Chapter 7 Bloodless Surgery and Patient Safety Issues

Jarrell Fox, Sandy L. Brown, RN, Rebecca Vigil, RN

“Bloodless” surgery? “NO BLOOD!” These requests most certainly have an impact on patient safety and quality of care in the surgical setting. Have you wondered why there is increasing international interest in nonblood medical and surgical management of patients? The answer may be surprising. Can those in the health care profession safely and compassionately accommodate patient requests to avoid blood transfusion?

The perception within the medical community is that when patients refuse blood, those patients actually are refusing reasonable medical care. This leaves patients and the medical personnel feeling frustrated. The medical professionals (physicians and nurses) believe they are facing an unnecessary barrier to traditional medical care, whereas patients feel frustrated at a perceived indifference to their personal beliefs (Remmers and Speer, 2006).

Patients who desire nonblood medical care are not limited to those who have a religious objection to its use. The principal reasons include a deeply held religious belief, personal concerns about the perceived risks involved, an increased awareness of available alternative strategies, and inadequate availability of safe blood products.

Blood products, as therapeutic agents, have been used routinely for decades but lack clinical trials and regulatory review by the U.S. Food and Drug Administration (FDA) required for other products used in medicine (Committee on Government Reform and Oversight, 1996). Blood is classified as a specialized form of connective tissue. Therefore a blood transfusion should be viewed as an organ transplant because it is living tissue. Medical professionals often view and prescribe it, however, more like a pharmaceutical agent. The most common published risk from blood transfusion is blood delivery error, which supports the notion that blood is handled as a pharmaceutical agent.

Over the past few decades the risk for associated complications with blood transfusion has raised safety concerns in the public, medical, and regulatory arenas. At the same time, data from clinical trials and medical practice have been collected looking at the outcomes of patients who refused blood versus those who received blood transfusion. This has brought to light positive outcomes achieved by using alternative modalities in the perioperative setting to reduce or avoid blood transfusions. These results include improved patient outcomes (Day, 2008; Nowak, 2008), shorter lengths of hospitalization (Vamvakas and Carven, 1998), reduced infection rates (Hill et al, 2003; Blachman, 2005), and significant cost savings (Shander et al, 2007).

These data also reveal a variance in transfusion practice between individual physicians and hospitals and demonstrate the need to standardize blood use protocols and procedures. Time and again in research and clinical experience, justification is found for revisiting a professional point of view on the use of blood transfusions.

The American Association of Blood Banks’ Circular of Information for the Use of Human Blood and Blood Components (2002) states, “red cell–containing components should not be used to treat anemia that can be corrected with specific medications.” Dr. Paul Hébert, critical care specialist at Ottawa General Hospital, Canada, agreed, after completing a landmark study on the effectiveness of blood transfusion practices on critically ill patients suffering from anemia. The study compared patients treated with liberal transfusion policies and those treated with more restrictive ones. He summarizes, “We’ve been transfusing blood for 50 years and no one’s ever bothered to find out how much to give. Now we know it’s safe to transfuse less” (Farmer and Webb, 2000).

It is increasingly apparent that, at the very least, less-risky options should be considered before resorting to the use of blood, but the question is, are they? Ask, what is the medical facility’s standard of care for treating anemia? What is my reaction when I see a patient’s laboratory report of a hemoglobin (Hgb) level of 8 or 9 g/dL? How do I react when a patient makes a request for alternatives to a professional recommendation of transfusion? This may require a paradigm shift within a health care institution and among individual health care professionals. Education is a key factor in accomplishing this. The purpose of this chapter is to provide insight into this emerging and fascinating field.

Major medical centers around the world have successfully implemented nonblood strategies and techniques with dramatic and even impressive results. A successful approach incorporates the collective efforts of a multifaceted team, including skilled physicians and surgeons, capable and compassionate nurses, supportive hospital administration, and appropriately equipped medical facilities.

MEDICAL ETHICS

Medical professionals are committed to applying their knowledge, skills, and experience in fighting disease and death. What health care providers believe is in the best interest of patients may not be what patients believe is best. Patients may have more holistic concerns that include their emotional, psychologic, social, spiritual, and physical well-being. Whether or not we agree with patients’ decisions to refuse blood, we have the responsibility to support patients in their constitutional right to refuse medical care just as if it were an aspirin or chemotherapy agent that they were refusing (Smith, 1997). According to Appelbaum and Roth (1983), 19% of patients at teaching hospitals refused at least one treatment or procedure, even though 15% of such refusals “were potentially life endangering.”

As John Stuart Mill (1952) aptly wrote, “No society in which these liberties are not, on the whole, respected, is free, whatever may be its form of government… Each is the proper guardian of his own health, whether bodily, or mental and spiritual. Mankind are greater gainers by suffering each other to live as seems good to themselves, than by compelling each to live as seems good to the rest.”

CASE STUDY

An otherwise healthy 57-year-old woman presents to an emergency department with right-sided abdominal pain and flulike symptoms of 5 days’ duration. Diagnostic laboratory results indicate a hemoglobin (Hgb) level of 10.5 g/dL, hematocrit (Hct) of 31%, and mildly elevated white blood cell count. Computed tomography (CT) scan confirms suspected appendicitis. The patient is prepared for emergent appendectomy. The on-call general surgeon, on seeing the patient and learning that she is one of Jehovah’s Witnesses, refuses to do the surgery because of her religious objection to the use of blood transfusions. The physician neither contacts another surgeon to transfer patient care nor writes an order for pain medication. The hospital’s house supervisor is not able to find an alternate surgeon on staff to accept the case. Their affiliated hospitals are contacted, and their on-call surgeons also decline the case.

Was this case handled ethically? Did the physician have a reasonable concern? Was there a way to accommodate the patient’s request without violating the surgeon’s personal ethics?

Ultimately the patient was medicated by an anesthesiologist, and a nurse arranged transfer by ambulance to a local facility with a transfusion-free medicine program. This facility’s on-call general surgeon consulted with the patient and her family and proceeded to surgery promptly. During the laparoscopic surgery it was discovered that the appendix had ruptured. The patient subsequently recovered from surgery and was discharged on postoperative day 2.

Thankfully, the views of the first surgeon are not shared by all surgeons. When discussing medical care of the Jehovah’s Witness patient population, Remmers and Speer (2006) highlighted that surgical and medical procedures once considered too risky for Witness patients “are now performed routinely with few complications.” The referenced literature includes reports of successful complex cardiac surgeries and pancreas, liver, and bone marrow transplantation. The authors note that the willingness of physicians to accommodate Witness patients’ request for “bloodless medicine” has led to great medical progress in transfusion medicine and blood conservation.

First Do No Harm

It is the goal of ethically responsible health care professionals to help and to heal people, not to inflict harm. Therefore we must always ask ourselves, does the benefit outweigh the risk? Does the informed patient agree?

ASSOCIATED RISKS FROM TRANSFUSION

Rachel Nowak (2008) recently reported in New Scientist, “Over the past decade a number of studies have found that, far from saving lives, blood transfusions can actually harm many patients. The problem is not the much-publicized risk for blood-borne infectious agents, such as HIV and hepatitis, but the blood itself.” Study after study has shown that transfusions, particularly those containing red blood cells (RBCs), are linked to higher death rates in patients who have had a heart attack, have undergone heart surgery (Murphy et al, 2007), or are in critical care. The exact nature of the link is uncertain, but it seems likely that chemical changes in aging blood, their impact on the immune system, and the blood’s ability to deliver oxygen are key factors.

Most experts now agree that the risk posed by the transfused blood itself is far greater than that of a blood-borne infection. “Probably 40 to 60 per cent of blood transfusions are not good for the patients,” says Bruce Spiess, a cardiac anesthesiologist at Virginia Commonwealth University in Richmond (Nowak, 2008). “There is virtually no high-quality study in surgery, or 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,” says Gavin Murphy, a cardiac surgeon at the Bristol Heart Institute (Nowak, 2008).

Disease Transmission

Although blood transfusion is considered “safer than it has ever been” (Goodnough et al, 2003), making a safer end product has meant increased cost and reduced supply of “acceptable” blood products. These “safer” transfusions still carry an inherent, although minimal, risk for transfusion-transmitted infections and an ever-more-apparent risk for emerging pathogens.

Immunomodulation

Neil Blumberg, MD, an authority on transfusion medicine and hematology, estimated that 10,000 to 50,000 persons in the United States die each year as a result of transfusion-related immunomodulation. Clinical trials consistently demonstrate an association between the number of transfusions and an increased number of nosocomial infections and multiple organ failures (Blumberg, 2004). Although causation has not yet been proved, the evidence to date gives us reason to proceed with caution (Shorr et al, 2005).

Human Error

A greater and less-appreciated risk than acquiring disease is human error, which reportedly occurs in close to 1 in 1000 transfusions. This error can be fatal if it results in the hemolytic reaction associated with ABO incompatibility, which reportedly occurs in 1 in 100,000 transfusions (Fauci et al, 1998).

Limitations of the Screening Tests

Screening is only as reliable as donors are in answering a screening questionnaire honestly. In an effort to make the blood supply safe, nucleic acid testing has helped in reducing the period in which some of the markers for human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and hepatitis C virus cannot be detected. The risk, however, is not zero. One need only review the FDA blood product recall lists to see that blood donated by high-risk individuals still makes it into the blood supply.

PROFESSIONAL CONSIDERATIONS

Given the ethical considerations and associated risks from transfusion, how can health care professionals safely deliver care to this patient population? For bloodless or transfusion-free care to be accomplished safely and successfully, three phases of patient care must be integrated vigilantly: (1) preoperative evaluation and preparation, (2) intraoperative strategies and techniques, and (3) postoperative monitoring and care.

It has been said that the most important roles of a nurse are to listen carefully and be observant. This could not be truer or more critical than in the perioperative setting. Some things that otherwise might tend to go unnoticed could be indicators that patients are in danger. In each of the three phases, it is imperative to continually assess the patient’s condition and alert the team to possibly significant changes. Assessing and managing anemia throughout these phases is discussed, and associated recommendations could be considered in each phase. Relying on nurses’ knowledge, experience, and instinct is a vital factor in caring for these patients safely and integral to avoiding unnecessary complications.

PREOPERATIVE CONSIDERATIONS

Medications/Supplements/Herbs

Is a patient on anticoagulants (e.g., warfarin) or antiplatelet drugs (e.g., clopidogrel or ticlopidine)? Many patients often do not mention taking Alka-Seltzer, because they do not realize that it contains aspirin.

Is a patient currently taking any of the following supplements or herbs that may contribute to increased bleeding times: ginkgo biloba (Rosenblatt and Mindel, 1997), garlic, cayenne, ginger, ginseng, and quinine (Cupp et al, 1999)? Table 7-1 lists herbal supplements and their corresponding complications.

TABLE 7-1 How Herbal Supplements Can Interfere With Surgery

Herbal Supplement	Possible Complications
Aloe vera	May cause increased intestinal muscle movement to digest food (peristalsis), may decrease effectiveness of water pills (diuretics) given after surgery
Bromelain	May cause bleeding or interact with antibiotics such as amoxicillin or tetracyclines
Danshen	May cause bleeding
Dong quai	May cause bleeding
Echinacea	May interfere with immune functioning, may alter effectiveness of immunosuppressant drugs given after transplant surgery
Ephedra	May cause abnormal heartbeat, may cause extreme high blood pressure and coma if combined with certain antidepressants and anesthesia
Feverfew	May cause bleeding
Garlic	May cause bleeding, may interfere with normal blood clotting
Ginger	May cause bleeding
Ginkgo	May cause bleeding
Ginseng	May cause bleeding, may cause rapid heartbeat, may cause high blood pressure
Goldenseal	May cause or worsen swelling and high blood pressure
Kava	May enhance sedative effects of anesthesia
Licorice (not including licorice candy)	May increase blood pressure
Omega-3 fatty acids	May cause bleeding if taken in doses greater than 3 grams a day
Senna	May cause electrolyte imbalance
St. John’s wort	May increase or decrease the effects of some drugs used during and after surgery
Valerian	May prolong the effects of anesthesia