Acute normovolemic hemodilution as a blood conservation strategy in a Jehovah’s Witness undergoing above-knee amputation: a case report
Abstract
Major surgery is frequently associated with significant blood loss, and allogeneic transfusion remains standard therapy. Jehovah’s Witness patients may refuse blood products for religious reasons, creating major perioperative challenges. Acute normovolemic hemodilution (ANH) is a blood conservation strategy that may be acceptable to these patients when performed using a closed-circuit system.
A 65-year-old woman with acute right lower-limb ischemia, initially classified as Rutherford grade IIA (marginally threatened limb), with rapid clinical progression requiring emergency above-knee amputation under general anesthesia. The patient, a Jehovah’s Witness, refused allogeneic blood transfusion. Preoperative hemoglobin was 9.7 g/dL with a hematocrit of 32.1%. After induction of general anesthesia and achievement of hemodynamic stability, acute normovolemic hemodilution was performed using a sterile closed-circuit system via a right internal jugular large-bore catheter. A total of 500 mL of whole blood (approximately 12% of estimated total blood volume) was withdrawn gradually with simultaneous colloid infusion to maintain normovolemia, and autologous blood was reinfused after surgical hemostasis. Surgery lasted 4 hours with an estimated blood loss of 1,000 mL. Intraoperative management included balanced general anesthesia, antifibrinolytic therapy, strict hemodynamic control, active warming, and reinfusion of autologous blood after surgical hemostasis. Hemodynamics and oxygenation remained stable throughout. Postoperative hemoglobin was 8.4 g/dL, and the patient remained hemodynamically stable without vasopressor support, with an uncomplicated clinical course.
ANH reduces red blood cell loss while preserving oxygen delivery through physiologic compensatory mechanisms. In patients with cardiovascular risk factors, conservative hemodilution targets are recommended. This case highlighting the importance of meticulous anesthetic planning, a conservative and reproducible ANH protocol, objective outcome reporting, explicit adverse-event monitoring, and formal ischemia severity classification to define urgency and perioperative risk.
Acute normovolemic hemodilution can be a feasible and safe blood conservation strategy in selected Jehovah’s Witness patients undergoing high-risk surgery, provided it is carefully planned, performed using a closed-circuit system, and supported by meticulous anesthetic management and close perioperative monitoring.
Keywords: Acute normovolemic hemodilution; blood conservation; Jehovah’s Witness; acute limb ischemia; anesthesia; case report.
Citation: Firdaus AF, Sudjud RW, Rismawan B. Acute normovolemic hemodilution as a blood conservation strategy in a Jehovah’s Witness undergoing above-knee amputation: a case report. Anaesth. pain intensive care 2026;30(3):395-399. DOI: 10.35975/apic.v30i3.3184
Received: January 10, 2026; Revised: January 15, 2026; Accepted: January 27, 2026
