Transfusion-free Surgery is a Treatment Plan for All Patients

AORN Journal, Nov, 1998 by Tricia Trovarelli, Barbara Kahn, Sharon Vernon

One of the founders of the bloodless medicine and surgery concept was Ronald Lapin, MD, at the Gold Coast Plaza Hospital in Norwalk, Calif. He developed techniques that would be used to treat Jehovah's Witnesses. It was very difficult for Jehovah's Witness patients to find physicians who were sympathetic to their special needs. Dr Lapin was an international speaker who was the subject of the book No Man's Blood.(5) Although he died in 1995, many centers that use Dr Lapin's techniques have formed throughout the United States and Europe.

Another surgeon who has been an advocate for bloodless surgery patients is Denton Cooley, MD. He performed the first bloodless open heart surgery in 1962 on a Jehovah's Witness patient. An article describing this surgery was published in 1964. Dr Cooley was a pioneer in performing intricate heart and vascular surgery without blood on adults and children. He concludes that "the risk of surgery in patients of the Jehovah's Witness group has not been substantially higher than for others."(6) Dr Cooley has performed 1,106 of these surgical procedures and writes

   In every instance my agreement or contract with the patient is maintained,
   that is, to use no blood. It has been validated by surgeons that good
   attitude is another factor with Jehovah's Witnesses. Jehovah's Witnesses do
   not have the fear of complications or even death that some patients have.
   The Witnesses have a deep and abiding faith in their belief and in their
   God.(7)

RED BLOOD CELL PRODUCTION AND ANEMIA

Red blood cells (RBCs) contain high concentrations of hemoglobin, which enables them to transport oxygen from the lungs to the body tissues. When the hemoglobin level is suboptimal, tissue hypoxia becomes a major concern in patients, especially during the postoperative period, when blood loss may exceed expected levels. Traditionally, patients who develop perioperative anemia are transfused with either allogenic or autologous blood to reverse the anemia by raising the concentration of available hemoglobin. Due to widespread concern over infectious disease, cost containment, and religious practices, however, it is imperative that patients have alternative options regarding blood transfusions when they undergo elective surgical procedures.

One unit of blood drawn from a donor contains 450 mL of blood with 60 mL to 70 mL of preservative-anticoagulant and can be stored safely for 21 to 44 days.(8) Packed RBCs also are used after surgery to increase the hemoglobin level without overloading the patient with fluid. Preoperative collection of autologous blood has been the preferred standard for elective surgery, including total joint replacement and spinal procedures. Although this appears to be a safe, effective way to correct surgical anemia, it is not always an option for all patients. A hemoglobin level of 110 g/L of blood is required for predonation in most blood collection centers.(9) Ten to 15% of patients referred for predonation have inadequate hemoglobin levels.(10) In one study, 15 of 45 female patients could not donate autologous units because of decreased iron stores and erythrocyte mass. (11)