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Rethinking blood transfusion

/ 09:24 PM September 12, 2013

Most physicians and hospital administrators are firmly entrenched in the belief that blood loss is an unavoidable part of major surgery and that blood banking and transfusion are the antidote to bleeding. Also, with the advances in blood screening, the public is assured that viral infections are significantly reduced—which is true.

However, what both physicians and patients have not realized are the silent complications of blood transfusion that can come in the future. One such bad outcome is the increased risk of surgical infection and possible transmission of infectious prions, or microscopic protein particles that are similar to viruses but with no nucleic acid that can lead to ailments like mad cow disease.

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Another hidden risk of blood transfusion is higher recurrence rate of colorectal cancer in patients given blood during or after surgery.

With this new information, I think it makes sense for us to now consider reducing these silent but significant complications of blood transfusion by adopting new ideas, such as the “patient blood management program.” Known also as “transfusion-free surgery,” the program is now in use in more than 120 hospitals in the United States, and in many more in Europe, Australia, and South Korea.

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One of these hospitals is Eastern Maine Medical Center in Bangor, of which I was a staff member when we started the program in 2006.

A study of patients who had blood transfusion from 1993 to 2009 was conducted at our hospital. In 1993 there were 1,550 patients who were given a blood transfusion. This number increased gradually to peak at 2,643 patients in 2006, when the patient blood management program started. In 2007 the number went down to 2,263, in 2008 to 1,736, and in 2009 to 1,608.

Translated in units of packed red cells, in 1993 it was 4,079 units, which gradually went up to 8,070 units in 2006. In 2007 the number of units went down to 5,924, in 2008 to 4,027, and in 2009 down to 3,456.

Similar trends also happened in the transfusion of platelets and frozen plasma. In heart surgery, the blood transfusion rate was between 44 percent in 1996 and 61 percent (the highest) in 2002. In 2006, when the patient blood management program was started, it was 48 percent. In 2007 the transfusion rate dropped to 28 percent, and in 2008 down to 16 percent.

With these results in heart surgery with less blood transfusion, Eastern Maine Medical Center reduced its cases of perioperative AMI (acute myocardial infarction), new onset of renal failure, perioperative infection, and stroke, as well as length of stay, without a change in number of deaths.

The question thus arises: Why not adopt this safer and less expensive practice of blood management in all hospitals in the Philippines?

But I see certain barriers to this new change in hospital practice, the biggest of which is how to change the mindset of surgeons and related healthcare professionals. It is extremely difficult to change the culture of hospitals and other institutions. Human nature is not comfortable with sudden change, especially if certain beliefs were learned in medical school and in a training program.

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Several years before I retired in 2008, a study on the use of cough medicines in treating children found that these did not benefit children and in fact had resulted in some deaths from overdose. It took me a number of months to abandon the practice of prescribing cough medication in spite of the study. This is also true with the use of antibiotics for ear infection. Many studies have concluded that most children with ear infections do not need antibiotics. It took me a couple of years to change my ways, to do away with prescribing amoxicillin and zithromax for ear infection.

How can we then take advantage of the proven benefits of less blood transfusion in heart operations and other surgeries?

My suggestion is for the Department of Health to study this new practice. I have no doubt that health officials will also conclude that it is indeed safer and less expensive to support transfusion-free surgery programs.

Another effective system is for heart and other patients due for operation to ask their surgeon to employ the transfusion-free method, if possible.

Actually, transfusion-free surgery was started by Dr. Denton Cooley in Texas in the 1950s because of the request of Jehovah’s Witness patients whose religion prohibits them from accepting blood transfusions. After about 15 years Cooley was able to report on the successful experience of 542 patients who underwent transfusion-free heart surgery.

With the advent of the Internet, smartphones, iPads, and other devices, I think that in a few years many surgeons and hospitals will join the more than 120 health organizations in the United States in adopting transfusion-free surgery in our homeland.

Dr. Leonardo L. Leonidas ([email protected]

gmail.com) retired in 2008 as assistant clinical professor in pediatrics from Boston’s Tufts University School of Medicine, where he was recognized with a Distinguished Career Teaching Award in 2009. He is a 1968 graduate of the University of the Philippines College of Medicine and now spends some of his time in the province of Aklan.

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