Let us use physiologic transfusion triggers: Favorable outcome in an 86-year-old Jehovah's witness with a haemoglobin nadir of 44g L-1

Abstract

The number of Jehovah's Witnesses worldwide is estimated at approximately 8.6 million. As Jehovah's Witnesses refuse administration of blood and blood-derived products on religious grounds, transfusion of red blood cells is not an option. It is especially problematic when anaemia develops acutely, as in non-elective surgery, as there is no time to optimise volume of red blood cells preoperatively. We present a case of an 86-year-old woman who underwent non-elective laparoscopic cholecystectomy due to gangrenous cholecystitis. Post-operatively the patient was hospitalised in an intensive care unit where the haemoglobin concentration reached nadir of 44 g L-1. Despite developing severe anaemia, the patient survived and did not suffer from long-term sequelae. To our knowledge, the patient presented here was the oldest patient who survived anaemia of such severity to date. When deciding on red blood cells transfusion clinicians should consider patient's physiologic response to anaemia, as tolerance of anaemia is variable among patients. Even elderly patients may tolerate severe anaemia, as it has been shown in our care report.

Anemia of critical illness: a narrative review

“…As transfusion of RBC at restrictive triggers still may not improve oxygen delivery in some patients, and may in fact be deleterious, so called 'physiological transfusion triggers' have started to be used in RBC transfusion decision making [71]. Even elderly patients may tolerate very low Hb concentrations [72].…”

Red blood cell transfusion practice in a single institution in Poland in 2018-2019 – Is there room for improvement?

“…Median pre-RBCT Hb concentration is slightly higher than recommended, however we do not know other factors that may have impact on decision to transfuse. Appropriate timing and dosing of RBCs still remains a major question, as patients can have favorable outcomes even with Hb concentrations below restrictive transfusion thresholds [7].…”

“…However transfusion practices may vary by an institution or even by a prescribing physician [5,6]. Decision regarding RBCT should be individualized and preferably take into account parameters of global and/or regional oxygenation [7]. In order to get specific information on RBCT practice in a local environment, and potentially improve RBCT practice, regular analyses have to be performed.…”

The Impact of Red Blood Cell Transfusion on Blood Lactate in Non-Bleeding Critically Ill Patients—A Retrospective Cohort Study

“…Tolerance of anemia depends on the fine balance between global oxygen (O 2 ) delivery (DO 2 ) and global oxygen consumption (VO 2 ). Even elderly patients with chronic heart failure may tolerate very low Hb concentration [5]. RBCT is used to increase DO 2 and improve the DO 2 -VO 2 balance.…”