By Nima Ahmady-Moghaddam, George Washington University
The choice of words may at first glance be misleading. For several years now, an increasing number of hospitals – including University Hospital in Newark, NJ, Georgetown University Hospital in Washington, DC, and Pennsylvania Hospital in Philadelphia, PA – have been implementing medical techniques and protocols that are geared towards minimizing and even eliminating the need for foreign blood transfusions before, during, and after elective surgical procedures. While this option has at first been available only to patients who decline blood transfusions for religious reasons (e.g., Jehovah’s Witness), hospitals are gradually making it accessible to everyone who is interested. Generally speaking, the necessity for blood transfusion during or after surgery is perpetuated by factors such as old age (65+ years), long duration of operation (300+ minutes), massive blood loss (1.000+ mL), and anemia (the deficiency of healthy red blood cells, which is associated with a ratio of less than 10 Hb/dl) . Although the practice of blood transfusion dates back to centuries ago and has been improved over the last decades, there are still some immediate risks, which range from minimal to fatal.
General Risks of Blood Transfusion
As medicine became more evidence-based and empirical, a number of retrospective observational studies have shown a correlation between transfusions and adverse outcomes in almost all surgical fields and critical care . One risk factor lies in viral and disease transmissions, the most notable being HIV, Human Lymphocytotrophic Virus, Hepatitis B and C, West Nile Virus, and Sepsis. The potential for contracting one of these diseases during a blood transfusion is minimal – statistical ratios range from 1:205,000 to 1:3,000,000 – but nonetheless present . According to some reports, the danger of disease transmission during blood transfusion becomes higher when patients have particular medical conditions. For instance, a twofold infection risk and a fivefold risk of death have been found in cardiac patients [2, 5]. Similar trends have been documented in patients with gastric cancer, where disease-specific and overall survival rates were observed to be lower for transfused than for non-transfused patients .
Furthermore, an array of transfusion reactions has been documented [4, 5]:
- Allergic reactions / hives: this occurs especially when the donor’s and the patient’s blood type do not match
- TRALI (Transfusion-Related Acute Lung Injury): lung damage occurs and makes breathing difficult
- Iron overload: too much iron in the blood, which occurs especially after receiving multiple blood transfusions; may lead to liver and heart damage
- Acute or delayed immune hemolytic reaction: an immune response to transfused red blood cells; may cause kidney damage
- TA-GVHD (Transfusion-Associated Graft-Versus-Host Disease): transfused white blood cells attack the patient’s cells; rare but often fatal
Transfusion reactions are common complications of blood transfusion . Further reactions include hypothermia, tachycardia, anaphylactic shock, and many others. Since transfusions are mainly needed for heavily invasive surgeries that involve a sufficient amount of blood loss (and subsequent immune system deficiency and general physical weakness), all of the above issues are even more detrimental to the patient than usual. A panel of experts gathered at the International Consensus Conference on Transfusion and Outcomes (ICCTO) in April 2009 and reviewed 555 separately commissioned studies that gave insights into the benefits and deficits of transfusions. Almost all of these reports found that transfusions have little benefit for the patient and in fact saw a link between transfusions and increased complications ranging from heart attack to death .
Along with these medical and physiological dangers, the psychological component of medical treatment should be noted as well. In general, the patient’s outlook on his / her recovery progress (i.e., whether the patient is optimistic or pessimistic) is said to affect the actual course and speediness of treatment. In several cases, patients have reported to feel sicker than they actually are when receiving a blood transfusion – this appears to be due to a social stigmatization of transfusions in general, labeling them as something given only to the tremendously unhealthy. In other words, it appears that transfusions may skew the patient’s perception of his or her condition and therefore have the potential of negatively affecting treatment progress even beyond the physical risks listed above.
Methods Used Before, During, and After ‘Bloodless’ Surgery
There is a general consensus in the medical community that blood transfusions should be given as a last resort. With that said, it seems plausible and beneficial to engage the patient in pre- and post-operative measures that will minimize the chance of having to receive a blood transfusion. As a result, hospitals are more actively advertising it and educating their patients. Methods include injections of recombinant erythroprotein (r-Hu-EPO) and iron to stimulate the production of red blood cells [7, 8]. This can be done before, during, and after surgery. Also, new laboratory blood testing techniques allow for precise measurements even with small amounts of blood, which allows for smaller samples to be drawn from the patient. Surgical techniques and instrumentation have also improved: with minimally invasive procedures, cautious operation by the surgeon, and instruments such as the argon beam coagulator (a scalpel that has a blood-clotting effect the instant it begins to cut), blood loss during surgery can be minimized substantially. Along with that, simple measures such as using warming blankets during surgery tend to result in less bleeding as well. Anesthetic techniques (e.g., lowering the blood pressure) have similar effects . If the surgery is planned weeks ahead of time, one can also acquire a large sample of the patient’s own blood, store it, and re-infuse it during or after surgery (this is called an autologous blood product) [7, 8]. The benefits of these methods and more ways of reducing the need for blood transfusion in hospitalized patients include reductions of recovery time, hospital stay, and cost and complications . As Dr. Zawadsky further noted, it also makes surgery more accessible to people who are reluctant to receive blood transfusion due to personal preference or religious beliefs. Most crucially, however, it eliminates most (if not all) of the health risks that have been linked to transfusions, making ‘bloodless’ surgery an important innovation in medicine with relevant social and health implications. Nevertheless, the use of blood transfusions will most likely not be eliminated altogether in the near future as it will still be the primary choice for acute emergencies where that involve severe blood loss. But for virtually any elective, pre-planned surgery, ‘bloodless’ appears to be the new way to go.
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