Transfusion-Alternative Strategies—Simple, Safe, Effective
(2000)
Duration: 29:30
https://www.jw.org/en/library/videos/#en/mediaitems/VODOrgBloodlessMedicine/pub-ivae_x_VIDEO
>> In Berlin, Professor Roland Hetzer at the German Heart Institute corrects a ventricular septal defect in a 10-month-old girl. In Jena, Professor
Johannes Schoelup [assumed spelling] at Friedrich Schiller University Clinic performs a liver resection.
>> In Jenna, Professor Johannes Scheele at Friedrich Schiller University Clinic performs a liver resection.
>> In London, Peter Ernshaw, a Fellow of the Royal College who practices at Guy's and St. Thomas Hospitals, performs a total knee replacement.
>> Challenging surgeries, but they share an added dimension. In each of these cases, the team had committed itself to operating without
allogeneic blood transfusion. Today [the year 2000], in 150 countries, more than 100,000 physicians have made a similar commitment to bloodless
medicine and surgery because they believe transfusion alternative strategies are simple, safe, effective. Many view the pioneering bloodless
major cardiovascular surgery of Dr. Denton Cooley in the 1950s as the beginning. He cooperated with patients who are Jehovah's Witnesses and
who, while seeking quality medical and surgical treatment, do not accept allogeneic blood transfusion. They observe the Biblical injunction, abstain
from blood. In 1977, Cooley's team published a report on their 20 years of experience with a consecutive series of 542 bloodless cardiovascular
surgeries. The report noted an acceptably low risk. Professor Richard Spence, a pioneer in transfusion alternative strategies.
>> The lessons we learned in the early stages of bloodless medicine and surgery with the Jehovah's Witness clearly translated over to all the rest
of our patients. So the field now really of blood conservation includes the use of multiple alternatives in a planned way to avoid the need to
transfuse the patient with someone else's blood. We have operated on newborns. We have operated on people in their 90's. And we use these
same techniques and approaches.
>> Professor Albert Huch speaking of efforts in the general patient population:
>> In the era when the risks of blood transfusion were not realized as they are today, 15% of all women in such a group of at-risk patients received
blood. Today this figure is far below 1%, even though we are a center for complicated cases.
>> We've now reduced our transfusion rate for knee replacements, knee division, knee replacements, I think on the order of 5% to 8%. Ideally,
we'd like to get it down to 0%.
>> Professor Hetzer points to one reason for such efforts.
>> Today at least 80% of the patients would strongly favor not to have blood transfusions.
>> And for legal and ethical reasons, today attention is increasingly being given to respecting the wishes of the patient. Experts also cite their
desire to avoid medical risks related to transfusing allogeneic blood.
>> Any unit that is donated into the blood bank, whether it's an allogeneic unit or a PAD unit, there's always the risk of administrative error and an
ABO mismatch. And a fatal hemolytic transfusion reaction.
>> Side effects include not only the transmission of viral diseases that everybody talks about, like HIV or Hepatitis B or C, but also new viruses
that are prevalent in the donor population. Also, parasitic diseases are more and more transmitted via blood transfusions.
>> The public health impact of transfusion immunomodulation is very difficult to estimate. And we've estimated that approximately in the United
States we can expect that 10,000 to 50,000 patients a year may be dying from transfusion immunomodulation-related causes.
>> Will existing viruses mutate and produce disease? There's no reason to believe that they won't.
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>> Many see these risks and the resulting costs, but feel that they have no alternatives to allogeneic blood. However, even the benefits of present
policies on the use of allogeneic blood come under question in view of a groundbreaking study by Dr. Paul Hebert of Canada. It compared a
liberal transfusion policy with a restrictive one in critically ill ICU patients. The results were surprising, particularly the mortality rates.
>> I talk about the Hebert paper where they showed more than 800 patients that lists transfusion results and improved outcome.
>> Other evidence showing the need to review policies on the use of blood comes from two earlier studies. Consider first the SANGUIS Study
published in 1994, part of a concerted action of the European Commission's Medical Research Program. The study analyzed transfusion rates in
major health care centers across Europe. Forty-three teaching hospitals were prospectively studied as to their routine transfusion rates for six
common standardized operations. The SANGUIS Study revealed that different institutions routinely transfused drastically different percentages
of patients for the same surgeries, varying from 0% at some institutions to 96% at others on coronary artery bypass graft. And from 0% to 100%
on total hip replacement.
>> The main lesson is the variability of transfusion practice from one center to another for the same specific operation.
>> In 1998 in Belgium, a follow-up study was published.
>> So all types of hospitals were included in the Belgium BIOMED transfusion study for surgery. And we found exactly the same range of
variability.
>> So, we are left with the conclusion that variability implies that a lot of these blood transfusion components are being given unnecessarily.
>> However, there is a positive note regarding two Belgian hospitals that participated in both studies. After the SANGUIS study, they changed
their transfusion policy.
>> They have somehow managed to reduce their blood consumption for major surgery like colectomy for cancer by a factor of five at least. The
hospitals stay was shorter, so we have no evidence of increased morbidity nor mortality.
>> In the light of what has been learned in the last few years, Professor Philippe van der Linden summarizes what many experts have concluded.
>> In view of the potential for a better patient care and reduced health care cost, blood conservation is not an option. It's a must.
>> But what is the foundation for an effective transfusion alternative program? Experts agree that it is a team approach.
>> It truly has to be a cooperative effort. A team effort to the approach. And it has to be tailored to the patient's condition as well as the operative
procedure. Some techniques are appropriate for some procedures and some surgeons, and not for others.
>> The various transfusion alternative techniques used by successful teams can be placed under three basic principles or pillars.
>> Preoperative planning involves to realize that the patient has not enough endogenous red blood cells for a planned operation. And this depends
not only on the hematocrit, but also on the estimated blood volume of a given patient, the estimated blood loss that the planned operation is
associated with. And also the transfusion threshold that can be considered reasonable or tolerable in this individual patient.
>> The first pillar can be defined as appropriate tolerance of anemia. This involves reconsidering the standard policy on anemia treatment. Some
still use a transfusion trigger of a hematocrit of 30% or a hemoglobin level of 10 grams per deciliter for all patients. Thresholds that date back to
an article by Adams and Lundy published in 1942.
>> I am really convinced that there is no place for the magic 10 grams.
>> Our experience with Jehovah's Witness has shown that first of all we don't need the hemoglobin levels we assumed were essential previously.
>> But there should be no hard or fast rule, or there should be no trigger. You can anesthetize patients for some procedures depending upon the
patient as low as 2 or 3 grams if necessary.
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>> All experienced physicians stress the importance of maintaining normal volemia via simple volume replacement. With adequate volume,
oxygen consumption is maintained over a wide range of hemoglobin levels. According to Professor van der Linden, the two main mechanisms
responsible for the maintenance of adequate tissue oxygenation are an increase in cardiac output, and an increase in tissue oxygen extraction. In
the range of hematocrit values illustrated, the amount of oxygen extracted from the red blood cells of a non-anemic person is practically the same
as that taken up from fewer red blood cells under acute normal volemic anemia. The first mechanism results from the decreased blood viscosity
and sympathetic stimulation. The second mechanism results from a redistribution of blood flow to areas of high metabolic demand and from
improved microcirculation.
>> I am really convinced that the better knowledge of the mechanism allowing the maintenance of adequate tissue oxygenation during acute
normo-volemic anemia could decrease the risk of blood transfusion.
>> What does experience with this principle alone reveal?
>> I halved our transfusion rate by simply saying could we lower our triggers from 10 to 8? And just taking a little more control over the
decision. That was very easy. That cost nothing.
>> We do know that we can allow patients to equilibrate to relative low hemoglobin levels without blood transfusions.
>> Obviously, it is important to plan ahead, especially if the patient for religious or other reasons refuses allogeneic blood. Preoperative planning
requires a careful clinical assessment of the bleeding risks, and a thorough laboratory screening including standard hematological
parameters. Based on the patient's condition this may include other tests such as the coagulation profile and tests for conditions contributing to
anemia. Next, there is the need to calculate the safety zone or tolerable red blood cell loss for a particular patient throughout perioperative
care. Here is how Professor Ernshaw explains his approach, using the example of joint replacement.
>> All you need is height and weight, male or female, initial hemoglobin hematocrit, and you can immediately work out what their blood volume
is. Next, either using your personal data and anybody who's done more than a few joint replacements should be able to go back and look at what
their typical loss is. So you'd want to know what loss there will be for that particular procedure. The only other thing you need to know is how
much can you tolerate? In other words, how low can you let this patient go?
>> What if the expected RBC loss is greater than the tolerable?
>> You can increase the blood loss that is tolerated by the patient by simply lowering the threshold of transfusion trigger. Or you can increase the
allowable blood loss by increasing the initial hematocrit of the patient, and therefore have the patient start or go into the operation with a higher
mass of red blood cells.
>> Several of these proactive techniques can be grouped under the second pillar, optimizing RBC mass.
>> We can expand the situating red blood cell mass of the patients before the operation. And this can be achieved with cheap hematinics like
iron, folic acid, Vitamin B12.
>> For selective cases recombinant erythropoietin, or EPO, combined with iron therapy can be used to treat anemia or to raise the presurgical
hematocrit to within a range of 45 to 50%. EPO is normally started 10 to 21 days prior to surgery. EPO illustrated by small particles increases
red cell production by affecting the survival, differentiation, and maturation of erythroid cells in the bone marrow.
In the late erythroblastic stage, the nuclei are expelled. Finally, the erythrocytes are pushed into the bloodstream. Note the acceleration of red
cell production with EPO. Besides the increase in RBC mass, under EPO treatment usually one week is gained.
Note the comparatively higher hematocrit rise under EPO therapy according to one study.
>> And by utilizing erythropoietin, we can increase the circulating hemoglobin by 1 gram deciliter for each week of treatment.
>> Recombinant human erythropoietin therapy is a tool that has also been shown to be effective as a blood conservation strategy. It's been
shown, particularly in orthopaedic procedures, in patients who are anemic. And by that, I mean whose initial hemoglobin is less than 13, or
hematocrit is less than 39%.
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>> Now, we use erythropoietin in very specific cases. Like for instance, all the children of Jehovah's Witnesses where we start to administer this
medication for the six weeks before the operation is given twice a week with a dosage of 400 units per kilogram.
>> If you combined the two principles, that is increasing the preoperative hematocrit and decreasing the threshold for allogeneic blood transfusion,
then you can allow an even larger blood loss to occur without the need for allogeneic blood transfusion. Now this allowable blood loss can be
further reduced certainly by surgical techniques, or by anesthesiologic techniques.
>> Thus, even such complex procedures as spinal surgery and redo open-heart surgery are routinely performed with an even wider safety zone
afforded by the third pillar of a transfusion alternative protocol either by minimizing the bleeding or by recovering shed blood. Let's consider
several important intraoperative techniques. Patient positioning is a simple cost-effective technique to reduce bleeding, local venous pressure
changes depending on the field's position relative to the heart, and lower pressure directly correlates with blood saved.
>> It's important to position the patient properly during orthopaedic surgery, in my experience makes a big difference in spinal surgery.
>> With pressure on the abdomen and thus on the paravertebral veins blood loss increases. With proper support avoiding abdominal compression
blood loss decreases. Another option to decrease venous pressure in some surgeries is to use regional instead of general anesthesia as shown
here prior to a caesarian section. A further technique is the maintenance of normothermia, especially during long operations.
>> If a patient is cool or cold by 1 or 2 degrees temperature, you are seeing a loss in ability of platelets and coagulation factors to work. So it's
essential that we keep the patients normothermic.
>> Normothermia is extremely important. And therefore, our operating theater temperature is 27 degrees in those major procedures, which
sometimes is hard for the surgeons, even for the anesthesiologists, but it's very good for the patient.
>> More directly, the patient's body can be warmed with a thermal suit or blankets. There are even simple machines to warm fluids before
infusion. Next, hemodilution.
>> The principles of hemodilution in terms of reduction of blood loss are really quite simple. If blood is removed from the patient immediately prior
to or immediately after induction of anesthesia, and replaced with a-cellular fluids, then when the patient bleeds intraoperatively the red cell loss
is less.
>> For every 100 ml's of whole blood lost by the patient, in the case of a patient with a hematocrit of 27% they're going to lose 27 ml's of RBC's
rather than the 45 ml's of RBC's they would have lost had we started the case at a hematocrit of 45%.
>> Additionally, the hemodilution procedure is acceptable to a number of Jehovah's Witnesses.
>> Hemodilution is certainly cost-effective. But not only that, it is also beneficial for the patient as it improves blood rheology as has been shown
by many studies.
>> Another transfusion alternative technique for selected surgeries is induced hypotension to lower mean arterial pressure
intraoperatively. Usually a drug is used to decrease systemic vascular resistance. This typically prevents up to 50% of blood
loss. Anesthesiologists urge caution when combining hypotension with hemodilution, because hypotension can interfere with the normal
redistribution of blood flow. A crucial factor that requires skill and patience is meticulous surgical hemostatis and technique.
>> I teach the residents to just gently score the skin and open it, and then use the cautery to get all the blood vessels.
>> The basic technique for a surgeon to control bleeding is to ligate the vessels. That’s true for all the vessels let's say down to 1 millimeter in
diameter. If there is some bleeding persisting there are coagulation techniques, best of which is at the moment argon beam population. We use
it routinely in liver transplantation.
>> Haemostatic agents [substances that help stop bleeding from a site] can also assist.
>> There is two types of agents. General agents that could be administered intravenously such as tranexamic acid or aprotinin. And surgeons
have also the possibility to use topical glues in order to better control the bleeding in the surgical field.
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>> Here, a fibrin glue pad is directly applied to the dissected surface of a liver. This product, containing a blood fraction, is accepted by a number
of Jehovah's Witnesses and others. The final intraoperative transfusion alternative is called cell salvage. If intraoperative bleeding becomes
heavy a cell salvage machine, often kept on standby, is able to recover the shed blood. As the blood flows through the device, some machines
simply filter out any debris. While other types include the additional step of washing the red cells as they circulate. A cell salvage machine can
save up to 50% of the blood that would otherwise be lost. Such devices are acceptable to a number of patients who are Jehovah's Witnesses.
>> Cell salvage is a very important technique, because when you use cell salvage the blood lost by the surgeon is not lost for the patient. Cell
salvage is usually used when you expect the blood loss in the range of 1 liter and more for an adult patient.
>> Perioperative blood salvage is a very useful technique for blood conservation because it's very easy to organize for the majority of
operations. Cardiovascular, orthopaedic, gynecological, and so on. So it can be widely applied in surgery.
>> Some machines allow cell salvage on a small child, expanding the horizons of the technique. Often simple cell salvage machines are also
very valuable in the post-operative setting.
>> What we tend to do, particularly for needs where it's often done with a tourniquet and there is no entropic loss, we salvage it immediately
afterwards. It's very simple and very useful, and moderately cheap, just the stuff that comes out, filter it and give it back. And we've been doing
that here now for about four years, and we're very pleased with the success rate.
>> Another important consideration for minimizing blood loss is the use of micro sampling for necessary tests. Micro sampling is critical in both
preoperative and post-operative care of infants and anemic adults. Professor Michael Obladen addresses the challenge presented by premature
infants.
>> It helps teaching the doctor the amount of blood really required and not to take more. Formerly it was if in doubt take half a milliliter more. And
we don't speak about milliliters anymore. We speak about micro liters. The whole process of sampling is documented in the baby's chart so that
everyone is aware about the cumulative amount of blood withdrawn.
>> Professor Ernest Moore on micro sampling adults.
>> You add up the blood samples it's remarkable how much is taken off in a week of the osteocare. So certainly using microtubule type of analysis
we can markedly reduce the number of cc's in blood loss today for sampling.
>> Physicians who advocate transfusion alternative strategies are often asked if these same strategies are applicable to trauma or emergency
care.
>> When you're looking at principles and patients who have trauma or massive blood, unanticipated blood loss, is first and foremost act
quickly. The cessation of bleeding, whether it's surgically or in other needs, must be the first principle. The second one is that one can apply
these modalities such as cell salvage under certain specific circumstances, and recoup the patient's own blood.
>> The anesthesiology bleed concept are to tolerate a certain degree of relatively low blood pressure. And to be a little restrictive in infusing
enormous amounts of volume, particularly before a surgical source control has been achieved. That means before the surgical bleedings have
been identified and stopped.
>> Perhaps one of the I think greatest advances in conserving blood and trauma has been the concept of so-called damage control surgery. That
is, once we open the patient's abdomen or chest and note that the patient is unable to coagulate, that we address the major bleeding vessels. Then
control the surface with pads and close the patient temporarily, allowing them to be taken to the Intensive Care Unit where they're resuscitation is
continued. And efforts to reverse those adverse effects on coagulation like hypothermia are specifically addressed.
>> In trauma management, re-warming is very important, because during advanced hypothermia, blood coagulation doesn't function properly and
therefore, the blood loss is larger.
>> Professor Moore reviews additional effective steps.
>> As you move into the Intensive Care Unit in the more complex problems, then I think the use of support becomes even more compelling in the
trauma patient. In a Jehovah's Witness patient, we have no delay in providing both erythropoietin and iron immediately after they arrive in the
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hospital. We may in fact do preemptive interventional radiologic evaluation of some organs. And embolize arteries that are not currently bleeding
actively, but are at risk for bleeding later.
>> This brief overview of strategies is properly viewed as a comprehensive concept.
>> To say there's a list of transfusion alternatives is correct, but that really does not get to the heart of the issue. And that is that we must use
those alternatives in multiple combinations focused on the patient.
>> Not everyone needs every strategy, the erythropoietin being a very good example of that.
>> Dr. Todd Rosengard has published two major studies on multi-modality blood conservation in coronary artery bypass operations performed
without allogeneic transfusion.
>> You know, when we looked at a series of 50 Jehovah's Witness patients and 100 patients in the general population, we found a shorter length
of stay and a lower cost using our blood conservation strategy.
>> Medicine gives every indication of rapid advancement in this new millennium. In the meantime.
>> I think all physicians should be interested in blood conservation strategies because there is substantial evidence that reductions in morbidity
and mortality, and reductions in cost can come with these strategies.
>> The less blood that is transfused in a given surgical program could be used as an index of the quality of that program.
>> I think that the safest transfusion is a transfusion never given.
>> And blood conservation is a very simple method which makes things rather smooth, less expensive, and with a better outlook for the patient.
>> I think there's some very simple, very cheap things you can do to help the majority of people. And this can be done in the smallest of hospitals.
>> Transfusion alternatives are safe. This is not just something I use for the Jehovah's Witness patient, for example. I use this for every patient
who comes to me. Transfusion alternatives clearly are good medical practice, sound medical practice, safe practice for our patients.
UPDATE:
At the bottom of jw.org, there’s a link to an entire section called “Medical Information for Clinicians” that’s packed with Videos and Information
Packets for health-care professionals who treat Witness patients. It even puts them in touch with the local representatives of the Hospital Liaison
Committee Network so they can get personalized assistance.
https://www.jw.org/en/medical-library
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