Doctors find patients do better without blood transfusions

A recent study suggests that Jehovah’s Witnesses are on to something. — In the Archives of Internal Medicine, doctors from the Cleveland Clinic reported last month that Witnesses who underwent cardiac surgery without a blood transfusion fared better than non-Witnesses in terms of infection and complication rates, length of hospital stays and short- and long-term survival.
Although the study, which compared 322 patients of each group, focused only on cardiac surgery, many doctors report similar trends in orthopedic, gynecological and neurosurgery.
In 1962, Dr. Denton Cooley pioneered so-called bloodless open-heart surgery on Jehovah’s Witness patients in Texas. Since then, the practice has evolved to the point that many surgeons, regardless of a patient’s religious beliefs, try to minimize the loss of blood each time they stand over the operating table.
“We’ve taken what we have learned in the management of the Jehovah’s Witnesses and are applying it to the general medical population as a whole,” said Jan Seski, medical director of Allegheny General Hospital’s Center for Bloodless Medicine and Surgery. “Blood in and of itself may be lifesaving. If you have a trauma patient that comes in after a motorcycle accident and they are bleeding to death, you need to use transfusions. But if you can avoid it, in some situations you will get a better outcome.”

Jehovah’s Witnesses refuse blood transfusions for religious reasons but many also fear the possibility of contracting blood-borne illnesses such as hepatitis or HIV/AIDS through transfusions.
There is not one specific methodology used when performing bloodless surgery. Hospitals take a “whole programmatic approach,” Seski said, and they must adapt to the needs of the patient. Nonetheless, certain procedures are used to increase blood counts and to prevent blood loss before, during and after surgery.
Before surgery, doctors attempt to normalize the patient’s blood count, as many are anemic. Patients who are anemic do not have enough healthy red blood cells, which are responsible for providing oxygen to body tissues.
Blood counts can be raised 1 gram per week by providing the patient with iron and synthetic growth hormones such as erythropoietin, which stimulate the bone marrow to produce red blood cells. The increased speed with which doctors can now boost blood counts to a safe level for surgery is especially significant, as patients with a malignancy are far better off when operated on sooner rather than later.
A hemodilution technique pioneered by Seski and others in 1977 at M.D. Anderson cancer center is one of a number of strategies used to save blood during surgery. It is a closed loop system that separates a patient’s blood into red blood cells and clear plasma. The machine returns the plasma and a saline solution to the patient’s body during surgery to equalize blood volume. The red blood cells are kept in the machine, however, and returned to the body at the end of surgery.
The postoperative care of a patient is also important, as blood can continue to be lost after a surgery is complete. Blood samples, for instance, can remove up to a pint per week. To minimize the loss, doctors now use pediatric tubes, drawing smaller amounts of blood while still gaining the necessary data from testing.
Smaller incisions have also reduced the amount of blood lost during surgery.
“We use a laparoscopic approach, and that allows us to really get folks up sooner out of bed because they are not having pain from a big incision,” said Dr. James T. McCormick, who specializes in colorectal surgery. “If you keep the wound size small, then obviously there is less opportunity for there to be an infection.”

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