One of Jehovah’s Witnesses with Gangrenous Foot and Severe Anemia: A Case Report

    


    


    Figure 1: 

    

The amputation of the right leg in the lower third of the thigh was performed under spinal anesthesia. We used perfluorocarbon solution (Perftoran^®, Perftoran NPO OAO, Russian Federation) as an oxygen-carrying agent, 200ml before and 200ml after the intervention. Intravenous tranexamic acid (15mg·kg^-1) was given prior to incision and 1.5mg·kg^-1·h^-1 during the surgery (total dose – 1300mg). Meticulous hemostasis was applied with only 30ml blood loss. The next day the patient was discharged from intensive care unit to continue the treatment in the surgical department (Figure 1). One week later the hemoglobin level increased to 6.8g·dL^-1 (hematocrit - 22.2%, mean corpuscular volume - 88.4fL) and she was discharged home.

Discussion

There are an increasing number of patients who are refusing blood transfusion for several reasons, the most widespread among them is belonging to the Jehovah's Witnesses. In some cases, they can present with severe or critical anemia. The refusal to receive a blood transfusion, even in a critical situation, can be a potentially fatal decision. This is where Jehovah's Witnesses differ as patients.

Lower hemoglobin level is associated with an increased mortality risk [2,3], but there are multiple strategies developed to provide care for the patients who refuse blood transfusions. One of them is to combine interventions in a comprehensive, multidisciplinary and multimodal blood management program. The program includes treatments to enhance endogenous erythropoiesis, reduce blood loss, increase oxygen delivery, reduce oxygen consumption and avoid iatrogenic anemia [4]. The approach improves outcomes without violating patient's beliefs and values.

In our opinion the severe anemia in our patient was caused by iron deficiency (serum iron – 5.8mmol·L^-1), chronic infection and moderately decreased kidney function (eGFR - 52ml·min^-1).

We started oxygen therapy at the admission to enhance tissue oxygenation. Also, we administered rHuEPO, iron, folate and vitamin B12 to assure endogenous erythropoiesis.

The majority of the authors recommend at least 40,000 IU of erythropoietin per week (or 300-600 IU·kg^-1·day^-1) [5], some recommend up to 40,000 IU·day^-1 [4]. We administered 32,000 IU week^-1 due to limited supplies of rHuEPO in the hospital at that moment.

Intravenous regimen with iron sucrose varies from 100mg daily to high-dose regimen with 500mg [4,6] or with iron carboxymaltose 20mg·kg-1 daily (maximum 1000mg) [7]. During the hospital stay a total dose of 862.5mg intravenous iron sucrose was administered to the patient, following our institutional protocol of 100mg intravenous iron sucrose every day or 200mg every second day (Figure 1).

Vitamin B12 and folic acid were administered empirically to provide substrate for erythropoiesis.

In the preoperative period the patient had well compensated severe anemia. Nevertheless, there was a need for surgical intervention and the survival of the patient was questioned due to the possible perioperative blood loss and the development of the fatal anemia. At that time, we had access to the oxygen-carrying agents as hemoglobin solution and perfluorocarbon. So, we considered the use of the bridge therapy with an oxygen-carrying agent to improve the outcome. The strategy was discussed with the patient. She refused the use of the hemoglobin solution (Hemopure^®, OPK Biotech, Cambridge, MA, USA) but accepted the use of the perfluorocarbon (Perftoran^®) as an approach [8]. We administered 200ml Perftoran^® before and 200ml after the surgery and did not give additional doses due to the absence of tachycardia, no ischemia on ECG and stable lactate levels.

From the third day, we continued iron therapy orally in a dose of 300mg·day^-1 (using a polypill with 100mg ferrous sulfate, 5mg folic acid and 10kg vitamin B12, that was administered three times a day). Our argument was the lack of the source of infection. The presence of the infection is actively contributing to the synthesis of hepcidin in considerable concentrations, a protein that prevents the absorption of iron in the gut. It has also been observed that a single dose of erythropoietin could rapidly decrease the concentration of hepcidin [11]. Our patient has received more than one.

The hemoglobin level increased on the seventh day after the surgery up to 6.8g·dL^-1 (or + 2g·dL^-1).

Conclusions

A comprehensive, multidisciplinary and multimodal blood management program is efficient when patients refuse blood transfusions. Critical anemia of 5g·dL^-1 is not always an absolute contraindication for surgery in those patients.

Using a multimodal blood management approach was possible to perform the leg amputation in a patient with severe anemia and to discharge her home one week after the surgery.

References

1. Religious and Ethical Position on Medical Therapy and Related Matters. Watch Tower Bible and Tract Society of Pennsylvania. 2012.
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