Transfusion Alternatives in Bloodless Surgery

      “In patients with intermediate hemoglobin levels, discretionary transfusion should be carefully considered, as the risks are marked, the benefits are unclear, and alternatives are available.”  -Blood Transfusion: Risks And Alternatives, Pulmonary Reviews

      “Public health officials are claiming that the blood supply is safer than ever, and that probably is true”, said Richard K. Spence, MD. Nevertheless, blood transfusions can have a number of deleterious consequences, cautioned Dr. Spence, Chief of Surgery at St. Agnes HealthCare in Baltimore. Perhaps the best way to think about transfusions, he added, is as “liquid organ transplants.”  -Pulmonary Reviews

      Questions about the safety of the blood supply
      Even before the AIDS blood scandal rocked the United States and the Tainted Blood Scandal hit Canada many other massive errors involving blood collection and safety had erupted over the decades. They were often quickly forgotten by the public - but not by historians, reporters and authors who have documented the long trail of one massive blunder after another. After each breach of confidence the blood industry has followed up by saying that ‘the blood supply is safer then ever’. Now after so many scandals the public is not forgetting and huge numbers of people are looking for transfusion alternatives that are safe and effective.

      An evidence of this is the sharp increase in the number of Bloodless Operations being performed in the United States on patients who refuse blood transfusions, not on the basis of religious conscience, but out of fear and concern for their health. Statistics reveal that a huge upsurge of Bloodless Operations are now performed on the general population, some say the figures have increased threefold - from 10% to 30%.

      "Regardless of legal liability, all governments have a moral responsibility to Canadians who placed their faith in the blood system, and, through no fault of their own, became infected." Ontario Premier Mike Harris wrote in a letter to Prime Minister Jean Chrétien. Read the entire report here.

      Additionally, the total number of Bloodless Operations are increasing worldwide as more and more hospitals open Bloodless Surgery Centers. Countries with large Hindu, Buddhist, and Arabic populations now have hospitals that offer transfusion alternatives to anyone who wishes. Concern about the safety of the blood supply is universal – not just in the United States.

      Seeking transfusion alternatives is now mainstream. Internationally respected institutions and doctors are spending massive amounts of money, time and energy learning about, investigating and instituting protocols for safe transfusion alternatives. More than ever Bloodless Surgery is for everyone.

      So rampant are concerns about the safety of blood that even blood banks and hospitals that may not offer Bloodless Surgery or any kind transfusion alternative are recommending the dangers and risks of blood transfusion. This is a huge shift in the medical industry.

      Take as an example the Royal Children’s Hospital in Melbourne, Australia. The hospital’s website is one of the few that delineates clearly and completely the risks of blood transfusions on the page entitled Blood Transfusion:

      Royal Children’s Hospital in Melbourne, Australia

      Adverse effects of transfusion

      ♦ Immediate Management of a Suspected Transfusion Reaction
      • Investigation Requirements
      • Immediate Adverse Effects of Transfusion
      • Febrile Reactions
      • Urticarial (Allergic) Reactions
      • Severe Allergic (Anaphylactic) Reactions
      • Acute Haemolytic Reactions
      • Bacterial Contamination
      • Transfusion-Related Acute Lung Injury
      • Volume Overload
      • Hypothermia
      • Citrate Toxicity
      • Potassium Effects
      • Summary table

      ♦ Delayed and Long Term Adverse Effects of Transfusion
      • Delayed Haemolysis
      • Alloimmunisation
      • Transfusion associated Graft Versus Host Disease
      • Immunomodulatory effects
      • Iron accumulation
      • Infectious Disease transmission

      Each blood product transfused carries a small risk of an acute or late adverse effect.

      This represents a shift in the mental attitude of some hospitals toward the ‘safety’ of blood transfusions.

      Hospitals that warn patients of all the many risks involved in allogeneic blood transfusions are to be applauded. More hospitals should accept the responsibility to clearly inform the public of the reality of the situation. Simply saying that the ‘Blood supply is safer than ever’ doesn’t tell the whole story.

      Blood transfusions are not safe even they may be ‘safer’ than ever. Bloodless Surgery on the other hand is safe – as safe as conventional surgery and in fact safer.

      More than viral transmission is a concern
      “Infection may be the least of the risks associated with allogeneic transfusions, though. Many well-performed studies have linked such transfusions to higher rates of disease recurrence and decreased survival in cancer patients, pointed out Dr. Spence.”  -
      Pulmonary Reviews

      It may be true - ‘the blood supply is safer than ever’. But how safe is it? Safer than ever simply means it is safer by someone’s scale of measurement. Saying the world is safer than ever because of a 30% reduction in the number of nuclear warheads is not saying much. The number of nuclear arms is still enough to destroy the planet about five times over. Few politicians will say the world is safe.

      Likewise, few of the blood banks, hospitals, and blood collection agencies will venture to say, “Blood is safe”. It is not. People are still contracting viral pathogens. People are still dying from tainted blood.

      Is blood “safer than ever”?
      Maybe so. But is it safe enough? Saying blood is safer than ever has to be taken in context. Those that say this are referring to the fact that more blood screening is done than ever before and that fewer people are getting pathogen borne illnesses than before. The statistics prove this – at least for Western countries.

      What is misleading about the statement “blood is safer than ever” is that it avoids the fact the post surgical mortality among those who receive blood transfusions is significantly higher than among those who do not. Multiple studies in multiple countries are bringing this to light. Blood is not safe. "[Blood] is the most dangerous substance we use in medicine," so said Nobel Prize Recipient Dr. Charles Higgins.

      “Patients who were given a transfusion had significantly higher mortality in intensive care and overall mortality than patients who weren’t.”  -BMJ

      “In this subgroup, 2,474 of 4,452 patients (56%) received a blood transfusion but had a higher 30-day mortality than patients with similar hemoglobin levels who did not receive a transfusion.”

      “After adjusting for baseline characteristics, transfusion was still associated with higher mortality.”  -Science Daily

      An epidemiologic survey of 3,534 patients in 146 western European ICUs, confirmed increased mortality rates (ICU and hospital) in transfused patients.  -The Journal of the Society of Anesthesiologists

      “Five-year mortality was more than twice as high in those who received perioperative blood transfusions than in those who did not.”  -Pulmonary Reviews

      “[For] patients who underwent coronary artery bypass grafting transfusion [is] associated with a 70% rise in five-year mortality.”  -Timothy Begany - Blood Transfusion: Risks And Alternatives, Pulmonary Reviews

      “Blood transfusion has often been shown to reduce cancer survival.”  -British Journal of Surgery

      Evidence about the “Nitrous Oxide Dilemma”
      “The ability of red blood cell transfusions to increase oxygen consumption has not been clearly demonstrated.” Hébert PC, Hu LQ, Biro GP. Review of physiologic mechanisms in response to anemia. -

      The following excerpt appears on other pages on MyBlood’s site and is presented here for the reader’s convenience:

      New research is adding a piece to the puzzle and providing a possible reason for why post-surgical mortality is higher among recipients of blood products – the nitrous oxide dilemma.

      New research from Duke University has suggested serious problems with stored blood. While donated blood may legally be stored up to 42 days it starts losing nitric oxide within three hours after leaving the donor’s body and within 24 hours are reduced by 70%. Nitric oxide is a gas produced in the body that promotes oxygen delivery to cells, tissues, muscles and organs.  Nitric oxide aids in the transference of oxygen from the red blood cells to the other cells in the body. Although the red blood cells may have enough oxygen they cannot reach the oxygen depleted cells begging for more oxygen allowing.  “The result can be a heart attack or even death.”  -Duke University Health System

      Imagine a truck full of food that comes to a grocery store where the employees are on strike. With no one to open the doors and offload the food from the truck to the store the food stays on the truck. No one can benefit from the ample supply of food because it cannot be delivered. A small town would soon starve if the problem isn’t remedied. Likewise, stored blood loses its ability to deliver the oxygen stored in its red blood cells. The oxygen is there but it can’t be delivered.

      “Dr. Ford likens the weeks-old blood often used for transfusions to ‘water from a dirty fish tank.’ Depleted of most of its oxygen-carrying capacity, the stored blood is not maximally beneficial to any patient.”

      No wonder of bag of blood looks like liquid scab. 

      No wonder so many are looking for a safe transfusion alternative.

      The fact is that blood quickly loses its ability to transport oxygen – and giving blood for its ability to increase the recipient’s ability to absorb oxygen has been one of the main reasons for transfusing blood. But this recent research concludes that the blood’s ability to transfer oxygen diminishes quickly.

      “Storage of allogenic blood creates functional degradation in oxygen-carrying red blood cells.”  -AORN Journal

      “Banked blood has little oxygen-delivering ability.”  -AORN Journal

      “The average unit of blood remains in cold storage for more than one-half the allotted 41 days and thus provides little improvement in tissue oxygenation when infused.”  -AORN Journal

      First in – First out. Every unit of blood transfused is the oldest blood available.

      “The rate of in-hospital death increased by 8.5 percent each additional day the transfused blood had been on the shelf.”  -New York Times

      Hospitals follow the same practice as do food stores and meat markets “First in First out”. This simply means that the first blood stored in the fridge is the first blood taken out and transfused. Or better put – “Old blood first – new blood second.” That is, the oldest blood is the blood used next for a transfusion. That old bag of blood in the fridge could be for your transfusion.

      Blood stock has to follow this time honored practiced. If the newest blood is transfused first then the oldest blood exceeds its shelf life – just like a quart of milk – and is thrown away. Since the Nitrous Oxide Dilemma highlights how fast blood is depleted of its ability to transport oxygen then it could explain why some patients have more adverse reactions than others – why some die and some don’t – why some have a post surgical mortality and others do not.

      Perhaps one day a study will be done to determine a relationship between the age of the blood transfused and mortality rates. Until then, there are plenty of safe and proven transfusion alternatives

      Transfusion alternatives are common and safe
      Traditionally blood transfusions have been given for two principle reasons: one, to increase blood volume. When a patient loses too much blood the volume of blood in his circulatory system drops and the patient can go into shock.

      Volume expanders
      Volume expanders have been used for as transfusion alternatives that have been in use for decades. Volume expanders do exactly what they say, expand the fluid volume in the circulatory system.

      Here is a list of safe volume expanders:

      • Normal saline solution (basically – water and salt)
      • Hypertonic saline (salt water containing a high concentration of salt)
      • Ringer’s lactate
      • D5W (A water solution with 5% dextrose)  (basically - water and sugar)
      • Hydroxyethyl starch (basically – water and starch)

      “An intravenous solution of hydroxyethyl starch is used to prevent shock following severe blood loss caused by trauma, surgery, or some other problem. It increases the blood volume, allowing red blood cells to continue to deliver oxygen to the body.”  It is sold under the names: Hespan and Voluven, according to Wikipedia.

      • Pentastarch
      • Hetastarch

      Volume expanders perform the exact same first purpose for giving blood – replace lost volume – but without the risks of a blood transfusion.  Volume expanders provide a safe and effective transfusion alternative.

      Building up red blood cell count
      “‘Clearly, recombinant erythropoietin should be on everyone’s mind as the first drug of choice to treat anemia in patients who do not need to be transfused,’ said Dr. Shander.”  -
      Pulmonary Reviews

      Dr. Shander is a world renowned expert in Bloodless Medicine.

      A second reason for transfusing blood is to increase the red blood cell count in order to increase the amount of oxygen delivered to the other cells in the patient’s tissues, muscles and organs. Modern hemapoietic medicines can build up the patient’s red blood cell count prior to surgery adequately enough to compensate for large losses of blood during surgery - thus avoiding giving blood for the same purpose. These medicines do not carry any of the risks that persist with blood transfusions.

      Bloodless Surgery is a safe transfusion alternative
      Bloodless Surgery involves much, much more than simply using hemapoietic agents and volume expanders. It is a science in itself and is quickly expanding. The goal of Bloodless Surgery is to avoid a blood transfusion completely. It includes complete care prior to, during and following surgery. Entire teams of Bloodless Professionals are trained in special techniques to care for the patient.

      Blood conservation during surgery is employed to minimize blood loss and blood salvage machines recycle blood that is lost and re-infuses it back into the patient. Special diets may be encouraged. Learn more here.

      Bloodless Surgery is being called the ‘wave of the future’ and the Golden Standard of care. But the future is here now. Any patient seeking surgery of any kind can choose more than just a transfusion alternative he can opt for Bloodless Surgery. It is safe, effective and actually cheaper than traditional surgery.

      In addition to avoiding the risks of contaminated blood the Bloodless Patient recovers faster and avoids the high post surgical mortality rates of the conventional patient.

      “The gift of death.”

      “The infection of thousands of Canadians with the AIDS virus and hepatitis C is Canada's worst- ever preventable public health disaster. It has also become one of its most prolonged legal sagas, featuring a high-profile public inquiry, almost $10 billion in legal claims and a criminal investigation.

      “At least 2000 recipients of blood and blood products contracted the human immune deficiency virus between 1980 and 1985. Another 30 000 transfusion recipients were infected with hepatitis C, a potentially debilitating liver disease between 1980 and 1990. About 8000 of those who received bad blood are expected to die as a result.”  -The Canadian Encyclopedia. Read the entire article here.

      Some may say that’s old news.

      Others may worry since “Many emerging pathogens will elude the stringent and sensitive donor testing already in place which, unfortunately, requires advanced technologies.” N L Nluban (Abstract) – Annals of the New York Academy of Science

      AIDS was once an emerging pathogen. It caught the blood industry off guard. Other pathogens will arise.

      What will the next pathogen be?
      Will the next path
      ogen cost thousands of lives and waste billions of dollars that cold be spent on transfusion alternatives, education and research into totally safe blood substitutes? The irony is this: Bloodless Surgeons and Bloodless Patients are not concerned about the next emerging pathogen. The technology is here right now. The billions wasted in Canada could have been spent on extending Bloodless Medicine to every single Canadian citizen who instead must worry about the next pathogen.

      For more information read the book “The Gift of Death: Confronting Canada's Tainted-Blood Tragedy” by Andre Picard.

      “Bloodless procedures have proven to be safer than blood transfusion because they help eliminate complications resulting from transfusions such as immunosuppression, infection, diseases from emerging pathogens for which our blood supply is not yet tested.”  -Dr. Patricia Ford, Pennsylvania Hospital

      Transfusion alternatives are better than blood
      “Alternatives are available.”  -
      Pulmonary Reviews

      When compared to all the dangers and risk of blood transfusion it can be said, and is being said by more than 100,000 Bloodless Surgeons worldwide – transfusion alternatives are safer than blood. Alternatives avoid the risks but deliver the benefits. They leave the patient with peace of mind. They have proven to be better than blood.

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