de Araújo Azi and coworkers report the case of a 27-year-old healthy female Jehovah’s Witness patient undergoing major spine surgery for thoracolumbar scoliosis. The patient refused cell salvage but accepted acute normovolemic hemodilution (ANH). Potential acceptance of coagulation factor concentrates e.g. cryoprecipitate, fibrinogen concentrate or prothrombin complex concentrate is not mentioned in the manuscript. Surgery was performed in two separate sessions. During the first part of surgery the patient was exclusively treated exclusively with ANH and Hb dropped from 12.7 g/dL to 8.6 g/L. The patient was then treated with EPO (600 IU/kg/week), oral iron, vitamin B12 and folic acid, and entered the second part of surgery 50 days later, again with a Hb of 12.9 g/dL. The following intraoperative blood conservation techniques were used: ANH, deliberate hypotension (MAP 50-65 mmHg), low-dose (460 mg) tranexamic acid, and reinfusion of unwashed shed blood. Nevertheless Hb dropped to 6.5 g/dL. During the first 14 postoperative hours Hb dropped further to a minimum of 1.4 g/dL and the patient had to be reintubated and sedated with ketamine. Dopamine was infused for hemodynamic stabilization. The patient was kept normothermic, hyperoxic ventilation was performed and laboratory tests were restricted to a minimum. EPO was administered in high doses (16,000 units daily) for 14 days and then reduced to 8000 units three times a week until day 20. The patient recovered and was discharged with Hb 9.1 g/dL on day 23 after surgery. Retrospectively, the critical Hb level of the patient (whereby oxygen delivery is lower than tissue oxygen demand) was estimated to be between 2.8 and 1.4 g/dL. This case report nicely demonstrates the extreme tolerance to anemia of a young healthy organism. Although the choice of the different blood conservation techniques remains debatable, they finally proved successful.

– Oliver Habler