Surgical techniques to use when transfusion drops out of the equation
By Robyn DeSantis Ringler, RN, Esq.
April 25, 2005
In October 1991 after a motor vehicle accident, Reason Farris, a 28-year-old man from Maine, lay in his car with a crushed pelvis. Drifting in and out of consciousness, Farris spoke of only one thing — blood. "No blood," he repeated to paramedics. "Don’t give me blood."
Farris said his refusal to have blood transfusions stemmed from his religious beliefs. Farris is a Jehovah’s Witness and explains that receiving blood or blood products would be, for him and other Jehovah’s Witnesses, a disobedient act against the laws of God and the Bible. This does not mean that Farris would refuse other medical treatment. In fact, he recalls lying injured in the car and fervently wanting to live. He hoped to receive every possible up-to-date medical treatment available, with the one exception of blood transfusions.
And he did. Farris reported that, at first, doctors and nurses at the Maine hospital seemed unable to accept his refusal of blood. Farris says they explained to him that patients are usually given transfusions when their hemoglobin drops below 8, and that Farris’s was 1.8. They tried everything to convince Farris and his wife to relent and accept transfusions. "If you don’t take it," they said, "you will die."
By Farris’s accounts, health care professionals then talked about forcing blood on him, but found they could take no legal action because he was not a minor. They talked of sending him to a Massachusetts "bloodless" medicine program, but he was too unstable. Farris remained in the Maine hospital for two months, where he received iron and volume expanders. Two surgeries over the next two years resulted in one leg being one-and-a-half inches shorter than the other. Still, he survived without transfusions.
Risks of transfusions
Although Farris refused blood for religious reasons, more and more people are refusing blood simply because of the risks inherent in transfusions. These risks became prominent in the public’s mind in 1983, when the potential transmission of HIV by transfusion became widely known.
Sherri Ozawa, RN, is the director of the New Jersey Institute for the Advancement of Bloodless Medicine and Surgery at Englewood Hospital and Medical Center, Englewood, N.J. Although she stresses that U.S. blood supplies are safer than ever due to the diligence of the American Red Cross and blood banks across the nation, she readily concedes that no one wants blood because there is always a risk.
"You can’t ever be sure with blood," Ozawa says. She lists some potential risks —
The American Red Cross uses donor screening and laboratory testing of donated blood to ensure that patients receive the safest blood products possible. A medical history is taken from each donor with the goal of excluding donors who may have bacterial, viral, or parasitic infections. Donors are asked questions about their sexual activities, injection drug use, prior HIV testing, sexually transmitted diseases, and exposure to or history of hepatitis, malaria, CJD, babesiosis, and Chagas disease.
- Transmission of infectious diseases, including HIV, viral hepatitis, malaria, Chagas disease, babesiosis, and Creutzfeldt-Jakob disease (CJD)
- mmune complications, such as rash and fever
- Problems caused by medication taken by the donor
- Problems caused by human error
Although for many years, much of the U.S. blood supply came from overseas, this has changed with the concerns about Mad Cow disease. Now, anyone who has traveled to Europe within the previous six months cannot donate in the U.S., and most of the blood supply is domestic.
Problems in the system
Although there are many threats to the blood supply, such as infection and disease, Ozawa believes the biggest threat is the supply itself. The pool of people who need blood is rising, particularly in the elderly, while the number of donors is shrinking. Every day, in some part of the country, there is a plea for blood, and Ozawa worries that someday there will not be enough to give to the patients who really need it. That is why she finds it troubling that there are no consistent guidelines on when blood should be given.
Blood transfusions are used according to different standards throughout the world, according to Ozawa. Generally, whether a patient is transfused simply depends on the habits of the doctor and institution. Ozawa says many transfuse based on a transfusion trigger. Some still go by what she calls "the old rule" that patients should be transfused if their hemoglobin drops below 10g/dL and hematocrit drops below 30%.
Ozawa believes this type of practice should stop. "This is contrary to everything in medicine and nursing. We go on evidence with everything else, but with blood, it’s completely arbitrary. Instead, we need to look at the patient. Blood should be given based on a constellation of factors [hemodynamic instability uncorrectable by volume replacement, heart rate and other vital signs, and blood count] and only after other treatment has not worked."
Alternatives to blood
Techniques designed to conserve blood and to be used as alternatives to blood are widely used at the N.J. Institute for the Advancement of Bloodless Medicine and Surgery at Englewood Hospital, particularly in the OR, Ozawa says. These include —
A decade of success
- Intraoperative Cell Salvage: A "cell-saver" machine recovers blood lost from the operative area, spins, washes, and filters it, and returns the patient’s own red blood cells back to his or her body.
- Normovolemic Hemodilution: Before surgery, the patient’s blood is "thinned" by draining blood out through a closed system and replacing it with fluid. When the patient loses blood during surgery, it is "thinned" blood. Fewer blood cells are lost. At the same time, the anesthesiologist returns the patient’s own whole blood through a closed system in constant contact with the patient’s own circulatory system.
- Postoperative Blood Salvage and Reinfusion: This allows the patient’s blood to be collected postoperatively and returned to the patient. Blood flows from the operative site into a device that filters the blood, which is then returned to the patient through an intravenous line.
The bloodless program at Englewood was started in 1994, initially to serve Jehovah’s Witnesses. Ozawa was asked to be the director because she is both a critical care nurse and a Jehovah’s Witness, with firsthand knowledge of the medical and religious issues many patients would face. She stresses that it is not a religious program, and this became particularly apparent when, after a short time, health care professionals at Englewood came to believe the Witnesses they thought were getting substandard care were actually getting a higher standard of care, according to Ozawa. Their health status was being bolstered before surgery and the alternatives to blood transfusions worked well, allowing them to thrive while avoiding the risks of blood transfusions. For that reason, the bloodless approach was adopted throughout the hospital.
Not every institution, however, is interested in adopting a bloodless program. Ozawa admits that many health care professionals are philosophically uncomfortable with caring for people who won’t accept blood. Cost is also an issue.
Edna Cadmus, RN, PhD, CNAA, senior vice president for patient care services, believes that the transition from a traditional to a bloodless approach was successful at Englewood because everyone was committed to having one standard of care across the institution. To accomplish this, nurses, physicians, and staff from every clinical department had to be trained in new techniques.
Staff nurses were educated to —
Robyn DeSantis Ringler, RN, Esq., is a frequent contributor to Nursing Spectrum.
- Use more IV iron in conjunction with erythropoietin to ensure adequate iron supplies when stimulating blood cell production
- Identify which patients would absolutely refuse blood transfusions
- Educate patients about risks, benefits, and alternatives to blood
- Question orders for routine blood work, when it might not be necessary (to avoid iatrogenic blood loss)
- Know the science of blood and bloodless medicine