Management Techniques Click here to learn about bloodless medicine practices that may provide alternatives to blood transfusions no blood. Our Staff The Center for Transfusion-Free Medicine at Penn Medicine provides patients with "no blood" services from highly skilled specialists and surgeons trained in bloodless medicine and bloodless surgery.
By taking advantage of this, the center can provide alternative routes of care. One such example includes giving patients erythropoietin, a hormone responsible for creating red blood cells, before and after surgery to stimulate the production of blood in anticipation of blood loss.
Patients may also receive other vitamins, such as vitamin K, that are critical for the formation of blood components. Blood loss can be further minimized by the use of advanced tools, such as the harmonic scalpel, a type of scalpel that cuts and cauterizes at the same time.
Additionally, technologies such as the intraoperative blood salvage system can actually recover lost blood from the operating table by washing the red blood cells with saline solution and returning the whole blood to the patient after the impurities and waste components have been removed. Finally, although still in the development phase, some research labs are investigating the efficacy of artificial hemoglobin synthesized from various chemical compounds called hemoglobin-based oxygen carriers that mimic naturally occurring human hemoglobin, which can then be used for transfusion.
Many patients are surprised to hear that they are being charged to receive their own blood. Also, autologous blood donation is not considered an acceptable option for Jehovah's Witness patients from a religious standpoint, since the blood has been separated from their body. There is an extensive arsenal of surgical, anesthetic, and pharmacological techniques that have been developed to minimize blood loss during surgery.
One of these techniques is acute normovolemic hemodilution. This involves removing and storing several units of blood in the operating room just before surgery. The patient's remaining blood is then diluted with either crystalloids or colloids to maintain a normal circulating blood volume. Any of this diluted blood that is lost during surgery will have fewer red blood cells and lowered levels of clotting factors.
The whole fresh blood that was stored is then readministered after surgery, or, if necessary, during the procedure. This procedure may also be acceptable to some Jehovah's Witness patients by using a modified technique known as closed-circuit acute normovolemic hemodilution, where the blood does not completely leave their system but remains in a continuous circuit with the patient's circulatory system.
Several pharmacologic agents are commonly used to reduce intraoperative blood loss. Aprotinin Trasylol is an antifibrinolytic that works to prevent bleeding by inactivating plasmin, an enzyme produced in the blood to break down fibrin, the major constituent of blood clots.
By inactivating plasmin, aprotinin prevents it from breaking down blood clots, and thus prevents bleeding. Aprotinin has been commonly used but has recently come under fire for increasing the risk of death, renal damage, congestive heart failure, and stroke.
The United States Food and Drug Administration currently recommends that it be used only when the risk of blood loss outweighs the risk of these adverse effects and stresses the importance of monitoring patients who receive this drug for organ toxicity. Other commonly used pharmacologic agents are antifibrinolytic aminocaproic acid Amicar and desmopressin DDAVP , which is thought to increase the levels of factor VIII in blood and increase von Willebrand's factor expression, helping to promote necessary clotting.
The blood substitute PolyHeme has also generated much interest, although it is just completing clinical trials and not yet available for patient use. PolyHeme is manufactured from human red blood cells using steps to reduce the risk of viral transmission. It has the advantage of being universally compatible and immediately available.
Minimizing blood loss from phlebotomy is another key strategy in blood conservation programs. There are several factors to be considered here. First, it is important to evaluate whether each blood test is absolutely necessary and to attempt to coordinate and consolidate blood tests. One study found that blood drawn from cardiothoracic intensive care patients ranged from to mL in a hour period, which is the equivalent of 1 to 2 units of blood.
Point-of-care testing is ideal since it uses smaller volumes for testing and results are immediately available, which enables care providers to correct abnormalities as quickly as possible. There are various techniques and commercially available closed-system devices for arterial and central line phlebotomy that can be used to avoid wasting the blood volume that is usually discarded to clear the line.
Perhaps the most controversial topic in blood management is the reevaluation of traditional transfusion triggers. There has been a considerable amount of research and discussion but little consensus on the ideal transfusion trigger. If experts agree on anything, it is that multiple factors, such as the patient's age, cormorbidities, and cardiopulmonary status, which may affect a patient's ability to compensate with a demand for increased cardiac output, must all be considered and that the transfusion point must be individualized for each patient.
The optimal point for transfusion is now considered the lowest level of hemoglobin necessary to meet that individual patient's tissue oxygen demands, which will ultimately depend on the patient's condition and circumstances.
It is vital that healthcare providers be aware of the potential risks of blood transfusion and recognize that it is not a "magic bullet. Blood transfusion carries significant risks from the transmission of infectious diseases, incompatibility issues, and immunological complications.
It is vital to continue to examine the risk-benefit ratio of blood transfusions to make the best possible decisions regarding this therapy, giving weight to the patients' wishes, their unique condition and set of circumstances, and the most current evidence available.
Table 2 provides a list of Web resources for those who are interested in learning more about bloodless care. As for Mr. Adams, his heart surgery went without complication and without the administration of blood. He was back home 4 days after his surgery and does not have to worry about later developing a transfusion-related disease. Like thousands of other patients, Mr.
Adams has benefited from the choice of bloodless care. Variability in transfusion practice for coronary artery bypass graft surgery persists despite national consensus guidelines: a institution study.
Review of the clinical practice literature on allogeneic red blood cell transfusion. Can Med Assoc J. Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient. Crit Care Med. Cardiovascular surgery in Jehovah's Witnesses. Report of operations without blood transfusion. Society for the Advancement of Blood Management. Blood Management Program database. Accessed October 4, A step beyond blood management, bloodless medicine avoids the use of blood products altogether, even blood from the patients themselves.
Pre-operation, a surgeon will go to great lengths to stabilize a patient and address any potential problems managing anemia, and identifying any bleeding or clotting deficiencies. Blood testing is limited, because every drop counts, and other potential sources of blood loss, such as menstrual bleeding or gastric ulcers, are taken into account. During an operation, a bloodless surgeon will use a larger surgical team to decrease the length of the procedure, resulting in less blood loss.
And after surgery, a patient will be monitored closely so that any postoperative bleeding can be quickly controlled and anemia can be avoided. Bodnaruk says that hospitals may not take such rigorous steps to prevent blood loss before, during, and after surgery if they have transfusion as a safety net.
For that reason, Bodnaruk says, one of the main objectives of HIS is to direct medical professionals to case studies, including peer-reviewed articles in medical journals, that can help them understand how bloodless medicine has been used in the past, even in complicated procedures like brain or open-heart surgery.
With the recent growth of patient blood management, the job has become somewhat easier. Throughout the s and early s, Wade worked as an independent consultant to more than hospitals around the country, helping them establish blood-management and bloodless programs. Wade says the payoff can be significant for hospitals, as well as the patients they serve.
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