The Management of Acute Blood Loss With Hemoglobin-Based Oxygen Carriers in Jehovah’s Witness Patients: A Case Series and Review of Literature
Authors: Sticco Kristin , Gokhale Amit , Ahmed Tahmeena , Spitzer Eric 
Published: September 2019

Abstract
Managing anemia and acute blood loss in critical patients has long been reliant on the judicious use of red blood cell transfusions. The primary goal of blood transfusion is the efficient delivery of oxygen to end organs, especially the brain. Provided that appropriate guidelines are followed, allogenic blood transfusions are considered a safe and effective therapeutic option. Some patients refuse or decline blood transfusions due to cultural and/or religious beliefs, with the most well known being followers of Jehovah’s Witnesses (JWs). For this patient population, hemoglobin-based oxygen carriers (HBOCs) are a potential therapeutic option. Hemoglobin-based oxygen carriers are infusible oxygen-carrying fluids prepared from purified human or animal hemoglobin, which do not need to be refrigerated or crossmatched. We describe our experience at our institution where three JW patients were administered HBOCs. As HBOCs are not approved by the Food and Drug Administration and undergoing clinical trials, a compassionate use protocol was used to obtain HBOC-201 or Hemopure (Biopure Corporation). We explored factors attributing to overall response to treatment and laboratory effects of HBOC use. The first patient (24-year-old male, recurrent gastrointestinal bleed) received 8 units over a period of 2 weeks of HBOC. Pretransfusion hemoglobin and reticulocyte counts of 3.8 g/dL and 18.15% and posttransfusion counts were 12.8 g/dL and 16.97, respectively, with stable vital signs and renal function. Patient 2 (49-year-old female, chronic renal failure) received 8 units of Hemopure over 1 week. Before HBOC and erythropoietin administration, her hemoglobin and reticulocyte count were 4.2 g/dL and 0%, respectively, with stable vital signs and renal function. Post, her hemoglobin levels increased to 11.4 g/dL with a reticulocyte count of 16.0%. Unfortunately, the third patient (61-year-old female) expired secondary to complications from her initially diagnosed pulmonary embolism and massive stroke. She had received two units of HBOC and experienced a rise in hemoglobin (2.9 to 4.1 g/dL) and reticulocyte count (0% to 2.7%) with stable vitals during administration. Rapid resuscitation along with HBOC administration correlated with improved recovery in two of the three patients and yet none experienced hypertensive events. Younger age (24 and 49 years old) and their comorbid conditions are two factors that could explain the positive response to administration of HBOCs. Hemoglobin and hematocrit levels were often inaccurate as well as platelet counts, electrolytes, and liver enzymes. Coagulation tests (partial thromboplastin time, prothrombin time) were also affected by HBOC use. Overall, the utilization of HBOCs was beneficial in the hemodynamic management of two of our JW patients who refused allogenic blood transfusions. Additional research is needed to further understand the effectiveness of HBOCs on this patient population.