Step 7: Strategies and techniques during surgery
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Albumin: This major protein constituent of blood is often given to individuals who need to retain more fluid in their bloodstream, such as burn victims or patients with liver failure or extremely heavy bleeding (hemorrhage). Albumin (along with clotting factors, growth factors, and immunoglobulins) is sometimes referred to as a minor blood fraction. If you are a Jehovah's Witness, whether or not you can accept treatment with a minor blood fraction may be considered an individual "matter of conscience."

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Allogeneic blood: Blood donated from another individual, which is typically stored and then provided through a transfusion. Jehovah's Witnesses do not accept allogenic blood.

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Anemia: A condition in which an individual's blood can't supply an appropriate amount of oxygen to their organs and tissues, either due to a low volume of blood, too few red blood cells in the blood, or too little hemoglobin or iron in the red blood cells. Patients who are suffering from severe anemia are sometimes more difficult to manage, unless they are treated by a team that is very experienced in transfusion-free medicine.

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Apheresis: A process used to obtain blood components (such as platelets) from a donor. The blood is removed from the donor, the necessary cells are harvested and retained, and the donor's plasma is returned to the donor. Donated platelets are considered a major blood fraction and are not acceptable to Jehovah's Witnesses. However, "therapeutic apheresis" may be acceptable to some Jehovah's Witnesses because it is a treatment performed on the patient's own blood.

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Blood banking: This is when blood is donated by a person for their own use or a specific individual's use at a later time. It is usually done because of fear that donor blood will not be available or might have contaminants, or because the person has a rare blood type. This procedure is not "bloodless medicine" because it involves blood storage and blood transfusions.

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Blood salvage: Blood salvage procedures collect blood lost during or after surgery. A variety of methods may be used to collect blood, including suction and drainage devices. The devices that are used are sometimes called "cell savers." Those who object to blood transfusions may feel comfortable with "closed loop" blood salvage, where the blood is never stored and retains a semblance of connection to the patient at all times.

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Cautery: Deliberate surgical destruction of tissue, either because the tissue is abnormal or to seal off a bleeding area. Cautery is a method of reducing bleeding during transfusion-free surgery. It may be achieved through heat, freezing, chemical scarring, electricity, light, and ultrasonic or microwave energy.

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Cell savers: Devices that capture and hold blood during or after surgery, so that the blood can be returned to the patient.

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Clotting: The complex chain of chemical events that produces a plug (clot) at the site of bleeding. It is important for a patient undergoing transfusion-free surgery to have good clotting ability, in order to reduce bleeding/blood loss. Certain medications may interfere with clotting, such as aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs; anticoagulants (such as Coumadin); vitamin E; and herbal preparations containing garlic or ginkgo biloba.

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Clotting factors: Chemicals that circulate in the blood and interact together to help cause blood clotting at the site of an injury.

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Coagulation: The conversion of liquid (blood) into a somewhat solid plug that can prevent further bleeding from a particular site.

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Colloidal solutions: Intravenous fluid solutions that contain water, salts, sugars, and protein. They may be given to replace the fluids, salts, and sugars that you will invariably lose during the course of surgery. Some colloidal solutions contain albumin -- a protein whose use is a matter of personal conscience for Jehovah's Witnesses.

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Cryosurgery: A surgical technique that uses extreme cold to destroy abnormal tissues in the body. It is sometimes used as a bloodless medicine technique -- by freezing tissue, bleeding is minimized.

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Crystalloid solutions: Intravenous fluid solutions that contain water, salts, and sugars. They may be given to replace the fluids, salts, and sugars that you will invariably lose during the course of surgery. Jehovah's Witnesses find cystalloid solutions such as Ringer's lactate and normal and hypertonic saline acceptable therapy.

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Donor: A person who gives blood. The donated blood may be stored and distributed to hospitals and medical centers to be given to a patient when needed (as a transfusion). When a patient receives whole blood in this way, this is considered traditional medicine -- NOT "bloodless medicine." However, donated blood may be used to harvest blood components that may be used during some bloodless procedures.

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Embolotherapy: Refers to various methods of blocking a bleeding blood vessel, preventing further blood loss. These include chemical agents that scar the inside of the blood vessel; mechanical agents that block a bleeding vessel, including metal coils and latex or silicone balloons; particles or microspheres, including gelatin foam; and injected liquid that quickly turns into a thicker gel-like or spongy mass to prevent bleeding from a vessel.

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Endoscopy: A scope that can be used to visualize the inside of the body, either through insertion into a tiny incision or by passing the scope through a body opening (such as the mouth or anus). Endoscopy is used to examine, biopsy, or surgically treat a variety of conditions. Types of endoscopy include arthroscopy (joints); bronchoscopy (bronchial tubes, lungs); colonoscopy/sigmoidoscopy (large intestine); colposcopy (vagina, cervix); gastroscopy (stomach, small intestine); laparoscopy (abdomen); and others. Endoscopy is considered a "minimally invasive" procedure, which results in reduced bleeding. It is therefore a valuable bloodless medicine technique.

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Erythropoietin: Erythropoietin is the name of a chemical normally produced by your body, primarily by your kidneys. Erythropoietin stimulates the bone marrow to produce red blood cells. Laboratory-made synthetic erythropoietin (e.g., Procrit, Epoetin alfa, Epogen, or Aranesp) may be administered prior to a bloodless surgery procedure in order to maximize your bone marrow's production of red blood cells. Other synthetic chemicals that mimic the activity of erythropoietin are in development.

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Fibrin glue: A substance made from human clotting factors. These clotting factors can be harvested from donor blood plasma or from a patient's own blood plasma. Fibrin glue can be applied to a bleeding vessel. It both blocks the vessel from bleeding and activates normal clotting/coagulation activity. Because fibrin glue is made from blood products, each individual will need to examine their own conscience to decide if its use is personally acceptable.

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Fluid expanders: Intravenous fluid solutions that are used to increase the volume of fluid in the circulating blood. The result is that when you bleed during surgery, your diluted blood contains a lower concentration of red blood cells.

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Gamma knife: A high-tech surgical tool that can be used for brain surgery. This technique utilizes a powerful and precise form of radiation to destroy tumors or abnormal blood vessels with less blood loss than a traditional scalpel.

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Harmonic scalpel: A surgical tool that uses ultrasound waves to cut tissue and seal bleeding vessels at the same time -- a helpful characteristic in transfusion-free surgery, because it helps keep blood loss to a minimum.

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Hemodilution: The process of making blood more dilute than normal. The result is that when you bleed during surgery, your diluted blood contains a lower concentration of red blood cells.

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Hemoglobin: A chemical within red blood cells that allows oxygen to be carried throughout the body.

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Hemophilia: A disease in which the blood clotting system is defective, resulting in an increased likelihood of serious bleeding after even minor injury.

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Hemorrhage: Heavy bleeding.

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Hemostasis: To stop bleeding.

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Hyperbaric: To be at higher-than-normal atmospheric pressure. Hyperbaric oxygen therapy is used in some facilities to assist bloodless medicine in certain situations. You enter a chamber and breathe pressurized oxygen, which concentrates oxygen in your blood.

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Hyperoxic: Having higher-than-normal oxygen saturation.

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Hypotensive: Having low blood pressure. Hypotensive anesthesia is a technique that lowers a patient's blood pressure below normal during surgery. Blood loss tends to be slower when your blood pressure is low. However, blood pressure must be maintained at a particular threshold to ensure that all of your body's organs and tissues are receiving blood, so the practice of hypotensive anesthesia requires great skill and extraordinarily careful monitoring.

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Intraoperative: During the course of an operation.

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Iron: A nutrient that is required by your red blood cells for good oxygen-carrying capacity. Iron is important for bloodless surgery and can be obtained from dietary sources like red meat or through supplements, such as ferrous sulfate or ferrous gluconate.

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Kidney dialysis: A procedure in which the blood is cleansed of toxins through an outside machine, replacing work that the kidneys normally do.

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Laparoscopy: A surgical technique in which a lighted scope is inserted into a tiny incision in the abdomen. Laparoscopy can be used to visualize the inside of the abdomen for diagnosis, to retrieve tissue samples for biopsy, and to perform surgery using tiny instruments that are also passed into the abdomen through tiny "keyhole" incisions. Laparoscopy is considered a "minimally invasive" procedure, which results in reduced bleeding and may therefore be valuable for bloodless treatment of some conditions.

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Laser surgery: A surgical technique that uses the energy from light to cut through tissues. It can reduce bleeding compared to traditional scalpels and may therefore be valuable for bloodless treatment of some conditions.

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Major fractions: Blood products containing plasma, red blood cells, white blood cells, and platelets. Jehovah's Witnesses do not accept major blood fractions as part of any treatment.

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Mediastinal autotransfusion: A procedure performed most commonly after heart surgery, in which the fluids (including blood) that collect in the chest during and after surgery are collected and then given back to the patient through an IV.

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Minimally invasive surgery: Procedures that use small surgical cuts and holes, or no cuts at all. These methods can greatly reduce the amount of bleeding and are therefore of great importance to bloodless medicine. An example is endoscopy, which uses scopes inserted into small cuts or body openings. Another example is lithotripsy, which uses sound waves to break up a kidney or other stone into smaller bits, allowing it to pass out of the urinary system without having created any incision at all.

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Minor fractions: Blood products containing clotting factors, albumin, growth factors, and immunoglobulins. Some Jehovah's Witnesses accept minor blood fractions as an individual "matter of conscience."

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Normothermia: Normal body temperature.

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Normovolemia: All people maintain a particular volume of fluid circulating throughout their bodies; this is referred to as "normovolemia." During surgery, you will be given balanced intravenous solutions (volume expanders) to replace the fluids, salts, and sugars that you will invariably lose during the course of surgery.

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Oximeter: A device that monitors the amount of oxygen carried by the hemoglobin in red blood cells. In bloodless medicine, any blood a patient loses is not replaced by transfusion, so it is extremely important to monitor how much oxygen the patient's body is receiving from the remaining blood.

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Plasma: The fluid component of blood, in which the various types of blood cells are suspended. Jehovah's Witnesses consider plasma to be a major blood fraction and do not consider it to be an acceptable part of treatment.

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Plasmapheresis: A type of apheresis that is used to separate plasma from blood. Blood is removed from a donor, the plasma is harvested and retained, and the donor's blood cells are returned to him or her. Plasmapheresis may also be performed on a patient's own blood as a treatment for certain conditions.

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Platelet: A component of blood responsible for blood clotting at the point of an injury to a blood vessel. Without platelets, our blood would not be able to clot and hemorrhaging or uncontrolled bleeding would result. Platelets are considered a major blood fraction and are not acceptable to Jehovah's Witnesses as part of any treatment.

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Platelet gel: A concentrate made from a patient's own blood plasma, mixed with calcium and clotting compounds produced in cows. Platelet gel concentrates can be applied during the course of surgery to control bleeding. As with fibrin glue, platelet gel concentrates are produced from plasma, so their use by some individuals is a matter of conscience.

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Primary blood components: Red cells, white cells, plasma, and platelets (also called major fractions). Jehovah's Witnesses do not accept primary blood components (major fractions) as part of any treatment.

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Procuren solution: A solution made from an individual's own blood. The growth factors in the patient's own platelets are harvested, and reproduced in a laboratory to create the procuren solution. This solution is then applied to a wound to improve healing capacity and shorten duration of healing.

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RBC nuclear scan: A test in which the individual's own red blood cells are harvested, tagged with radioactive material, and then returned to the individual. Imaging scans are then performed that will highlight areas of bleeding, because the tagged red blood cells will be seen leaking from these areas.

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Scalpel: Originally, a scalpel was a very sharp, small knife used to perform surgery. Now a scalpel can use a variety of energy sources to cut through tissue, including light (laser scalpel), microwaves (microwave-coagulating scalpel), ultrasonic energy (ultrasonic and harmonic scalpels), and radiation (gamma knife).

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Stereotactic/Stereotaxic: A technique for locating the exact area needing treatment by using advanced imaging techniques that verify the three-dimensional coordinates of the abnormal area. By pinpointing the exact area, the surgeon can minimize the amount of cutting (and hence bleeding) that occurs during surgery.

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Transfusion: The delivery of blood products to an individual to replace blood that is lost during surgery or from injury. The blood or blood products are usually donated anonymously or through blood banking, then stored until the time they are needed. At that point, the blood products are administered through an intravenous (IV) line into a patient's vein. A blood transfusion is what bloodless medicine seeks to avoid.

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Ventilation: To provide a patient with oxygen.

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WBC nuclear scan: A test in which an individual's own white blood cells are harvested, tagged with radioactive material, and then returned to the individual. Imaging scans are then performed that will highlight areas of infection, because the tagged white blood cells will migrate to these areas.

A variety of strategies and techniques may be used during your surgery to keep your procedure bloodless, including those described below.

Monitoring your blood oxygen levels

For bloodless surgery to be a success, it is crucial that your blood oxygen levels be monitored continuously throughout the course of your surgery and recovery. One device used for this purpose is called a pulse oximeter, which clips onto a finger or toe. The device does not require that blood be drawn for testing. Instead, it uses infrared light technology across the skin to provide an estimate of how much oxygen is being carried by the hemoglobin in your red blood cells.

Reducing blood tests

Monitoring hospital patients has traditionally involved regular blood testing, sometimes once or twice daily. When bloodless medicine is practiced, the number of blood tests is reduced as much as possible, and the tests generally employ the latest techniques in "microsampling." Microsampling uses extremely tiny amounts of blood, sometimes only drops, in order to obtain the laboratory information required.

Anesthesia-related techniques

The anesthesiology team can employ a number of techniques to improve the success rate of bloodless surgery, including:

  • Carefully maintained body temperature: In bloodless medicine, it is important to carefully monitor body temperature and keep it from dropping below normal. Some studies have shown that patients who have lower-than-normal body temperatures during surgery (called hypothermia) lose more blood during surgery. Furthermore, when you are chilled and begin to shiver, your system uses more oxygen.
  • Hypotensive (low blood pressure) anesthesia: This technique lowers a patient's blood pressure below normal during surgery. Blood loss tends to be slower when your blood pressure is low. However, blood pressure must be maintained at a particular threshold to ensure that all of your body's organs and tissues are receiving blood, so the practice of hypotensive anesthesia requires great skill and extraordinarily careful monitoring.
  • Hyperoxic ventilation: This is the administration of pure (100%) oxygen during surgery. The oxygen is delivered through a mechanical ventilator, a machine that helps an anesthetized patient breathe. Pressurized oxygen is supplied through a breathing tube inserted through the mouth and into the trachea. Hypertoxi ventilation quickly boosts the concentration of oxygen carried through the bloodstream. Very high levels of inspired oxygen, however, may be toxic to the lungs, particularly if you are taking certain medications (such as Amiodarone).

Research continues to examine the effects of various forms of anesthesia (local, regional or general) on the amount of blood lost during surgery. For example, some research has suggested that if you have spinal or epidural anesthesia for your hip replacement surgery, you may experience less blood loss during surgery than you would with general anesthesia.

Intravenous fluid replacement

All people maintain a particular volume of fluid circulating throughout their bodies; this is referred to as "normovolemia." During surgery, you will be given balanced intravenous solutions (volume expanders) to replace the fluids, salts, and sugars that you will invariably lose during the course of surgery.

Intravenous solutions that contain salts and sugars are called crystalloid solutions. Intravenous solutions that also contain starches, gelatins, or proteins such as albumin are called colloidal solutions. Your health care team may choose to use either crystalloid or colloidal solutions depending on your medical condition, the amount of fluid and blood loss you've experienced, and your blood pressure. Because albumin is harvested from donated human blood plasma, its use is a matter of personal conscience for Jehovah's Witnesses.

Hemodilution

In a technique known as "normovolemic hemodilution," some of your blood is deliberately withdrawn or re-directed, and you receive an equal quantity of intravenous fluids. Thus, your blood is diluted ("hemodilution") but the normal volume is maintained ("normovolemia"). The result is that when you bleed during surgery, your diluted blood contains a lower concentration of red blood cells. At the end of the surgery, the more concentrated blood that was originally withdrawn is returned. When normovolemic hemodilution is performed using a "closed system" (the withdrawn blood continues to circulate and is not actually stored), some Jehovah's Witnesses find this therapy acceptable.

"Intra-operative hemodilution" is a similar technique, although no blood is withdrawn from the patient. Instead, the patient's blood is simply diluted with extra amounts of fluid expanders (intravenous solutions containing salts, sugars, and sometimes other substances like albumin). Again, the theory behind this practice involves diluting the patient's blood so that when the patient bleeds, he or she is losing fluid that contains fewer red blood cells.

Minimally invasive surgery

As with most medical procedures, choosing the least invasive method can frequently result in the lowest risk of complications or blood loss. For example, having a kidney stone removed through a lithotripsy procedure (in which sound waves are used to break up a kidney stone into smaller bits, allowing it to pass out of the urinary system without having created any incision at all) is sometimes preferable to having it removed via an open surgical incision.

Methods to control blood loss during surgery

During the course of nearly all types of surgery, blood vessels will be disrupted, causing some bleeding. The practice of "meticulous hemostasis" refers to a surgical team's scrupulous attention to even the most minute areas of bleeding during the course of surgery. The theory is that by preventing the loss of even small amounts of blood, the surgical team is protecting the patient's red blood cell supply.

A variety of tools exist to quickly stop bleeding blood vessels. Specialized surgical equipment use heat to seal the ends of cut blood vessels (electrocautery), in order to prevent blood from leaking out. The "argon beam plasma coagulator" uses argon gas and high-frequency electrical current to keep bleeding under control.

Learn More

Other ways to block bleeding vessels -- embolotherapy

New "instruments" for surgery

When compared with the old, traditional surgical scalpel, many of the newer instruments for performing surgery have the potential for causing far less blood loss. Such instruments include:

  • High-tech scalpels that combine the ability to cut tissue and seal bleeding vessels at the same time, such as the harmonic scalpel (which uses ultrasound waves) and the microwave-coagulating scalpel.
  • The gamma knife may be used for brain surgery. This technique utilizes a powerful and precise form of radiation that can destroy tumors or abnormal blood vessels.
  • Laser surgery harnesses the energy from light to cut through tissues.
  • Cryosurgery destroys abnormal tissue through freezing.
  • Stereotactic surgery (also called stereotaxic surgery) is often performed on the brain, and involves careful, three-dimensional locating of the area that requires surgery. First, advanced imaging techniques (such as CT and MRI scans) pinpoint the precise location to be operated on. Once this area has been carefully defined, an elaborate frame is created to hold the patient's head in position. The surgery is then performed through tiny "burr" holes in the skull, often using electrodes and electrical current to operate on deep brain tissues.

Patient position

Depending on the type of procedure being undertaken, certain surgical positions decrease bleeding, while maintaining optimal blood flow and oxygen delivery to the most crucial organs (for example, the heart and brain). One such position, the Trendelenburg, places the patient on a downward slope, with the chest and head lower than the abdomen and legs.

Blood-boosting agents and other medicines

During and after surgery, blood-boosting medications and supplements may be administered to stimulate your bone marrow to produce red blood cells and help resolve any anemia that may have developed due to unavoidable surgical blood loss. Agents that may be given include erythropoietin, iron supplements, vitamin B-12, and folic acid. If any of your other blood elements are low, you may be receive Neupogen or GM-CSF to boost white blood cell production and/or interleuken-11 to encourage platelet production.

For heart bypass surgery, liver surgery, and joint replacements, you may be given a protease inhibitor (aprotinin) or antifibrinolytic medication (epsilon-aminocaproic acid and tranexamic acid). These drugs improve platelet functioning and stabilize blood clots, thus reducing the amount of blood lost.

Other medications that might be given to help improve your blood's ability to clot include desmopressin (DDAVP), vasopressin, and phytonadione (vitamin K).

Blood salvage procedures

Blood salvage procedures collect blood lost during surgery (intra-operative blood salvage) or after surgery (post-operative blood salvage). The devices that are used are sometimes called "cell savers."

Blood collected during or after surgery may be cleaned and then returned to the patient, restoring blood levels without the use of an actual transfusion. Some religious groups that object to blood transfusions feel comfortable with blood salvage procedures if they involve completely closed-loop systems, so that the blood is never stored and retains a semblance of connection to the patient at all times.

Intra-operative blood salvage is particularly useful for patients who have undergone:

  • Heart surgery
  • Surgery on the vascular system
  • Orthopedic surgery
  • Liver transplantation
  • Spleen removal (splenectomy)
  • Surgery for an ectopic pregnancy
  • Traumatic injury

A variety of methods may be used to collect blood. Blood collected while using a heart-lung bypass machine during open-heart surgery can be reused, as can blood suctioned from the surgical field and blood that collects within drainage devices.

Some closed-loop systems automatically clean and filter blood before it is returned to the patient. Other systems simply suction up and collect lost blood. These systems require a separate step in order to clean and filter the recovered blood.

Blood recovered from certain types of abdominal surgery may have come in contact with intestinal bacteria (for example, during surgery for a ruptured appendix or perforated intestine). In such cases, the risks of potential bacterial contamination must be examined with respect to the patient's overall condition.

If the patient has suffered life-threatening blood loss, it may be preferable to risk the reinfusion of blood that could be contaminated with bacteria. Similarly, some researchers are concerned that cancer patients who undergo blood salvage procedures might receive blood that contains active cancer cells. The surgical team must carefully consider the risk-benefit ratio for a particular patient in this situation.

 

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Review Date: 5/10/2007

Reviewed By: Corey Cutler, M.D., M.P.H., F.R.C.P.C, Department of Medical Oncology, Dana-Farber Cancer Institute; Instructor in Medicine, Harvard Medical School, Boston, MA. Review provided by VeriMed Healthcare Network.


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