By Alex Ashley
In the mid-1660s, the English physician Richard Lower performed an unprecedented medical feat.
“[I] selected one dog of medium size, opened its jugular vein, and drew off blood, until … its strength was nearly gone,” he wrote. “Then, to make up for the great loss of this dog by the blood of a second, I introduced blood from the cervical artery of a fairly large mastiff, which had been fastened alongside the first.” After Lower “sewed up the jugular veins,” the animal recovered “with no sign of discomfort or of displeasure.”
It was the world’s first successful blood transfusion.
Today, some 350 years later, Lower’s influence is significant: More than 14 million transfusions take place in the U.S. each year. In the relatively simple procedure, healthy blood is transferred into a patient’s body through an intravenous (IV) line. The donated blood replaces blood lost during injury or surgery, or blood that’s not producing enough red cells. According to the American Red Cross, a patient in a U.S. hospital needs a blood transfusion every two seconds.
But some members of a small but vocal subset of the medical community envision a future where transfusions are rare, and maybe even someday obsolete.
Their proposed alternative: patient blood management, a collection of medical practices and surgical techniques to help doctors minimize blood loss and avoid transfusions. And some have set their sights even further to bloodless medicine, which requires doctors to carry out normal medical procedures—including surgery—without transfusing the patient with blood, red cells, plasma, or platelets.
A patient in a U.S. hospital needs a blood transfusion every two seconds.
Patient blood management, a concept that first emerged around15 years ago, emphasizes preventative measures to reduce the risk of a patient needing a transfusion. For example, physicians practicing blood management might screen and treat patients for anemia in the weeks before surgery; during an operation, they might use medications or certain techniques to minimize bleeding.
Because a blood transfusion can have complications, blood-management proponents argue that avoiding the practice altogether is in patients’ best interest. Even if the blood is the right type, for example, a patient can have an allergic reaction to the blood itself. Multiple transfusions can cause an overload of iron in the body, damaging the liver or heart. In very rare cases, transfusion can also cause graft-versus-host disease, a condition where white blood cells in the new blood attack the bone marrow.
So, they’re asking: If doctors can avoid a transfusion, why wouldn’t they?
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In 1984, the HIV virus was identified; in 1989, the Hepatitis C virus. As major infectious threats to the national blood supply became more prevalent, the medical field took a closer look at how it was handling blood.
“For many years, the emphasis was on making blood safer,” says Eduardo Nunes, the senior director of standards, advocacy, and patient blood management at the AABB (a membership organization for the field of transfusional medicine, formerly known as the American Association of Blood Banks). In 1997, the U.S. Department of Health and Human Services founded the Advisory Committee on Blood and Tissue Safety and Availability; the following year, the AABB founded the National Blood Data Resource Center to compile data on blood donation and transfusion.
But more recently, Nunes says, attention has shifted: “Now, our focus is on being more efficient in our use of blood products.” In 2005, the organization changed its name from “American Association of Blood Banks” to reflect a widening focus. In the years that followed, AABB—which is the main accrediting body for blood banks and transfusion programs in the U.S.—ramped up its educational offerings on blood management for members. Last year, the organization published its first set of guidelines for patient blood management.
Nunes says the new guidelines will serve as the basis for a new blood-management accreditation program that AABB plans to launch in the near future, and that it hopes will significantly increase the number of hospitals that practice blood management.
“We’re trying to position ourselves as clinical partners to hospitals,” Nunes says, helping them to understand how they can safely reduce the number of transfusions performed and the amount of blood used.
Some of the most vocal advocates for widespread blood-management programs, Nunes says, are Jehovah’s Witnesses, who number roughly 8 million worldwide. A core part of their faith is the refusal of blood transfusions, based on the Biblical commandment to “abstain from blood,” which they interpret to include both ingesting blood (e.g. eating meat with blood in it) and receiving it intravenously. In the past few decades, he says, Jehovah’s Witnesses have developed extensive medical-outreach programs to raise awareness of surgical techniques that align with their religious beliefs.
Nunes says he has interacted with Witnesses extensively over the years through his work with AABB, inviting church representatives to address AABB members at workshops and seminars.
“As a group of patients,” Nunes says, “Jehovah’s Witnesses are very well informed … The way they have been able to organize and educate their community, and then to work with the medical community to make sure they know how to care for them, is really very impressive.”
The blood is “recycled” from their own bodies rather than transfused from someone else’s.
“It really is a model for how a patient population with unique needs can really get serious about helping medical professionals meet them,” he adds.
For example, intraoperative blood salvage—a medical procedure that involves recovering blood lost during surgery and reintroducing it into a patient’s body—has become the main alternative to transfusion for Jehovah’s Witnesses, because the blood is “recycled” from their own bodies rather than transfused from someone else’s. Another blood-management technique often used with Witness patients is hemodilution, in which blood is diverted away from the body into a closed system that remains in constant contact with the body, an extension of the patient’s own circulatory system. There, blood is infused with a saline solution or other fluid and reintroduced back into the patient, as a way to make up for lower blood volume without adding new blood. (Both of these practices are accepted by some Witnesses, but not all; refusal of a blood transfusion is an absolute, but beyond that, the church advises its members to make their own treatment decisions.)
To promote these techniques and help the medical field better understand how to care for them, Jehovah’s Witnesses maintain a network of Hospital Liaison Committees (HLC), regional groups of church elders who are trained as doctor-patient liaisons. Members of the HLC also provide patients with bedside comfort, much like a chaplain.
At the Jehovah’s Witnesses’ world headquarters in New York, a department called Hospital Information Services (HIS) oversees training for the roughly 1,800 HLCs worldwide, including around 140 in the U.S., and works on larger-scale outreach efforts to teach hospitals about caring for Jehovah’s Witness patients. HIS will also arrange doctor-to-doctor consults, pairing a less experienced doctor with one that is more familiar with Witness patient needs.
Zenon Bodnaruk, the associate director of clinical affairs at HIS, says the church established the HLC network as its formal medical-outreach program in the 1970s, a few decades after its ban on blood transfusions was introduced in 1945. (The church was founded in the 1870s.) In the years after the ban, Bodnaruk says, efforts to reach out to doctors were infrequent and disorganized. “Clinicians were saying, ‘Jehovah’s Witnesses are coming into our hospitals and then denying blood transfusions. What do they want from us?’ So we said, ‘Let’s approach the medical community and help them understand our needs.’”
“Clinicians were saying, ‘Jehovah’s Witnesses are coming in and then denying blood transfusions. What do they want from us?’”
Blood-management programs are a positive step, he says, but the ideal situation for Jehovah’s Witnesses would be a bloodless program. A step beyond blood management, bloodless medicine avoids the use of blood products altogether, even blood from the patients themselves. Pre-operation, a surgeon will go to great lengths to stabilize a patient and address any potential problems (managing anemia, and identifying any bleeding or clotting deficiencies). Blood testing is limited, because every drop counts, and other potential sources of blood loss, such as menstrual bleeding or gastric ulcers, are taken into account. During an operation, a bloodless surgeon will use a larger surgical team to decrease the length of the procedure, resulting in less blood loss. And after surgery, a patient will be monitored closely so that any postoperative bleeding can be quickly controlled and anemia can be avoided.
Bodnaruk says that hospitals may not take such rigorous steps to prevent blood loss before, during, and after surgery if they have transfusion as a safety net.
For that reason, Bodnaruk says, one of the main objectives of HIS is to direct medical professionals to case studies, including peer-reviewed articles in medical journals, that can help them understand how bloodless medicine has been used in the past, even in complicated procedures like brain or open-heart surgery. With the recent growth of patient blood management, the job has become somewhat easier.
Jan Wade is a Jehovah’s Witness who has been involved with his local HLC in Bellingham, Washington, for several years. Throughout the 1990s and early 2000s, Wade worked as an independent consultant to more than 300 hospitals around the country, helping them establish blood-management and bloodless programs.
“[I] would do an audit of the hospital’s blood use and find areas where they weren’t being efficient,” Wade says; he would then help hospitals develop systems to more carefully manage their blood supplies, including cost-effective ways to implement blood-management techniques.
“If we cannot demonstrate any benefit of a transfusion, all we’re offering patients is risk.”
Wade says the payoff can be significant for hospitals, as well as the patients they serve. According to the University of Pennsylvania’s Center for Bloodless Medicine and Surgery, blood-management programs help hospitals cut down on unnecessary blood draws and the amount they spend acquiring and storing blood. Blood management has also been linked to shorter patient recovery times and reduced risk of infection.
Some blood-management experts say that the practice may also help reduce the number of medically unnecessary transfusions. In a 2011 study in the journal Transfusion Medicine Reviews, researchers analyzed nearly 500 previously published case studies of “typical inpatient medical, surgical, or trauma scenarios” in which blood transfusions were used. Around 59 percent of those transfusions were “inappropriate,” the researchers determined, while around 12 percent of transfusions were deemed medically necessary (the authors were unsure about the remaining 29 percent).
“If we cannot demonstrate any benefit of [a] transfusion,” says Aryeh Shander, the study’s lead author and the executive medical director at the Institute for Patient Blood Management and Bloodless Medicine and Surgery in Englewood, New Jersey, “all we’re offering patients is risk.”
Five years ago, Shander, who also serves on the Advisory Committee on Blood and Tissue Safety and Availability, was asked to manage a $4.7 million federal grant from the Department of Defense to Englewood Hospital to train military healthcare professionals in bloodless medicine and surgery techniques. Blood management is a key part of medical care for soldiers as well as for Jehovah’s Witnesses, he explains: For injured combatants far away from a source of evacuation, a blood transfusion may not be an option.
In 2013, Englewood lost its grant when funding dried up. But Shander says that during his three years of funding, he and his colleagues were able to create “a very robust curriculum,” writing educational materials and organizing blood-management workshops for the Department of Defense. With the loss of DOD funding, Shander began offering the curriculum to civilian physicians’ and nurses’ groups as well. He and his colleagues also used the funds to create an online library of medical literature on patient blood management, which they continue to update.
Proponents of blood-management hope that work like Shander’s will help to push the practice into mainstream healthcare—and some, like Nunes, believe that the fast pace of today’s medical research means it will happen sooner rather than later.
“I think you’re going to see some very intense activity around patient blood management for quite a while,” he says. “And hopefully the precepts we are preaching today will simply become integrated into [medicine] and become the norm.”
[This story appeared in The Atlantic on June 8, 2015. You can read the story at its original source here: http://www.theatlantic.com/health/archive/2015/06/blood-management-bloodless-medicine-transfusions/395054/#disqus_thread]
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