Accommodating Patients Requests For Medical Treatment Without
Allogeneic Blood
Slide 3
Bloodless Medicine and Surgery Defined Use of New and Existing
Techniques, Procedures, Technology, and Equipment to reduce or
eliminate the need to use allogeneic (donor) blood
Slide 4
Englewood Hospital & Medical Center Bloodless Institute
Patients from 40 States in USA Patients from 40 Countries Major
Cardiac, Orthopedic, Vascular, Neurological, Gynecological,
Hepatic, Thoracic, Urologic Surgery Hundreds of Transfers from
Other Hospitals including those claiming to be Bloodless
Centers
Slide 5
Bloodless Medicine and Surgery - A Multidisciplinary Effort
Surgeons Anesthesia Personnel Nurses Internists Hematologists
Administrators Ancillary Staff Pharmacy Lab Blood Bank
Slide 6
Englewood Hospital and Medical Center-Bloodless Institute 200+
Physicians Six dedicated staff members Patient Intake and care
coordination Patient Education, Advance Directives Preoperative
patient preparation Patient Advocacy Four Medical Directors Regular
nursing, physician, staff education Regular community
education
Slide 7
Bloodless Medicine and Surgery Why? Crisis in Blood Supply and
Availability Blood Borne Disease Risks Patient refusal/reluctance
Cost Considerations
Slide 8
Bloodless Medicine and Surgery - Why? Patients choice * Blood
is a precious fluid Increasing Elderly Population By 2030, annual
shortfall of 4 million units in USA Less than 5% of eligible
population donates in USA Blood Transfusion is associated with
Significant Cost
Slide 9
Reasons That Support Bloodless Medicine and Surgery Blood
therapy is expensive-proven risks and hazards Public health
concerns Shortage of blood nationally Medical devices and
pharmaceuticals facilitate bloodless care No significant increase
of morbidity and mortality Overall decrease in healthcare costs
Enhances practical clinical experience Growing patient population
supplies data for more education Supports patients rights and
autonomy Good economics
Slide 10
Who are the Patients? Religious Motivation Primarily* Jehovahs
Witnesses Non - Religious Motivation Concern over blood safety
Personal/Family Member History of Problematic Transfusion
Vegetarians
Slide 11
Jehovahs Witnesses and Associates - World Population 1985 -
7,792,109 1995 - 13,147,201 2000 - 14,872,086 2007 -
16,675,113
Slide 12
Jehovahs Witnesses Do Not Refuse Medical Care - only blood
transfusions Refusal of Blood not a RIGHT TO DIE Issue Actively
Pursue Non Blood Medical Management
Slide 13
Jehovahs Witnesses Do Accept Various Surgical, Medical,
Anesthesia, Nursing Modalities to Conserve/Preserve Blood All Other
Types of Standard Medical Care
Slide 14
Slide 15
Fractional Components Medical/Scientific Line of Reasoning
Realistic consideration of physical Risks vs. Benefits
Conscientious Line of Reasoning Thoughtful consideration of other
Risks vs. Benefits (i.e. spiritual)
Slide 16
Blood Fractions - Examples ALBUMIN (EPO) IMMUNE GLOBULINS
CLOTTING FACTORS (some) CRYOPRECIPTATES HEMOGLOBIN BASED PRODUCTS
More and More Available
Slide 17
Making the Decisions - Medical Line of Reasoning Blood
Fractions are fundamental tools in hands of Physicians Many non
blood alternatives fit into these categories Some used only in the
face of imminent loss of life, so small risk of disease is
tolerable
Slide 18
Accommodating Patients Legal and Ethical Principles Bodily Self
Determination Upheld by US Supreme Court and State Courts Right to
Refuse Treatment Special Considerations for Minors
Slide 19
Risks of Blood Transfusions Incompatibility (ABO and other
groups) (ABO and other groups) Infectious complications Infectious
complications Immunomodulatory Immunomodulatory Resource
availability Resource availability Risk to Benefit Ratio Risk to
Benefit Ratio
Slide 20
Blood Collection and Transfusion - US in 1999 13,225,000
allogeneic units collected 12,020,000 allogeneic units transfused
226,000 lost to screening (1.7%) 787,000 outdated (5.9%) 112/1709
(6.6%) of hospitals cancelled surgery because of no blood
Slide 21
Slide 22
Transfusion Behavior (Survey) 1997 US physicians: 100 MDs all
specialists. At what Hb. would you be transfused? Hb. of 9 gms/dl0%
Hb. of 7 gms/dl+/-5% Hg. of 5 gms/dl+/-14% Lower?+/-19.5% > 78%
have Tx. Patients with Hb. ~9.0 gms Role of guidelines in
Transfusion Medicine Bifano et.al.
Slide 23
Bloodless Institute & Risk Management No Legal Cases or
Consequences attributable to Bloodless Program Patients sign
Release of Liability Form on admission No change in Hospitals
Liability Insurance Coverage
Slide 24
Hospital Liability? The court allowed the plaintiff's
negligence action against the hospital for not having given
recipient notice of the danger of transfusions. Estate of Jane Doe
v. Vanderbilt University, Inc. 1993
Slide 25
Bloodless Care and Cost Savings Cost of acquiring ONE unit of
Packed Red Blood Cells is approximately $225 US* TRUE cost much
higher (transport, storage, administration, potential
complications) Study found allogeneic transfusions associated with
$1000-$1500 US incremental Hospital costs
Slide 26
Management of Anemia Careful Evaluation and Diagnosis Accurate
History and Physical Avoid and/or Manage Preoperatively if at all
Possible Recombinant Human Erythropoietin (Epoetin Alfa)
Slide 27
EPO DOSING REGIMEN 300-600 Units/Kilogram, from three to ten
weeks before Surgery, Subcutaneously or Intravenously Postoperative
Bleeding GI Bleeding Oncology Postpartum GYN Bleeding
Slide 28
Adjuvants to EPO Folic Acid (1 mg/day) Vitamin B-12 Ascorbic
Acid (500 mg/day) Iron (Oral or Intravenous )
Slide 29
Bloodless Medicine and Surgery - Intraoperative Surgical
Management Meticulous Hemostasis Electrocautery Laser Surgery Argon
Beam Coagulation Tissue Adhesives Cell Salvage
Slide 30
Bloodless Medicine and Surgery - Anesthesia Management
Embolization Positioning of patient Hypotensive anesthesia Induced
hypothermia ACUTE NORMOVOLEMIC HEMODILUTION Aprotinin, DDAVP,
Tranexamic acid, conjugated estrogens
Slide 31
Iatrogenic Blood Loss Average ICU Patient can lose 1000 ml or
more of blood PER WEEK from phlebotomy for laboratory testing
Slide 32
Routine Blood Testing Routine Blood Tests are often UNECESSARY
in Patients who refuse transfusion, or if no changes in clinical
management will result from information obtained
Slide 33
Transfusion Immunomodulation Multiple studies show that
transfusion is associated with increased risk of earlier cancer
recurrence, lack of response to cancer treatment, and serious
postoperative infection.
Slide 34
Slide 35
SHOT - Serious Hazards Of Transfusions 24 month study in UK and
Ireland (1996-1998) 424 hospitals surveyed 39% (164) responded
Outcome measures Death wrong blood - wrong patient acute and
delayed transfusion reactions Acute lung injury Graft vs. host
reaction Purpura Infections
Slide 36
SHOT - Serious Hazards Of Transfusions 366 major adverse events
reported 52% were due to wrong blood to patient 22 total deaths 3 -
ABO 12 - infections, 4 - bacterial*, 7- viral, 1 - malaria*
Slide 37
When does a patient get transfused? Really?
Slide 38
Slide 39
Risks of blood transfusion ( Per unit of blood U.S.A. ) Minor
allergic reactions1:100 Viral hepatitis (A,B,C,D,G)1:50,000
Hemolytic reactions1:6,000 Fatal hemolytic reactions1:600,000 HIV
infection1:420,000* HTLV-I/II1:200,000 Bacterial infections1:2,500
Acute lung injury1:500,000 Anaphylactic shock1:500,000 Graft Vs.
host diseaseRare Immunosuppression1:1
To all who received blood from January 1991 to December 1996 in
a New York/New Jersey hospital Here is important information from
the New York Blood Center for anyone who received a transfusion of
red blood cells, platelets, or plasma in a New York or New Jersey
hospital between January 1991 and December 1996. During that
period, there may have been a problem with the way New York Blood
Center performed testing of blood for viral infections. As a
result, recipients of donated blood products during that period may
face a potential risk of transfusion-transmitted infections, such
as HIV and hepatitis.
Slide 42
Risk versus Benefit Known risks include disease transmission,
reactions, immunomodulation Benefit of blood unproven Storage
dramatically diminishes bloods effectiveness as O2 carrier Known
risks outweigh perceived benefits
Slide 43
What is Acceptable Risk? To patient To physician To society
Age-based? Diagnosis-based?
Slide 44
Blood Transfusion is Life Saving? NO proof except when used as
volume replacement in resuscitation There are safer, equally
effective alternatives such as saline and colloids NO trials that
demonstrate better survival from blood transfusion
Slide 45
NJ Institute of Bloodless Medicine and Surgery Patient Totals
Year # pt Mortality 1994 5100 1995 6501 1996 1,0571 1997 1,2671
1998 1,9491 1999 2,5401 2000 2,7511 2001 3,0471