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Physician Update - Call It a Bloodless Coup

Physician Update Spring 2013

Call It a Bloodless Coup

Date: April 1, 2013

Hopkins uses some 60,000 units of blood products a year. “That alone,” says Steven Frank, “justifies prudence.”
Hopkins uses some 60,000 units of blood products a year. “That alone,” says Steven Frank, “justifies prudence.”

Though some form of the “bloodless surgery” that lowers the need for transfusions has been around almost two decades, a new body of clinical research looks to cement its hold at Johns Hopkins and extend it to more patients. Also, new work suggests now may be the time to rethink assumptions about blood-banking. 

“We’re seeing that we can do a lot more with less blood during surgery and afterward,” says anesthesiologist Steven Frank, medical director of The Johns Hopkins Hospital’s umbrella program for bloodless medicine and surgery. “Our aim is to reduce transfusions by 10 to 20 percent throughout our medical system. 

“The tactics we use don’t only benefit those who traditionally refuse transfusions for personal concerns about contamination or, like the Jehovah’s Witnesses, for religious beliefs. We’ve come to see bloodless surgery as best practice for more patients in general.”  

What drives the new goal, Frank says, are four landmark studies—the most recent including Johns Hopkins data. All the trials followed large numbers of patients during hospital stays, comparing survival based on whether or not their hemoglobin levels had been boosted by transfusions. The trials varied in details, though all involved very sick people experiencing blood loss. 

“The bottom line,” says Frank, “was that patients held to a lower hemoglobin reading before getting transfusions* did just as well or better than those transfused at a traditional higher triggering point. So we see no advantages in routinely giving extra blood. All you do is introduce cost and risk.

“Transfusions aren’t necessarily benign,” he adds. Transfused patients are two to three times more likely to get acquired infections. Also, receiving donor blood sparks antibodies that work against future transfusions.

Just-out work from Hopkins adds another consideration: the blood supply. Yes, worldwide shortages exist in banked blood. But banking itself warrants a second look. Blood banks’ equivalent of a “sell by” date—six weeks—is likely off, Frank says. He and colleagues show that blood starts becoming “stale” after three weeks. Red blood cell membranes stiffen, which can slow passage in capillaries. That likely explains transfused patients’ slightly higher risk of cardiac complications.

One remedy, however, lies in reducing blood bank demand. 

 So the hospital program goes beyond modern tactics that recycle blood lost during surgery, shrink operating fields through robotics or beef-up patients’ presurgical red cell count. Tactics are increasingly patient-tailored. And research continues on best practice. A large hospital database, for example, showed Frank’s team how a simple $9 IV-based device that one Hopkins critical care unit used halved blood loss during testing.

The benefits of blood conservation, Frank says, are clear: They lower risk. They lower cost. And they improve outcomes.  


*The gold standard has long been 10 grams of hemoglobin per deciliter of blood. Hopkins is considering a new 7-8 g/dl threshold for many patients.


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