Advent of ‘bloodless medicine’ helps some patients avoid transfusions

Before Andrea Acerra, 45, had a hysterectomy due to heavy menstruation in November, she received an iron infusion to boost her red blood cell count and avoid the need for a transfusion.

“I was just worried about the side effects of the iron, but there weren’t any,” said Acerra, senior medical assistant in Bay Shore, NY.

South Shore University Hospital in Bay Shore, where Acerra was treated, offers bloodless medicine as an option. The program screens people to see if they are candidates for bloodless surgery. Until now, surgeons have performed various procedures there using bloodless medicine techniques.

Also known as patient blood management, it is used when a transfusion is not an option for religious reasons or safety concerns. This concept was spawned by the community of Jehovah’s Witnesses, who believe that it is against God’s will to receive blood from another person.. There are more than 8.6 million Jehovah’s Witnesses in the world.

Bloodless medicine became more widely used in the 1980s due to fears that donated blood could be contaminated with HIV and hepatitis C. This is no longer an issue as blood donations in the United States are screened for these and many other infectious diseases.

Still, “there is a significant portion of the population that is unable or unwilling to receive a blood transfusion,” said Dr. Aaron Harrison, associate medical director and gastroenterologist at South Shore.

And thanks to bloodless medicine techniques, many of them won’t have to, he added.

Having bloodless medicine as an option became even more important during the pandemic when donor blood supplies dwindled, triggering a nationwide shortage. “We don’t have blood available, so if we can get by without using blood and doing things safely, that’s ideal,” Harrison said.

At South Shore, patients like Acerra are identified prior to surgery and if they are anemic or unable or unwilling to receive a blood transfusion, they are placed on a blood sparing or blood stimulation protocol.

“We educate our doctors to bring up the fact that we can raise blood counts before surgery, to alleviate blood loss and the need for a transfusion,” Harrison said.

“It’s exciting because I don’t think anyone in the country has a patient screening process,” added Dr. John Davis, director of surgery at South Shore.

The hospital already works closely with the local Jehovah’s Witnesses community, so the new program is a natural fit, he said.

In addition to the use of iron and the hormone erythropoietin (EPO), which tells the bone marrow to produce more red blood cells, there are other ways to reduce the risk of blood transfusion before surgery.

For starters, “we can reduce the number of blood tests before the procedure and use smaller tubes to draw blood,” Davis explained.

Another way to reduce a person’s risk of needing a transfusion is to stop using blood thinners before surgery so they don’t bleed as much, said program medical director Dr Steven Frank. of Bloodless Medicine and Surgery at Johns Hopkins Hospital in Baltimore.

It is also important to stop taking certain herbal medications, vitamin E, and nonsteroidal anti-inflammatory drugs (NSAIDs), as they can increase the risk of bleeding during procedures.

“Keeping people warm during surgery also helps because even mild hypothermia increases bleeding during surgery, and keeping blood pressure lower can also reduce bleeding,” Frank said.

A drug known as tranexamic acid can be given to control bleeding, he said.

And then there’s technology that collects the blood you lose, washes it away, and returns it during surgery. “This is considered the centerpiece of blood conservation,” Frank said.

The advent of robotic surgery has also reduced the risk of blood loss during surgery, he said. “Yes, robotic surgeries involve smaller incisions than open surgeries, but the main difference is less bleeding and less need for transfusion,” Frank said. “It’s like day and night.”

Blood transfusions can save lives, but they also carry their share of risks.

Donating blood isn’t ideal, Davis said. “Blood is old and the number of cells in any unit that are efficient and carry oxygen is a fraction of the total amount.”

People can also have an allergic reaction to the blood itself, Frank said. “It is well known and proven that blood banked for transfusion can put you at risk of nosocomial infection because it suppresses your immune system,” he said.

Transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), and transfusion-related immunomodulation (ABT) (TRIM) are all risks associated with blood transfusions. TACO and TRALI are pulmonary complications that are leading causes of transfusion-related deaths, Frank said.

“People forget about TRALI, TACO and TRIM, which are far more common than getting HIV or hepatitis C from a blood transfusion,” he said. “Your chances of getting HIV or hepatitis C from a blood transfusion are the same as those of being struck by lightning – about 1 in 2 million.”

Bloodless medicine is becoming more mainstream due to the list of potential benefits, Frank said. “We all benefit from what we have learned from the community of Jehovah’s Witnesses,” he said. “With proper planning, with the right people and the right techniques, almost any surgery can be performed without transfusions.”

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