The article explores the management of anemia in patients who refuse blood transfusions, such as Jehovah’s Witnesses, often due to religious beliefs. It focuses on strategies within “Bloodless Medicine and Surgery” (BMS) protocols, which are designed to respect patients’ preferences while addressing severe anemia. These protocols include optimizing hematopoiesis using erythropoiesis-stimulating agents, iron supplementation, and vitamins to enhance red blood cell production. Additionally, they emphasize minimizing blood loss through methods like reduced phlebotomy, precise bleeding control during surgeries, and improving hemostasis with clotting agents. To counteract anemia’s effects, BMS also incorporates measures to enhance oxygen utilization, including mechanical ventilation, sedation, and temperature management when required.

The article presents three case studies illustrating the practical application of BMS strategies. In one case, a man with gastrointestinal bleeding was treated with iron infusions, erythropoietin, and supportive care, avoiding transfusions despite life-threatening anemia. Another case involved a woman with postpartum hemorrhage, managed with uterine tamponade, clotting factor concentrates, and tranexamic acid, alongside surgical interventions like hysterectomy when necessary. The third case describes a teenage patient undergoing complex spinal surgery, with preoperative planning that included autologous blood recovery and infusion, as well as meticulous monitoring and clotting factor management.

The authors highlight that the principles of BMS have informed the development of “Patient Blood Management” (PBM), which applies blood-conserving techniques universally to enhance patient outcomes and reduce reliance on transfusions. However, challenges remain, such as variability in patients’ acceptance of blood products or derivatives, ethical and legal dilemmas—especially with minors—and the necessity for interdisciplinary collaboration and advanced preparation. Overall, the article underscores that respectful, individualized care and innovative strategies can lead to successful outcomes for patients who refuse transfusions and benefit broader patient populations through PBM programs.

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