Every day every hour, there are people in hospital theaters and operating rooms undergoing surgical procedures; some very traumatic; such as in the instances of accidents, as well as others, are scheduled like surgeries to corrects defects. Or perhaps incase of bodily damages; which result from the prevalence of diseases; such as kidney transplant.
When these surgical procedures are carried out
When this happens, massive blood loss results; and the basic way of replenishing it is through blood transfusion.
But not all patients appreciate blood from donors or other blood products due to personal concerns about the presence of diseases and pathogens in the donor’s blood.
Moreover, beliefs both traditional and religious may prevent a person from seeking external blood such as the case of believers of Jehovah Witness Christian denomination. That said; such patients will always yearn for bloodless medicine.
However, this entails medical procedures and methodologies which are designed to monitor, protect and enhance the regulation; as well as efficiency of the already existing blood supply of the patient undergoing a surgical procedure.
For patients undergoing traumatic situations the bloodless techniques may involve special procedures during surgery or collection as well as reuse of the blood lost during surgery; while for patients whose surgical procedures are planned earlier, they may have to undergo some special dietary plans or medications; which are geared towards ensuring that minimal blood will be lost during their surgical procedures.
This site’s history
This website was initially belonged to a medical group of physicians and nurses who were committed to the education and research of blood conservation through a body called Physician and Nurses for Blood Conservation, hence PNBC. Their mission was;
PNBC has established and intends to continue to develop a national network of blood conservation programs that will provide education on; and evaluate the safe and cost-effective use of blood, blood products and available alternatives.
Specifically, PNBC will:
- Conduct research that will provide insight into appropriate alternatives to blood transfusion.
- Provide evidence-based education to health care professionals and patients about blood, blood products; and available options to optimize patient care and minimize the demand for blood and blood products.
This website includes information content; which will enlighten and educate people about blood conservation.
We all have a duty to preserve life as humans and to learn more about this, just read the article below; which I found from their previous website. They really had amazing content that you will love.
Setting Up Program for Blood Conservation
Now that you have identified interested Committee members to help you in building your program; you should ensure you have a basic understanding of the different strategies of blood conservation that exist on the Canadian market.
The Preoperative, Intraoperative, and Postoperative strategies sections provide an overview of the commonly available blood conservation strategies in Canada. Obviously you will have to take inventory of the strategies available within your own institution to create your program. This may include the allocation of funds for those new strategies implemented; as a result of the program.
An overall discussion of all the strategies available within your institution
This will have to take place with your multi-disciplinary team of experts on your committee. However, this will allow you to create appropriate inclusion and exclusion criteria for each strategy; as well as identifying where and when different strategies will be combined to produce the best benefit for the patient.
The strategies used may also be dependent on the type of surgery identified through your program, as not all strategies are appropriate for all surgical and patient types. All of this information will be important when building your Surgical Algorithm.
Surgical Algorithm by Surgery Type
Remember the goal of a Blood Conservation program is to provide optimal patient outcomes with the lowest exposure to unnecessary risks. The program will allow healthcare professionals to effectively plan blood conversations strategies relative to a surgical procedure.
To these ends, blood conservation is a continuum of patient care; which, when appropriately implemented, optimizes outcomes and health resource utilization. It is a planned process of patient management.
This allows the healthcare professional to consider all available options:
- Prior to surgery to reduce preoperative anemia
- During surgery to minimize red blood cell (RBC) loss
- Pre, intra and post-operative anemia control, which may negatively affect patient recovery and quality of life.
At each stage, the goal is to control anemia by either minimizing RBC loss or increasing RBC mass and avoiding exposure to additional risks. There are three stages in a blood conservation continuum; in which blood conservation strategies can be considered. Each will need adjustment depending on the type of surgery; as well as the availability of techniques, devices and products at your institution.
By way of example, the following file outlines blood conservation strategies with specific reference to Orthopedic Surgery.
Create a 2 to 4 Week Lead-Time Before the Surgical Date
The Preoperative Stage will ideally commence with Patient Assessment approximately 2 to 4 weeks prior to the planned surgery. This will allow for sufficient lead-time to appropriately implement blood conservation strategies used during this time period. However, the importance of this lead-time is to ensure preoperative blood conservation strategies can be employed safely and effectively prior to surgery.
Changing the pre-admission lead-time can be as easy as educating key people responsible for booking this date. Identifying the people who need to be made aware of these changes; as well as understanding their needs in order to assist you in making these changes will be key to your success. You will remember that this was a point of identification within the Patient Care Map.
Presentation material was described to you in the Program Introduction. You may consider one of these presentations for use during an education opportunity with key individuals involved in this process; such as the Surgeon’s secretary or the Pre-admission nursing staff. This time change will ensure better preoperative patient care and safety, and may also cause fewer cancellations.
Assess the Patient
Many surgeries result in significant blood loss; which in the past automatically triggered allogeneic blood transfusion. While transfusing donated blood may have been an appropriate anemia management strategy historically; it is no longer considered the standard of care in many circumstances. Within the framework of a Blood Conservation program; allogeneic transfusion as an acute response to RBC loss during surgery happens considerably less frequently.
By conducting a planned perioperative hematological assessment and developing a blood conservation plan, healthcare professionals and patients have many more appropriate strategies; from which to choose.
The two most important pre-surgical predictors of transfusion are:
This is possible
Using blood conservation strategies, to minimize the risk of exposure to allogeneic blood; if planning for blood conservation is exercised using all available options by the healthcare professional as well as the patient. These pre-surgical predictors are key elements to begin building your Surgical Algorithm.
Low preoperative hemoglobin accompanied with moderate to high blood loss during surgery will lead to low postoperative hemoglobin; which can have a significant impact on patient recovery, as well as risk of transfusion. A common post-operative problem in patients undergoing surgery is low hematocrit; which may result in feelings of fatigue and unwillingness to start rehabilitation.
Increasing a patient’s preoperative hemoglobin level
This may lead to higher post-operative hemoglobin, and facilitate patient participation in rehabilitation; resulting in shorter recovery times.
A study by Keating et al reported a significant correlation between higher post-operative hematocrit and patient readiness to resume normal activities for patients undergoing total joint arthroplasty. There was also a significant correlation between post-operative hematocrit levels; as well as muscle strength.
Results from epoetin alfa
Studies have also demonstrated that anemic patients with Hb levels ≤ 130 g/L have a narrower safety margin for perioperative blood loss; and are more likely to require allogeneic blood. These results were similar to that found by deAndrade et al. in 1996; who stated that the risk of transfusion in patients with baseline Hb levels > 100 to ≤ 130 g/L was much higher than in patients with baseline Hb levels > 130 g/L.
Included in the preoperative assessment are three key indicators of patient readiness for surgery; which may also influence the chosen blood conservation strategy. These include patient history taking, anemia assessment; as well as identification; along with control of bleeding diathesis too.
a) History Taking and Physical Examination
As a matter of fact, history taking is a normal and essential part of preparing any patient for a surgical procedure. Patient Assessment and Patient History are examples of what you may want to use in your program. Also included; are examples of a Pre-Admission Form and Pre-op History Form. History taking may be the job of the referring physician or may take place in pre-admission.
In general a good patient history must involve:
Laboratory considerations include prothrombin time (PT); partial thromboplastin time (PTT); complete blood count, including creatine (crt); platelets, Hb, and hematocrit (Hct). A Hematological consult will be needed in patients with a history of prolonged bleeding episodes.
b) Assessment of Anemia
In adults, anemia usually is considered as hemoglobin less than 120 g/L in females; and in men; Hb less than 140 g/L. The major physiological consequence of anemia is a reduction in the oxygen-carrying capacity of the blood.
Many physiological adaptations maintain tissue oxygenation during anemia; including increased cardiac output, increased tissue blood flow, as well as increased oxygen release to tissues. Anemia is a manifestation; if not a potentially serious medical condition that may need to be referred for further investigation.
A patient’s anemia assessment can be easily obtained by taking a recent hemoglobin or hematocrit level. We have already reviewed hemoglobin as a predictor of allogeneic transfusion. Existing blood conservation programs have used this information as a guide for developing Surgical Algorithms within their institution; by establishing a preoperative hemoglobin target. Evaluating preoperative hemoglobin will be the starting point of each algorithm by surgical type.
|Preoperative hemoglobin||— Degree of risk for transfusion|
|> 130 g/L||– Low risk|
|110 to 130 g/L||– Moderate risk|
|< 110 g/L||– High risk|
c) Identification and Control of Bleeding Diathesis
Lastly, it is important that the patient be assessed in terms of hereditary or acquired bleeding disorders. This may involve identifying family and personal history of abnormal hemostasis or bleeding; and of particular importance, the need to consult with a Hematologist.
Key factors include:
Now that you have taken a thorough patient history and assessed their anemia
You can now begin to create a Surgical Algorithm of available options to implement a specific patient and/or surgery blood conservation plan. The plan may involve one or many options for a given patient undergoing elective surgery. All the options available to each patient; for a particular surgery; must be outlined in a Surgical Algorithm; which can be used as a step-by-step guide to constructing the patient’s blood conservation plan.
As we learned in the overview of a Blood Conservation program, there are many strategies; which may be available, but not all strategies are available all of the time. Practice Policies provides an overview of available options and the time at which they may be employed. Therefore, as a healthcare professional; you will hold a key position to evaluate the information, retrieve the necessary consultation; as well as set a patient’s blood conservation plan in motion.
Check the Surgical Algorithm here.
Although the Jehovah’s Witness patient is the most easily identifiable patient who may refuse blood and blood products due to religious beliefs; there exist other patients who may refuse the receipt of blood for other reasons.
We have briefly discussed the Jehovah’s Witness patient in terms of their importance in increasing awareness and acceptance of blood conservation strategies throughout the surgical continuum. It is therefore important to recognize that a Jehovah’s Witness patient; along with those with similar convictions, are unique when compared to other surgical patients.
Allogeneic blood transfusion and stored autologous blood (PAD) is not acceptable to this group of individuals. Thus, even in the most extreme circumstances transfusion is not to be considered.
The purpose of this chapter is to give you an understanding of the belief system; and some practical clinical guidance for appropriately managing these patients within your Blood Conservation program.
There are several key points to consider when managing a Witness patient, which include:
- Jehovah’s Witnesses seek out modern, scientific medicine when they need it; they do not practice “faith healing” and are not anti-medicine.
- Witnesses do not accept allogeneic blood transfusions (whole blood, red cells, white cells, platelets, and plasma) or stored autologous blood. Acceptance of fractions of blood components is considered a matter for each patient to decide. This includes products containing fractions of plasma (e.g., immune globulins, clotting factor concentrates) and fractions of cellular components (e.g., red-cell substitutes).
- Except in emergency situations, a physician can decline to enter into a fiduciary relationship with a patient who places unacceptable conditions on a treatment plan; as long as the physician assures that the patient is not abandoned.
Hospital Information Services (Canada) at the national office of Jehovah’s Witnesses; as well as the Hospital Liaison Committee Network for Jehovah’s Witnesses; are in the process of preparing a resource document for the development of hospital policies and procedures for the care of patients requesting alternatives to allogeneic blood transfusion. Copies of this document, once available; can be obtained by contacting:
Hospital Information Services (Canada)
Watch Tower Society
P.O. Box 4100 (13893 Highway 7)
Halton Hills (Georgetown), Ontario
Canada L7G 4Y4
+1 800 265-0327
Fax: +1 905 873 4510
Your blood conservation expertise
He or she will put you in good stead to assist in the management of a Witness patient; or another who refuses blood for other reasons. It may require you to learn a few additional skills; modify some routine practices. Perhaps identify other resources to ensure good patient management.
The following principles should be followed when caring for the Witness patient:
- Accept the limitation that allogeneic blood cannot be used.
- Use alternatives to allogeneic blood whenever possible and appropriate.
- Discuss consequences with the patient; including the potential for life-threatening hemorrhage and possible death if not transfused.
- If unable or unwilling to treat a Jehovah’s Witness patient, stabilize and transfer the patient to a sympathetic institution, such as a center for Bloodless Surgery. Also discuss the risk and benefits of potential life-saving procedures.
- Contact the local Hospital Liaison Committee for Jehovah’s Witnesses for information and help.
- In an emergency or if a patient is unconscious; look for an advance directive.
- Seek legal assistance when dealing with an unconscious or incompetent adult.
In addition, it will be helpful to have an understanding of the Witness patient’s position on various blood management modalities; along with the ways in which anemia can be managed in this patient population.
Position of Jehovah’s Witnesses Regarding Transfusional Therapies
|Accepted||Not Accepted||Individual Decision|
Blood Cell Growth Factors, such as:
|Whole blood and Primary Components:
Stored autologous blood (predonation)
|Intra- & Postoperative Autotransfusion:
Products containing the above blood fractions
Management of the Anemic Patient who Refuses Blood:
Effect of Therapy
Minimize iatrogenic anemia:
Reduce hemorrhagic loss:
Maximize blood production:
Maximize cardiac output:
Increase oxygen content:
Decrease metabolic rate:
Informed consent is a legal term for the process of education of the patient ; or substitute decision-maker (SDM); usually initiated by the attending physician or surgeon, about the benefits, risks, as well as alternatives of the proposed therapeutic treatment or procedure.
However, the expectation is that the patient (or SDM) will be able to make an informed decision once provided with the information. The notion of consent is grounded in the ethical principles of patient autonomy and respect for persons.
- Autonomy refers to the patient’s right to make free decisions about his or her health care.
- Respect for persons requires that the health care professional refrain from carrying out unwanted interventions, and that they foster patient’s control over their own lives.
Before any treatment or procedure occurs
Patients with the exception of applications under the Health Act and the Mental Health Act; have the right to decide whether they wish to receive the treatment or procedure. It allows the patient (or SDM); to preserve the primary decision-making role in determining a course of treatment.
As part of this process, the physician must conform to a standard of disclosure regarding benefits and risks of a particular therapy. This standard requires that a physician disclose information; which the physician knows or ought to know, that a reasonable person in the patient’s position would wish to be aware of prior to making a decision about undergoing a treatment or procedure.
Information provided by the physician:
- A description of the blood product or component
- Benefits of treatment
- Risks of treatment
- Alternative treatments (including benefits and risks)
Opportunity for questions and clarification:
- Patient or (surrogate) understands
- Patient decides on basis of complete information
- Perhaps if the patient agrees or refuses consent. You may find these consent form examples useful during your discussions: Consent for Procedure; consent for Blood and Blood Products; Autologous Consent, and a Blood Refusal Form.
- Documentation rationale, discussion surrounding implementation of a process of Informed Consent for blood and blood products arose from the Interim Report of the Commission of Inquiry on the Blood System in Canada; (Krever Commission, 1995).
The report recommended:
- That the licensing bodies of the medical profession require; in their standard of practice, that the treating physician obtain the informed consent of the patient to the administration of blood and blood products; and in such a way that patients in Canada, barring incompetence or an emergency surgical procedure, will be informed of the risks and benefits of, and alternatives to; allogeneic blood transfusion.
- The risks, benefits and alternatives are presented in language the patient will understand; and in a manner that permits questions, repetition, and sufficient time for assimilation.
- That the discussion between the physician and the patient take place well in advance of the surgical procedure or blood therapy. This will enable the patient to employ some of the alternatives to an allogeneic blood transfusion; and to allow the patient to participate in a meaningful way in the decision relating to the administration of blood and blood products.
- And finally; that the treating physician document in the patient’s medical chart that he or she has discussed the risks, benefits as well as alternatives to blood transfusion with the patient.
In very general terms, the patient should be informed of:
- The reason why blood may be administered;
- The anticipated benefits;
- As well as the material risks; including potentially serious complications, even if the risks are uncommon; and
- The alternatives to allogeneic blood transfusion, including risks and benefits of the alternatives.
The patient must have an opportunity to ask questions, and receive clear answers in a language he/she understands. Physicians are advised to document the discussion in the patient’s chart. A specific notation by the physician outlining the discussion is a form of evidence that a discussion indeed took place. Experience has shown however; that this is not always standard practice and is difficult to monitor.
There are several goals to consider in the development of a process:
- Ensure a degree of flexibility surrounding consent, to allow safe transfusion practice and provision of safe patient care.
- Ensure the patient receives information (verbal +/- written) in an adequate amount of time that would allow access to alternatives.
- And ensure the process would assist physicians with compliance in documentation of the Informed Consent. i.e. a form
- Ensure a process is designed that would facilitate monitoring. (All elective presurgical bookings requesting blood products should include consent).
There are several factors; which may influence the process of changing any existing consent policy regarding the transfusion of blood or blood products.
Questions that need to be addressed are:
- Will the change in policy be institutional, regional or could it be a provincial directive (as in British Columbia)?
- And in what format will consent be documented? In a separate form, included in an existing consent form, or accepted in chart notation.
- Is there support from within your institution?
- What products would require consent?
- What policy changes need to take place to ensure compliance?
- How would compliance be monitored?
- Who would be responsible for obtaining consent? (There may be provincial differences. Check with legislative/regulatory agencies).
- When would be a good time to implement Informed Consent? Are there competing/conflicting interests occurring simultaneously?
Assemble the stakeholders to solicit their input in planning. Depending on institution size and structure, the team may include; representation from the Blood Transfusion Service, Medical Affairs, Risk Management, Anesthesia, Surgery, Medicine, Perioperative Services (all departments); Nursing (Critical Care areas, Hematology, Oncology, OB/GYN); Staff Development, Patient Education, Laboratory and Hospital Media Services. All of these individuals may already be part of your Blood Conservation Committee.
Your committee will also be an ideal place to identify a person(s) responsible for coordinating the implementation process in order to meet established timelines. Select a practical implementation date considering other initiatives being implemented or simply the time of year. i.e. Vacation.
Expect delays, and of course, some resistance. Change never comes easily. Don’t try to “re-invent the wheel!”
Establish Intraoperative Strategies
a) Acute Normovolemic Hemodilution (ANH)
ANH conserves blood by intentionally lowering the hematocrit before surgical blood loss occurs; so that less RBC volume is lost for any given amount of whole blood shed. Autologous blood is collected immediately before or after induction of anesthesia; and involves diluting the erythrocyte concentration without decreasing intravascular volume.
This is done by withdrawing up to four units of whole blood, storing the blood temporarily; and replacing the volume with crystalloid and colloid solution.22 ANH is greatly underutilized in operating rooms. The reason is because it requires added work. Until recently, lacked compelling and cost-effective supportive data.
There exist Inclusion/Exclusion criteria for ANH. These criteria will be largely dependent on the comfort level. Also, training existing amongst the Anesthesiology staff in your hospital. It will also be dependent on the type of surgery and applicability of this blood conservation strategy. These factors influence whether this is a viable procedure to include in the Surgical Algorithm. Consideration of ANH must occur pre-surgically; as blood collection devices and if applicable; technology staff, must be scheduled to ensure availability during the surgery.
118 patients undergoing ANH for surgical procedures associated with significant blood loss (expected blood loss > 1,000 ml) were studied. Thirty-six patients had known actively treated coronary artery disease. Therefore, all patients had more than two units of blood removed; (average 2.8 units) following induction of anesthesia.
Nevertheless, all were hemodiluted in the operating room and normovolemia was maintained. All patients were monitored with standard anesthesia monitoring and with “ST-segment” analysis. And all 118 patients tolerated ANH. Along with successfully completed surgery without exposure to allogeneic blood. There were no complications due to acute anemia or hypovolemia. This trial is consistent with other larger controlled series of the efficacy of ANH.23,24
Two other prospective; randomized trials comparing ANH and predonation in patients undergoing total knee25 or hip26 arthroplasty found both techniques to be equivalent in reducing allogeneic blood exposure. As well, increasing preoperative hematocrit levels with erythropoietin therapy and accepting lower post-hemodilution hematocrit levels can; alike PAD, improve the efficacy of hemodilution.27
New equipment for intraoperative blood collection
This is constantly being introduced into clinical practice. Some of these devices will help mechanize the ANH process, allowing better volume accounting and less blood handling. Single operator instruments will improve acceptance in the anesthesia community by lessening the work that is currently required. New equipment will also increase the acceptability of the process for Jehova’s Witness patients (see Jehovah’s Witness Patient); who require the blood to remain in continuity with the patient’s circulation.28
Acute Normovolemic Hemodilution
b) Intraoperative Cell Salvage
Intraoperative blood salvage; in which shed blood is retrieved from the surgical site, can be achieved by use of cell-salvage equipment. The shed blood that is suctioned from the operative site is mixed with an anticoagulant; such as heparin or citrate; then collected in a reservoir with a blood filter. After, the blood is forced into a spinning centrifuge bowl; while the plasma overflows into a waste bag.
Saline is used to wash the cells (to remove the effects of the anticoagulants); which are then reinfused into the patient. Cell saver equipment has been used extensively in surgery since the 1970’s. It has found a place in cardiac, orthopedic, vascular, neurosurgery (spines); as well as trauma surgical procedures.
Alike ANH, intraoperative and postoperative cell salvage use will be largely dependent on the comfort level and training existing amongst the Anesthesiology staff in your hospital; as well as on availability of the necessary equipment and support staff. It will also be dependent on the type of surgery and applicability of this form of blood conservation.
Again, this will also influence whether this is a viable procedure to include in the Surgical Algorithm. Consideration of intraoperative cell salvage must occur pre-surgically; as blood collection devices and if applicable, technology staff, must be scheduled to ensure availability during the surgery.
Intraoperative Blood Cell Salvage
c) Plasma Volume Expanders
Non-blood volume expanders may be useful alternatives to allogeneic blood transfusion. Plasma expanders can be divided into crystalloids; colloids that increase oncotic pressure; and those blood substitutes that have the capacity to transport oxygen.
- Are preferred in patients with hemorrhage in whom the restoration of intravascular volume is often of higher priority than replacement of RBC.
- They can correct volume deficit in both the intra- and extravascular space. To maintain normovolemia, three to four times the amount of blood lost is usually required when crystalloids are used.
- Include products such as hydroxyethylstarch (Pentastarch). Albumin is another product in this category; however, because it is blood based, it is not acceptable to patients wanting to avoid human blood products. (See Jehovah’s Witness)
- Exert significant oncotic pressure by virtue of their high molecular weight
- Larger volumes of colloid remain in the intravascular space for longer periods when compared to crystalloids; thus hemodynamic resuscitation is more rapid, complete, and longer lasting.
d) Hemostatic Drugs
Careful hemostasis during any surgical procedure; as well as efficient time use, can help decrease the loss of blood. Hemostatic agents; such as collagen pads, thrombin powders, and fibrin glue stop vessel oozing. Both aminocaproic acid and tranexamic acid have antifibrinolytic activity in humans. These products are effective; even when bleeding is not associated with laboratory signs of excessive fibrinolysis.
Since both drugs enter the extravascular space and accumulate in tissues; the basis for their efficacy is thought to be the inhibition of tissue fibrinolysis; as well as the consequent stabilization of clots. Aprotinin has been found to be most effective in reducing the proportion of patients receiving allogeneic transfusions; and of those requiring re-sternotomy because of bleeding. Desmopressin is probably only effective in patients treated previously with aspirin.
Indications for the Use of the Antifibrinolytic Drugs Tranexamic Acid and Aminocaproic Acid in the Treatment of Excessive Bleeding36
|Clinical Situation||Study||Grade of Evidence*|
|Primary menorrhagia||Bonnar and Sheppard||A|
|Upper gastrointestinal bleeding||Henry and O’Connell||A|
|Dental extraction in patients with coagulation disorders||Walsh et al Forbes et al Sinder-Pedersen et al||A|
|Bleeding associated with thrombocytopenia||Mannucci et al
Burroughs et al
|The evidence has been graded as A, B, or C as follows: A denotes that the therapeutic value of desmopressin has been demonstrated by clinical trials evaluating its safety and efficacy; B that safety and efficacy have been demonstrated by well-conducted studies but no clinical trials; and C safety and efficacy have been demonstrated by case studies or reports but no well-conducted studies.|
Aprotinin inhibits the initiation of both coagulation and fibrinolysis induced by the contact of blood with a foreign surface. It does not affect platelet function. It is administered intravenously in an initial loading dose; followed by a continuous infusion.
It has been proven effective in cardiac and orthotopic liver transplantation surgeries along with other modalities. Most reactions to Aprotinin occur when the product is administered a second time within six months after the first exposure; and are not severe.
Plasma concentrations of factor VIII, the clotting factor that is deficient or defective in patients with hemophilia A; and von Willebrand factor; the adhesive protein that is deficient or defective in patient’s with von Willebrand’s disease, can be increased for a short time by the administration of desmopressin.
These effects; which mimic replacement therapy with blood products; form the rationale for the use of desmopressin in the treatment of patients with hemophilia A or von Willebrand’s disease; both of which are congenital bleeding disorders. The evidence of efficacy is so clear that no controlled clinical trials have been judged necessary.
Indications for the Use of Desmopressin in the treatment of Excessive Bleeding
|Clinical Situation||Study||Grade of Evidence*|
|Mild hemophilia A or type I von Willebrand’s disease||Mannucci et al
Kobrinsky et al
de la Fuente et al
|Congenital defects of platelet function||Rao et al
DiMichele and Hathaway
|Uremia||Mannucci et al||C|
|Cirrhosis||Mannucci et al
Burroughs et al
|Drug-induced bleeding (aspirin, ticlopidine)||Kobrinsky et al
Mannucci et al
|The evidence has been graded as A, B, or C as follows: A denotes that the therapeutic value of desmopressin has been demonstrated by clinical trials evaluating its safety and efficacy; B that safety and efficacy have been demonstrated by well-conducted studies but no clinical trials; and C that safety and efficacy have been demonstrated by case studies or reports but no well-conducted studies.|
Tissue Adhesives, eg., glues, sealants
Fibrin glues have become the most important of these topical agents. Their application is to both control bleeding and repair underlying defects. They have been proven useful in cardiovascular and trauma surgeries. After repeated exposure with bovine thrombin used with fibrin glue, inhibitors of bovine thrombin; and/or factor V were found in children as well as adults causing life threatening bleeding abnormalities. Human and especially human autologous fibrin glue may avoid these problems. Hemostatic Agents.
e) Surgical Techniques and Instruments
The harmonic scalpel, gamma knife; as well as argon beam coagulator; are some of the advanced surgical instruments now available for improved hemostasis. However, the use of these instruments along with minimally invasive surgical approaches; such as laparoscopy, endoscopy, and interventional radiologic procedures can dramatically reduce blood loss at surgery. In addition to the surgical procedure; the quality of the surgical technique accounts for a large part of the variation in bleeding after the operation. Along with the frequency and number of allogeneic transfusions.
Catheter-based vascular techniques; such as selective arterial embolization, use of covered vascular stents and endoluminal arterial tamponade can play a role in hemorrhage control if critical bleeding is limited to accessible sites.
As well, pneumatic tourniquets are used on extremities during orthopedic and neurosurgical procedures; to help create a bloodless field. Only licensed personnel should apply them. They require careful attention to prevent complications. It should be noted that; the use of arterial tourniquets significantly reduced intraoperative blood loss in patients undergoing total knee arthroplasty. But not the rate of allogeneic transfusion. Even after limited tourniquet time; ischemic damage was found.
g) Hypotensive Anesthesia45
Especially where high blood loss is anticipated; controlled hypotensive anesthesia is sometimes used to help reduce blood loss. By lowering the patient’s blood pressure with certain pharmacological agents; less blood is lost during the procedure; bony surfaces bleed less and are improved for implant fixation. Surgical time is also shortened.
Your hospital experience may have already taught you that the best way to meet your goals; is a good marketing and sales platform. This means that you have clearly defined objectives, benefits, measurements; as well as structure; to your Blood Conservation program that hospital administration will be willing to support.
We learned from the introductory section that a Blood Conservation program is multi-disciplinary, and functional. Identifying interested healthcare professionals from the hospital will positively influence hospital administration. Ideally, you will acquire representation from Surgery, Anesthesia, and Hematology for part of the initial team.
You may also want to include a nursing manager; ideally from pre-admission; as well as a pharmacy staff member who will be able to address some of the costs associated with a program of this nature.
Develop a Business Plan
A Business Plan will establish the foundation of your Blood Conservation program. Your toolkit provides two examples of business plans; which can be used as a guide for the development of your own plan.
Key components of the business plan include:
- RationaleIncluded in the business plan is an appendix entitled Published Literature. This will help in building the rationale.
- Program Structure. This section should include an in-depth look at the structural needs of the program including the:
- Identification of committee members;
- Role and function of the committee;
- Hospital funding requirements.
It is always a great idea
It’s good to have considered alternative funding sources if you are planning on adding substantial cost to hospital administration; and if available, references from established Blood Conservation programs.
You may want to contact us for this purpose. It is important to understand that particularly when financial considerations are at hand; it may take some time to receive a go or no go decision. However if the cost is minimal; which it may well be in your institution; the decision may be an easy one.
In some institutions
Funding has been provided for a nurse, who will occupy the role of Perioperative Blood Conservation Coordinator (PBCC). This is a dedicated position within the auspices of the program. This position may provide a coordinated effort; to facilitate the management of a surgical patient within a Blood Conservation program. But may not be necessary if appropriate education is given to the attending nurses involved in the care of a surgical patient. A job description and rationale for a Perioperative Blood Conservation Coordinator is available.
We’ll look at the program structure in more depth as we evaluate the various blood conservation strategies in Setting Up the Program.
Identification of a Surgical Service
It will be important to identify a surgical service which experiences high blood loss; and where transfusion concerns are an issue, in order to show the greatest impact for your program. You might consider orthopedics, neurosurgery (spines) or other invasive surgeries. Selecting one surgical service will also allow you to make the introduction of the program manageable.
This will also be the first step in preparing a Patient Care Map and Surgical Algorithm; which will be fundamental to your program. These tools will be reviewed later in this section. Selecting one surgical service will also illustrate to hospital administration that you will start small; and work the kinks out, before this becomes a full-blown hospital program involving all surgical types.
This section should identify the return on investment that the hospital can hope to achieve. These need not all be financial returns; but may include things like staff and patient satisfaction.
Nonetheless, program measurement will be imperative for the longevity of the program. Hospital administration will need to know how the benchmark for the program will be set; whether by retrospective chart review or existing data; and how improvements in patient care and resource allocation will be measured upon the implementation of the program. Program measurement and patient satisfaction are discussed in Program Measurement.
The completion of a business plan for the program
However, this will be critical to the next few steps. It will provide the basis for discussion with hospital administration. Also, it will provide a guide for establishing a Blood Conservation Committee. Once these elements are in place; tactical components to implement a Perioperative Blood Conservation program can be considered.
Establish a Meeting
|Establish a meeting with the hospital CEO and/or key senior administrators|
The purpose of this meeting will be to provide an executive summary of the program to Hospital Administration. The business plan will provide the foundation for this presentation.
You should select a presentation style that is comfortable for you. This may include the use of transparency overheads, flip charts; and/or a computer projection device. However, the business plan can be used as a leave-behind; providing those who participate in this meeting with more detailed information.
Establish a Blood Conservation Committee
|Establish an in-hospital Blood Conservation Committee|
Once program approval has been established, you should develop a committee to assist in the development of your Blood Conservation program. Ideally; you will also enlist the support of your initial team members in recruiting new membership.
Additional team members should include representatives from:
- Pre-admission (particularly a nurse manager)
- Hematology and/or Transfusion Medicine, Anesthesiology, Surgery
- Nursing (OR, Post-Anesthetic Care Unit, In-patient Unit, Clinical Unit, Pre-Admission)
- Blood Bank
- A representative from patient services
- Information Technology (IT)
- Perfusion Services (if applicable to the institution)
- Autologous Clinic (if applicable to the institution)
Organize a Meeting
|Organize a meeting for your Perioperative Blood Conservation Committee|
Once you or a member of your initial team has met individually with each potential Committee member; you should establish a meeting for the group to begin work.
As a follow-up you should:
- Send a letter to the entire Blood Conservation Committee confirming their commitment to the committee using an Introductory Letter and,
- Confirm the date, venue and Agenda
Conduct a Meeting
|Conduct a meeting with your Blood Conservation Committee|
Your first meeting will be an ideal time to re-use the presentation you prepared for senior administration. This will give everyone an opportunity to begin at the same level of understanding in terms of both the present; as well as future needs of the program.
Identify Roles and Responsibilities
Identify Roles and Responsibilities of Committee Members
You will also want to identify roles and responsibilities for your Committee members. This includes the identification of individuals; who will be responsible for producing one of various different components involved in implementing the program.
Timelines for each task should also be developed and summarized for the group to measure their progress. Your toolkit contains a Task Chart; which can be used as a summary of all agreed upon tasks, timelines, as well as responsibilities.
Activities necessary to establish the program include:
A Program Benchmark
As a matter of fact, if you had existing data, you may have used it within your business plan. If not, you may have been able to use data produced from a similar program at another institution to state your case; but now you must benchmark the program using your own data. Program Measurement will help you in identifying key data elements for use while conducting a retrospective chart review. (i.e. a chart review on blood utilization in your own institution. You can point out what specific types of surgeries have the highest transfusion rates.)
A Patient Care Map
The purpose of a Patient Care Map is to identify when and where the patient interacts with healthcare professionals; until the time of their surgery. This includes the identification of services administered during the time of the patient visit. In order to create a patient care map; you will need to consider several elements including:
- Surgical Type (Orthopedics, Neurosurgery, etc.)
- Surgical Consult (see Setting Up the Program)
- Timing before the surgical date
- Current Informed Consent practices
- Current practices for managing a Jehovah’s Witness Patient
- Establish the Pre-Admission Process (see Setting Up the Program)
- Who establishes the pre-admission date versus surgical date?
- Is there currently enough lead-time to establish preoperative blood conservation strategies? If not, how can this be changed? You will need a 2-4 week lead-time.
- Does Pre-admission or the General Practitioner conduct:
- Patient History;
- Anemia Assessment (see Setting Up the Program)
- Hematological Assessment?
- What is the length of time spent by the patient in pre-admission? What consultantions and testing can take place during this time? Who will intervene with a preoperative blood conservation strategy? (see Setting Up the Program)
Once developed, the Patient Care Map will help you to:
- Develop patient education tools and understand the best place for their intervention;
- Identify where specific data elements can be collected;
- Identify what other potential resources exist to assist in the development of the guide;
- Develop a Surgical Algorithm.
- A Surgical Algorithm (see Setting Up the Program) should include the establishment of:
- A preoperative hemoglobin benchmark for intervention with a blood conservation strategy;
- Inclusion/exclusion criteria for available and future blood conservation strategies;
- Key decision points before the surgery takes place.
- Specifically, the Surgical Algorithm will require you to ask questions pertaining to:
- The use of therapy such as iron and folic acid by the patient;
- The implementation of preoperative, intraoperative and postoperative blood conservation strategies;
- Elements which may cause the surgery to be delayed;
- The predictors of allogenic transfusion.
- A Surgical Algorithm (see Setting Up the Program) should include the establishment of:
Patient Education Materials
There may be a wide range of materials necessary to establish your program within a surgical practice. However, it is important to remember that these tools can be developed over time. Initial pieces may include:
- A patient pamphlet outlining available Options.
- Patient instructions on Preoperative Autologous Donation.
Healthcare Professional Materials
This may include numerous pieces; but more importantly, must reflect the needs of your Patient Care Map.
- Presentation material to highlight the Blood Conservation program and the benefits by specialty or job function. Hospital Administration, Program Implementation and Evaluation, Program Introduction, Surgery Continuum, Program Update, Anemia Series.
- Patient criteria for Inclusion and Exclusion in various blood conservation strategies. (See Setting Up the Program)
- Guidelines for patient history and anemia assessment. (See Setting Up the Program).
- Pre-admission booking instructions to ensure 2-4 week lead-time with pre-admission. (See Setting Up the Program.)
- GP/FP Instructions on the administration of epoetin alfa and the need to have an accurate hemoglobin level, on behalf of the patient coming into the preadmission unit. GP/FP Hb Instructions
- Frequently Asked Questions (FAQ’s)
- Physician Information – PAD
Informed Consent Guidelines
Most hospitals already have some existing tools for practicing Informed Consent. When a Blood Conservation program is implemented, patients must be made aware of available alternatives in addition to consenting for both the surgery and receipt of blood. (See Informed Consent for more details)
Perioperative Blood Conservation Coordinator (PBCC)
As we have already discussed, this position may not be needed. If you did decide to acquire a dedicated nurse for the purposes of the program; a member of the Committee will need to:
- Formalize a job description
- Establish a reporting and salary structure
- Identify status of position as per hospital policy
- Identify the appropriate process for identifying potential candidates
|Establish Regular Meeting Times and Minute Taking|
Here’s what’s important
It is important that your Committee meet at regularly scheduled intervals. These times should be established clearly and identified before the completion of each meeting. The success to launching your program will be to keep the momentum moving; as these initial phases of introduction are completed.
Included in this process; is the task of recording Meeting Minutes to ensure that key decisions and responsibilities are not lost over time.
It will also provide motivation to the Committee; who needs assurance that progress is being made. Meeting minutes will also provide a continual selling opportunity for healthcare professional and senior administration support; as well as acknowledgement of a well-organized program.
For the Patient
(Use the Glossary to help you define terms in italic)
While the supply of blood in Canada is the safest it has ever been; little progress has been made nationally in educating physicians and consumers on, and standardizing the practice of Transfusion Medicine in Canada. Recently, many physicians across Canada have made attempts to develop national guidelines for blood products and alternatives; which will provide evidence-based material for physician/patient discussions.
What is a Blood Product?
Blood taken from donors is used for:
- Non-manufactured products, which include red blood cells, fresh frozen plasma, platelets, and cryoprecipitate
- Manufactured products made from plasma which includes coagulation factors, plasma proteins, and albumin
Indications for Transfusions:
Since the tragedy of the 1980’s; the indications for transfusion of blood products have been studied and guidelines established.
Basically, a transfusion may be needed if:
- You lose more than 20% of your blood, i.e. 4 cups;
- You are anemic (anemia) and there is medical concern about oxygen carrying capacity;
- And your platelet or clotting factors are low or not working properly.
Co-existing medical conditions; such as cardiac and respiratory disease may necessitate a higher transfusion trigger before red blood cells are given. Your physician will utilize these guidelines; and a thorough understanding of your medical history, to determine your transfusion requirements to see you through your surgery safely.
What are the Infectious Risks of Transfusion?
Blood is collected from healthy volunteer donors who are screened by the Canadian Blood Services (CBS). Each unit of whole blood is tested for various viruses that cause various diseases; such as Hepatitis B, Hepatitis C, and various forms of HIV. As a result of these tests; the risk for contracting any of these diseases from a blood transfusion is extremely low.
Currently the greatest risk for infectious transmission is bacterial contamination from handling and storage of collected units. CBS recently introduced nucleic acid testing (NAT) for Hepatitis C; which allows for quicker identification of potentially contaminated units.
NAT testing is also being considered for HIV screening.
Infectious Risks of Transfusion
|HIV*||1 in 913,000|
|Hepatitis B||1 in 83,000 to 1 in 200,000|
|Hepatitis C||1 in 250,000 to 1 in 500,000 or less|
Bacterial Agents (sepsis)
|1 in 10,000 morbidity from platelets; <1 in 1,000,000 for fatal reactions from red blood cells.|
|Hemolytic Reactions (acute)||1 in 24,000; fatal 1 in 600,000|
|Hemolytic Reactions (delayed)||1 in 2,500; fatal 1 in 6,000|
* Adapted from the Physician’s Guide 2001, Informed Consent for Blood and Products, produced by the British Columbia Provincial Coordinating Office.
|For more information go to www.healthlinkbc.ca|
Non-Infectious Risks of Transfusion.
While much attention has been focused on the infectious risks of blood transfusion; the greatest risk, in terms of morbidity and mortality, comes from non-infectious causes. Various factors including clerical errors, age of the collected units, and the amount and spee;d in which units are transfused, can lead to many potentially major complications. Your physician takes all of these issues into consideration before a blood transfusion takes place.
Sometimes there is incompatibility between a unit of donor blood and the recipient’s blood; which can cause a breakdown of red blood cells in the recipient. Your doctor will use a testing method before the transfusion, called “cross-matching” to ensure that this does not take place. Despite this, various factors; including clerical error; have led to incompatible units being transfused.
Febrile or pruritic reactions occur in up to 1 per cent of transfusions. These reactions are due to the presence of trace proteins; such as white blood cells (WBC) and platelets in the unit of red blood cells. Usually these reactions can be treated and the transfusion allowed to continue. The recent introduction of WBC leukocyte ; depleting filters by CBS should further reduce the incidence of these reactions.
Some studies have suggested that blood transfusions may increase the chances of infection or malignancy occurrence by altering the recipient’s immune system. While such studies are inconclusive; the introduction of leukocyte-reducing filters may be protective.
Effects of Aging Donor Blood.
Red blood cells can be kept in refrigerated storage for up to 35 days. However, over this time, changes in the binding of oxygen to hemoglobin and potassium levels contained in this blood, can occur. This can effect the ability of the red blood cells to release oxygen once transfused, an important reason to replace hemoglobin using a blood transfusion.
However, the blood transfusion can also increase potassium levels; which can be associated with cardiac complications, including palpitations; and in extreme cases, cardiac arrest (heart failure).
Is defined as significant bleeding as seen in trauma and some surgeries; where 10 or more units of red blood cells have been transfused within 24 hours. Massive transfusion of red blood cells and other fluids causes a dilution of platelets and clotting factors. This may result in further blood loss due to a dilution coagulopathy.
Therefore, other blood products such as platelets, fresh frozen plasma; and cryoprecipitate may be required to restore normal levels of these clotting factors. Because red blood cells are stored at 4° Celsius, hypothermia can occur with massive transfusions despite the utilization of fluid warmers. Hypothermia below 34 degrees Celsius is associated with a coagulopathy and a poorer outcome in trauma patients.
Alternatives to Blood Transfusion.
The major focus in the perioperative period is the development of strategies; along with the implementation of various modalities, to reduce the chances of requiring a blood transfusion. The indications for blood products are either medical or surgical.
Recombinant technology has replaced the need for blood products in some medical conditions; as well as blood substitutes are being actively researched for use during surgery. Unfortunately, access to strategies or blood conservation modalities vary from region-to-region and hospital-to-hospital. Following are the blood conservation modalities that are currently available.
Alternatives to Blood Products
|Autologous Pre-Donation||Refrigerated (35 days); frozen blood from patient|
|Surgical techniques||electrocautery; tourniquets; lasers|
|Medications||Iron; antifibrionolytics; erythropoietin|
|Anesthesia techniques||regional anesthesia; hypotensive technique|
In elective surgery where blood transfusion is anticipated, certain patients may be able to donate their own blood. One to four units of blood may be pre-donated during the 35 days prior to surgery depending on the patient’s medical status and hemoglobin level. Iron therapy should be initiated during this period of time.
This process is more costly than the regular donor service and is also less efficient in that 40 to 80 per cent of these units end up being discarded. The reason is because there is not enough surgical blood loss to warrant a transfusion. There is also some concern that these autologous units may end up being transfused when they are not indicated; because there is a false sense of security that it is the patient’s own blood. Therefore, it is safe. As stated previously; human error has resulted in the wrong units being transfused. Nonetheless, the indication for transfusion of autologous units should be the same as donor blood.
In this process, at the time of surgery; 20 to 40 per cent of the patient’s blood is removed and replaced with non-blood solutions. As a result there are fewer red blood cells lost with bleeding; because the blood lost contains fewer red blood cells. After the surgical blood loss is over; the blood removed earlier in the operative period is returned to the patient.
Surgical and Anesthesia techniques.
The use of electrocautery, laser; as well as new surgical techniques have resulted in a marked decrease in the amount of blood lost during surgery. Similarly, regional anesthesia and controlled hypotension (low blood pressure); are two anesthetic techniques that reduce blood flow and blood loss at the surgical site.
This is used in non-cancerous or non-tumor surgeries in which a large amount of blood loss in anticipated (vascular, orthopedic, trauma); the blood is collected through specialized suction catheter. Then the blood is washed, removing any contaminants, and red blood cells are returned to the patient. Some centers also use a passive blood loss collector; which can return on-going blood loss to the patient through an appropriate filter without washing out some important proteins in the plasma removing any contaminants.
Pre-operatively, iron, folate; or Vitamin B12 therapy can be employed to correct deficiency in stores that may be causing anemia. Erythropoietin can be used to stimulate the bone marrow into producing red blood cells providing sufficient iron (ferritin) stores. Peri-operatively, antifibrinolytics; such as aminocaproic acid, tranxemic acid, and aprotinin prevent further bleeding by blocking the breakdown of clot, which would lead to more bleeding.
Currently, there are no oxygen carrier substitutes available; however, two types of artificial oxygen carriers are currently undergoing clinical trials.
Although the regulatory controls of the Canadian blood system have federal jurisdiction, the provinces control the actual supply and utilization. The Canadian Blood Services reports to the provincial Health Ministries, as do the hospitals. One issue that has not been resolved in many provinces, despite being legislated in some; is the issue of informed consent for the transfusion of blood products.
As a matter of fact, some argue that blood transfusions are a treatment like antibiotics that should be covered in a general consent form; while others state that blood products are living tissues and therefore warrant special consideration. Certainly the public, in response to past tragedies; expects the right to be informed of all risks and benefits of blood transfusion and blood conservation strategies.
On another note; many hospitals have developed patient information pamphlets that explain most of the risks as well as benefits. British Columbia has provided a Physician’s Guide as a resource to assist with patient’s concerns and questions.
Blood products are the safest they have ever been. However, the risk of contracting a viral infection or having a severe negative outcome are extremely remote at this time. The guideline for blood transfusion and the use of blood conservation strategies is inconsistent across Canada. Whether or not a patient receives a transfusion; depends to some extent on where the patient lives and the physicians involved in their care.
If alternatives can be shown to be as safe as blood products, their cost-effectiveness needs to be explored. As well, contingencies have to be developed in the event that blood products ever again become a safety issue; or that the demand outstrips the supply.
- Thi is a rotein found in the blood plasma.
- A condition in which a patient has fewer than a normal number of red blood cells or amount of hemoglobin.
- An allergic reaction to a foreign body which can be life threatening.
- A drug that retards the break down of blood clots.
- Blood or Blood Products:
- Replacement of blood and/or blood products due to insufficient levels.
- Clotting Factors:
- Factors that assist the blood in the process of coagulation.
- Coagulation Factors:
- Factors that assist the blood to clot.
- A concentrated preparation of Factor VIII, fibrinogen and vW Factor, prepared by cold precipitation of plasma.
- The process of reducing the concentration of a solution or substance.
- Dilution Coagulopathy:
- An abnormality of coagulation due to the dilution of coagulation factor.
- A person who givers (or donates) their blood.
- A hormone produced in the kidney that stimulates red blood cell production.
- Having a fever.
- Folic Acid:
- This is a vitamin of the B complex required for normal bodily functions.
- A protein rich in iron.
- An iron-containing protein in red blood cells that carries oxygen to the body s organs and tissues.
- Blood pressure lower than normal.
- Body temperature lower than normal (usually below 36° Celsius).
- Element found in hemoglobin.
- A white blood cell.
- The clear fluid of blood and lymph in which cells are suspended.
- A cellular component of whole blood that is important in the process of blood clot formation.
- Regional Anesthesia:
- Blockade of the sensory and often control of muscle function, using local anesthesia. (e.g epidural or spinal anesthesia)
- Red Blood Cells:
- A cell in the blood which contains hemoglobin and transports oxygen to vital organs.
- Transfusion Trigger:
- The hemoglobin level at which a physician may decide to transfuse a patient.
- Vitamin B12:
- This is a substance found in certain foods (and supplements) that is necessary in small amounts for normal bodily functions.
Patient Checklist :
- Was I informed that I might need blood during my surgery?
- Was I informed of the risks and benefits of a blood transfusion?
- What are the possible complications of receiving a blood transfusion from donated blood?
- What are the risks of not having a blood transfusion?
- Do I understand the importance of my hemoglobin prior to surgery?
- What are my alternatives to receiving donated blood?
- Why would I pre-donate my own blood?
- Can I get reactions to my own blood?
- If I do decide to pre-donate my own blood; what do I need to do to prepare? Example diet, iron pills, fluids
- What happens to my blood after I have donated?
- How many units would I need to donate?
- Will I get my own blood back during or after my surgery?
- What if I did not donate enough blood?
- What are the side effects of Erythropoietin?
- Where do I receive my injections?
- Do I pay for Erythropoietin?
- Will my surgeon be using anything during my operation to decrease my changes of receiving blood?
- Can I refuse a blood transfusion?
- Is there any literature/pamphlets/video that I can take home and read about blood and blood conservation?
- If I have more questions who can I call?
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