What is it?
The Center for Bloodless Medicine and Surgery at Hartford Hospital in Connecticut defines bloodless surgery as, “… surgical and/or medical treatment without the administration of blood or blood related products.” Bloodless surgery has been called the "Gold Standard" because of its known advantages over traditional surgery. During my 20-year career as a nurse and clinical consultant, I have witnessed numerous cutting-edge medical techniques that help plans receive improved patient results while saving money. Bloodless surgery and medicine, however, has been around for almost five decades, yet it is just now receiving the recognition it warrants. New studies and research have shown that bloodless surgery and medicine is not only cost-effective, but quickly becoming a standard of care because it typically results in fewer complications and post-surgery procedures.
In my current position as a clinical consultant with HCC Life Solutions, HCC Life's Healthcare Risk Management (HCRM) medical management program, I often receive inquiries from our clients about bloodless surgery and how it can lead to both clinical and financial outcomes. To help our clients better understand this proven medical practice, I have developed a set of frequently asked questions and their answers.
When is it done?
The practice has been incorporated into many areas of care including surgeries for general, cancer, neuro, oral/maxillofacial, orthopedic, pediatric, trauma, organ transplants and vascular. It is also being utilized for services in the areas of HIV/AIDs, cardiology, hematology and neonatology, to name a few.
For example, an Allegheny General Hospital gynecologic surgeon developed a bloodless surgical technique for removing large uterine fibroids, which spares the uterus. This surgical approach even allows for the possibility of future child bearing. Typically the removal of the tumors (myomectomy) results in large amounts of blood loss requiring multiple transfusions, often leading to removal of the uterus (hysterectomy). The bloodless surgical technique involves isolating and clamping off all blood vessels to the reproductive organs to temporarily shut off blood flow to that area. The fibroids are removed and the uterus is then reconstructed using tissue from the abdominal wall to reduce the formation of adhesions that could later cause infection and/or bleeding. Lastly the clamps are removed and the incision is closed.
Why is it done?
Bloodless medicine and surgery is an approach to health care that began in the 1960’s as a simple avoidance of the use of transfused blood or blood-related products. A variety of infectious agents have been found in the nation’s blood supply including; hepatitis A, B and C, malaria, syphilis, cytomegalovirus, Epstien-Barr virus, Creutzfeldt-Jacob virus (which causes the human form of “mad cow” disease), West Nile Virus, HIV/AIDS and other viral infections. The practice reduces the risk of blood product diseases. Of equal importance, bloodless medical and surgery reduce the potential risk for negative outcomes due to administration errors and adverse reactions.
New research is constantly proving the complexity of blood. Because it is a liquid organ, it does not transplant well. A 2007 news release from the University of Pennsylvania School of Medicine stated that one expert in the area, “likens the weeks-old blood often used for transfusions to ‘water like a dirty fish tank’. Depleted of most of its oxygen carrying capacity, the stored blood is not maximally beneficial to any patient.”
Donated blood for transfusions is stored and administered on a first-in, first-out basis so the oldest blood is always administered. Current blood bank policies allow blood stored up to 42 days to be used for transfusions. As donor blood ages, it looses critical amounts of the nitric oxide that helps deliver oxygen to the body, therefore potentially causing major harm to the patient. Beginning in the second week of storage, serious hemorrhagic disorders develop, including the decrease of blood cell deformability secondary to shape abnormalities, acidosis and the decrease in blood clotting. Most blood substitutes are experimental and are rarely used, although they can be approved under the compassionate use protocol.
Cost savings can be significant
According to noblood.org, the average cost of a bloodless heart surgery is only $16,345 while the average cost of a heart surgery using blood transfusions is $23,415. Dr. Patricia A. Ford, medical director of The Center for Bloodless Medicine and Surgery, Pennsylvania Hospital, Philadelphia said in a Feb. 22, 2007 Bottom Line's Daily Health News article, “many hospitals have a $2 million or $3 million budget for blood…even a 10% reduction in blood use can really have a significant impact.”
Where is it done?
About one year ago, HCC Life Solutions, a department of the HCRM division of HCC Life, received a request for bloodless transplant accommodation. At that time, we could only locate two bloodless transplant facilities. That number has grown by leaps and bounds to more than 200 bloodless surgery centers worldwide, including 100 facilities in the US alone. Even Australia began supporting bloodless surgeries, as “the Department of Health of the Government of Western Australia recently acknowledged patient blood management as an evidenced-based patient-focused medical and surgical concept, being in full compliance with the Australian Council on Healthcare Standards, and decided to implement it as a standard of care statewide between 2008 and 2012.” (Anesthesiology, 2008).
Who performs it?
Bloodless surgery techniques involve meticulous study and skill. While a cooperative surgeon, a surgeon who is agreeable to avoid the use of blood products, will practice blood-conserving techniques, that does not mean he/she is qualified to do a bloodless surgery. Even though more than 100,000 surgeons worldwide, including military surgeons, have been trained in this particular area, more bloodless surgery health practitioners are needed to meet the high demand. Training for surgeons, anesthesiologists, perfusionists and nurses are provided by bloodless surgery and medicine centers and some medical device companies.
How is the practice applied?
To ensure optimal success of a bloodless surgery, care begins prior to the surgery. Recommendations given to patients before surgery could include:
- Female hormone therapy, especially estrogen which protects cells from damage by allowing them to hold their healthy shape.
- A diet high in iron or supplements with ferrous sulphate or ferrous gluconate, vitamin C or folic acid, which help boost oxygenation.
- Medications that raise red or white blood cell counts and hemoglobin levels, such as Erythropoietin, which stimulates production of red blood cells, or oxygen carriers such as perflurocarbons or hemoglobin substitutes.
- Aprotinin, amiocaproic acid, desmopressin, vasopressin or vitamin K.
- Coconut water, the sterile liquid from young green coconuts/endosperm, can substitute for plasma because it has the same electrolyte balance of blood. Historically it was used during World War ll when the nation’s blood supply was low.
- Anesthesia techniques may include volume expanders such as crystalloids/colloids, hypotensive anesthesia, hypothermia or normovolemic hemodilution and hyperoxic ventilation.
- A surgical method often used in bloodless surgeries is intraoperative autotransfusion, where the patient's own blood is suctioned directly from the operative site, then washed and replaced directly back into the patient.
- A variety of surgical devices, such as ultrasonic scalpels, microwave coagulating scalpels, argon beam coagulators, laser surgery, selective embolization and the new harmonic scalpel, a vibrating laser that cauterizes as it cuts, are common with bloodless surgeries.
- Techniques such as platelet gel, fibrin glue, and use of pediatric tubes for limited micro blood sampling are also popular blood conservation techniques.
The cries about blood shortages are real. The nation's donated blood supply is 100% dependant upon a steady core of altruistic donors, whose numbers are fast declining. Studies show that patients have fewer infections and shorter hospital stays, therefore making bloodless surgery and medicine an excellent approach to address blood shortages. Additionally, there are no barriers to the bloodless medicine, as all of its techniques are FDA-approved and non-experimental.
Bloodless surgery and medicine is not a fad. It’s healthcare of the future that's been around for decades.
By Diane Anderson, RN
Clinical Consulting Specialist HCC Life Insurance Company
If you have any additional questions about bloodless medicine, or would like to learn about how HCC Life Solutions can help plans maximize effective management of claim dollars and clinical opportunities, contact Diane Anderson at (877) 843-5743.
About the Center for Bloodless Medicine & Surgery. Hartford Hospital. Web <http://www.harthosp.org/bloodless/AboutTheCenterforbloodlessSurgery/
Ford, Patricia A. "Bloodless Surgery: Safer, Smarter Surgery Goes Mainstream." Bottom Line's Daily Health News 22 Feb. 2007.
Landis, Lee-Ann. "New Choices for Patients: Transfusion-Free Medicine for Jehovah's Witnesses and Transfusion-Wary." December 5, 2007. Web <http://www.eurekalert.org/pub_releases/2007-12/uops-ncf120507.php>.
NoBlood, Inc., noblood.org.
Society for the Advancement of Blood Management, www.sabm.org.
Spahn, Donat R., Holger Moch, Axel Hofmann, James P. Isbister. "Patient Blood Management: The Pragmatic Solution for the Problems with Blood Transfusions." Anesthesiology 109 (2008): 951-953.