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Nicolas Jabbour, M.D. explains Transfusion-Free Surgery
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| | Bloodless surgery or transfusion-free medicine and surgery can be defined as a surgical procedure without the use of PRBCs, FFP or platelets. The Jehovah’s Witness community, due to their religious beliefs regarding the administration of blood or blood products, has sought this particular approach to surgery without the use of blood transfusion. However, several medical and technological developments in this field that were initially designed to accommodate Jehovah’s Witness patients have been found to be extremely useful for the rest of the patient population in regard to the overall blood usage.
Nicolas Jabbour, M.D., FACS, NZTI Medical Director, Oklahoma city, Oklahoma, was a lead surgeon of the team that performed the world’s first bloodless live-donor liver transplant in a Jehovah’s Witness patient, and has initiated a transfusion-free program at INTEGRIS. It is the first such program in the state.
The following will review the issues related to blood products, the pre-operative preparation of patients for bloodless surgery, the intra-operative technique to be used and the post-operative care in these patients.
| 1. Issues Related To Blood Transfusion |
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Availability |
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Currently an estimated 12 million units of blood are being used annually in the United States. More than 60 percent of the blood is used in surgery and more than half of it is used in patients older than 60 years of age. Several advances in the surgical treatment of many diseases, along with the aging of the U.S. population, will lead to a potential shortage of blood and blood products in the future. |
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Safety of Blood Products |
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Although blood products are relatively safe, they still carry a certain risk of transmission of viral diseases. Currently the risk of transmission of hepatitis C is estimated to be 1 in 100,000 units, hepatitis B is 1 in 60,000 units and HIV is 1 in 300,000 units. These diseases can be devastating and have led to a significant increase in the prevalence of hepatitis C in this country as a result of the lack of diagnosis of hepatitis C prior to 1989. In the United States there are more than 4 million people estimated to be infected with hepatitis C, many due to blood transfusions. The current accurate diagnosis of hepatitis C does not preclude the emergence of other viral infections in the future.
Besides the transmission of viral diseases, the blood may cause other hidden risks that include potential immunosuppressive effects of the blood that may increase the risk of post-operative infection and potentially the risk of tumor recurrence following surgery for cancer. Several studies have documented these findings in a scientific manner. (Reference) |
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Cost of Blood Products |
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The average cost of a unit of blood in this country is approximately $340.00. However, this does not include the potential additional costs associated with complications from a blood transfusion. The development of fever would require an extensive work-up in the post-operative period. Several reports have documented significant decrease in the cost when bloodless surgery is used as opposed to the routine surgical procedures. Including the costs of infectious complication and other complications related to blood transfusion, certain authors estimated the cost of a unit of blood to be around $500.00 or more. This will account for more than 7 billion dollars in total costs in the United States for blood transfusions. |
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| 2. Pre-Operative Approach To Bloodless Surgery |
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Optimizing the patient in the pre-operative period can enhance the safety of bloodless surgery. For most surgical procedures this can be accomplished by raising the red cell mass using erythropoietin along with iron, folic acid and multi-vitamins. The following is the recommended approach based on several scientific publications.
- Response to erythropoietin is dose related and independent of age and sex
- The half life is four to five hours for I.V. use and 19-22 hours for S.C. injection
- 72 hours dosing interval induces a higher reticulocyte count than a 24 hour one
- Dose greater than 900 IU/Kg/wk. is unlikely to be beneficial
- Hemoglobin is expected to rise by day three, the equivalent of one unit of blood is produced by day seven and up to five units of blood may be produced by day 28
- Pre-operative erythropoiesis can be achieved within two to four weeks
- Iron supplementation is beneficial even in patients with normal iron stores
- Patients with inflammatory response to either tumor or infection may be refractory to erythropoietin treatment.
By following the above principles optimal red cell mass can be achieved in most patients prior to surgery. If patients fail to respond within four weeks of optimal therapy they should be operated on without further delay if the surgery is feasible. |
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| 3. Intraoperative Approach to Bloodless Surgery |
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Surgical Techniques |
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Bloodless surgery cannot be achieved successfully if meticulous and careful surgical techniques are not observed in the operating room. Blood transfusion is used only to correct severe blood loss. In patients with a normal coagulation profile, most surgical procedures can be performed without blood or blood product transfusion. Local hemostatic agents along with an Argon Beam Coagulator may be helpful in selected patients. |
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Cell Salvaging |
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A modified cell salvaging apparatus using an extracorporeal circuit can be applied to most Jehovah’s Witness patients. This technique will allow the salvage of red cells but depletes the blood saved from platelets and clotting factors, therefore its application in patients with severe blood loss may lead to coagulopathy. The heparin used to preserve red cells is usually washed out prior to reinfusion and should not by itself cause any clotting disorder. This technique is typically used during clean surgery without malignant tumors; however, several reports have suggested its safety in patients with tumor as long as the tumor remains intact within normal tissues. Cell salvaging should be avoided in patients with gross infection since bacteria are not completely washed. |
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| 4. Postoperative Management of Patients Following Bloodless Surgery |
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More than 30 percent of blood transfusions in the intensive care setting is due to blood lost from testing. Therefore, postoperative blood testing should be limited to necessary tests and done in pediatric tubes from peripheral sticks.
In patients with acute postoperative anemia efforts should be directed to minimize oxygen consumption and improve oxygen delivery. This can be achieved using some of the following principles:
- Increase cardiac output
- Maintain intravascular volume
- Supplement oxygen (mechanical ventilation may be required)
- Bed rest and sedation
- Control fevers and chills
- In selected patients paralysis with mechanical ventilation and/or hypothermia may be required
- Increase red cell mass using erythropoietin and iron supplementation.
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Conclusion:
Using the above principles, bloodless surgery can be performed for most surgical procedures in most patients.
REFERENCES
- Weiskopf, Richard B. M.D.; Viele, Maurene K. M.D., etal, Human Cardiovascular and Metabolic Response to Acute, Severe Isovolemic Anemia. JAMA 279(3);217-221. 1998
- E. Levine, A. Rosen, L. Sehgal, etal, Physiologic Effects of Acute Anemia: Implications for a Reduced Transfusion Trigger. Transfusion 30(1):11-14. 1990
- D.H. Biesma, A.Van De Wiel, Y.Beguin, etal, Post-Operative Erythropoiesis is Limited by the Inflammatory effect of Surgery on Iron Metabolism. European Journal of Clinical Investigation 25:383-389. 1995
- Lawrence T. Goodnough, M.D. and Terri G. Monk, M.D.. Erythropoietin Therapy in the Perioperative Setting. Clinical Orthopaedics and Related Research 357:82-88. 1998
- Mario Cazzola, Francesco Mercuriali and Carlo Brugnara. Use of Recombinant Human Erythropoietin Outside the Setting of Uremia. Blood 89(12):4248-4267. 1997
- Goodnough, Lawrence T.; Monk, Terri G,:Andriole, Gerald L. Current Concepts: Erythropoietin Therapy. The New England Journal of Medicine 336(13):933-938. 1997
- Edward A. Levine, M.D., Arthur L. Rose, PhD., etal. Treatment of Acute Postoperative Anemia with Recombinant Human Erythropoietin. The Journal of Trauma 29(8):1134-1139. 1989
- Carson JL, etal. Post-Operative Infections. Transfusion 39(7):694-700. 1999
- Tartter, PI, etal. Post-Operative Infections. American Journal of Surgery 176(5):462-466. 1998
- Jabbour N, Singh G, Mateo R, Sher L, Strum E, Donovan J, Kahn J, Peyre C, Henderson R, Fong TL, Selby RR, Genyk Y. Live Donor Liver Transplantation Without Blood Products: Strategies Developed for Jehovah’s Witnesses Offer Broad Application. Annals of Surgery Vol. 240, No 2: 350-356, August 2004.
- Jabbour N, Singh G, Cheng A*, Boland B, Mateo R, Genyk Y, Selby RR, Zeger G. Recombinant Human Coagulation Factor VIIa in Jehovah’s Witness Patients Undergoing Liver Transplantation. American Surgeon No. 2:175-179, February 2005
- Jabbour N, Singh G, Thomas D, Stapfer M, Mateo R, Sher L, Selby RR, Genyk Y. Transfusion-Free Techniques in Pediatric Live Donor Liver Transplantation. Journal of Pediatric Gastroenterology and Nutrition 40:521-523, April 2005
- Jabbour N, Singh G, Bramstedt K, Brenner M, Mateo R, Selby RR, Genyk Y. To Do or Not to Do Living Donor Hepatectomy in Jehovah’s Witnesses: Single Institution Experience of the First 13 Resections. American Journal of Transplantation 5: 1141-1145, May 2005
- Jabbour N, Singh G, Mateo R, Sher L, Genyk Y, Selby RR. Transfusion Free Surgery: Single Institution Experience of 27 Consecutive Liver Transplants in Jehovah’s Witnesses. Journal of the American College of Surgeons Vol 201 No 3: 412-417, September 2005.
- Jabbour N, Gangandeep S, Shah H, Mateo R, Stapfer M, Genyk Y, Sher L, Zwierzchoniewska M, Selby R, Zeger G. Impact of a Transfusion-Free Program on Non-Jehovah’s Witness Patients Undergoing Liver Transplantation. Arch Surg. 2006;141:913-917
- Jabbour N(ed), Transfusion-Free Medicine and Surgery. Blackwell Publishing, Oxford, UK, September 2005
- Jabbour N. Basic Principles of Bloodless Medicine and Surgery. In Jabbour N (ed), Transfusion-Free Medicine and Surgery. Blackwell Publishing, Oxford UK, Chapter 13, pp 283-291, 2005
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