When Blood Transfusion Translates To An Early Death

Kat Piper

Mounting evidence that routinely giving blood transfusions to patients could actually increase their risk of death or other complications has prompted calls for medical staff to be more cautious about who they administer transfusions to.

Jehovah's Witnesses refuse blood transfusions based on a passage from the Bible, which forbids them to "eat blood," but many still successfully undergo operations including open-heart surgery. This, say some surgeons and anaesthetists, should be the way most operations are performed.

Higher death rates
The danger is not from infections such as HIV but from something to do with the blood itself. Many studies over the past ten years have shown that transfusions, particularly of those involving red blood cells, are linked to higher death rates in patients who have had a heart attack, heart surgery, or who are in critical care.

Although the exact nature of the link is not yet known, it seems likely that chemical changes in ageing blood, their impact on the immune system, and the blood's ability to deliver oxygen are key. "Probably 40 to 60 percent of blood transfusions are not good for the patients," said Bruce Spiess, a cardiac anaesthesiologist at Virginia Commonwealth University in Richmond, to New Scientist.

Transfusions first became part of medical procedure during World War One when they were used as a last resort to treat soldiers who had lost a lot of blood. Its usage is now no longer confined to cases of catastrophic bleeding, but is often employed as a routine treatment for patients undergoing surgery or intensive care.

Background
The rationale behind giving transfusions is that by giving patients red blood cells, oxygen is better transported around the body thereby increasing the chances of survival. A healthy person has 120 to 170 grams per liter of haemoglobin—the oxygen-carrying protein in red cells—in their blood, usually with 35 to 50 percent of their blood volume being composed of red cells. Doctors commonly decide to give patients a transfusion if the haemoglobin levels fall to between 70 and 100 grams per litre.

Less effective blood
A 1999 Canadian study of 838 critical care patients found that significantly fewer patients (22 versus 28 percent) died in hospital when treatment with transfusion was limited to patients with haemoglobin levels of less than 70 grams per litre. In 2004, a study published in the Journal of the American Medical Association showed that heart attack patients with red blood cell levels of over 25 percent were three times more likely to die or have another heart attack within 30 days of having a transfusion.

A U.K. study of almost 9,000 heart surgery patients between 1996 and 2003 supports this finding, and indicates a six-fold increase in the risk of death after 30 days with a three-fold increase in the risk within one year following surgery. Transfusions were also associated with more infections and higher incidences of stroke, heart attack, and kidney failure. These complications were usually linked to a lack of oxygen to body tissues.

Little benefit
"There is virtually no high-quality study in surgery, or in intensive or acute care—outside of when you are bleeding to death—that shows that blood transfusion is beneficial and many that show it is bad for you," said Gavin Murphy, a cardiac surgeon at the Bristol Heart Institute and leader of the U.K. study.

Recommendations ignored
Many experts are now worried that guidelines are being ignored. They suggest that transfusions should only be given as a last resort and that preventing blood loss in the first place whilst ensuring patients are not anaemic before they undergo surgery should be prioritised.

"Usually when there is any clinical uncertainty about a treatment you don't give it, but with transfusions we do," said James Isbister of the Royal North Shore Hospital in Sydney, Australia, who is an adviser to the Australian Red Cross Blood Service. But Mr. Isbister still encourages people to donate blood as it is used to treat other conditions as well as extreme blood loss.

The specific reasons why blood transfusions appear to be harmful to some patients are not yet fully understood and further research is being strongly encouraged by health authorities, including the U.S. National Institutes of Health.

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Bloodless Surgery Tops Agenda Among Non-Jehovah's Witnesses

JOSIE HUANG

Over the last five years, surgeons have replaced Iris Carr's knees, repaired a hip, removed a gall bladder. They have opened her chest to slice away a tumor from her heart.

Not one of those times was she given any blood.

A Jehovah's Witness, Carr is forbidden from getting blood transfusions. So she built up her blood level ahead of time by taking bioengineered drugs and intravenous iron supplements. During open-heart surgery, when blood loss is particularly heavy, Carr's doctors at Maine Medical Center in Portland suctioned off blood that had pooled around the incisions so it could be washed in a machine and returned to her body.

Carr returned home to Cape Elizabeth slightly anemic, but within a couple weeks her blood count was back to normal. And she did not develop any of the infections that can result from receiving someone else's blood: "I'm glad I went through with it," Carr, 89, said.

Bloodless medicine used to be geared toward people with concerns about transfusions. But studies showing that skipping transfusions results in faster recoveries -- and therefore lower hospital costs -- has more medical leaders saying the practice should be for everybody. Maine's largest hospitals are the latest to join a movement among medical facilities to turn no-transfusion medicine from an offering by some of its doctors into a standard of care.

Eastern Maine Medical Center in Bangor started a blood management program with a medical director more than a year ago, while Maine Med this year hired a medical director to lead theirs. A committee of doctors from different departments at Central Maine Medical Center in Lewiston has been meeting on the issue since last spring.

All three hospitals have spent the last several years on reducing transfusions in cardiac surgery, which historically has higher rates of transfusion. Today, both EMMC and Maine Med transfuse roughly a quarter of their patients. CMMC did not provide figures.

"Patients always ask, 'What are the chances of me getting a blood transfusion?'" said Dr. Robert Kramer, a cardiac surgeon who works on quality improvement projects at Maine Med. "We used to say 50/50. Now it's less, and we're hoping to get it even lower and lower."

There still is a need for transfusion in certain situations: the victim of a car crash, or a woman who keeps bleeding after giving birth, may have lost so much blood that a transfusion is the only option.

But even in emergencies, blood conservation techniques can be used so that transfusions can be kept to a minimum, according to the Society for the Advancement of Blood Management, which represents more than 120 blood management programs around the country.

Not only is bloodless medicine safer, it removes the need to buy blood, an increasingly expensive commodity, the group said.

Ten years ago, a unit of blood cost $75 but now it is about $300, said Dr. Jonathan Waters, society president and Chief of Anesthesia Services at Magee-Womens Hospital of the University of Pittsburgh Medical Center. "Those costs have gone through the roof," Waters said. Most of the cost is coming from rigorous testing to make sure blood doesn't contain pathogens and viruses such as HIV or hepatitis. As a result the blood supply is the safest it has ever been, Waters said.

COMPLICATIONS STILL OCCUR

But blood recipients still risk developing transfusion-related problems such as renal or respiratory failure or an infection because the donor's blood is suppressing the patient's immune system. There is also the chance the patient will receive the wrong blood type and develop a bad reaction. For much of the last half-century, the medical community saw the benefits of transfusions as outweighing the risks. The value of donated blood gained wide recognition during the world wars, when advancements in blood storage and distribution helped to save soldiers on the front lines.

After World War II, American Red Cross blood centers and independent blood banks began to crop up across the country.

Interest in finding alternatives to transfusions began to surface with the rise of AIDS during the 1980s. There was also a growth in the number of Jehovah's Witnesses, who believe the Bible prohibits transfusions. An oft-cited verse comes from Genesis: "Only flesh with its soul -- its blood -- you must not eat."

Doctors, on an individual basis, have offered bloodless medicine for decades. In Maine, there are 90 of these doctors, up from just one in the 1970s, according to the Jehovah's Witnesses.

It took longer for hospitals to recognize transfusion-free medicine. The first hospital programs debuted in the 1990s, and began to use multiple blood conservation methods on a large scale.

In the weeks leading up to surgery, a patient could take synthetic erythropoietin or EPO, which stimulates production of red blood cells in the bone marrow.

On the day of the surgery, doctors could remove blood from the patient -- so fewer red blood cells will be shed -- to be returned to the body later. To make up for the lost volume, patient are injected with donated plasma -- the yellowish liquid that blood cells float in -- and saline solution.

OTHER STRATEGIES

Another strategy is to use a "cell-salvage" machine that collects blood pooling during the surgery and filters out the impurities for reinfusion into the body. After the surgery, doctors would make sure to draw smaller amounts of blood for testing than was taken in the past.

At Englewood Hospital, which has one of the oldest and busiest bloodless medicine programs in the country, the transfusion rate among patients receiving coronary artery bypass grafting -- one of the most common surgeries -- is down to 8 percent, said the program's medical director Dr. Aryeh Shander.

Maine hospitals are hoping for similar outcomes by formalizing blood management programs. Dr. Irwin Gross, who runs the EMMC program, said his challenge is to work with a medical establishment -- including doctors, nurses and technicians -- who have been hard-wired to see transfusions only as a life-saving tool.

"There's a lot of work to do in terms of education, changing physician practices and changing hospitals systems so the care is uniform," Gross said. The American Red Cross said the rise of bloodless medicine has taken some of the pressure off the donor blood supply.

"If somebody uses a blood conservation method -- and not a unit of blood -- that makes the unit available to another patient who may need it," said Dr. Patricia Pisciotto, chief medical officer of the Northeast Division of the Red Cross.

But Pisciotto added that bloodless medicine is not commonplace enough to reduce the need for volunteer donors. The Red Cross in Maine said it typically has only several days' worth of blood at any given time.

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Bloodless Surgery: Safer And Cost Saving For Patients

ANI
The pioneer of transfusion-free bloodless surgery has revealed just why the technique is so beneficial, especially for patients wary of transfusions or those whose religion does not allow for it.

People such as Jehovah's Witness patients believe that accepting blood from a source other then themselves defies the scriptural teachings that their religion holds steadfast.

"Jehovah's Witness patients no longer have to die for want of blood," says Patricia Ford, MD, a hematologist/oncologist and Medical Director of the Center for Bloodless Medicine and Surgery at Pennsylvania Hospital, part of the PENN Medicine hospital network.

Dr. Ford is one of the pioneers of bloodless surgery and has been teaching its technique to doctor's around the world.

One technique a bloodless surgery can employ is called "cell salvage" in which blood lost during surgery is siphoned from the body, passed through a filter for cleaning and returned to the body.

The physician can also use it during surgery to limit blood loss and to avoid the need for transfusion of blood from sources other than the patient.

Originally developed to meet the needs of the Jehovah's Witness community, bloodless surgery is transfusion-free and is acceptable to Jehovah Witness followers because they are being reinfused with their own blood.

Bloodless surgery and medicine is a viable and life-saving option for these patients and those wary of the safety of the blood supply, and it is safe for a growing number of surgical and medical conditions, except for acute leukaemia and traumatic injury.

"Bloodless procedures have proven to be safer than blood transfusion because they help eliminate complications resulting from transfusions such as immunosuppression, infection, diseases from emerging pathogens for which our blood supply is not yet tested," said Dr. Ford.

"The hospital stay is also shorter for our bloodless patients, a cost savings for the patient and the institution," she continues.

Pennsylvania Hospital in Philadelphia is one of the pioneering centres for bloodless medicine and surgery.

Dr. Ford likens the weeks-old blood often used for transfusions to "water from a dirty fish tank." Depleted of most of its oxygen-carrying capacity, the stored blood is not maximally beneficial to any patient.

Prior to surgery, Dr. Ford prepares patients carefully - using medicines to build red blood cells, and managing their haemoglobin count. A higher haemoglobin level lowers the risk of transfusion.

Dr. Ford has performed the largest number of successful stem cell transplants without blood transfusion of anyone in the world. Among the procedures for which Dr. Ford has prepared patients for bloodless medicine and surgery are cardiothoracic surgery; radical hysterectomies, prostatectomies, cystectomies, and repair of aneurysms, chemotherapy management, and total hip and knee surgery.

The bloodless team at Pennsylvania Hospital has saved the lives of many Jehovah's Witness patients who otherwise would not have received care.

"We see patients from all over the country who come to us for our expertise in bloodless medicine. The needs of the Jehovah's Witness community have helped us develop practices that can not only save their lives, but can also benefit the entire patient community," concluded Dr. Ford.

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Read Between The Lines - Are transfusions the holy grail?

Stephen Cauchi

The Age

"IT TAKES someone special to give blood" says the Australian Red Cross Blood Service's slogan — which makes 500,000 Australians every year quite special. But could their altruism be misplaced?
The answer, according to American cardiothoracic specialist Bruce Spiess, may well be yes. During last week's annual scientific meeting of the Australian and New Zealand College of Anaesthetists, Professor Spiess, from the Virginia Commonwealth University, poured scorn on the belief that blood, or at least the transfusion of it, was the elixir of life.
"Blood transfusions are a religion. They have never been safety or efficacy tested," he said. "Drug options are carefully tested and regulated through prospective, randomised double-blind testing, but blood transfusion stands apart in that it has predominantly been believed to be helpful and evolved as a pillar of modern medicine."
Professor Spiess cited a Swedish study involving Jehovah's Witnesses, whose religion forbids them to accept transfusions. It showed that 499 Witnesses who had open-heart surgery had better survival rates than other open-heart patients.
The problem with transfusions is not transmission of diseases such as HIV or hepatitis, which are screened for by blood banks, but post-operative complications such as pneumonia, wound infection and organ failure, some of which can be fatal.
Blood transfusions could indeed cause "major morbidity or even mortality", said Professor James Isbister, of the University of Sydney. "Increasingly, evidence and experience is suggesting that blood banking and transfusions medicine have excessively focused on supply rather than the demand/patient perspective."
Because blood is given free, it is a cheap alternative to treatments such as drugs. A statement from the Australian and New Zealand College of Anaesthetists said: "In Australia, the economics of blood discourages the use of alternatives because Australians donate blood and the Red Cross gives it to hospitals free … alternatives to transfusion include minimising blood loss and maximising oxygenation."
Professor Spiess told the conference of anaesthetists — the profession responsible for half the transfusions associated with surgery — that campaigns to encourage blood donation had helped shape the notion that all transfusions were good. Women received more transfusions than men, with worse outcomes from heart surgery a particular problem.
The Australian Red Cross Blood Service, which administers the nation's blood banks, referred The Sunday Age to Larry McNichol, head of anaesthesia at the Austin Hospital. Dr McNichol, who is also chairman of a Department of Human Services committee on transfusions, said his friends were "gobsmacked" when he told them about the problems with blood.

"They were saying, 'How can you say blood isn't fantastic, it saves people's lives'," he said.
"It is fantastic, it's a gift and it's saved lots of lives. But it's also important to realise that for everything there is a side-effect. It's just that it's taken us a long time to start building up the evidence for the potential adverse effects of having a transfusion."
Transfusion is needed when hemoglobin — the oxygen-containing protein in red blood cells — falls below a certain level, endangering the body's ability to transport oxygen. But the level at which transfusion is required, said Dr McNichol, is debatable.
"We were always taught that if (hemoglobin) drops below 10 (grams per deci-litre) you should perhaps give (the patient) some blood. What we're really saying, and Bruce Spiess articulated it really well, is that there is no scientific basis for the figure of 10. Somebody just said, it sounds around about the right figure."
There is evidence, said Dr McNichol, that some anaesthetists were giving blood when the count fell as low as seven. In general, the right level depended on the patient's condition.
For Jehovah's Witnesses in surgery, there is a range of strategies. Drugs can be taken that boost hemoglobin, reducing the need for transfusion or reducing surgical bleeding. During some forms of surgery, the patient's blood can be collected, washed, and pumped back into the body.
There are also ways to treat blood so it becomes less likely to cause side-effects. One is the removal of white blood cells. The other is bacterial testing of platelet bags. Both measures have received federal funding, bringing Australia into line with Britain, Europe, Canada and most of the US. Despite such measures, the growing consensus is: transfuse only when necessary.
"It's not an insignificant thing to have to give a patient a unit or two of blood because these things can be bad for you," Dr McNichol said. "What the emphasis is on now is saying what can we at the clinical coalface do to minimise the chances of patients having to have blood."

"They were saying, 'How can you say blood isn't fantastic, it saves people's lives'," he said.
"It is fantastic, it's a gift and it's saved lots of lives. But it's also important to realise that for everything there is a side-effect. It's just that it's taken us a long time to start building up the evidence for the potential adverse effects of having a transfusion."
Transfusion is needed when hemoglobin — the oxygen-containing protein in red blood cells — falls below a certain level, endangering the body's ability to transport oxygen. But the level at which transfusion is required, said Dr McNichol, is debatable.
"We were always taught that if (hemoglobin) drops below 10 (grams per deci-litre) you should perhaps give (the patient) some blood. What we're really saying, and Bruce Spiess articulated it really well, is that there is no scientific basis for the figure of 10. Somebody just said, it sounds around about the right figure."
There is evidence, said Dr McNichol, that some anaesthetists were giving blood when the count fell as low as seven. In general, the right level depended on the patient's condition.
For Jehovah's Witnesses in surgery, there is a range of strategies. Drugs can be taken that boost hemoglobin, reducing the need for transfusion or reducing surgical bleeding. During some forms of surgery, the patient's blood can be collected, washed, and pumped back into the body.
There are also ways to treat blood so it becomes less likely to cause side-effects. One is the removal of white blood cells. The other is bacterial testing of platelet bags. Both measures have received federal funding, bringing Australia into line with Britain, Europe, Canada and most of the US. Despite such measures, the growing consensus is: transfuse only when necessary.
"It's not an insignificant thing to have to give a patient a unit or two of blood because these things can be bad for you," Dr McNichol said. "What the emphasis is on now is saying what can we at the clinical coalface do to minimise the chances of patients having to have blood."

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Jehovah's Witnesses Have High Survival Rate After Surgery

Dan Oakes

The Age

SURGEONS could save lives by treating people as if they were Jehovah's Witnesses, a visiting US specialist told a conference yesterday.

Addressing the the annual scientific meeting of the Australian and New Zealand College of Anaesthetists, cardiothoracic specialist Bruce Spiess said blood transfusions hurt more people than they helped.

Jehovah's Witnesses refuse to accept blood transfusions, but Professor Spiess said a study in Sweden of 499 Witnesses showed their survival rates were higher than people who received transfusions.

He described blood transfusions as "almost a religion", because physicians practised them without any solid evidence that they helped.

"Blood transfusion has evolved as a medical therapy and it's never been tested like a major drug," he said. "A drug is tested for safety and efficacy, blood transfusion has never been tested for either one.

"There's a number of people around the world who are coming to these same conclusions and it's becoming more obvious that the old risks of hepatitis and AIDS have been defeated by blood bankers, and now what we're dealing with are events that make patients worse."

Transfusions increased the probability of post-operative complications, including pneumonia and wound infections.

"I think we need to focus on every possible mechanism we can to keep your own blood," Professor Spiess said.

"If you come to surgery, we should ethically treat every patient as if they were a Jehovah's Witness and say, my goal is to not to transfuse you and to use every other technique I possibly can, and then only as a very last result transfuse you."

He emphasised that in cases of severe trauma, blood transfusions were necessary, but pointed out that the majority of transfusions were of comparatively small amounts of blood.

Another area in which Professor Spiess is prominent is that of synthetic blood, which is composed of teflon-like fluorocarbons that carry oxygen far better than our own blood.

"We've just completed a study with traumatic brain injury — you're talking motor vehicle accidents and guns and head trauma — and we've just had a dramatic breakthrough with head trauma using the fluorocarbons as a way to deliver oxygen to the traumatised brain."

Professor Spiess is also researching the use of synthetic blood as a cure for decompression sickness, on behalf of the US Navy.

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Canonsburg Hospital Offer Course On Bloodless Medicine And Surgery

Lynda Guydon Taylor,
Pittsburgh Post-Gazette

Blood transfusion can be an issue for some patients facing surgery either on religious grounds or because of safety concerns.

For anyone considering it, Canonsburg General Hospital will host a two-hour program at 1:30 p.m. April 14 on alteratives to transfusion.

The Allegheny General Hospital Center for Bloodless Medicine and Surgery will sponsor the free program. Normally, such programs are well attended, drawing as many as 100 people, said Deborah Tatro, a center coordinator.

Last year, more than 200 patients, a majority of whom were Jehovah's Witnesses, requested bloodless surgery, Ms. Tatro said. Although Canonsburg as part of the West Penn Allegheny Health System is hosting the program, it does not offer the procedures involving alternatives.

If someone has concerns about transfusion, Ms. Tatro said, he or she is encouraged to choose a hospital with available equipment and which does the procedure all the time.

Procedures involving bloodless surgery and medicine have been evolving since the 1950s, she said. The term bloodless medicine was coined by Dr. Denton Cooley, who did open heart surgery in the 1950s. There are a number of techniques used in bloodless surgery and medicine. A few of the methods follow:

The cell saver system, also known as intraoperative blood salvage, captures blood lost during an operation and returns it to the patient during surgery.

To reduce blood loss during surgery, certain devices are used to clot blood vessels.

Hemodilution temporarily replaces blood with intravenous fluids to limit blood loss during surgery.

There are several benefits to bloodless surgery. When it comes to cost, Ms. Tatro said, bloodless surgery is no more costly than transfusion and in many ways can be less expensive. Furthermore, those who do not receive transfusions tend to recover faster and experience a shorter hospital stay. Bloodless surgery also can reduce infections and complications.

One group of patients with historic concerns about blood transfusion are Jehovah's Witnesses. The church has established hospital liaison committees in 125 cities worldwide to advise patients about biblical law on which Jehovah's Witnesses oppose transfusion.

The committee's role is to act as liaison between a follower and the patient's hospital.

As chairman of Pittsburgh's Hospital Liaison Committee, Paul Jones advises Jehovah's Witnesses in the city and surrounding area. Opposition is based on passages in Genesis, Leviticus and Acts referring to not consuming or partaking of blood. For example, blood must be drained from animal meat before consumption.

"We believe when blood is spilled, it needs to be poured out and not used," said Mr. Jones, Pittsburgh Jehovah's Witness overseer.

Some procedures involve using fractions of blood in which white and red blood cells and platelets are removed, leaving plasma, a yellowish liquid. Each person has to decide whether he or she will accept those minor fractions, he said.

"Once you get beyond blood transfusion, we leave it up to one's conscience," Mr. Jones said, stressing Jehovah's Witnesses are not opposed to medical treatment, just to transfusion and abortion.

The religion does, however, allow for the cell-saver system.

Coincidentally, Charles Taze Russell established the modern day religion in the 1870s on Pittsburgh's North Side.

"Pittsburgh has always been on the leading edge [regarding transfusion]. The philosophy in Western Pennsylvania is treating the whole person and honoring their request," Mr. Jones said.

The first hour of the Canonsburg presentation by Dr. Lance Weaver, a general surgeon, will be devoted to alternatives to transfusion while the second hour will focus on helping Jehovah's Witnesses make a decision, Ms. Tatro said.

Anyone interested in attending the program should register by calling 1-877-284-2100.

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