Doctors Take a New Look at Bloodless Surgery

JANET, a Canadian woman, explained to her son why she had AIDS. She had contracted the disease from her husband before he died. In turn, her husband, a hemophiliac, had likely got AIDS through a blood fraction. Nightmares like this are just one of the factors that have prompted the medical community to reconsider giving blood transfusions as standard practice. Indeed, a headline in The New York Times this year declared: “‘Bloodless’ Surgery Gains New Acceptance.”

Several medical conferences have highlighted the increased interest in bloodless surgery. Among those held last year were two in the United States (Boston and Atlanta), one in Canada (Winnipeg), and one in Latvia (Riga), which was an international conference for Eastern Europe.

After over 50 years of reliance on blood transfusions, why did more than 1,400 professionals from 12 countries attend these four conferences heralding bloodless surgery as “the way of the future,” as one newspaper headline expressed it? What did these conferences highlight regarding new drugs, equipment, and techniques that can affect treatment available to your family?

Why the Search for Alternatives?

A prime motivation is the inability to safeguard blood supplies. For example, Toronto’s Globe and Mail, of January 31, 1998, comments on Canada’s “tainted-blood tragedy” of the 1980’s: “Hepatitis C is a potentially debilitating liver disease for which there is no cure. . . . As many as 60,000 Canadians may have been infected with the virus through tainted blood, which means as many as 12,000 could die as a result of blood-borne hepatitis.”

Although newer screening procedures have greatly lessened the threat, Justice Horace Krever said to the conference held in Winnipeg: “Canada’s blood supply never was absolutely safe, and never can be. The use of blood inevitably entails risks.” And the risks of transmitting disease or causing severe reaction increase with each additional unit of blood given.

In Riga, Dr. Jean-Marc Debue, of the Clinique des Maussins, in Paris, concluded: “We physicians had to reconsider our usual therapeutic approach. . . . Blood transfusion has extended the lives of many patients, but it has also poisoned the lives of others by giving them an incurable disease.”

Procedures for screening blood for contaminants tend to lag behind new threats of disease and thus may not protect against them. For example, Dr. Paul Gully, of Ottawa, Ontario, Canada, observed: “Hepatitis G is a newly described RNA virus; transmission through transfusion has occurred but the current risk is unknown.”

An additional danger was reported in a special medical issue of Time magazine: “Transfusions can suppress the immune system, . . . leaving a patient open to infection, slower healing and a longer recovery time.”

Another factor is financial savings. In the United States, according to Time magazine, each blood transfusion can cost $500. And in some places, the blood supply is dwindling because there are fewer donors.

Further savings to patients who have bloodless surgery result from lower infection rates and shorter hospital stays. Speaking in Winnipeg, Durhane Wong-Rieger, of the Canadian Hemophilia Society, said about bloodless surgery: “We feel it is essential. It’s cost-effective and would definitely improve the health of patients.”

There is also an increased demand for bloodless surgery by a wider constituency of patients. Dr. David Rosencrantz, of Legacy Portland Hospitals (Oregon, U.S.A.), stated that initially “100% of those who came to us did so on religious grounds.” However, now at least 15 percent prefer medical alternatives to blood transfusions, but not because of religious conscience.

A Variety of Views

At the four conferences, a major point of consensus was that using one’s own blood is far safer than using blood donated by other humans. Because of this, some recommend storing one’s own blood before an operation. However, many noted that there is no time to store blood in emergencies. Also, there is the religious objection of Jehovah’s Witnesses to using any stored blood.*

Dr. Bruce Leone, of Duke University, North Carolina, U.S.A., told the Canadian conference: “Preoperative donation [of one’s own blood] is expensive, labor intensive, does not eliminate the most common cause of transfusion-associated morbidity [which is clerical—that is, office or procedural—error] and requires significant time prior to surgery.”

Many physicians advocate continuing to develop medications and techniques that drastically reduce the use of transfused blood. They contend that blood transfusion should be employed only in emergency situations. On the other hand, others now essentially eliminate blood transfusions altogether from their practice. They point to extremely difficult operations—hip replacement, complex neurosurgery, open-heart surgery on infants and adults—performed without transfusion, with rapid patient recovery.

To date, there are over 100 hospitals worldwide with bloodless programs, of which more than 70 are in the United States. In fact, there are now more than 88,000 doctors worldwide who are cooperating with patients who do not want blood.

New Techniques

At the Atlanta conference, speaker after speaker acknowledged having developed a particular technique first when treating Jehovah’s Witnesses.* Many reflected the sentiments of Dr. James Schick, of Encino-Tarzana Regional Medical Center, Los Angeles, who noted that because of new procedures developed while working with premature babies of Jehovah’s Witnesses, he now uses 50 percent less blood with all his tiny patients. Of course, such new procedures have also proved valuable with adults.

Dr. Jean-François Hardy, of the Montreal Heart Institute, noted: “Bloodless surgery cannot be achieved with the help of any single therapeutic intervention . . . Rather, this objective can only be achieved by the combination of various strategies.”

Among the new techniques are (1) preoperative preparation, (2) prevention of blood loss during surgery, and (3) postoperative care. Obviously, all surgical approaches are greatly affected by the time factor, that is, whether there is time beforehand to build up a patient for surgery or no time because emergency surgery must be performed.

The ideal approach to bloodless surgery is preoperative treatment that increases blood cell counts and improves general health. This includes high-potency iron supplements and vitamins as well as, when appropriate, doses of synthetic erythropoietin, a drug that stimulates the patient’s bone marrow to produce red blood cells at an accelerated rate. Technology that permits microanalysis makes it possible to draw less blood for testing and yet get more results from that which is drawn. This is vital for premature infants and older patients who have lost considerable blood.

Also helpful are volume expanders, fluids administered intravenously to increase blood volume. The hyperbaric oxygen chamber too is used in certain facilities to help supplement the oxygen needs of a patient who has suffered severe blood loss. In Atlanta, Dr. Robert Bartlett explained that the oxygen chamber is a powerful asset but must be used carefully because oxygen in high doses is toxic.

For the second step, prevention of blood loss during the operation, there is an array of new instruments and technologies. They help to minimize blood loss; are less invasive, minimizing both blood loss and trauma; or help immediately to capture and reuse the patient’s own blood that would have been lost during surgery. Consider just a few of the new techniques.

◼ An electric cautery device uses heat to stop vessels from bleeding.

◼ The argon beam coagulator helps stop bleeding during surgery.

◼ The harmonic scalpel employs vibration and friction to cut and cause blood clotting at about the same time.

◼ During certain types of surgery, such drugs as tranexamic acid and desmopressin are often used to increase blood coagulation and lessen bleeding.

◼ Hypotensive anesthesia reduces blood loss by lowering blood pressure.

Also significant is the improvement in intraoperative blood salvage machines. During an operation, these recover and immediately reuse the patient’s own blood, without having to store it.* Newer machines, while remaining connected to the patient, can even separate blood into components and reuse those that are needed.

After the conference in Riga and upon hearing of Latvia’s need, Jehovah’s Witnesses in Sweden donated two cell-saver machines to Latvia. The arrival of the first one and the benefits of bloodless surgery created so much enthusiasm in Latvia that the event received national television coverage there.

Postoperative care often includes many of the same blood-building regimens used in preoperative preparation. However, care of nontransfused patients after surgery is often easier than that of those transfused. Why?

Striking Results

While techniques that eliminate the use of blood often require more work prior to and during surgery, surgeons have noted that patients benefit because of having shorter postoperative recovery times. They do not suffer from complications that often accompany transfusions. Reduced hospital stays for patients who have not been given blood have been documented.

Dr. Todd Rosengart, of The New York Hospital-Cornell University Medical Center, observed that their eight-step blood conservation strategy permitted complex open-heart surgeries to be performed confidently without blood. Dr. Manuel Estioko, of Good Samaritan Hospital in Los Angeles, spoke of their “extensive experience with hundreds of open-heart operations without blood.” Dr. S. Subramanian reported success with bloodless open-heart surgery on children at Miami Children’s Hospital.

Orthopedic surgery, particularly hip replacement, is a challenging area. Yet, Dr. Olle Hägg, of Uddevalla Hospital in Sweden, reported in Riga that combining “surgical strategy and precision” had allowed them to reduce blood loss significantly for patients who are Jehovah’s Witnesses. Indeed, Mr. Richard R. R. H. Coombs, of Imperial College School of Medicine, London, said that “99.9 percent of all orthopedic surgery can be done without . . . blood transfusions.”

The Future

The number of hospitals and doctors using bloodless methods continues to increase. And conferences where such knowledge is exchanged have been extremely helpful, as physicians learn of alternatives that have been tested successfully and are being used regularly.

Dr. Richard Nalick, of the University of Southern California School of Medicine, said: “There is an ever-increasing population that desires medical and surgical treatment without blood . . . Bloodless medicine and surgery represents a state-of-the-art approach and should not be misunderstood as a less effective ‘alternative therapy.’”

As the problems related to blood transfusions continue and public demand for alternatives increases, the future of bloodless surgery seems bright.

[Footnotes]

[Picture on page 20, 21]

More and more doctors are honoring their patients’ wishes regarding bloodless surgery