February 22, 2018

Each year in the U.S., some 20 million blood transfusions are performed. But for a growing subset of patients, such procedures are not an option due to personal preferences, religious beliefs, or biological conditions such as advanced sickle cell disease with antibodies.

In those circumstances, physicians can turn to a bloodless approach that avoids the need for transfusion. Remarkably, such approaches, which use a variety of clinical and laboratory methods, have been shown to not only reduce blood loss but also to speed recovery, minimize infection and reduce the length of hospital stays.^1-2

The Center for Bloodless Medicine and Surgery is a world leader in bloodless care. Launched in 2012, it is one of only two centers nationwide to earn level 1 certification—the highest level of accreditation—from The Joint Commission. Center director Steven Frank is a renowned expert in blood conservation methods. He and his multidisciplinary team of clinical specialists harness bloodless approaches not only for routine surgeries but also for complex procedures, such as cardiac, thoracic, pancreas, liver, orthopaedic, oncologic, neuro and vascular surgeries. These are procedures that other bloodless programs may decline to consider.^{1, 3}

The methods that underlie bloodless approaches focus on two major goals: reducing bleeding and blood loss, and optimizing hemoglobin levels and coagulation. Frank and his colleagues work toward these goals by leveraging a suite of medications, clinical tools and techniques that can be used before, during and after surgery.⁴

 

Preoperative Care

A vital aspect of preoperative bloodless care is to identify and treat any preexisting anemia well in advance of the surgical procedure. Methods range from oral iron therapy to intravenous iron treatment combined with erythropoiesis-stimulating agents. A second key consideration is to quantify the expected amount of blood loss (adjusted for the type of surgery and the expertise of the surgeon) with respect to the patient’s estimated total blood volume. This can help inform assessments of target hemoglobin levels pre- and post-surgery. Another critical issue is for patients to cease anticoagulant medications or herbal remedies that promote bleeding.

 

Intraoperative Care

With some fairly straightforward approaches, such as avoiding hypothermia and hypertension, clinicians can minimize blood loss during surgery. More intensive measures, such as acute normovolemic hemodilution (ANH) and autologous blood salvage (also known as cell saver), can also help. In addition, the use of antifibrinolytics, such as tranexamic acid (TXA), can reduce blood loss by about 30 percent by preventing clot breakdown. At Johns Hopkins, clinicians are exploring optimal TXA dosing regimens.5 Finally, a suite of surgical methods, including minimally invasive approaches, meticulous surgical techniques, and use of topical hemostatic agents and advanced electrocautery tools, are also key components in the bloodless medicine toolbox.

 

Postoperative Care

A combination of approaches can be followed post-surgery to minimize blood loss. Perhaps the most significant one is to reduce secondary blood loss due to phlebotomy for laboratory tests—a significant issue, particularly among ICU patients. One practical method to achieve this is to use smaller phlebotomy tubes, including microtainers, which hold about a half-milliliter of blood—a 95 percent reduction in the amount of blood sent for testing for a typical adult patient.

 

For more information, visit the Center for Bloodless Medicine and Surgery.

To refer a patient, call 877-474-8558

 

 

References

Frank SM et al.: Risk-adjusted clinical outcomes in patients enrolled in a bloodless program. Transfusion 2014, 54:2668-77.

Resar LM et al.: Bloodless medicine: Current strategies and emerging treatment paradigms. Transfusion 2016, 56:2637-2647.

Resar LM, Frank SM: Bloodless medicine: What to do when you can't transfuse. Hematology Am Soc Hematol Educ Program 2014, 1:553-8.

Frank SM, Scott AV, Resar, LM: Bloodless medicine and surgery: Top 10 things to consider. Anesthesiology News 2016, http://anesthesiaexperts.com/uncategorized/bloodless-medicine-surgery-top-10/.