Jehovah ’ s Witness Patients in Cardiac Surgery : A Retrospective Chart Review

Objective: To describe outcomes of Jehovah’s Witness patients undergoing cardiac surgery at our center, and relate these to a comparable group of non-Jehovah’s Witness patients. Methods: Twenty-five adult Jehovah’s Witness patients underwent cardiac surgery between January 2008 and June 2013. Pre-operative characteristics, operative data and outcomes were obtained through retrospective chart review. Data was similarly collected on twenty-five non-Jehovah’s Witness patients, manually matched for baseline characteristics. Outcomes were compared between groups. Results: Baseline characteristics were well-matched between groups, with the exception of pre-operative ejection fraction and diabetes which differed slightly. Low patient numbers precluded statistical analysis for some outcome measures, and resulted in a lack of power to demonstrate significant differences in others. In-hospital deaths were reported in 2 Jehovah’s Witness patients versus 0 in non-Jehovah’s Witness patients; there were no re-operations in either group. There was a non-significant trend to more acute complications in the nonJehovah’s Witness group. Non-Jehovah’s Witness patients stayed in hospital an average of 3.1 days longer than Jehovah’s Witness patients. Fibrinogen concentrate (available in our center since 2010) was administered to 2Jehovah’s Witness patients and 8 non-Jehovah’s Witness patients received blood products. Conclusions: The low number of Jehovah’s Witness patients precludes detection of statistically significant differences in outcome compared with non-Jehovah’s Witness patients undergoing cardiac surgery. Nonetheless, it appears that Jehovah’s Witness patients may undergo cardiac surgery with favorable outcomes. This study serves as a basis to track outcomes of these patients, as increasing emphasis is placed on blood management in the surgical patient. Perspective: As Jehovah’s Witness (JW) patients do not accept whole blood products, they are at presumed higher risk of morbidity and mortality during major surgery. We demonstrate that JW patients can safely undergo cardiac surgery with similar outcomes to non-JW patients. If blood management techniques contribute significantly to positive outcomes in JW patients there may be a role for increased use in non-JW patients. Central message: Favorable outcomes in Jehovah’s Witness patients undergoing cardiac surgery are relevant as more emphasis is placed on blood management Research Article Volume: 1.1 Received date: April 26, 2018; Accepted date: June 29, 2018; Published date: July 03, 2018. *Corresponding Author: Dr. Myron Kwapisz, Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, 1278 South Park St, Halifax, N.S., Canada, B3H 2Y9, Phone: 902-473-4326; Fax: 902-473-3820; E-mail: myron.kwapisz@nshealth.ca Citation: DeCoste R, Kwapisz M, Mingo H, Kent B, et al. (2018) Jehovah’s Witness Patients in Cardiac Surgery: A Retrospective Chart Review. J Anesthe Advan Res 1(1) Copyright: © 2018 Myron K. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Open Access 1 Citation: DeCoste R, Kwapisz M, Mingo H, Kent B, et al. (2018) Jehovah’s Witness Patients in Cardiac Surgery: A Retrospective Chart Review. J Anesthe Advan Res 1(1) Abbreviations ACPB Cardiopulmonary bypass CVICU Cardiovascular intensive care unit JW Jehovah’s Witness STS Society of Thoracic Surgeons Figure 01: Jehovah’s Witness patients may undergo cardiac surgery with favorable outcomes Introduction Blood management is an important consideration during cardiac surgery. In addition to the invasive nature of any cardiac procedure, there is a risk of substantial blood loss related to hemodilution, platelet dysfunction, low fibrinogen levels and prolonged cardiopulmonary bypass (CPB) time [1]. As a result, transfusion rates in the literature range from 20–80% [2]. For religious reasons, Jehovah’s Witness (JW) patients do not accept whole blood products, although some may choose to accept fractions such as cryoprecipitate, albumin and fibrinogen [3]. As a result of this practice, they are at high risk for morbidity and mortality during invasive procedures. Recent advances in perioperative blood management strategies may allow JW patients to undergo complex procedures with J Anesthe Advan Res Volume: 1.1 Citation: DeCoste R, Kwapisz M, Mingo H, Kent B, et al. (2018) Jehovah’s Witness Patients in Cardiac Surgery: A Retrospective Chart Review. J Anesthe Advan Res 1(1) 2 better outcomes. However, these advances, which include pre-operative administration of iron and erythropoietin, anti-fibrinolytic therapy, cellsaver technology and acute normovolemic hemodilution, may carry their own inherent risks (e.g. thromboembolic complications as a result of erythropoietin administration) [2,4,5]. Given recent changes in practice surrounding the management of perioperative blood conservation, this study aimed to describe outcomes of JW patients undergoing cardiac surgery at our center and compare these with a similar group of non-JW patients in the period 2008–2013. Methods Ethics committee approval and waiver of consent were obtained (NSHARS/2014-063, July 18, 2013). JW patients (N=25) who underwent cardiac surgery at the Queen Elizabeth II Health Sciences Centre from January 2008 to June 2013 were identified, and matched manually (1:1) from a set of baseline characteristics with a group of non-JW patients (N=25) through the Maritime Heart Centre database. Characteristics employed in matching were age (>18 years), sex, body mass index, procedure, urgency of procedure, previous sternotomy, renal failure (defined as creatinine greater than 176 μmol/l, to correspond with the definition used by the Maritime Heart Centre database), peripheral/cerebral vascular disease, diabetes, and Ejection Fraction (EF) less than 40%. Standardized differences were calculated for all characteristics. Data regarding the outcomes of study patients was collected via retrospective chart review on electronic charts and via the Maritime Heart Centre database. Statistical comparisons were attempted using McNemar’s test, paired t-test, repeated measures analysis of variance (ANOVA) and Wilcoxon signed rank test where appropriate. The power of these comparisons, were hampered by the low number of patients included in the study. Of note, all patients undergoing elective cardiac surgery at our institution are seen preoperatively in an anesthesia assessment clinic for medical optimization. In addition, patients with anemia, bleeding risk or transfusion refusal (e.g. JW patients) are evaluated through a perioperative blood management program. This involves a nurse assessment and multidisciplinary optimization approach that may include pre-operative medications, intraand post-operative blood products as accepted and required by the patient, as well as the discussion and use of blood conservation strategies. The following blood conversation strategies are used routinely at our institution: Preoperative intravenous Iron, erythropoietin, anti-fibrinolytic therapy with tranexamic acid, cell saver, Acute Normovolemic Hemodilution (ANH) and retrograde autologous priming (Table 2). Results In total, 25 JW patients underwent cardiac surgery at this center during the study period. Manually, JW patients were matched with a group of non-JW patients (standard difference less than or equal to 0.1) for all characteristics except pre-existing diabetes and ejection fraction (Table 1). Blood conservation methods were more commonly employed in the JW population. Both groups received anti-fibrinolytic therapy with intravenous tranexamic acid (Table 2). Comparisons of mean preoperative, post-operative, and operative change in hemoglobin are shown in table 3. No statistical difference was observed between groups for change in hemoglobin, with a p-value from repeated measures ANOVA of 0.19 for group effect and 0.68 for the interaction of group and time. As a result of the small sample size, it was not possible to demonstrate statistically significant comparisons in the majority of outcomes examined. In addition, in some cases it was not possible to utilize statistical comparisons reliably. Results for outcomes studied are shown in Tables 4 and 5. There were more in-hospital deaths in the JW group (2 vs. 0) and more inhospital complications in the non-JW group. Mortalities were secondary to low cardiac output syndrome complicated by anemia and a valvular failure. Of note, since its introduction at our center in 2010, 2 JW patients have received fibrinogen concentrate and 8 non-JW patients have received blood products. The JW patients who were given fibrinogen concentrate received 2 g after reversal of heparin with protamine. Of those non-JW patients who received blood products, all eight received packed red blood cells (median 2 U, range 1–8); one patient also received 2 bags of platelets (1 bag is equal to ~250 ml of platelets from four pooled donations) and 3 U of fresh frozen plasma. Table 1: Baseline characteristics of study groups Variable JW (N=25) Non-JW