Dr. Thomas Kickler, an expert in bloodless surgery as well as conventional, transfusion-based methods, answers common questions about bloodless health care.

Question

Bloodless medicine and surgery is preferred by individuals who have religious convictions that exclude the use of stored blood products. Besides adhering to an individual's religious beliefs, are there other reasons why bloodless surgery might be the preferred method?

Dr. Kickler

Some patients cannot receive blood transfusions because their bodies have already made antibodies against the markers found on some red blood cells. This means that if they are given red blood cells with these markers, their antibodies will automatically attack and destroy the transfused red blood cells. The medical consequences of this reaction (called alloimmunization) can be very serious. It may not be possible to find fully compatible donor blood that will not provoke this reaction.

Other patients are concerned about the risk of disease transmission and refuse donor transfusions.

Question

What conditions are particularly amenable to bloodless techniques?

Dr. Kickler

Bloodless techniques are best applied to elective surgical procedures in which there is a predictable amount of blood loss.

Question

Are there conditions that might be less amenable to bloodless techniques? How about other factors, such as age and gender, that might make an individual a less promising candidate for bloodless surgery?

Dr. Kickler

Patients who are suffering from severe anemia, who are experiencing an active hemorrhage, who are known to have disorders that interfere with blood clotting, who have suffered trauma, or who require a liver transplant are sometimes more difficult to manage, unless they are treated by a team that is very experienced in transfusion-free medicine.

Question

Would you expect more complications in patients undergoing bloodless procedures?

Dr. Kickler

Yes, although some of these complications are dependent on whether the patient delays in coming to the hospital and initiating treatment, and whether complications of anemia, bleeding, and shock have already set in. Furthermore, the complication rate is dependent upon the specific diagnosis, patient's age, and the presence of other complicating illnesses, such as heart disease.

Depending upon the specific type of therapy or procedures employed, there may be increased risks. For example, acute normovolemic hemodilution, a procedure done to expand the liquid portion of the blood volume, may not be safely done in severely anemic patients, or in patients who have severe heart disease. This procedure is sometimes performed prior to surgery, so that when bleeding occurs, a smaller number of red blood cells are lost, proportionately, when compared with bleeding without hemodilution.

Iron is often given to patients with iron deficiency in order to stimulate blood production. Treating patients with intravenous iron, however, may result in severe allergic reactions. Some patients are given hematopoietic growth factors, such as recombinant human erythropoietin, a natural hormone produced by the body to stimulate red blood cell growth. These medications may not be appropriate for all patients. Using some pharmacologic hemostatic agents may have side effects; aprotinin is associated with allergic reactions, and aminocaproic acid may cause blood clots or a condition called disseminated intravascular coagulation.

Question

Should a patient go anywhere in particular to seek bloodless treatment? What should a patient look for in a bloodless surgery center? In a surgeon?

Dr. Kickler

It is important that patients who wish to receive bloodless care try to seek treatment in an institution with an organized bloodless medicine program. It is preferable that the institution have practice guidelines in place, and that the medical care team be specifically trained and experienced in bloodless medicine. Surgeons, anesthesiologists, hematologists, and nurses are all integral parts of a successful bloodless medicine program.

Dr. Thomas Kickler serves on the editorial board of Transfusion and The Journal of Transfusion Alternatives. He is board-certified in three specialties: internal medicine, and hematology. Dr. Kickler is professor of medicine, oncology, and pathology at the Johns Hopkins University School of Medicine.