Bloodless medicine: what to do when you can't transfuse

Abstract

A better understanding of risks associated with allogeneic blood transfusions (ABTs), along with a growing population of patients who do not accept transfusions, have led to the emergence of new treatment paradigms with "bloodless medicine." In this chapter, we review prior studies describing management and outcomes in patients who refuse transfusion (referred to as "bloodless patients" herein) and summarize the approaches used at our institution. Bloodless management for surgical patients includes treatment of preoperative anemia, use of autologous blood salvage, and minimizing blood loss with procedures. Other adjuncts for both medical and surgical patients include minimizing blood loss from laboratory testing using pediatric phlebotomy tubes and conservative testing. Anemia can be treated with erythropoiesis-stimulating agents, as well as iron, folate, and B12 when indicated. Although there are limited retrospective studies and no prospective studies to guide management, prior reports suggest that outcomes for surgical patients managed without ABTs are comparable to historic controls. A recent risk-adjusted, propensitymatched, case-control study of outcomes of all hospitalized patients who refused ABT at a large academic health center showed that bloodless management was not an independent predictor of adverse outcomes. Surprisingly, there was a lower overall mortality in the bloodless group and discharge hemoglobin levels were similar for both bloodless and control groups. Further research is now needed to optimize therapy and identify novel interventions to manage bloodless patients. Lessons learned from bloodless patients are likely to benefit all patients given recent evidence suggesting that patients who avoid ABTs do as well, if not better, than those who accept transfusions. Learning Objectives• To describe patient populations for whom transfusions are not an option • To discuss prior studies with outcomes and "bloodless medicine" • To outline currently available approaches to manage anemia or bleeding in "bloodless patients" • To discuss areas in need of further research to advance bloodless medicine

Hemoglobin thresholds for transfusion in pediatric patients at a large academic health center

“…A comprehensive blood management program typically uses evidence-based guidelines for RBC transfusion derived from published trials that are sufficiently powered. [28][29][30][31][32][33][34] Although most prior studies evaluating restrictive triggers have been performed with adult patients, [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][18][19][20][21][22][23][24][25][26][27][28] there are a limited number of published studies that focus solely on pediatric patients. 17,[24][25][26] One such study investigated newborns (PINT) who may have higher baseline Hb levels.…”

Preoperative treatment of anemia and outcomes in surgical Jehovah's Witness patients

“…Blood transfusion is among the most common procedures performed in hospitalized patients; however, advances in our knowledge of the risks associated with transfusions and a growing population of patients who wish to avoid transfusions have led to new treatment paradigms for anemia. [1][2][3][4] The majority of patients requesting management without transfusions (frequently denoted "bloodless") are members of the Jehovah's Witness (JW) faith, comprising over 8 million individuals worldwide with 1.2 million in the United States. 5 JW doctrines forbid transfusion of "primary" blood components (red cells, platelets, leukocytes, plasma) while individual clotting factor concentrates and albumin may be accepted at the individual's discretion.…”

“…5 JW doctrines forbid transfusion of "primary" blood components (red cells, platelets, leukocytes, plasma) while individual clotting factor concentrates and albumin may be accepted at the individual's discretion. [4][5][6] Most will accept autologous blood collected from the surgical field using an instrument (cell saver) that is physically contiguous with the body, although autologous blood donated preoperatively is generally not accepted. 4,5 These patients present unique challenges, particularly in the setting of anemia and surgical procedures associated with significant blood loss.…”

The blood-saving effect of vasopressinergic V1 receptor agonists in urologic oncology

“…Очевидно, что у пациентов, подвергающихся он-коурологическим операциям, является обоснованным применение кровосберегающих технологий и прин-ципов так называемой бескровной медицины (blo odless medicine), которая улучшает исходы лечения при различных состояниях, сопровождающихся кровопо-терей [3,[6][7][8].…”