “Jehovah's Witness” faith,A person who belongs to “Jehovah's Witness” faith,
believes that as per directives inbelieves that as per directives in
The BibleThe Bible ( New Testament: Acts, 15 : 28/29)( New Testament: Acts, 15 : 28/29)
“Keep abstaining from“Keep abstaining from
blood,”blood,”
In patients posted for planned elective surgery:In patients posted for planned elective surgery:
• Consideration to optimize the patients G.C.Consideration to optimize the patients G.C.
• To reduce blood loss intra-operatively.To reduce blood loss intra-operatively.
• Correction of Anaemia by giving oral or parenteralCorrection of Anaemia by giving oral or parenteral
Iron preparation pre-operatively.Iron preparation pre-operatively.
• Pre-assessment of inevitable blood loss intra-Pre-assessment of inevitable blood loss intra-
operatively and planning of surgery according tooperatively and planning of surgery according to
the absolute need.the absolute need.

19.  Use of proper technique to ensure :Use of proper technique to ensure :
• Meticulous Haemostasis during the surgery.Meticulous Haemostasis during the surgery.
• Minimize duration of surgery by using enlargedMinimize duration of surgery by using enlarged
expert surgical team.expert surgical team.
• Use of Topical haemostatic agents- Ab-gel, HaemolockUse of Topical haemostatic agents- Ab-gel, Haemolock
or Use of Systemic haemostatic agent – Tranexamicor Use of Systemic haemostatic agent – Tranexamic
acidacid
• Use of electro-cautery, thermal balloon, laser.Use of electro-cautery, thermal balloon, laser.
• Mechanical occlusion of blood vessels by ligationMechanical occlusion of blood vessels by ligation
vascular clips, clamps.vascular clips, clamps.
Controlled Hypotensive AnesthesiaControlled Hypotensive Anesthesia

20. But our patient for emergency Laparotomy with Hb of 8gm%
with high risk of blood loss,who refused for transfusion of
blood and all kinds of blood products posed a challenge for
the maintenance of cardiovascular stability
intraoperatively. The volume replacement with only
crystalloids was also unsuitable and risky as patient was
also anaemic.
So we decided to use Tetrastarch –Voluven
• It is of vegetative origin & it fulfills the religious criteria ofIt is of vegetative origin & it fulfills the religious criteria of
patient of not accepting any blood related productspatient of not accepting any blood related products
• It has a minimal tendency to produce allergic reactionIt has a minimal tendency to produce allergic reaction
• Does not interfere with coagulationDoes not interfere with coagulation
• Remains in the intra-vascular compartment for longerRemains in the intra-vascular compartment for longer
duration (6-8hrs)duration (6-8hrs)
• It improves microcirculation.It improves microcirculation.
• It maintains good Oxygen saturationIt maintains good Oxygen saturation
• Does not cause volume overload, especially in compromisedDoes not cause volume overload, especially in compromised
patients.patients.

21. WITH THIS EXPERIENCEWITH THIS EXPERIENCE
&&
AS THE WORD SPREADAS THE WORD SPREAD
AROUND, BY THIS TIME WEAROUND, BY THIS TIME WE
HAVE DONE A SERIES OFHAVE DONE A SERIES OF
THESE PATIENTS IN OUR O.T.THESE PATIENTS IN OUR O.T.

22. Sr.NoSr.No Type ofType of
SurgerySurgery
Elect/EmergencyElect/Emergency AnesthesiaAnesthesia
1.1. Expl.Expl.
LaparotomyLaparotomy
EmergencyEmergency GAGA
2.2. SplenectomySplenectomy ElectiveElective GAGA
3.3. LSCSLSCS EmergencyEmergency SASA
4.4. ORIFORIF
(humerus)(humerus)
ElectiveElective GAGA
5.5. ORIF (Femur)ORIF (Femur) ElectiveElective SASA
6.6. CholecystectoCholecystecto
mymy
ElectiveElective GAGA

23. Sr.NoSr.No Type ofType of
SurgerySurgery
Elect/EmergencyElect/Emergency AnesthesiaAnesthesia
7.7. LSCSLSCS EmergencyEmergency GAGA
8.8. HerniorrhaHerniorrha
phyphy
ElectiveElective SASA
9.9. HerniorrhaHerniorrha
phyphy
ElectiveElective SASA
10.10. DHSDHS
fixationfixation
ElectiveElective CSECSE
11.11. ORIF (tibia)ORIF (tibia) ElectiveElective SASA
12.12. ORIFORIF
(femur)(femur)
ElectiveElective SASA

24. PROPOSED PROTOCOLPROPOSED PROTOCOL
• For elective/ emergency surgeries underFor elective/ emergency surgeries under
Regional Anaesthesia:Regional Anaesthesia:
 Pre loading with a Colloid : Tetra starchPre loading with a Colloid : Tetra starch
 Intra-op. continued use of colloidIntra-op. continued use of colloid
 Post-op. colloid upto 30ml/ kg/ 24 hoursPost-op. colloid upto 30ml/ kg/ 24 hours..
• For elective/ emergency surgeries underFor elective/ emergency surgeries under
General Anaesthesia:General Anaesthesia:
 Intra-op. continued use of colloids along withIntra-op. continued use of colloids along with
crystalloidscrystalloids
 Post-op. colloid upto 30ml/ kg/24 hoursPost-op. colloid upto 30ml/ kg/24 hours..
Our experience with this protocol has been veryOur experience with this protocol has been very
gratifying and our surgical colleagues are quitegratifying and our surgical colleagues are quite
satisfied !!satisfied !!

25. CONCLUSIONCONCLUSION
• ““JEHOVAH’S WITNESS” PatientsJEHOVAH’S WITNESS” Patients
pose a peri-operative challengepose a peri-operative challenge
• A proper planning and meticulousA proper planning and meticulous
pre-op. preparation is neededpre-op. preparation is needed
• If emergency surgery is needed:If emergency surgery is needed:
gravity & risk is increasedgravity & risk is increased
• We, with our ongoing experience haveWe, with our ongoing experience have
proposed a protocol which works veryproposed a protocol which works very
well!well!