NoBlood

Unique Aspects for a Bloodless Approach

Surviving a medical emergency is determined within the first hour of the crisis, the golden hour. During this precious time period all possible resources are pulled together for the preserving of life. While specialized skills are learned by emergency medical technicians, doctors, and other members of the emergency medical support team, a bloodless approach to this scenario requires some additional considerations that may be new to this team.

Stop the Bleeding!

In many instances of medical emergencies there are two basic approaches to the problem. Some prefer a conservative approach which allows the doctor to observe the patient and run an array of tests. From this, the most comprehensive picture of the clinical problem can be ascertained and a thorough plan put into action. This careful approach has much merit and in some instances may be the best process; however, this is not always the case when bleeding is a major concern.

The body has a finite amount of blood running through the veins at any given moment. The amount is approximately 67 cc's (ml's) per kilogram of body weight. This means that an average 70 kilogram man (154 pounds) has in his body 4,690 cc's of blood, or roughly 4.5 liters (about 1 gallon and 1 Qt) of blood. However, if a patient is loosing blood there is only so much time before the patient reaches a critical condition. At 25% of lost blood volume (about 1.2 quarts) the patient can be experiencing shock and organ perfusion problems. At 50% lost volume (about 2.5 quarts), the patient is at a high risk for serious morbidity or mortality.1 What can be done?

Initial Management

From the onset, volume management is a key factor in caring for the patient with acute blood loss anemia.1 Determining which resuscitation fluid is best depends upon the state of the patient. Some doctors opt for a crystalloid solution while others prefer colloid solutions. While neither is the absolute best, each has its advantages. In massive blood loss there may be problems with a decreasing blood albumin concentration, allowing for the watery part of the blood to leak into the lungs and other parts of the body due to deficient oncotic forces. Such leakage in a patient with severe clinical problems may make a difficult situation worse. This is where a colloid solution would serve best. For the most part, crystalloids are typically best for lesser blood volume replacement due to their ease of use and ready availability.

The next important step is to stop the bleeding. In an initial review of emergency management of patients who refuse blood products, such as Jehovah's Witnesses, there has been a marked improvement when a more aggressive approach to management is taken. In one report, the mortality rate was 75% for individuals in cases where management was conservative; however, when immediate surgery was performed within the first 24 hours and every effort was made to limit blood loss, the morality rate dropped to only 20%.2 Though this aggressive approach may be new to some, it has proven effective in avoiding the use of blood in emergencies and is easy to understand when one considers that there is only so much blood that can be lost before problems occur.

Return What is Lost

If severe hemorrhage occurs from an external site, the lost blood normally cannot be salvaged, as is typical with severe lacerations and compound fractures. There is another group of bleeding injuries that are internal in nature and although the blood is lost from the circulatory system, it is not necessarily out of the body.

Bleeding that occurs into the abdominal cavity such as from a ruptured spleen, or into the lung cavity, can many times be recirculated back into the patient. A technique known as red cell salvaging, most commonly used during surgery, can be used in such cases. [For some with religious objections this may be a concern.] The red cell salvaging device is able to suction up the blood that has bled out, wash and filter the blood, and then return the red blood cells back to the body. In essence, the patient is giving themselves their own transfusion.3, 4, 5, 6 This can also be accomplished in some cases of fractures of the femur and other areas where blood can pool.

Conclusion

Once the patient has been stabilized, with adequate fluid resuscitation and returning of any blood loss via red cell salvaging devices, the doctor can now make preparations for the next aspects of bloodless management for the acutely ill patient.

• Hillman RS, "Acute Blood Loss Anemia" Hematology, Fourth Edition,
  1990
  


• Spence RK, "Pancreaticoduodenectomy Without Homologous Blood Transfusion
  in an Anemic Jehovah's Witness" ARCH-SURG, 1992, March, Vol. 127,
  No. 3


• Timberlake GA, "Autotransfusion of Blood Contaminated by Enteric
  Contents: A Potentially Life-Saving Measure in the Massively Hemorrhaging
  Trauma Patient?" J-TRAUMA, 1988, June, Vol. 28, No. 6


• Giordano GF, "An Analysis of 9,918 Consecutive Perioperative Autotransfusions" SURG-GYNECOL-OBSTET,
  1993, February, Vol. 176, No. 2


• Grimes DA, "A Simplified Device for Intraoperative Autotransfusion" OBSTET-GYNECOL,
  1988, December, Vol. 72, No. 6


• Karczewski DM, "The Efficiency of an Autotransfusion System for Tumor
  Cell Removal From Blood Salvaged During Cancer Surgery" ANESTH-ANALG,
  1994, Vol. 78