Successfully Managing Severe Anemia in a Trauma Patient Who Refused Blood Transfusion: A Case Report

Patient: Male, 71-year-old Final Diagnosis: Traumatic hemothorax with multiple rib fractures (1(st), 2(nd), 7(th)–12(th) right ribs; 1(st)–9(th), 11(th) left ribs), compression fracture of thoracic vertebrae (T10), closed Left iliac pelvic bone fracture and pneumomediastinum Symptoms: Bleeding • dyspnea • severe anemia Clinical Procedure: Abdomen CT • arterial line catherization • central venous catheterization • chest CT scan • chest tube • chest xray • endoscopy • tracheostomy Specialty: Critical Care Medicine • Surgery OBJECTIVE: Management of emergency care BACKGROUND: Surgical management in patients who undergo traumatic blood loss but who refuse blood transfusion can be challenging, but physicians and surgeons must comply with the wishes and beliefs of their patients. This report describes the management of severe anemia, with hemoglobin level of 2.5 g/dL, in a 71-year-old male Korean trauma patient who declined blood transfusion. CASE REPORT: A 71-year-old man was admitted to hospital with severe blood loss following trauma. He declined blood transfusion due to his religious belief as a Jehovah’s Witness. On day 4, the patient’s hemoglobin level dropped from 7.7 to 3.9 g/dL. Despite the need for blood transfusion, the patient refused. Hence, therapeutic strategies, including crystalloid fluid resuscitation, bleeding control, vasopressor support, erythropoietin administration, supplementation with iron, folic acid, and vitamin B12, coagulopathy correction, oxygen consumption reduction, and mechanical ventilation were implemented. Following 16 days of supportive management, the hemoglobin reached 7.4 g/dL. However, it suddenly decreased on day 41 (2.5 g/dL) due to episodes of melena secondary to an actively bleeding gastric ulcer, which was successfully managed with endoscopic hemostasis. Despite increased vasopressor dosage and addition of vasopressin and hydrocortisone, the patient became unresponsive with persistent hypotension. Methylene blue was used as the final therapeutic agent. The patient responded well and subsequently recovered without blood transfusion. CONCLUSIONS: This report has presented the clinical challenges of managing the case of a patient who requires but declines blood transfusion and has highlighted the approach to clinical care while respecting the wishes of the patient.