Jehovah's Witnesses // A fear, in the 1980s, of HIV transmission // The idea that bloodless surgery might lessen costs and improve care
Do We Need So Much?
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Bloodless surgery is something of a misnomer. There’s bound to be bleeding, even when an operation is performed using minimally invasive techniques that require only small incisions. What bloodless surgery strives for, however, is to limit any transfusion of banked or donated blood. When patients, usually for religious reasons, can’t accept someone else’s blood, a series of other measures may be put in place. Well ahead of time, blood tests for anemia can determine whether a patient needs to receive intravenous iron to increase the number of red blood cells. Before surgery, physicians often order a unit of whole blood removed from a patient and replace it with saline intravenously to restore the volume of circulating blood, then the unit is reinfused post-surgery. Clotting medications can be given, and the surgical team may use a cell saver, a machine that suctions, purifies and recycles blood lost during surgery. And post-surgical blood drawing is minimized.
For Mark Sanchez, a 61-year-old Jehovah’s Witness in New York City, the willingness of New Jersey’s Englewood Hospital and Medical Center to take such measures made him choose that hospital over more famous institutions in Manhattan. He signed documents confirming that because of his religious beliefs, he’d rather die than undergo a transfusion. The four-hour operation, for an obstructed bowel, went well, and Sanchez was home five days after surgery. Within a couple of weeks, he was back at work. “Everyone was surprised how quickly I recovered, and I basically haven’t had any problems,” says Sanchez, a clinical social worker.
Most people are willing to accept blood transfusions, which save the lives of as many as 4.5 million Americans each year. They are crucial in some operations or after accidents or other trauma. Yet while the risk of receiving contaminated blood—a real danger during the early days of the AIDS epidemic—is very low today, there are other concerns about the safety, cost and effectiveness of routine transfusions, and some people believe bloodless medicine strategies should become mainstream. Blood “management”—using blood carefully but appropriately, with the goal of minimizing transfusions—is good practice for all patients, says Harvey G. Klein, chief of the National Institutes of Health’s Department of Transfusion Medicine.
Large-scale studies suggest that blood is given too often, and last year, the American Medical Association and the Joint Commission identified transfusion as one of the five most overused medical treatments. A growing body of research links transfusions to serious potential complications, including immune system suppression, inflammation, renal and pulmonary injury, and even death. Studies show that transfused patients also have longer hospital stays and more time in intensive care units. Moreover, with donated blood increasingly expensive and sometimes in short supply, hospitals have economic motivations for restricting transfusions. “Blood management seems to be coming of age,” says Lawrence Goodnough, director of transfusion services at Stanford University Medical Center. “But I think a lot of the momentum may be due to hospitals’ budgetary concerns.”
The Stanford hospitals launched a formal blood management program in July 2010, and there are now an estimated 200 blood management initiatives, with more in development at an estimated 100 hospitals. “Some, like ours, are comprehensive, while others may use just one or two strategies, such as cell salvage techniques or presurgical anemia management,” says Patricia Ford, medical director of the Center for Bloodless Medicine and Surgery at Pennsylvania Hospital in Philadelphia. It’s one of about 100 centers recognized by the community of Jehovah’s Witnesses as specialists in bloodless surgery.
Advocates argue that blood management offers a rare opportunity to improve outcomes, reduce risks and minimize costs all at the same time. Yet while some hospitals have been voluntarily implementing transfusion guidelines based on recommendations from medical societies or other authorities, many more have held back. “Most hospitals don’t have the time, the money, the expertise or the tools to put comprehensive programs in place,” says Tim Hannon, a physician and founder of Strategic Healthcare Group, a blood management consulting firm based in Indianapolis that has worked with more than 100 hospitals.