Case Presentation:
R.C. is a 42‐year‐old G3P2 Jehovah's Witness who presented to the E.D. in her 17th week of pregnancy with vaginal bleeding. A bedside ultrasound showed fetal demise and the patient was admitted for a dilatation and extraction. Her procedure was complicated by bleeding which required emergent arterial embolization by interventional radiology. A balloon tamponade was placed inside the uterus. Her Hgb dropped to 2.9 g/dL. She refused a blood transfusion but did accept an initial transfusion of FFP and platelets. She was admitted to the ICU. Her treatment included oxygen via nasal cannula, hyperbaric oxygen twice a day, IV iron, folate, B12, a PPI, Epogen, limited blood draws and limited activity. Hemopure, a hemoglobin‐based oxygen carrier (HBOC), was refused by the patient. She was discharged home 13 days later with a Hgb of 5.9 g/dL.
Discussion:
There are several strategies available to hospitalists in the resuscitation of the patient refusing a blood transfusion. New advances such as Hemopure, currently available under experimental protocols, may soon play a more prominent role in our ICUs, trauma centers and medicine floors. It can be stored at room temperature with a self‐life of 36 months and is compatible with all blood types. Hyperbaric oxygen uses a high partial pressure of oxygen to increase the oxygen carrying capacity of plasma and therefore oxygen delivery to tissues. The use of hyperbaric oxygen is limited by its availability at specialized centers. While the process of hematopoiesis takes time, providing the key building blocks will expedite this process. This includes iron, B12, folate and a stimulus such as Epogen.
Conclusions:
A Jehovah's witness with profound anemia who refuses blood products requires meticulous care and maximal therapy with alternative treatments. Hospitalists need to be aware of the key components of bloodless medicine which include limiting blood loss, decreasing oxygen demand, increasing blood production, increasing oxygen supply, and using alternative oxygen carriers if available and accepted by the patient.
Author Disclosure:
D. Childers, none.