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Less blood is really more, transfusion critics say

As a doctor and a patient, Dale Reisner knows the value of donated blood. But when the Seattle obstetrician had to have heart surgery four years ago, she did everything possible not to get a single drop.

“I don’t have any religious problems with it. If I was near death, I definitely would have taken blood, no question,” said Reisner, who is fine now at age 62. “But if I could avoid a transfusion by better pre-op preparation, then I was interested.”

In the arena of bloodless medicine, Reisner is among a small but growing number of patients motivated not by religious mandates, but by the potential health hazards of donated blood.

Long dominated by Jehovah’s Witnesses — whose faith forbids blood transfusions — bloodless surgeries and blood conservation programs are now attracting mainstream patients worried about what some experts say are clear risks, including more infections, longer recuperation, increased illness and even death.

"The best blood is in your own veins,” said Dr. Lori Heller, medical director of the blood management program at Swedish Medical Center in Seattle, where Reisner had her surgery — without any transfusion. “We want to think before we transfuse.”

Decades of experience with Jehovah’s Witness patients, including 1.5 million members in the United States, has helped propel the new emphasis on blood management, said Sherri Ozawa, clinical director of the Institute for Patient Blood Management at Englewood Hospital and Medical Center in New Jersey.

“In the early days, it was, ‘We have Witness patients, what in the world do we do with them?’” she recalled. “Now we believe it should be the standard of care.”

Change in attitudes about blood

More doctors, from cardiac surgeons to orthopedists, are offering patients ways to conserve their own blood and avoid transfusions. From drugs that boost blood levels before surgery to cell salvage and blood diversion techniques during operations and lower thresholds for giving blood at all, the techniques are a sea change in the attitude that more blood is always better.

“There’s a movement across the country to use less blood,” said Dr. Marisa Marques, a professor of pathology at the University of Alabama at Birmingham Hospital, who has led a new program that has cut blood use there by at least 25 percent since 2003. At the same time, she said blood costs for the hospital fell by $3.5 million per year.

The number of U.S. hospitals with blood management programs has jumped from about 70 in 2002 to about 110 today. That’s still a fraction of the 5,815 registered hospitals in the country, but others are looking to adopt some of the techniques, said Dr. Darrell Triulzi, a professor of pathology at the University of Pittsburgh and vice president of the board of directors of AABB, an association of blood banks and professionals.

However, Triulzi and other critics caution that while thoughtful blood management is a good goal, the downside of transfusion isn’t as clear-cut as some advocates claim. Some studies have shown negative associations in patients who receive transfusions, but not that the blood caused the problems.

“You can’t tell whether it’s sicker patients that are getting transfused, or whether it’s from the transfusion itself,” he said.

In the U.S., which sucked up 14.4 million units of blood in 2007, blood use has been growing at about 2 percent to 3 percent a year. However, it’s expected to be flat when new figures come out this fall, Triulzi said. Part of that is fueled by the economic downturn, which put a damper on elective surgeries and left fewer patients with health insurance to pay for necessary operations. But part of it is fueled by a philosophical shift, particularly among some doctors.

“I shudder when I think about it,” said Heller, a cardiac anesthesiologist. “We used to just routinely transfuse.”

The shift started in about 1999, when first studies in Canada indicated that patients who got transfusions seemed to do worse than those who didn’t. Since then, the awareness has grown, said Dr. Timothy Hannon, a former Navy flight surgeon who founded Strategic Blood Management, an Indianapolis consulting firm hired by hospitals interested in cutting blood use.

“As our knowledge of transfusions has progressed, we find that transfusions are less beneficial than we once thought and more harmful,” Hannon said.

For some docs, transfusion is a habit

Still, many doctors today turn to transfusion as an automatic practice, giving borderline anemic patients smaller amounts of blood — often just one to two units — out of habit, said Hannon, who consulted worked with some 30 hospitals since 2001.

The trouble with that, said Marques, whose hospital hired Hannon, is that every blood transfusion is like a miniature organ transplant, with the potential for reactions, errors and infections.

“Anytime we’re exposed to someone else’s blood, we’re exposed to antibodies we’ve never seen before,” she said. “People think blood is lifesaving, but complications are the price you pay.”

Studies have shown that blood transfusions are associated with higher levels of hospital-related infections, pneumonia and central-line sepsis, a blood infection.

They’re also linked to longer stays in the hospital and the ICU, research indicates. In 2007, there were 72,000 transfusion-related adverse events in the U.S., according to the AABB’s most recent figures. Of those, 11,000 were severe problems and 40 people died.

For consumers haunted by the HIV outbreaks of the 1980s, transmitted infections were a reason to fear blood. Today, however, the estimated risk of a major viral infection from a unit of blood is very low — about 1 in 1 million units of blood, according to a 2008 study in the journal Advanced Studies in Medicine.

By contrast, the risk of complications not related to infection — such the potentially fatal condition known as TRALI, or transfusion-related acute lung injury — is estimated to be about 1 in every 5,000 units of blood component transfused, and possibly more.

In addition, recent studies have shown that storing blood too long reduces its ability to carry oxygen in the body and increases chances of complications.

Use blood, but with care

Sometimes, however, blood transfusions are the only solution to save lives, notes the American Red Cross, which generally supports conservation efforts. In cases of severe trauma or anemia, transfusions are appropriate, agreed Hannon, a practicing anesthesiologist who orders blood himself. 

The trick, he said, is to be judicious. Make sure patients aren’t anemic before they show up for surgery. Build up their blood with iron or erythropoietin, or EPO, a hormone that promotes the formation of red blood cells. Reduce the amounts of blood draws or eliminate some tests entirely.

“If you are in the ICU for five or so days, you’re going to get an extra unit of blood because the vampires have taken so much,” Hannon said. “We have a lot of wastage.”

At the crux of the controversy over blood use centers is disagreement over the so-called “hemoglobin trigger,” the level at which a patient must be transfused.

Normal hemoglobin levels are about 15 grams per deciliter for young adults. Doctors in many fields have traditionally called for transfusions when patients’ levels fall much below 10 grams/dl and definitely when they get around 8 grams/dl.

But advocates like Hannon say it can be perfectly safe to hold off on transfusions in otherwise healthy people until their levels fall much lower. That, said Triulzi, is where some doctors draw the line.

“The question is, can we let them go down to the 7 to 7.5 range, or do they need to be transfused at the 9 range?” he said.

Right now, guidlines for blood transfusions are variable and subject to interpretation, so most doctors rely on past practice and their assessment of how sick a patient might be.

Triulzi said many doctors are waiting for long-term data — and clear guidelines. But Hannon said doctors and patients shouldn’t simply wait for research conclusions to consider changes in blood practice. They should educate themselves — and their patients — now about ways to use less blood.

“This is not zealous, this is not crazy, this is not fringe medicine,” he said, adding later: “Good hospitals want to get even better. They want to do the right thing. They just need to know what that is."