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'Bloodless' surgery avoids risks of transfusion

/ Source: The Associated Press

When Irv Shapiro found out he needed surgery to fix a ruptured heart valve, one of the first questions he asked his doctor was whether he should donate his own blood.

He hoped to avoid being transfused with someone else's blood, but wasn't thrilled with the idea of spending weeks before surgery having pints of his own blood drawn and put in storage. So when he found out that Pennsylvania Hospital offered a third option — once only available to Jehovah's Witnesses — it was a relief.

"Not needing a blood transfusion, not having to get blood taken out of me, and a fast recovery time — I was OK with all of that," said Shapiro, 60, a founding partner of an architectural firm and heavy traveler.

Pennsylvania Hospital is now able to offer so-called "bloodless surgery" to 90 percent of its patients who want it, joining a small but growing number of bloodless medicine programs around the country that also serve the general public. Advocates put the number at about 120.

Many states have bloodless surgery centers or hospitals that perform no-transfusion surgery for Jehovah's Witnesses, who believe the Bible forbids transfusions, but not for the general public.

Some hospitals are now providing no-transfusion surgery to more patients because of advances in equipment and changes in protocols.

Bloodless surgery techniques vary depending on the type of operation, but can include efficient heart-lung bypass machines that circulate a patient's blood during surgery; using high-tech scalpels that clot the blood as they cut tissue; or freezing tissue before it's excised.

There is also pre-surgery planning. Doctors start seeing patients weeks before surgery to prepare.

Among the benefits are reductions in recovery time, hospital stay, cost and complications — as well as an estimated $20,000 in savings per patient, said Dr. Charles Bridges, the Pennsylvania Hospital cardiologist who performed Shapiro's surgery.

The general consensus in the medical community is that it is best to avoid donor blood transfusions whenever possible, but that transfusions remain an important lifesaving strategy. The American Medical Association endorses "autologous" blood transfusion — giving a patient his own blood — but takes no specific stance on no-transfusion surgery.

Pennsylvania Hospital has for at least a decade performed all kinds of no-transfusion surgery on Jehovah's Witnesses, Bridges said. In the year that no-transfusion heart surgery has been offered to patients, Bridges estimated that he has performed between 50 and 75 — up from about 10 just a few years earlier.

Heart surgery, because it is associated with extensive blood loss, is more difficult to do "bloodless" than other operations. In traditional open-heart surgery, a patient may need up to six units of red blood cells, four units of plasma and 10 units of platelets, according to the American Red Cross.

"People used to think of open-heart surgery as this draconian thing," Bridges said. "Now we have what really is a kinder, gentler open-heart surgery."

The best no-transfusion candidates typically are those needing only one procedure _ repair of a single heart valve or a single bypass, for example. It also can be done in more complex operations, however.

About six weeks after Shapiro's surgery to fix his damaged mitral valve, he was back at work part time.

"I feel very lucky that I was told about the transfusion-free option and that I was a perfect candidate for it," he said.

From pre- to post-surgery, the goal is conserving the patient's own blood, Bridges said.

"There's no downside to it that we can see, and there's certainly no downside that's been documented," Bridges said.

About a month before no-transfusion surgery, blood tests are conducted. Anemic patients receive weekly injections of medications, as well as intravenous iron supplements, to increase their red-blood-cell count.

During surgery, blood that gets suctioned or sponged out of the body cavity is salvaged, and highly efficient pumps keep blood circulating while the heart and lungs are stopped. After surgery, less blood is taken for post-operation tests.

"You have to be meticulous, you have to be organized, and you have to really work as a team before, during and after surgery," Bridges said.

Patients who choose the no-transfusion option eliminate the risk of blood-borne infection and complications from clerical errors. They also get out of the hospital an average of one day earlier and avoid potential transfusion-related complications including immune system suppression, inflammatory response, and renal or respiratory failure, Bridges said.

Bloodless surgery is also preferable to having patients transfused with their own blood, Bridges said. Blood that has been stored degrades and deforms outside the body and doesn't flow through blood vessels or carry oxygen as well when it goes back in.

The trend toward avoiding transfusions is gaining momentum among doctors and patients, said Dr. Patricia Ford, director of Pennsylvania Hospital's Center for Bloodless Medicine & Surgery. Transfusions are lifesavers during emergencies, but they can be avoided in most elective operations, she said.

"There is a movement that, for a lot of us, started as part of caring for Jehovah's Witnesses and learning about blood conservation and management," said Ford, who also is president-elect of the Society for the Advancement of Blood Management, a Wisconsin-based advocacy group.

The group said that the number of bloodless medicine programs nationwide has risen from 100 to about 120 in the past six years. The American College of Surgeons, a division of the American Medical Association, said it does not keep statistics on bloodless surgery.

"Transfusions are like getting a transplant; they can be risky and should be a last resort," Ford said. "Frankly, all of the things we use are available to every hospital. ... The hope is that every hospital will do this eventually."