Updated: December 22, 2003

	One technique used in blood management is to take microsamples (drawing smaller amounts of blood) for testing.

When Nadia F. learned of the treatment options for her cantaloupe-sized fibroid tumor, she did her homework and decided on surgery. She aced her next assignment–to locate an experienced gynecologist who would respect her wishes for a “bloodless” procedure–by finding Dr. Winsome Parchment, an obstetrician/gynecologist at University Hospital and an assistant professor of obstetrics and gynecology at New Jersey Medical School.

“I chose Dr. Parchment not only because of her commitment to bloodless surgery,” says Ms. F., a Jehovah’s Witness, “but because she was affiliated with a teaching hospital and had performed the procedure many times. I was more concerned about what type of incision she would use than the blood issue–that’s how comfortable I was. I knew my beliefs regarding blood would be respected.”

As it turns out, Ms. F. lost more blood in pre-procedure testing than during the surgery itself. By using meticulous surgical techniques, Dr. Parchment didn’t even need the epinephrine-based drug to constrict blood vessels or the cell-saver technology that were available. Ms. F. left the operating room minus the fibroid and with her desired “bikini” incision. Dr. Parchment left the operating room knowing she had respected her patient’s wishes, but what’s more, practiced good medicine.

A year and a half later, Ms. F. is pleased to report she has no scar and was back to work as a designer/decorator in a month. She recommends Dr. Parchment to all her friends.

Bloodless Medicine is Good Medicine

It’s common knowledge that Jehovah’s Witnesses do not accept blood transfusions on religious grounds. It’s also recognized that some people don’t want transfusions because, despite more rigorous screening of donated blood, they are concerned about the transmission of HIV or hepatitis B or C. What might not be known is that there’s been a mammoth change in thinking by the medical community about blood transfusions that’s science based, with more than 500 articles as proof.

“There’s an avalanche of data that supports bloodless medicine,” says Dr. Edwin A. Deitch, medical director of the University Center for Bloodless Surgery and Medicine and chairman of the Department of Surgery at New Jersey Medical School. “We now know that receiving donated blood can suppress the immune system, and that the risks of transfusions can be greater than that of anemia. Because of these developments, University Hospital has a institution-wide commitment to bloodless medicine and surgery that permeates every department. We study bloodless procedures scientifically and practice them clinically.” Doctors in more than 30 specialties are committed to bloodless care at University Hospital.

Doctors have fewer reasons today to transfuse blood than in the past. There’s new thinking about how to treat anemia, a lower-than-normal red blood count that can make a person feel tired, dizzy, or weak. According to the National Center for Health Statistics, about 3.4 million Americans are considered anemic, most of them women. A complete blood count, by which a person’s hemoglobin level can be measured, is one tool used to diagnose anemia. Hemoglobin is the part of a red blood cell that carries oxygen; the normal range of hemoglobin in men is 13-18 grams per 100 milliliters and in women, 12-16 grams per 100 milliliters. Previously, when an anemic person’s hemoglobin level fell to 10, a blood transfusion was ordered. Today, it’s widely accepted that people can function well with lower amounts of red blood cells, and it’s not until a level of  7 that a transfusion is even considered.

The Bloodless Concept

The term “bloodless” can be a stumbling block. After all, people need blood to live. What the term refers to, in essence, is a strategy that embraces conservation and replacement measures. Reduce the amount of blood loss to begin with, and the chance it will need replacement becomes more remote. Stimulate the production of red blood cells before surgery, and anemia becomes less of a possibility afterward. Salvage, clean and return a person’s “lost” blood during an operation, and it’s unlikely the patient will need anyone else’s.

“If a patient donates her own blood before surgery and then afterward gets it back, is that bloodless or bloodfull? Obviously, it’s bloodfull,” says Dr. Robert Heary, a neurosurgeon, director of The Spine Center at University Hospital, and an associate professor of surgery at New Jersey Medical School. “As a general rule, surgeons have always been taught to keep bleeding to a minimum. What’s changed is the recognition that it’s in the patient’s best interest not to transfuse blood.”

“Bloodless” can also mean different things to different people. “Some patients won’t accept blood transfusions or products under any circumstances. Others will say, ‘I’d rather not have a transfusion, but if it’s absolutely necessary, then OK,’” says Michelle Thomas, BSN, RNC, coordinator of University Hospital’s bloodless program, which enrolls about 500 patients each year. “We have a protocol in place throughout the hospital that ensures a patient’s wishes are followed. And our doctors not only respect the beliefs of a bloodless patient, they back it up with skill.”

One way a patient can make her bloodless preferences known, says Ms. Thomas, is through an advance directive. In the event a patient can’t communicate with a doctor, this document can state her medical wishes on a variety of issues, from life support to blood transfusions.

Putting The Tools to Work

A "cell-saver" technology collects blood as it is lost during surgery, cleanses it, and places it back in the patient's body, all in a continuous loop.

Bloodless medicine can be practiced in many ways, some of which aren’t even noticeable to the patient. When bloodwork is taken, for example, the phlebotomist can use smaller tubes; with some blood tests, smaller amounts of blood are needed than before. A “bloodless” oncology patient might be started on red blood cell-boosting drugs sooner in treatment than other oncology patients, says Ms. Thomas.

When a surgery is planned, there are many bloodless approaches that can be used. There can be measures taken to bolster the patient’s red blood count ahead of time--the use of iron supplements and erythropoieten, a medicine that stimulates production of red blood cells, for example.

The anesthesiologist also has a pivotal role in bloodless care, with such options as hypotensive anesthesia, which lowers the patient’s blood pressure and results in reduced blood loss. The surgeon can use surgical lasers and argon beam coagulators, practice careful cutting techniques, and clamp blood vessels to minimize bleeding. When there is excess bleeding, “cell saver” technology can collect the blood, cleanse it, and place it back in the patient’s body.

Laparoscopic, or minimally invasive, surgeries significantly reduce the amount of bleeding. Instead of a large incision, several small openings are made so that special instruments can be placed within the patient’s body.

“There’s very little blood lost in most routine decompressive spine surgeries when minimally invasive techniques are used,” notes Dr. Heary. "But for ‘open’ reconstructive procedures, I recommend that patients donate their own blood if their beliefs allow them to do so. If not, we then would use hemodilution more aggressively." Hemodilution is a technique where one or more units of blood are taken from a patient immediately before surgery and replaced with IV fluids to compensate for the missing blood. The patient’s blood is diluted, so fewer red blood cells are lost. The blood that was drawn is slowly returned to the patient through a continuous circuit.

As an ob/gyn, Dr. Parchment says it’s important for her to know early on if her patients have bloodless preferences. “I need to be aware what products they will and won’t accept, and especially in the case of pregnant women, maximize hemoglobin levels,” she says. “Because miscarriage can occur at any time in a pregnancy, the bloodless patient needs to seek medical help at any sign of bleeding.”

If a woman is hemorrhaging after the birth of her baby, there are several ways to stop the bleeding, Dr. Parchment says–repair of lacerations within the uterus or vagina, vigorous uterine massage, medications that cause the uterus to contract and thus press down on bleeding vessels, and arterial embolization, where through interventional radiology, a catheter is placed and small particles are delivered to stop the bleeding in a vessel.

Bloodless in the E.R.

Planning ahead is a key element of bloodless medicine and surgery. But what happens during an emergency? Dr. David Livingston, chief of trauma at University Hospital and professor of surgery at New Jersey Medical School, says the trauma team focuses on minimizing blood loss in all situations. “One way to do that in select patients without resorting to a traditional operation is by the use of angiography and arterial embolization,” explains Dr. Livingston. "This is especially useful for patients with liver and spleen injuries or pelvic fractures. In patients that will accept blood, we can minimize the need to give donated blood by collecting  the patient's own blood that’s been lost and autotransfuse it back into the patient’s body.”

When the trauma doctors and nurses know that a patient does not want to receive a transfusion, those wishes are respected. But in an emergency situation, the patient is often unable to speak for himself. “On a rare instance, we have started a transfusion, but a family member arrived and told us that the patient did not want blood, so we stopped,” says Dr. Livingston. “When a patient is identified as bloodless, the system is in place and works well.  People should understand that following an accident, your wallet or purse indicating your wishes may not arrive in the Emergency Department with you.” A person’s bloodless status, he adds, can be noted on an emergency medical bracelet.

While many of the bloodless techniques used for planned procedures are used in the trauma center, one notable exception is the drug used to stimulate production of red blood cells. “Procrit doesn’t seem to work well in trauma applications, and that’s an area we are researching with support of a National Institutes of Health grant,” says the trauma surgeon.

Commitment to Bloodless

Today, University Hospital is one of the few hospitals in the country to have a bloodless medicine and surgery program. In time, says Dr. Deitch, that will change. “Bloodless procedures and techniques are being taught in medical schools today,” he says. “In the next 10 to 20 years, I see bloodless practices becoming the norm, rather than a rarity.”

“And while the equipment and technology make bloodless medicine and surgery possible, I truly believe that they are secondary to the mindset of why we have them: to practice the best medicine we can.”

For more information on the Center for Bloodless Surgery & Medicine at University Hospital, call 1-888-BLD-LESS (1-888-253-5377) or visit our web site at:

http://www.theuniversityhospital.com/bloodless