Bloodless surgery is an approach to health care that began in the 1960s as simple avoidance of the use of transfused blood. It has grown over the last four decades, however, to include changed attitudes toward blood conservation as well as new technologies that minimize the need for transfusions during surgery. The Center for Bloodless Medicine and Surgery at Hartford Hospital in Connecticut defines bloodless surgery as "...surgical and medical treatment without the administration of blood or blood-related products."
The new interest in bloodless surgery has emerged from a variety of religious and social concerns as well as medical, legal, and economic issues.
Religious and ethical considerations
One of the earliest motivations for bloodless surgery was finding ways to treat Jehovah's Witnesses who needed emergency surgery without offending their beliefs about blood transfusion . Many of the larger bloodless surgery centers in the United States serve areas with a large population of Jehovah's Witnesses. The specific Biblical passages that Witnesses cite as the basis for their objections are Genesis 9: 4–5, in which God forbids eating animal "flesh with its blood"; and Acts 15:29, in which the Apostles ask their first converts to "abstain from blood" as well as from other forms of immorality. Mainstream commentators generally understand the first passage as referring to eating an animal that is still alive, and the second as referring to a controversy among early Christians between Jewish and Gentile converts. A group within the Jehovah's Witnesses community, the Associated Jehovah's Witnesses for Reform on Blood (AJWRB), is a good resource for readers interested in the range of views among contemporary Witnesses regarding blood transfusions and in the Witnesses' interpretation of the Bible.
Respect for the religious beliefs of a specific group, however, is related to a more general ethical concern for patients' rights. While a majority of bloodless surgical procedures are still requested by Jehovah's Witnesses, as of 2003 the proportion of other patients requesting bloodless surgery is rising and is expected to continue to increase. Whereas in 1998 only 10% of bloodless surgical procedures were performed on non-Witnesses, by the end of 2002 the proportion had risen to 30%. The number of medical centers in the United States that offer bloodless surgery has expanded from about 20 in 1996 to over 70 as of 2002. While the increased demand for bloodless procedures stems partly from concerns that will be discussed in the following sections, it also reflects changing attitudes on the part of patients. One nurse has described patients enrolling in bloodless surgery programs as "proactive" people who are aware that they have choices about health care and expect medical professionals to respect their decisions. This attitude is a considerable change from the "doctor knows best" passive acceptance that characterized previous generations of patients. Hospitals with bloodless surgery centers emphasize the importance of patients' ethical rights to privacy and self-determination as well as their legal rights to refuse treatments that they find objectionable.
The most important non-religious reason that patients give for requesting bloodless surgery is concern about the safety of blood transfusions. These fears are related to the quality of the American blood supply as well as the process of blood transfusion itself.
- Bloodborne diseases. Many patients are afraid of contracting diseases such as AIDS and hepatitis from allogeneic (donated) blood. The risk of contracting these specific diseases has been vastly reduced over the past 40 years. According to Dr. Gregory Nuttall, chair of the Committee on Transfusion Medicine of the American Society of Anesthesiologists, the risk of contracting hepatitis from transfused blood has decreased from one chance in 10 in the 1960s to less than 1:100,000 by 2000. The risk of contracting HIV infection has been reduced by a factor of 10,000 since the virus was first identified in 1983. Unfortunately, these statistics do not reassure patients who are concerned about the possibility of being infected by disease agents that have not yet been identified as bloodborne. In addition, as of 2003 there is no way to screen potential blood donors for four diseases caused by parasites (malaria, babesiosis, Chagas' disease, and Lyme disease) and one disease caused by prions (Creutzfeldt-Jakob disease), even though the Centers for Disease Control (CDC) have recorded cases of transfusion-transmitted malaria, babesiosis, and Chagas' disease in the United States.
- Transfusion reactions related to medical errors . In contrast to the reduction of risk from infection, there has been little reduction of risk since 1960 of noninfectious serious hazards of transfusion, or NISHOT. NISHOT statistics include mistransfusion and ABO/Rh-incompatibility. Although transfusion errors are only a small percentage of all medical errors reported in North American hospitals, they are the most common cause of serious mortality and morbidity associated with blood transfusions. About 25 patients die each year in the United States from transfusion errors involving ABORh incompatibility. These errors are due to misidentification of type-and-crossmatch samples, laboratory errors, or misidentification of the transfusion recipient. Even patients who donate their own blood (autologous donation) in preparation for elective surgery cannot be completely certain that their blood will be correctly labeled and used during their operation.
- Immune system reactions. Allogeneic blood has been shown to disrupt the immune system and reduce longevity in cancer patients. Other studies have shown that transfused donor blood suppresses the production of B-cells and T-cells in recipients.
- Availability of blood. Many healthcare professionals are concerned about the growing shortage of blood for surgical procedures in the United States. Some blood types are less common than others; in addition, there are often seasonal shortages of blood. In January 2003, the American Red Cross, American Association of Blood Banks, and the federal Department of Health and Human Services issued an urgent appeal for blood donations; many hospitals had less than a one-day supply when a seven-day supply is considered optimal. There is an increasing demand for blood; three million pints of blood are used in the United States every year just for elective surgery. In addition, many surgical procedures require large amounts of blood or blood products. According to the Center for Molecular and Cellular Therapy at the University of Minnesota, a liver transplant requires six to 10 units of red blood cells, 20 units of plasma, and 10 units of platelets, while a bone marrow transplant takes one to two units of red blood cells every other day for two to four weeks plus six to eight units of platelets daily for four to six weeks.
The cost of allogeneic blood transfusions is higher than most people realize. One hospital in New Jersey estimates that each blood transfusion costs the patient about $500. Another cost analysis published in the American Journal of Surgery concluded that even though the donated blood itself is free, the costs of preparing, storing, transporting, and unpackaging the blood come to $1,003 to $1,043 per patient receiving a transfusion—and this figure does not include treating the medical complications associated with allogeneic blood transfusion.
A significant problem confronting blood banks in the United States is the growing proportion of older Americans in the general population. Their numbers are not matched by any corresponding increase in the donor population; it is estimated that only 5% of American adults give blood regularly. Although a wide cross-section of the public can be found at blood drives, several studies have shown that the statistically average donor is a college-educated married Caucasian male between the ages of 30 and 50 with an above-average income. As of 2003, the elderly comprise about 13% of the American population, but use about 25% of transfused blood. The aging of the so-called baby boomer generation, which represents a large segment of the population, is expected to lead to a critical shortage of blood by 2030. The rise in the number of complex orthopedic procedures associated with high-volume blood loss that are performed largely in elderly patients contributes to the likelihood of a severe blood shortage over the next two decades.
Another demographic change that affects the size of the population eligible to donate blood is the increased popularity of tourism and the rising number of people stationed in other countries by their employers or the military. People who have been exposed to or have a history of certain diseases from living abroad are either indefinitely or permanently deferred from giving blood. Detailed policies regarding donor deferral from the American Red Cross and the Department of Defense can be found in All About Blood , a booklet from the American Association of Blood Banks (AABB) that can be downloaded free of charge from the AABB web site.
Bloodless surgery covers a wide variety of changes in medical practice as well as new equipment and technological innovations.
Preoperative assessment of patients
A patient seeking bloodless elective surgery is carefully evaluated for a history of unexpected bleeding or clotting problems after medical or dental procedures. He or she will also be asked about a family history of bleeding disorders.
The patient's blood will be tested to determine hemoglobin levels. In most cases, he or she will be given medications to build up hemoglobin levels prior to surgery. These are discussed in more detail below.
Care is taken to minimize the number and size of blood samples drawn for presurgical testing . The invention of microanalyzers allows hospital laboratories to run blood tests on samples of blood that are 30–60% smaller than those previously collected, and to use the same blood sample for multiple tests.
Reducing blood loss during surgery
NEW INSTRUMENTS AND SURGICAL TECHNIQUES. The invention of several types of new surgical instruments has allowed surgeons to perform a variety of procedures with minimal blood loss. Miniaturized endoscopes make it possible to perform surgery on the abdomen and spine through very small incisions, often shorter than 1 in (2.5 cm) in length. The invention of argon beam coagulators, electrocautery devices, and harmonic scalpels—which use a combination of ultrasound vibration and friction to clot blood at the same time as cutting—also help to make transfusions unnecessary. In addition, surgeons are being trained to use extra caution during surgery and to clamp or cauterize open blood vessels as quickly as possible.
PERFORMING DIFFICULT PROCEDURES IN STAGES. Blood transfusions can sometimes be avoided by scheduling lengthy surgical procedures in two stages. Although this approach requires additional exposure to general anesthesia, it can shorten the overall length of the patient's hospital stay. The patient can be discharged after the first operation relatively quickly and build up his or her hemoglobin levels before the second procedure. In addition, the second surgery can be completed without the need for allogeneic blood.
HYPOTENSION. Hypotension in surgery refers to the intentional lowering of the patient's arterial blood pressure during the procedure. Lowering blood pressure has been shown to reduce blood loss and the consequent need for transfusions. It also shortens the length of time spent in the operating room . The limitation of hypotension is that it cannot be used in surgical procedures requiring tissue grafting or in patients with coronary artery disease.
HEMODILUTION AND BLOOD SALVAGE TECHNIQUES. Hemodilution is a technique in which whole blood from the patient is withdrawn before surgery for temporary storage and replaced with crystalloid or colloid solutions that restore the normal fluid volume of the blood without adding new blood cells. The patient thus loses fewer red blood cells during surgery. At the close of the operation the patient's own blood is reinfused, thus minimizing the possibility of transfusion error or a transfusion reaction. Hemodilution has been approved and recommended by experts at the National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health (NHI).
Blood salvage , which is also called autotransfusion, involves an automated recovery system that collects the patient's blood during surgery in a cell separation device. This device separates the red blood cells from other blood components, washes them, and concentrates them for reinfusion. As of 2003, however, autotransfusion cannot be used in patients with malignant tumors or active infections.
Reevaluation of postoperative anemia
Another change that has affected the frequency and number of blood transfusions is the reevaluation of anemia and its effects on the body. At one time patients were automatically given blood transfusions if their hemoglobin level fell below 10 g/dL. More recent studies have shown that patients can tolerate hemoglobin levels of 5 g/dL or even lower as long as the fluid volume of the blood is adequate. These findings have led medical professionals to question the wisdom of using blood as a "medication" for treating anemia. At present, the so-called transfusion trigger is a hemoglobin level of 7 g/dL, evaluated in the context of the patient's overall clinical condition.
Red cell substitutes
Researchers are presently investigating the possibility of manufacturing substitutes for red blood cells that would reduce the cost of transfusions while improving patient safety. As of 2002, the two approaches that have been explored are cell-free hemoglobin solutions and perfluorocarbon solutions. Neither approach has yielded satisfactory results so far; the hemoglobin solutions have a short half-life, and the perfluorocarbon solutions would be difficult to administer intravenously. Further research in this area is underway.
Preparation for nonemergency bloodless surgery includes a registration process as well as medical preparation. In most American hospitals, a person who wants to register for bloodless surgery makes an appointment with the coordinator of the program. The coordinator, who is usually an RN, reviews the patient's request for bloodless care with him or her. The patient is then given an advance directive and enrollment form to sign. The documents are kept on file with the patient's preadmission chart. After the patient is admitted, he or she is given a red (or other distinctive color) wristband with the words "Do Not Administer Blood Products." Signs and stickers with the same warning are attached to the patient's bed and the front of the patient's chart. These identifiers are necessary because most hospitals with bloodless surgery programs do not operate special units; their patients are admitted to all hospital services together with other patients.
After the patient has signed the advance directive, he or she is given a copy that may be reproduced and given to friends or relatives in the event of an emergency. Some bloodless surgery centers give pre-enrolled patients wallet cards that can be attached to a driver's license, in the event that the patient needs emergency care and is unable to speak for him- or herself.
One of the basic components of bloodless surgery programs is presurgical treatment intended to boost the oxygen-carrying capacity of the patient's blood. Patients are given erythropoetin, or EPO, several weeks before surgery. The usual dose is 600 units per kg of body weight once a week for three weeks. EPO is a hormone that stimulates the bone marrow to produce more red blood cells, as many as seven times the normal amount. The greater number of red cells increases the blood's ability to carry oxygen. In addition to the EPO, patients are given iron supplements, most commonly ferrous sulfate, iron dextran, or vitamin B.
Patients who have been treated in bloodless surgery centers are generally satisfied with the care they receive. Hospitals have found that patients recover faster with fewer complications; several centers have reported that patients requiring inpatient procedures leave the hospital on average a full day earlier than patients who have had conventional transfusions.
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American Association of Blood Banks (AABB). 8101 Glenbrook Road, Bethesda, MD 20814-2749. (301) 907-6977. http://www.aabb.org .
American Red Cross (ARC) National Headquarters. 431 18th Street, NW. Washington, DC 20006. (202) 303-4498. http://www.redcross.org .
Associated Jehovah's Witnesses for Reform on Blood (AJWRB). P. O. Box 190089, Boise, ID 83719-0089. http://www.ajwrb/org .
Division of Blood Diseases and Resources. The National Heart, Lung and Blood Institute (NHLBI). Two Rockledge Center, Suite 10138, 6701 Rockledge Drive, MSC 7950, Bethesda, MD 20892-7950. http://www.nhlbi.nih.gov/about/dbdr .
National Blood Data Resource Center (NBDRC). 8101 Glenbrook Road, Bethesda, MD 20814-2749. (301) 215-6506. http://www.nbdrc.org .
Physicians and Nurses for Blood Conservation (PNBC). P. O. Box 217, 6-2400 Dundas Street West, Mississauga, ON L5K 2R8. (905) 608-1647. http://www.pnbc.ca .
Society for the Advancement of Blood Management (SABM). 350 Engle Street, Englewood, NJ 07631. (866) 894-3916. http://www.sabm.org .
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Rebecca Frey, PhD