The Use of Barbiturate Coma as Salvage Therapy in a Postoperative Jehovah's Witness Patient with Life-Threatening Anemia

Management of the patient who refuses blood products based on religious grounds poses ethical and clinical challenges, especially when the degree of anemia becomes life-threatening. In this report, we present the case of a 52-year-old Jehovah's Witness with sickle cell disease in whom he and his family refused blood products for the treatment of severe anemia associated with profound and progressive acidosis, acute oliguric renal failure, and hemodynamic instability. Attempts carried out during the first 3 hospital days to stabilize the patient using standard therapies to support oxygen delivery as well as the use of sedation, pain control, temperature control, neuromuscular blockade, and mechanical ventilation to reduce oxygen demand were not successful. Thus, because oxygen consumption by the brain represents approximately 20 per cent of the body's oxygen needs, and pentobarbital's primary action is as a central nervous system depressant, the induction of pentobarbital coma was instituted to reduce cerebral oxygen consumption. The institution of pentobarbital on hospital Day 3 was sufficient to acutely stabilize the patient's deteriorating metabolic state and ultimately was associated with survival. Thus, we conclude that there is a potential role for barbiturate coma in Jehovah's Witness patients who refuse blood transfusions and dying of anemia when other modalities of support are not sufficient.