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When non-medical people refer to their "blood count" they are usually referring to just their hemoglobin or hematocrit values. The hematocrit is the ratio of red blood cells to the total blood volume, and is given as a percentage of the whole blood volume. The hemoglobin is the oxygen-carrying molecule within the red blood cells. Its value is given in units of weight, namely, the number of grams of hemoglobin in a liquid measure of blood. In the US and Canada it is grams per deciliter (g/dL), but in Europe grams per liter (g/L) is the preferred scale.

• The normal hemoglobin values for a male range from 13 g/dL to 18 g/dL, with an average of 15 g/dL.
• The normal hemoglobin values for a female range from 12 g/dL to 16 g/dL, with an average of 14 g/dL.
• The normal hematocrit for a male ranges from 45% to 52%, with an average of 48%.
• The normal hematocrit for a female ranges from 37% to 48%, with an average of 42%.

In the past, a hemoglobin of 10 g/dL, or a hematocrit of 30% was considered the trigger for the transfusion of red blood cells to correct anemia prior to surgery. However, these days a more conservative approach is favored by many clinicians, and transfusion decisions are now more likely to be made after evaluating the patient's overall condition. Patients without cardiovascular disease, diabetes or other underlying problems have survived with hemoglobin values as low as 1.4 g/dL (See The Transfusion Trigger - Indications for Red Cell Therapy)

Next month we will examine the normal ranges for white blood cells and platelets, and what happens when abnormal numbers of these cells are present.

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Medicines Containing Blood Products

by Ms. Jan Grossberg, RN, BSN - NoBlood Editorial Team

Our Guide to Medicines Containing Blood Products is taking shape!

We now have quite a number of medications that can begin to be formatted into the draft of a Guide. Thanks to all who have responded to the call for data on medicines that contain any kind of blood product. Please keep them coming!

Here is a sample of some of the responses we received:

• markeldredge remarked about how many physicians appear to be unaware that EPO (Procrit&reg contains human albumin, and that it still is not available in an albumin-free formulation here in the U.S. Mark has also provided a list of other medications that contain some blood component or fraction, along with data sources. Thanks, Mark!
• shirleyltucker pointed out that some, in violation of their consciences, have agreed to accept EPO at the assurance of their doctor that it does not contain any blood fraction, when, in fact, the doctor simply did not know that it does. She mentioned that many health care professionals are also unaware that recombinant Factor VII contains albumin. How important it could be to patients and health care professionals alike to get our Guide out there in the hands of the medical community!
• It was very interesting to learn from ldpharmtec that Botox® is one of the medications that does, indeed, contain human albumin! I know of people who have had in injections to cervical nerves for migraine headache, but who most likely were unaware of this. The most commonly known use for Botox® is cosmetic "wrinkle abatement".
• Thanks to lori-carlson and Johnean Hansen, for providing links to pertinent information about this drug, including its lesser-known use in treatment of gastrointestinal conditions.
• Additional thanks to Johnean Hansen for making us aware of the information in Dailey’s Notes on Blood. I am certain that will prove valuable in compiling the information for the Guide.
• E. Crum, RN provided information on two products made with minor blood fractions: Proferrin Forte contains a substance derived from the red blood cells of cattle, and rabies vaccine is processed in a culture that contains albumin. Thanks, Liz, for supporting our Med Guide effort!

One important step, of course, as others have recognized in the past, is that each and every drug must be thoroughly researched to confirm what blood component it contains, and, if possible, what quantity. This involves obtaining accurate data regarding the specific ingredients and method of production, preferably from the product manufacturer or some other recognized authority such as a reputable lab. An authoritative source must be available for each entry in the Guide. The efforts of all who have already provided their input are most appreciated.

Our vision is to put a working draft together in the next several months, if possible, with a view toward perfecting a finished product for eventual publication in hard copy. Obviously, an online version is the most feasible and practical immediate goal. If any of our Registered Users would like to help in procuring data about the medications we already know of, I urge you to send me a private message and I will let you know how you can help. The more people who get involved, the faster we can get to an excellent and usable end product!

If you are interested in participating in the development of this feature, please contact me.

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Article Summary: Cost, quality, and risk: measuring and stopping the hidden costs of coronary artery bypass graft surgery.

Morgan TO. Am J Health Syst Pharm. 2005 Sep 15;62(18 Suppl 4):S2-5. Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19107, USA. timorg@pahosp.com

PURPOSE: Blood conservation programs have been successfully implemented in hospitals in which an overarching commitment to the reduction of the number of blood transfusions existed. This review will describe the rationale and some of the considerations involved in starting such a program.

SUMMARY: Management of a hospital's blood supply is a high pressure area dominated by a resource shortage, increasing costs, a medical community that has been trained to use transfusion, public awareness and concern, and to a lesser extent an increasing body of evidence suggesting that transfusions are often deleterious. The implementation of new techniques and protocols to conserve blood during surgery can be facilitated if a physician champion addresses the medical staff and the hospital administrators clear political and budgetary issues. With a team approach and an understanding of the clinical and economic evidence supporting less blood use, many of the hurdles can be overcome.

CONCLUSION: Blood conservation programs offer a solution to the multiple problems that surround blood use. When successfully implemented, such initiatives reduce safety concerns, hospital spending, and the dependency of hospitals on the national blood supply and improve clinical outcomes and patient satisfaction.

Full text of this item requires a subscription to American Journal of Health-System Pharmacy Online.

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Update on Tawnya Nissen Guardianship Litigation

by Ms. Jan Grossberg, RN, BSN - NoBlood Editorial Team

Last month Ms. Michelle Thomas reported on a Jehovah's Witness that was barred from making medical decisions for his comatose wife. We are very happy to report that she has awakened! She was in a coma for a month and has now directed that her husband, Chris Nissen, act as her health care agent for any future medical decisions on her behalf. She further banned any family members from ever making any health care decisions on her behalf. An Iowa court had previously ordered that her father be appointed as her health care agent during the time she was comatose, despite the fact that the legal precedent has generally been that health care decisions may be made by a spouse in the event that a person is unable to speak for him or herself.

The issue in this case turned upon the fact that Chris Nissen is one of Jehovah’s Witnesses. When Tawnya became unable to speak for herself, he asserted that his wife is also a practicing Witness whose wishes are that she not be given a blood transfusion under any circumstances. Unfortunately, Tawnya’s Advance Medical Directive card, which most Jehovah’s Witnesses carry, could not be located, and the court declined to assume that the husband’s assertions regarding his wife’s preferences actually reflected her true desires for her care. Tawnya’s father is not one of Jehovah’s Witnesses, and is critical of their Bible-based refusal to accept blood transfusions. He was able to obtain “limited guardianship” on the basis of his assertion that Tawnya’s life was being put at risk by her husband’s refusal to allow her to have a blood transfusion. The father claimed Tawnya had told him she would be willing to take a transfusion if it was necessary to save her life. Upon awakening, however, Tawnya confirmed that her husband had properly represented her wishes when he declined to allow her to be transfused (transfusion had been contemplated as potentially necessary to treat Tawnya’s condition, but it was never actually administered).

Two points emerge as significant in this guardianship conflict.

• First, had Tawnya carried a current Advance Medical Directive and Durable Power of Attorney card, had the information it contains been made part of her medical record, and had she informed her family of her stand at the time she first prepared this legally binding document, this litigation would most likely have never occurred.
• Second, it is of interest, especially in the shadow of the recent Terri Schiavo case, that guardianship of a married, adult woman no longer residing in her father’s household was so readily awarded by the Iowa judge to her father, rather than remaining with the husband. In Terry Schiavo’s case, her parents fought unsuccessfully for over nine years to get a Florida court to remove her husband as guardian (especially when he had already started a new family with another “spouse&rdquo. In the Schiavo case the husband automatically became the health care proxy for his wife, and the courts there were loth to disturb that legal relationship. The law in most states appears to provide that, when a person cannot make his or her own medical decisions and does not have a medical directive, “next of kin” assumes authority to speak for the incapacitated individual. Does the law so radically differ in Iowa, or is it only different in the case of Jehovah’s Witnesses and decisions regarding blood transfusions? Under what theory of law did the Iowa court justify depriving Tawnya’s husband of guardianship?

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Polyheme, Its Impact On You and Healthcare

by Ms. Jan Graziani, LPN/LVN - Swedish Covenant Hospital, Noblood Editorial Team

Due to the audio recording release of the presentation by Dr. Steven Gould to the stockholders of Northrup regarding  the PolyHeme® Trial III and due to the release of information that is very close at hand regarding the outcome of those trials, we will extend further our request for input to anyone who has information they would care to share until the next issue of NoBlood Bulletin. Many thanks to those you gave us articles and further insight regarding the PolyHeme® Trial III, and FDA consideration of this "artificial blood".

If you are interested participating in the development of this feature, please contact me.

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Question Regarding: HIV and Blood Fractions

MikeGarcia posted this interesting question Sep. 26, 2006:
"Does anybody know if HIV tainted blood loses the HIV in the fractionalization process, thus making the injection of blood fractions "safe""?

ybunch replied Sep. 27, 2006:
"Most fractions that come from the pharmacy are heat treated or washed with detergent. Therefore, HIV would not be a concern as truly outside the body, it is a weak virus. However, a few years back some of Factor VIII was removed from the market do to fear of Creutzfeldt-Jakob or mad cow disease. There was some reported cases of that transmission with Human Growth Hormones. Since we really don't know the mode of transmission, or what can destroy it, it remains a matter of concern. However, that is a concern with even the meat you eat. A good book to read is "Deadly Feasts". Biological fractions, such as Cryo [Cryoprecipitate], is different. They carry the same risk as any blood product. Hope this helps. yvette"

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Unanswered Questions, Can You Help?

by Larry Eitel, Executive Director

A hallmark of our community is the willingness to jump in to help others. Can you be of assistance with any of these:

Procrit to Aranesp posted Sep. 9, 2006 by kscalici
Does anyone have a guideline or "practice" of switching bloodless patients from EPO to DARBO inpatient at a certain point? We continue to use EPO for bloodless inpatients who are anemic depending on how anemic and how fast we need to get them up we may start out daily for a couple days, give three times a week or once a week.
We have a long term inpatient who should have been switched to DARBO because she is now chronically anemic. Thought we would try to develop a standard like - give EPO until Hgb on the upswing, signs and symptoms improve, after 1 week of EPO etc.
Anyone know what I'm looking for?

Zinc deficiency in anemia posted Sep. 6, 2006 by rvigiltmspcoord
I've recently been doing research on the role zinc plays in iron deficiency anemia and immune response. Does anyone have any experience in zinc supplementation in conjunction with iron? - Rebecca Vigil, RN

Fractions - Uniqueness posted Aug. 6, 2006 by Paul Chaplin
Just as an individuals blood is unique to them, do blood fractions (such as immunoglobulins) have any sort of marker that make them unique to the individual? Or are the proteins from which they are built essentially the same for everyone?

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Call for Submissions

by Ms. Jan Grossberg, RN, BSN - NoBlood Editorial Team

Although we are a public forum and not a physician or nurse-run website, many of our registered users here on NoBlood are credentialed health care professionals, perhaps with advanced degrees and research backgrounds, perhaps with many years of clinical experience overseeing bloodless medicine programs. Others simply are bright people with a passion for quality health care. The NoBlood community at large is made up of individuals who come here to seek and share current knowledge and important information about health care, especially when it involves the use of blood or blood products. Most are eager and willing to share their knowledge and experience with others. With these things in mind, we urge you to put all that expertise and passion to use on behalf of our community in an even more tangible way. We appeal to you to make your important contribution to the growing knowledge base that NoBlood offers to its users.

Submit an article for publication
We hereby invite you to prepare and submit articles for editorial review and publication on NoBlood, or to submit any previously written articles you would like to publish on NoBlood. These articles should be written in scholarly style, with appropriate references, discussing subjects or presenting research pertinent to bloodless health care, blood management, or other appropriate topics related to medical management of patients who prefer to limit or avoid exposure to blood or blood fractions. As you can see by the kinds of forums that exist on NoBlood, there is a broad spectrum of topics that might form the basis for your writing. The pros and cons of available treatments or medications might be one topic. The way in which certain blood management techniques are actually done might be another. We thank in advance those of you who readily respond to this call for submissions..

Articles should be submitted electronically as follows:

• as MS Word-compatible document
• include accurate citations for all works or websites referred to in the article
• all tables or graphics must be in JPEG or GIF file format
• include author’s full name, address, institution of affiliation, if any, and contact email
• send as attachment by email to editors@noblood.org

Submitted articles will be reviewed by the NoBlood Editorial Team, and authors will be notified of acceptance or suggestions for modification within two weeks of submission. (For help with correct style and citations, see The Ohio State University Libraries Citation Style Guides, or contact editors@noblood.org). Articles will be published on NoBlood in a separate publications section of the website. The exact date of publication will be determined by the NoBlood Editorial Team. The editors reserve the right to make changes in accepted manuscripts, for clarity and space considerations.

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Join the NoBlood Team

by Ms. Sharon Grant - NoBlood Editorial Team

In our last issue we encouraged those of our registered users who have interest in volunteering some of their ‘spare’ time to work with us to contact us. We are very happy to say that as a result, our NoBlood Team of volunteers is growing. Nonetheless, we continue to need helping hands to assist in a variety of activities. While the help of those with clinical expertise is essential to providing quality information, we also have a need for non-clinician expertise.

Thanks to the Internet and improving tools, it is now possible and very satisfying to participate from your home during times convenient to you. Through the use of tools such as Skype, web conferencing, email, and the good old fashion telephone, it is possible to participate in virtual teams on a variety of editorial and technical activities. Not only can you become more familiar with bloodless healthcare, you can learn how to use software tools that will enhance other aspects of your professional and personal lives.

At the moment, we have special needs in the following areas:

• Editorial Team: We are especially looking to further strengthen our Editorial Team. Do you have experience in writing, researching, editing, etc. clinical information?
• Web Development Team: Maintaining and improving a heavily used website involves many technical related activities. Do you have expertise in any aspects of web development?

If you can devote a small amount of your time per week, please email us and provide contact information along with a brief summary of your background and skills to ersonnel@noblood.org">personnel@noblood.org or call (858) 866-9311. Thank you!!

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Please Show Your Support!

by Larry Eitel, Executive Director

We gratefully thank those who have helped us become the number one resource on the web devoted to bloodless healthcare. This is directly attributable to the generous, hard work of volunteer members and the generosity of our supporters. Today, NoBlood receives approximately 20,000 visits each month from people who seek to educate themselves and to network with healthcare professionals advancing bloodless medicine and surgery.

Please show your support by doing your part to help cover our growing expenses. These include core staff services, professional accounting and legal services, computer hardware and software, high-speed internet connection services, and more. Donations are accepted through PayPal (which accepts credit card payments). See how. We also accept donations by check or money order. Please mail your donation to:

Because Bloodless Healthcare International, Inc., the publisher of NoBlood, is a registered 501(c)3 charitable organization, your donation is tax-deductible.

If you would like to discuss further how you can financially support the mission of NoBlood, please contact me.

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