The Growing Demand for Bloodless Medicine and Surgery
“All those dealing with blood and caring for surgical patients have to consider bloodless surgery.”—Dr. Joachim Boldt, professor of anesthesiology, Ludwigshafen, Germany.
THE tragedy of AIDS has compelled scientists and physicians to take additional steps to make the operating room a safer place. Obviously, this has meant more stringent blood screening. But experts say that even these measures do not ensure zero-risk transfusions. “Even as society expends great resources on making the blood supply safer than ever,” says the magazine Transfusion, “we believe patients will still try to avoid allogeneic [donor] transfusions simply because the blood supply can never be completely safe.”
Not surprisingly, many doctors are becoming wary of administering blood. “Blood transfusions are basically no good, and we are very aggressive in avoiding them for everybody,” says Dr. Alex Zapolanski, of San Francisco, California.
The general public too is becoming aware of the dangers of transfusions. Indeed, a 1996 poll revealed that 89 percent of Canadians would prefer an alternative to donated blood. “Not all patients will refuse homologous transfusions as do Jehovah’s Witnesses,” states the Journal of Vascular Surgery. “Nonetheless, the risks of disease transmission and immunomodulation offer clear evidence that we must find alternatives for all of our patients.”
A Preferred Method
Thankfully, there is an alternative—bloodless medicine and surgery. Many patients view it not as a last resort but as a preferred treatment, and with good reason. Stephen Geoffrey Pollard, a British consultant surgeon, notes that the morbidity and mortality rates among those who receive bloodless surgery are “at least as good as those patients who receive blood, and in many cases they are spared the postoperative infections and complications often attributable to blood.”
How did bloodless medical treatment develop? In one sense the question is rather odd, since bloodless medicine actually predates the use of blood. Indeed, it was not until the early 20th century that transfusion technology had advanced to the point where it was routinely used. Nevertheless, in recent decades some have popularized the field of bloodless surgery. For example, during the 1960’s noted surgeon Denton Cooley performed some of the first open-heart operations without the use of blood.
With the rise of hepatitis among transfusion recipients during the 1970’s, many doctors began looking for alternatives to blood. By the 1980’s a number of large medical teams were performing bloodless surgery. Then, when the AIDS epidemic broke out, these teams were repeatedly consulted by others who were eager to adopt the same techniques. During the 1990’s many hospitals developed programs that offer bloodless options to their patients.
Doctors have now successfully applied bloodless techniques during operations and emergency procedures that traditionally required transfusions. “Major cardiac, vascular, gynaecological and obstetrical, orthopaedic, and urological surgery can be performed successfully without using blood or blood products,” notes D.H.W. Wong, in the Canadian Journal of Anaesthesia.
One advantage of bloodless surgery is that it promotes better-quality care. “The surgeon’s skill is of the greatest importance in the prevention of blood loss,” says Dr. Benjamin J. Reichstein, a director of surgery in Cleveland, Ohio. A South African legal journal says that in certain instances surgery without blood can be “quicker, cleaner and less expensive.” It adds: “Certainly the aftercare treatment in many instances has proved cheaper and less time-consuming.” These are just a few of the reasons why some 180 hospitals around the world now have programs specializing in bloodless medicine and surgery.
Blood and Jehovah’s Witnesses
For Bible-based reasons, Jehovah’s Witnesses refuse blood transfusions.a But they do accept—and vigorously pursue—medical alternatives to blood. “Jehovah’s Witnesses actively seek the best in medical treatment,” said Dr. Richard K. Spence, when director of surgery at a New York hospital. “As a group, they are the best educated consumers the surgeon will ever encounter.”
Doctors have perfected many bloodless surgery techniques on Jehovah’s Witnesses. Consider the experience of cardiovascular surgeon Denton Cooley. Over a period of 27 years, his team performed bloodless open-heart surgery on 663 of Jehovah’s Witnesses. The results clearly demonstrate that cardiac operations can be successfully performed without the use of blood.
True, many have criticized Jehovah’s Witnesses for their refusal of blood. But a guide published by the Association of Anaesthetists of Great Britain and Ireland calls the Witnesses’ position “a sign of respect for life.” In truth, the Witnesses’ rigorous stand has been a major force behind safer medical treatment becoming available for all. “Jehovah’s Witnesses in need of surgery have shown the way and exerted pressure for improvements in an important sector of the Norwegian health service,” writes Professor Stein A. Evensen, of Norway’s National Hospital.
To assist doctors in providing treatment without the use of blood, Jehovah’s Witnesses have developed a helpful liaison service. Presently, more than 1,400 Hospital Liaison Committees worldwide are equipped to provide doctors and researchers with medical literature from a data base of over 3,000 articles related to bloodless medicine and surgery. “Not only Jehovah’s Witnesses, but patients in general, are today less likely to be given unnecessary blood transfusions because of the work of the Witnesses’ Hospital Liaison Committees,” notes Dr. Charles Baron, a professor at Boston College Law School.b
The information on bloodless medicine and surgery that has been compiled by Jehovah’s Witnesses has been of benefit to many in the medical field. For example, in preparing material for a book entitled Autotransfusion: Therapeutic Principles and Trends, the authors asked Jehovah’s Witnesses to provide them with information about alternatives to blood transfusion. The Witnesses gladly granted their request. With gratitude the authors later stated: “In all our reading on this subject, we have never seen such a concise, complete list of strategies to avoid homologous blood transfusion.”
Progress in the medical field has caused many to consider bloodless medicine. Where will this lead us? Professor Luc Montagnier, discoverer of the AIDS virus, states: “The evolution of our understanding in this field shows that blood transfusions must one day die out.” In the meantime, alternatives to blood are already saving lives.
b By invitation, Hospital Liaison Committees also make presentations to hospital medical staff. In addition, if their assistance is specifically requested, they help patients to have early, open, and continual communication with the physician in charge.
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What Some Doctors Say
‘Bloodless surgery is not only for Jehovah’s Witnesses but for all patients. I think that every doctor should be engaged in it.’—Dr. Joachim Boldt, professor of anesthesiology, Ludwigshafen, Germany.
“While blood transfusions are safer today than in the past, they still pose risks, including immune reactions and contracting hepatitis or sexually transmitted diseases.”—Dr. Terrence J. Sacchi, clinical assistant professor of medicine.
“Most physicians have knee-jerk reactions with transfusions and just give them out liberally and indiscriminately. I don’t.”—Dr. Alex Zapolanski, director of cardiac surgery at the San Francisco Heart Institute.
“I don’t see any conventional abdominal operation that in a normal patient routinely requires blood transfusion.”—Dr. Johannes Scheele, professor of surgery, Jena, Germany.
Dr. Joachim Boldt
Dr. Terrence J. Sacchi
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Bloodless Medicine and Surgery
Some of the Methods
Fluids: Ringer’s lactate solution, dextran, hydroxyethyl starch, and others are used to maintain blood volume, preventing hypovolemic shock. Some fluids now being tested can transport oxygen.
Drugs: Genetically engineered proteins can stimulate the production of red blood cells (erythropoietin), blood platelets (interleukin-11), and various white blood cells (GM-CSF, G-CSF). Other medications greatly reduce blood loss during surgery (aprotinin, antifibrinolytics) or help to reduce acute bleeding (desmopressin).
Biological hemostats: Collagen and cellulose woven pads are used to stop bleeding by direct application. Fibrin glues and sealants can plug puncture wounds or cover large areas of bleeding tissue.
Blood salvage: Salvaging machines recover blood that is lost during surgery or trauma. The blood is cleansed and can be returned to the patient in a closed circuit. In extreme cases, liters of blood can be recovered using such a system.
Surgical tools: Some devices cut and seal blood vessels simultaneously. Other devices can seal bleeding on large areas of tissue. Laparoscopic and minimally invasive instruments allow surgeries to be performed without the blood loss associated with large incisions.
Surgical techniques: Thorough operative planning, including consultation with experienced clinicians, helps the surgical team to avoid complications. Prompt action to stop bleeding is essential. Delays greater than 24 hours can greatly increase patient mortality. Dividing large surgeries into several smaller ones decreases total blood loss.
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Bloodless Medicine—The New “Standard of Care”?
AWAKE! discussed the benefits of bloodless medicine and surgery with four experts in the field.
Besides patients who for religious reasons refuse blood transfusions, who else are showing interest in bloodless medicine?
Dr. Spahn: In our center those requesting bloodless medicine are usually extremely well-informed patients.
Dr. Shander: In 1998 the number of patients who refused blood for personal reasons exceeded the number of patients who refused blood for religious reasons.
Dr. Boyd: There are, for example, patients with cancer. It has been shown many times that if they don’t receive blood, they progress better and they don’t have as much recurrence of the disease.
Dr. Spahn: We often treat university professors and their families without using blood. Even the surgeons request that we avoid transfusions! One surgeon, for example, came to us about his wife, who needed an operation. He said: “Just make sure of one thing—that she does not get a blood transfusion!”
Dr. Shander: Members of my anesthesia department said: ‘These patients who are not getting blood are doing just as well and maybe even better. Why do we have to have two standards of care? If this is the best care, we should apply it to everybody.’ So now we are looking for bloodless medicine to become the standard of care.
Mr. Earnshaw: It just so happens that bloodless surgery is particularly relevant to Jehovah’s Witnesses. However, this is how we want to treat everybody.
Is the bloodless approach more expensive or less expensive?
Mr. Earnshaw: This is cost saving.
Dr. Shander: There is a 25-percent reduction of cost with bloodless medicine.
Dr. Boyd: If only for that reason, we should use it.
How far have we advanced in the use of bloodless medical management?
Dr. Boyd: I think it’s very progressive. It’s by no means at an end. Each time we turn around, we find some good new reason not to use blood.
Dr. Donat R. Spahn professor of anesthesiology, Zurich, Switzerland
Dr. Aryeh Shander assistant clinical professor of anesthesiology, United States
Mr. Peter Earnshaw, FRCS, consultant orthopedic surgeon, London, England
Dr. Mark E. Boyd professor of obstetrics and gynecology, Canada
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The Patient’s Role
▪ Talk to your doctor about nonblood alternatives before the need for treatment arises. This is especially important for pregnant women, parents with small children, and the elderly.
▪ Put your wishes down in writing, especially if a legal document is available for such a purpose.
▪ If your physician is not willing to treat you without blood, seek a physician who will comply with your wishes.
▪ Since some alternatives to blood require time to be effective, do not postpone seeking treatment if you know that you need an operation.