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Resar LMS, Wick EC, Almasri TN, Dackiw EA, Ness PM, Frank SM. Bloodless medicine: current strategies and emerging treatment paradigms. Transfusion 2016; 56:2637-2647. [PMID: 27473810 DOI: 10.1111/trf.13736] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 06/04/2016] [Accepted: 06/05/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Advances in our understanding of the risks associated with allogeneic blood transfusions (ABTs) and the growing number of patients who wish to avoid ABTs have led to the emergence of new treatment paradigms for "bloodless" medicine and surgery. STUDY DESIGN AND METHODS Here, we review prior studies and summarize current strategies for bloodless care used at our institution. We advocate three basic principles: 1) diagnosing and aggressively treating anemia, 2) minimizing blood loss from laboratory testing and invasive procedures, and 3) identifying and managing bleeding diatheses. Anemia is treated with erythropoiesis-stimulating agents as well as iron, folate, and B12 when indicated. Low-volume phlebotomy tubes are used for laboratory testing. Autologous blood salvage is used for childbirth and surgical patients who have the potential for substantial bleeding. RESULTS Although there have been few retrospective studies and no prospective studies to guide management, prior studies suggest that outcomes for surgical patients managed without ABTs are comparable to those of historic controls. CONCLUSIONS Given the emerging evidence that patients who avoid ABTs do as well if not better than patients who accept ABTs, further efforts are needed to determine whether all patients could benefit from bloodless strategies. Bloodless approaches in selected patients could reduce risks, improve outcomes, and decrease costs for all patients.
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Affiliation(s)
- Linda M S Resar
- Department of Medicine (Hematology), the, Baltimore, Maryland. .,Department of Oncology, the, Baltimore, Maryland. .,Institute for Cellular Engineering, the, Baltimore, Maryland.
| | | | | | - Elizabeth A Dackiw
- Department of Anesthesiology/Critical Care Medicine, and the, Baltimore, Maryland
| | - Paul M Ness
- Department of Medicine (Hematology), the, Baltimore, Maryland.,Department of Pathology (Transfusion Medicine), The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, and the, Baltimore, Maryland
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Frank SM, Wick EC, Dezern AE, Ness PM, Wasey JO, Pippa AC, Dackiw E, Resar LMS. Risk-adjusted clinical outcomes in patients enrolled in a bloodless program. Transfusion 2014; 54:2668-77. [PMID: 24942198 DOI: 10.1111/trf.12752] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 04/27/2014] [Accepted: 04/30/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although clinical outcomes have been reported for patients who do not accept allogeneic blood transfusion (ABT), many previous studies lack a control group, fail to use risk adjustment, and focus exclusively on cardiac surgery. STUDY DESIGN AND METHODS We report a risk-adjusted, propensity score-matched, retrospective case-control study of clinical outcomes for inpatients who did not accept ABT (bloodless, n = 294) and those who did accept ABT (control, n = 1157). Multidisciplinary specialized care was rendered to the bloodless patients to conserve blood and optimize clinical outcomes. Differences in hemoglobin (Hb), mortality, five morbid outcomes, and hospital charges and costs were compared. Subgroups of medical and surgical patients were analyzed, and independent predictors of outcome were determined by multivariate analysis. RESULTS Overall, mortality was lower in the bloodless group (0.7%) than in the control group (2.7%; p = 0.046), primarily attributed to the surgical subgroup. After risk adjustment, bloodless care was not an independent predictor of the composite adverse outcome (death or any morbid event; p = 0.91; odds ratio, 1.02; 95% confidence interval, 0.68-1.53). Discharge Hb concentrations were similar in the bloodless (10.8 ± 2.7 g/dL) and control (10.9 ± 2.3 g/dL) groups (p = 0.42). Total and direct hospital costs were 12% (p = 0.02) and 18% (p = 0.02) less, respectively, in the bloodless patients, a difference attributed to the surgical subgroup. CONCLUSIONS Using appropriate blood conservation measures for patients who do not accept ABT results in similar or better outcomes and is associated with equivalent or lower costs. This specialized care may be beneficial even for those patients who accept ABT.
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Affiliation(s)
- Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland
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Abstract
Recombinant human erythropoietin (rhEPO) is arguably the most successful therapeutic application of recombinant DNA technology till date. It was isolated in 1977 and the gene decoded in 1985. Since then, it has found varied applications, especially in stimulating erythropoiesis in anemia due to chronic conditions like renal failure, myelodysplasia, infections like HIV, in prematurity, and in reducing peri-operative blood transfusions. The discovery of erythropoietin receptor (EPO-R) and its presence in non-erythroid cells has led to several areas of research. Various types of rhEPO are commercially available today with different dosage schedules and modes of delivery. Their efficacy in stimulating erythropoiesis is dose dependent and differs according to the patient's disease and nutritional status. EPO should be used carefully according to guidelines as unsolicited use can result in serious adverse effects. Because of its capacity to improve oxygenation, it has been abused by athletes participating in endurance sports and detecting this has proved to be a challenge.
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Affiliation(s)
- M. Joseph John
- Department of Clinical Haematology, Haemato-Oncology and Bone Marrow Transplant Unit, Christian Medical College, Ludhiana, India
| | - Vineeth Jaison
- Department of Medicine, Christian Medical College, Ludhiana, India
| | - Kunal Jain
- Department of Medical Oncology Unit, Christian Medical College, Ludhiana, India
| | - Naveen Kakkar
- Department of Clinical Haematology, Haemato-Oncology and Bone Marrow Transplant Unit, Christian Medical College, Ludhiana, India
| | - Jubbin J. Jacob
- Department of Endocrine and Diabetes Unit, Christian Medical College, Ludhiana, India
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Jassar AS, Ford PA, Haber HL, Isidro A, Swain JD, Bavaria JE, Bridges CR. Cardiac Surgery in Jehovah's Witness Patients: Ten-Year Experience. Ann Thorac Surg 2012; 93:19-25. [DOI: 10.1016/j.athoracsur.2011.06.029] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/09/2011] [Accepted: 06/14/2011] [Indexed: 11/15/2022]
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Choi YY, Seo D, Choi D, Kim JH, Lee KJ, Ok SY. Comparison of Blood Transfusion Free Pancreaticoduodenectomy to Transfusion-Eligible Pancreaticoduodenectomy. Am Surg 2011. [DOI: 10.1177/000313481107700127] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Even though the surgical techniques and perioperative care have improved, blood transfusions are still often required for the patients undergoing pancreaticoduodenectomy (PD). But complications from blood transfusions, poor prognosis of blood transfused patients, cost, and availability of blood products demand transfusion free (TF) surgery in the PD patients. The purpose of this study is to compare clinical outcome of TF pancreaticoduodenectomy with transfusion-eligible (TE) PD. We had investigated the possibility of blood TF treatments for the patients who underwent PD from December 2005 to August 2007. There were 41 cases of PD performed by one surgeon with the same method: 14 patients of the TF group and 27 patients of the TE group. Most of the TF group patients received perioperative blood augmentation and intraoperative acute normovolemic hemodilution. The results of statistical analysis between TF and TE group showed that there were no statistical differences in intraoperative data and postoperative outcomes, except preoperative hemoglobin levels, type of operations, and transfusion amount. To our best knowledge, this is the first successful PD program in selected patients as a series of operations without blood transfusion. TF PD can be done successfully in selected patients without severe complications.
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Affiliation(s)
- Yoon Young Choi
- Department of Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Daekwan Seo
- Laboratory of Experimental Carcinogenesis, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Dongho Choi
- Department of Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jung Hoon Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Kyung-Jae Lee
- Departments of Occupational Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Si Young Ok
- Departments of Anesthesiology, Soonchunhyang University College of Medicine, Seoul, Korea
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Pompei E, Tursi V, Guzzi G, Vendramin I, Ius F, Muzzi R, Auci E, Badano LP, Livi U. Mid-term clinical outcomes in cardiac surgery of Jehovah's witnesses. J Cardiovasc Med (Hagerstown) 2010; 11:170-4. [DOI: 10.2459/jcm.0b013e3283330752] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Magner D, Ouellette JR, Lee JR, Colquhoun S, Lo S, Nissen NN. Pancreaticoduodenectomy after Neoadjuvant Therapy in a Jehovah's Witness with Locally Advanced Pancreatic Cancer: Case Report and Approach to Avoid Transfusion. Am Surg 2006. [DOI: 10.1177/000313480607200514] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although the morbidity and mortality rates associated with pancreaticoduodenectomy (PD) have been improving over the past several decades, perioperative transfusions are often needed. Here, we review the preoperative planning and overall management of a Jehovah's Witness patient with locally advanced pancreatic cancer who would not accept blood transfusion. Management of this case is reviewed, along with the relevant literature regarding major surgery in the Jehovah's Witness population. The use of neoadjuvant chemoradiation was used successfully in locally advanced disease, allowing surgical resection. In addition, we outline a cogent strategy using pre-, intra-, and postoperative techniques to minimize blood loss and maintain hemoglobin at acceptable levels thereby preventing the need for transfusion. These strategies, once in place, may be able to reduce transfusions in all patients having major resections for malignancy.
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Affiliation(s)
- David Magner
- Department of Surgery, Division of General Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - James R. Ouellette
- Department of Surgery, Division of Surgical Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joseph R. Lee
- Department of Surgery, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Steven Colquhoun
- Department of Surgery, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Simon Lo
- Department of Pancreatico-biliary Endoscopy, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nicholas N. Nissen
- Department of Surgery, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
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Ootaki Y, Yamaguchi M, Yoshimura N, Oka S, Yoshida M, Hasegawa T. Efficacy of a criterion-driven transfusion protocol in patients having pediatric cardiac surgery. J Thorac Cardiovasc Surg 2004; 127:953-8. [PMID: 15052189 DOI: 10.1016/s0022-5223(03)01318-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Low-hematocrit bypass is one technique used to prevent allogeneic transfusion during cardiopulmonary bypass. The purpose of this study is to determine the efficacy of a criterion-driven transfusion protocol and the effect of low-hematocrit bypass with moderate hypothermia in pediatric cardiac surgery. METHODS Seventy-five children who underwent cardiopulmonary bypass with low-hematocrit bypass for repair of congenital heart disease were studied. Criteria for red blood cell transfusion included anemia with a hematocrit level of less than 15% during bypass and 20% after bypass. During cardiopulmonary bypass, venous oxygen saturation, hematocrit values, and regional cerebral oxygenation were continuously monitored. Arterial lactate levels were measured postoperatively. RESULTS All patients had an uncomplicated perioperative course, and no perioperative death occurred. Twenty-two patients (29.3%) received a transfusion, and 53 (70.7%) patients did not. The hematocrit levels before and after modified ultrafiltration in the transfused group (21.6 +/- 5.5%, 26.6 +/- 6.5%) were significantly higher than those in the nontransfused group (18.9 +/- 3.7%, 23.1 +/- 4.1%) (P <.05). There was no significant difference between the group's arterial lactate levels immediately after admission to the intensive care unit and 1 day after the operation. The arterial lactate levels 6 hours after the admission to the intensive care unit for the nontransfused patients were higher than with the transfused patients (4.3 +/- 3.0 versus 2.5 +/- 1.5 mmol/L, (P <.05). For arterial lactate level, the relation with patients' weight had the highest correlation (R = 0.678, P <.0001). CONCLUSIONS A criterion-driven transfusion program can be effective, and low-hematocrit bypass with a hematocrit value below 20% may affect lactate production or clearance from the body.
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Affiliation(s)
- Yoshio Ootaki
- Department of Cardiothoracic Surgery, Kobe Children's Hospital, Hyogo, Japan.
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Abstract
The introduction of recombinant human erythropoietin (RHuEPO) has revolutionised the treatment of patients with anaemia of chronic renal disease. Clinical studies have demonstrated that RHuEPO is also useful in various non-uraemic conditions including haematological and oncological disorders, prematurity, HIV infection, and perioperative therapies. Besides highlighting both the historical and functional aspects of RHuEPO, this review discusses the applications of RHuEPO in clinical practice and the potential problems of RHuEPO treatment.
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Affiliation(s)
- T Ng
- Phase One Clinical Trials Unit Ltd, Plymouth, UK.
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Suess S, Suess O, Brock M. Neurosurgical procedures in Jehovah's Witnesses: an increased risk? Neurosurgery 2001; 49:266-72; discussion 272-3. [PMID: 11504102 DOI: 10.1097/00006123-200108000-00005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Because of the growing numbers of members worldwide in the sect of Jehovah's Witnesses, the refusal of blood and blood products due to religious reasons is increasingly encountered in clinical practice. As an alternative to blood transfusion, Jehovah's Witnesses accept blood-free volume substitution, and they sometimes accept the intraoperative reinfusion of autologous blood via a so-called cell saver. The aim of this study was to examine whether the refusal of blood transfusion affects the surgical indications for neurosurgery and whether morbidity and mortality rates are higher after neurosurgical interventions in Jehovah's Witnesses. METHODS The pre-, intra-, and postoperative hemoglobin and hematocrit values as well as coagulation parameters of a group of Jehovah's Witnesses (n = 103) were compared with those of a valid control group. RESULTS The total intraoperative blood loss during spinal and intracranial surgery in Jehovah's Witnesses was often less than in controls, which suggests a less traumatic surgical procedure. Hemodynamically relevant blood loss occurred in two spinal and four intracranial interventions. The patients were managed without receiving blood transfusions or blood products, although increased time in the intensive care unit and increased convalescence days were necessary. Mean surgical times were 17.5 minutes longer for spinal interventions and 36.7 minutes longer for intracranial interventions than for patients in the control group. This may be attributed to a more careful and thus slower surgical technique and to longer and more extensive hemostasis. The length of hospitalization was 15% longer for Jehovah's Witnesses than for controls. CONCLUSION The morbidity and mortality rates for Jehovah's Witnesses undergoing neurosurgery were not higher than those of the control group. Thus, it can be concluded that Jehovah's Witnesses did not have a higher risk when microsurgical techniques and extensive anesthetic monitoring were applied during neurosurgery. Because the surgical success rate for Jehovah's Witnesses corresponded to that of the control group, the increase in costs because of longer treatment times is compensated in the long run by avoiding a lengthier illness, sometimes with more expensive conservative therapy.
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Affiliation(s)
- S Suess
- Department of Neurosurgery, University Hospital Benjamin Franklin, Free University of Berlin, Germany.
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Suess S, Suess O, Brock M. Neurosurgical Procedures in Jehovah’s Witnesses: An Increased Risk? Neurosurgery 2001. [DOI: 10.1227/00006123-200108000-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Christopoulou M, Derartinian H, Hatzidimitriou G, Iatrou I. Autologous blood transfusion in oral and maxillofacial surgery patients with the use of erythropoietin. JOURNAL OF MAXILLOFACIAL SURGERY 2001; 29:118-125. [PMID: 11308290 DOI: 10.1054/jcms.2001.0200] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Autologous blood transfusion presents few infectious or immunologic side effects. The aim of the present study was to determine the impact of autologous blood transfusion with or without recombinant human erythropoietin (rHuEPO) in patients who underwent elective maxillofacial operations. Material: Seventy eight consecutive patients (29 men and 49 women) underwent elective maxillofacial operations during the years 1990-95. Study design and Methods: The patients were randomly assigned to three groups: In group 1, 30 patients preoperatively underwent autologous blood predonation with intravenous injection of erythropoietin 600 IU/kg after each blood predonation and autologous blood transfusion intraoperatively; in group 2, 28 patients underwent the same procedure without erythropoietin and in group 3, 20 patients underwent homologous transfusion serving as control group. All patients received ferrous sulphate daily by mouth, preoperatively until one week postoperatively. Results: Group 1 patients showed higher levels of haematocrit, haemoglobin and red blood cell count pre- and postoperatively than the group 2 patients. It was also shown that the use of rHuEPO contributed to an improvement of the blood parameters of the patients in the group 1 compared with those of the patients in groups 2 and 3. Copyright 2001 European Association for Cranio-Maxillofacial Surgery.
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Affiliation(s)
- Maria Christopoulou
- Department of Oral and Maxillofacial Surgery (Head: Prof. A. P. Angelopoulos), Evangelismos Hospital, Athens, Greece
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Booke M, Schmidt C, Van Aken H, Asfour B, Stanojevic D, Rolf N. Continuous autotransfusion in a Jehovah's witness undergoing coronary artery bypass grafting. Anesth Analg 1999; 89:262-3. [PMID: 10389828 DOI: 10.1097/00000539-199907000-00066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Booke M, Schmidt C, Van Aken H, Asfour B, Stanojevic D, Rolf N. Continuous Autotransfusion in a Jehovah's Witness Undergoing Coronary Artery Bypass Grafting. Anesth Analg 1999. [DOI: 10.1213/00000539-199907000-00066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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