Management and clinical outcomes for patients with gastrointestinal bleeding who decline transfusion

PLOS ONE RESEARCH ARTICLE Management and clinical outcomes for patients with gastrointestinal bleeding who decline transfusion Jessica O. Asiedu1, Ananda J. Thomas ID1, Nicolas C. Cruz1, Ryan Nicholson ID1, Linda M. S. Resar2, Mouen Khashab3, Steven M. Frank ID1* a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, United States of America, 2 Department of Hematology, Johns Hopkins Medical Institutions, Baltimore, MD, United States of America, 3 Department of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States of America * Abstract OPEN ACCESS Background Citation: Asiedu JO, Thomas AJ, Cruz NC, Nicholson R, Resar LMS, Khashab M, et al. (2023) Management and clinical outcomes for patients with gastrointestinal bleeding who decline transfusion. PLoS ONE 18(8): e0290351. https:// doi.org/10.1371/journal.pone.0290351 The national blood shortage and growing patient population who decline blood transfusions have created the need for bloodless medicine initiatives. This case series describes the management of gastrointestinal bleed patients who declined allogeneic blood transfusion. Understanding the effectiveness of bloodless techniques may improve treatment for future patients while avoiding the risks and cost associated with transfusion. Editor: Mabel Aoun, Faculty of Medicine, SaintJoseph University, LEBANON Study design and methods Received: February 23, 2023 Accepted: August 5, 2023 Published: August 25, 2023 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0290351 Copyright: © 2023 Asiedu et al. 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. Data Availability Statement: Our anonymized data is available through BioStudies via accession number S-BSST1169 (https://nam02.safelinks. protection.outlook.com/?url=https%3A%2F% A retrospective chart review identified 30 inpatient encounters admitted between 2016 to 2022 for gastrointestinal hemorrhage who declined transfusion due to religious or personal reasons. Clinical characteristics and patient blood management methods utilized during hospitalization were analyzed. Hemoglobin concentrations and clinical outcomes are reported. Results The most common therapy was intravenous iron (n = 25, 83.3%), followed by erythropoietin (n = 18, 60.0%). Endoscopy was the most common procedure performed (n = 23, 76.7%), and surgical intervention was less common (n = 4, 13.3%). Pre-procedure hemoglobin was <6 g/dL in 7 patients, and <5 g/dL in 4 patients. The median nadir hemoglobin was 5.6 (IQR 4.5, 7.0) g/dL, which increased post-treatment to 7.3 (IQR 6.2, 8.4) g/dL upon discharge. One patient (3.3%) with a nadir Hb of 3.7 g/dL died during hospitalization from sepsis. Nine other patients with nadir Hb <5 g/dL survived hospitalization. Conclusions Gastrointestinal bleed patients can be successfully managed with optimal bloodless medicine techniques. Even patients with a nadir Hb <5–6 g/dL can be stabilized with aggressive PLOS ONE | https://doi.org/10.1371/journal.pone.0290351 August 25, 2023 1 / 10 PLOS ONE Bloodless management of gastrointestinal bleeds 2Fwww.ebi.ac.uk%2Fbiostudies%2Fstudies%2FSBSST1169&data=05%7C01%7Cjasiedu3%40jhmi. edu%7C7b2fda42e41845911dfe08db99edd4cc% 7C9fa4f438b1e6473b803f86f8aedf0dec%7C0% 7C0%7C638273019012796990%7CUnknown% 7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLC JQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0% 3D%7C3000%7C%7C%7C&sdata= UU9dEcdaxpWr9Zp8vhOanMpOidG9tu% 2F3WVy2LXf0ebQ%3D&reserved=0). anemia treatment and may safely undergo anesthesia and endoscopy or surgery for diagnostic or therapeutic purposes. Methods used for treating bloodless medicine patients may be used to improve clinical care for all patients. Funding: Supported by a grant from the New York Community Trust (https://nam02.safelinks. protection.outlook.com/?url=https%3A%2F% 2Fwww.nycommunitytrust.org%2F&data=05% 7C01%7Csfrank3%40jhmi.edu% 7Cb2144ba3dafe43749bca08db984b6f35% 7C9fa4f438b1e6473b803f86f8aedf0dec%7C0% 7C0%7C638271222446869035%7CUnknown% 7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDA iLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6M n0%3D%7C3000%7C%7C%7C&sdata=03 HPQVk9fuZSjvs2LejNrCp1Vr1AH4P4zncaB6 CmomU%3D&reserved=0). Haemonetics provided support in the form of salaries for the author S.M.F. The company and their employees did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript and only provided financial support in the form of authors’ salaries and/or research materials. The specific role of this author is articulated in the ‘author contributions’ section. Allogeneic blood transfusion (ABT) is one of the most common hospital procedures in the U.S [1]. However, there is currently a growing population of patients who decline ABT due to religious or personal reasons. Members of the Jehovah’s Witness religious group account for a major portion of this population [2]. In 1945, a doctrine was passed by Jehovah’s Witnesses which prohibits its members from receiving ABT [3]. This is based on interpretation of certain passages in the Bible that equate a person’s blood with their soul. An example of this is Leviticus 17:14 which states, “You must not eat the blood of any creature, because the life of every creature is its blood; anyone who eats it must be cut off” [4]. Additionally, while medical innovation has made ABT a relatively safe procedure, there are still many associated risks, such as transfusion-associated circulatory overload, transfusionrelated acute lung injury, and acute hemolytic reactions [5]. These risks, along with the recent blood shortages that have resulted from the COVID-19 pandemic, and the continuing increase in healthcare costs associated with ABT have driven the need for alternative care known as patient blood management (PBM) [6]. Bloodless medicine is specialized care that combines a variety of PBM methods with the goal of avoiding ABT [3]. Bloodless medicine goes beyond simply withholding ABT, and includes various techniques utilized to reduce blood loss and stimulate red blood cell production. This includes methods such as the use of pediatric phlebotomy tubes to minimize blood loss from laboratory testing, and the treatment of anemia through agents like iron and erythropoietin [2]. These methods become even more critical in the management of patients suffering from active hemorrhage, especially with occult bleeding, as is often the (...truncated)