Purpose/Background: Jehovah's Witnesses represent a unique subset of colorectal surgery patients given their religious refusal of blood products. Perioperative anemia stemming from both acute blood loss and chronic inflammation can be present in as many as 23 to 56% of patients with colorectal cancer, with iron deficiency anemia being the most prominent presentation. Perioperative anemia and blood transfusions are independent risk factors for morbidity and mortality in non-cardiac surgical patients.
Methods/Interventions: In this paper, we outline an evidence guided protocol designed to manage the diverse preoperative etiologies of anemia in Jehovah's Witness patients presenting for colorectal surgery by addressing erythropoiesis, iron deficiency, chronic inflammation, correction of coagulopathies, minimization of blood loss, and perioperative nutrition.
Results/Outcomes: We implement a standardized preoperative questionnaire outlining individualized acceptance of major fraction blood products, minor fraction blood products, and hematopoietic agents. If accepted based on religious preferences, our protocol begins patients on recombinant erythropoietin at 40,000U subcutaneous daily with adjunct IV iron gluconate 100mg daily. The combination of recombinant erythropoietin with IV iron has been shown to raise hemoglobin and decrease perioperative blood transfusion. 100mcg intramuscular vitamin B12 daily and 1mg oral folate daily addresses vitamin malabsorption and global macronutrient deficiencies related to chronic inflammation that can contribute to poor erythropoiesis. 500mg oral Vitamin C daily addresses hepcidin mediated intestinal iron malabsorption in states of chronic inflammation. Minimizing unnecessary phlebotomy, using pediatric phlebotomy tubes, and institutional implementation of standardized Jehovah's Witness pathways decreases perioperative blood loss and, potentially, severe anemia. Vitamin K and PCC may be utilized as needed to address underlying coagulopathy that may contribute to intraoperative blood loss. A robotic surgical approach is routinely employed given a significant decrease in intra-operative blood loss and transfusion rate when compared to both open and laparoscopic approaches. We utilize tranexamic acid which has been demonstrated to decrease major bleeding complications without an increase in cardiovascular safety outcomes in colorectal surgery patients. Furthermore, we routinely use oxidized regenerated cellulose powder (SURGICEL) which has been shown to be effective in obtaining hemostasis in mild-to-moderate surgical bleeding. Judicious use of venous thromboembolism chemoprophylaxis until the post-operative period may be considered in carefully selected patients understanding the increased risk of VTE in colorectal patients with cancer and chronic inflammation. Finally, emphasis is placed on perioperative nutritional optimization.
Conclusion/Discussion: We present this well tolerated and evidence guided protocol as an outline for management of perioperative anemia in Jehovah's Witness patients given the high prevalence of multifactorial anemia in colorectal patients and perioperative risks of severe anemia. Ongoing data collection regarding outcomes in Jehovah's Witness patients undergoing colorectal surgery with preoperative anemia will elucidate the potential efficacy of this institutional protocol.
