Trends: Bloodless surgery on the rise at nation's hospitals, reduces cost and infection
To augment small-scale tactics for combating the blood shortage, hospital administrators have turned their attention to more far-reaching strategies, such as bloodless surgery programs and blood substitutes.
Blood conservation offers sustainable alternative to transfusions
Hospitals that utilize conservation programs can reduce and sometimes eliminate reliance on preoperative donation and donor transfusions. Many blood-conservation programs focus on a combination of four modalities: erythropoietin therapy, acute normovolemic hemodilution (ANH), intraoperative blood salvage, and platelet sequestration.
The most accepted technique—cell salvage—processes and reinfuses blood shed during surgery. The suctioned blood is treated with anticoagulants, drawn into a disposable reservoir, and stripped of contaminants in a cell-salvage machine. Studies have long found that cell-salvage techniques significantly reduce the need for donated blood during cardiac procedures (Schmidt et al., Annals of Thoracic Surgery, April 1996).
Research performed by the Advisory Board's Clinical Advisory Board division indicates that conservation programs can yield impressive cost reductions, due in part to the low cost of subsequent salvage units. While each pint of donated blood must be purchased, crossmatched with the patient, and then transfused—accruing operating costs on a unit by unit basis—cell salvage expenses are spread over each unit recycled. Thus, the second unit of salvaged blood costs a hospital $30 or less, compared with $270 for a second unit of donated blood—resulting in net savings of $570 by the third salvaged unit.
Artificial blood: A progressively more viable option
See Graphic on Blood Substitutes -
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Artificial-blood advocates say many products are within two years of reaching the market, but some medical professionals are still skeptical (Cimons, Los Angeles Times, 6/18/01; Rackl, Chicago Daily Herald, 7/23/01). The four products furthest along in development are summarized in the graphic below.
Supplies of these products could significantly ease shortages, Dr. Linda Chambers, senior medical officer at the Red Cross, told the Los Angeles Times. If blood substitutes receive approval, low-volume, nontrauma hospitals could replace donated blood reserves with artificial substitutes. Such procedural changes would free up large quantities of blood for high-volume trauma centers in greatest need.
Striking a balance between advantages and drawbacks
Though many researchers tout the advantages of blood conservation and artificial blood, physicians and blood-bank administrators emphasize that the products and procedures are still in need of fine tuning.
In conservation, many ANH trials have been criticized for flawed study design, and the few completed randomized trials have found no differences in the need for donor transfusions between predonation and ANH groups (Bryson et al., Anesthesia and Analgesia, January 1998; Goodnough et al., NEJM, 2/18/99). In addition, the traumatic nature of cell salvage has led many companies to search, with some difficulty, for washing methods that will leave more red-blood cells intact and conserve platelets.
While artificial blood has an extended shelf life, the potential to be used in patients of any blood type, and a low risk of harboring disease, it does not contain platelets and plasma, and loses its oxygen-carrying capacity in a day or two, compared to months for transfused red-blood cells. Safety also is a concern, particularly since Baxter Healthcare found an unexpectedly high number of deaths—24 out of 52 participants—in a 1998 blood-substitute trial. Furthermore, high costs may deter widespread use: Current prices range from $300 to $1,000 per unit, compared to $150 to $200 per donated unit (Chicago Daily Herald, 7/23/01).
As the current blood shortage persists, options for managing the crisis exist, ranging from small procedural changes to large-scale strategies. While some tactics are still experimental, such as the use of blood substitutes, others are more tried and true, such as cell-salvage programs.
“Bloodless surgery allows a patient to recover a lot faster because of not having a foreign body added to their system to suppress the immune system,” says Melvin Satterfield, program administrator of Atlanta Medical Center’s bloodless surgery program. According to the Atlanta Business Chronicle, physicians use laser and harmonic scalpels, argon beam coagulators and drugs that help minimize blood loss to avoid use of transfusions of banked blood during a procedure.
The technique can be used on a range of procedures, from CABG to hip replacements or cancer removals. And although some hospitals like Atlanta Medical Center perform most of their bloodless surgeries for patients who will not accept donor blood for religious reasons, more advanced bloodless medicine programs in other cities like Houston, Chicago and Los Angeles often have a 50-50 mix of religious and non-religious patients (Glier, 2/8).
Evidence of cost-savings
Apart from the benefit of conserving blood and reducing the risk of complication for patients, bloodless surgery has proved to provide financial benefits for hospitals, patients and insurance companies alike. Clinical Advisory Board research indicates that conservation programs such as bloodless surgery can result in substantial cost reductions (Surgical Blood Conservation). The cost of bloodless medicine compared with regular surgery can be the same or “significantly lower,” says one expert, although the actual cost depends on the procedure. According to the Atlanta Business Chronicle, fewer complications means shorter hospital stays and fewer medications, potentially translating into savings of thousands of dollars per day. In addition, administrative costs go down as the hospital is able to cut back on cost of storage and cross-matching of the blood. Moreover, bloodless surgery does not require serious retraining of physicians or additional schooling. It’s really a “no-brainer” says one physician (Glier, 2/8).
Source: The Health Care Advisory Board, Daily Briefings, February 8, 2002.
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