SAVING BLOOD, SAVING LIVES
Unnecessary transfusions and an expected donor shortage are behind a Canada-wide study that includes Royal Columbian and VGH
Routinely topping up patients with a pint of blood before surgery is now an old-school approach in Canada as hospitals try to preserve a precious resource while avoiding dangerous complications.
And these new blood conservation techniques may have also saved Bill Gardiner’s life.
As a Jehovah’s Witness, the 80-year-old South Surrey resident declined all transfusions last February as he headed into emergency heart surgery to repair a torn aorta, even though his surgeon told him he would likely die on the operating table. He’d arrived at hospital with unbearable pain in his neck and shoulder; no sensation at all in his legs. Gardiner was on blood thinners which meant a greater risk of fatal bleeding during the 10 hours of surgery ahead.
Almost a year later he says he’s “doing pretty much everything I did before — but maybe just a little bit slower.”
Although Gardiner’s faith-based rejection of blood products sets him apart from most Canadians, his experience in the operating room is becoming more common. Advances in surgical techniques mean less bleeding during many operations, even cardiac procedures which traditionally required heavy blood use. And his body’s ability to form clots was monitored throughout the operation by a device that’s being tested in 12 hospitals across Canada to see if it helps conserve blood.
Dr. Sukh Brar is an anesthesiologist at Royal Columbian Hospital in New Westminster who was part of Gardiner’s surgical team. The machine under study is called ROTEM (short for rotational thrombo-elastometry), an advancement on traditional methods of analyzing blood which require up to an hour to run a sample to a lab and back.
“I want to know within five or 10 minutes what exactly the patient needs in the operating room when they’re critically ill,” says Brar. “These new cutting edge tests allow us to deliver the right product to the right patient at the right time for the right reason.”
Test indicates which, if any, blood products are needed — red blood cells, platelets or plasma — a duty that falls to the anesthesiologist during surgery.
Research over the past decade has shown patients can come out in better shape if doctors carefully monitor them before, during and after surgery to determine if blood is really needed rather than administer an unquestioned transfusion.
“People understand there are complications from any treatment,” says Brar. “We’ve seen both at our hospital and throughout Canada that as sites become more critical in appraising who needs blood transfusions, the complication rates have gone down and patients have improved outcomes.”
Documented problems arising from blood transfusions include receiving the wrong type, infections, allergic reactions, changes in the immune system or iron overload in the blood.
The current study involving cardiac units at Royal Columbian and Vancouver General Hospital and 10 others across Canada is an expansion of research led by Dr. Keyvan Karkouti of Toronto General Hospital’s anesthesiology department. His study, to be published in January in the journal Anesthesiology, compared 1,300 patients who had heart surgery as usual in 2012 with 1,200 similar patients who had operations in 2013 under a blood-conservation plan. Doctors noted the amount of blood lost over a five-minute period along with results of blood tests conducted in the operating room to decide which blood products to administer. It found transfusions of red blood cells, platelets and plasma fell by about half with no harm to the patients. Damage to kidneys from inappropriate transfusions also fell in the second group.
Taking such a standardized approach marks a dramatic change from the current practise of deciding what’s best for the patient based on the experience of the medical team at hand in the operating, says Brar.
Ontario is the only province with an official blood-conservation program called OnTraC which Brar says could be a model for B.C. hospitals because it’s been shown to save money while enhancing patient health.
Long before an operation, there are ways to reduce the chances that a blood transfusion is needed, says anesthesiologist Dr. Terry Waters who is coordinating VGH’s participation in the study. VGH has had a blood management program since 2002 that can prepare patients months before a scheduled high blooduse operation such as repeat knee and hip replacements, spinal surgery or removing cancerous tumours from the bladder or uterus.
Forty per cent of non-cardiac patients are anemic before surgery, says Waters, a condition in which there are not enough healthy red blood cells to carry oxygen throughout the body. It can be caused by chronic illness and internal bleeding, which are more difficult to treat before an operation, but also by low iron in the blood which is simple to correct with medication if promptly detected.
“The big problem is getting patients referred to us in a timely fashion,” says Waters.
Blood boosters, like the type used illegally by world-class cyclists to improve their performances, can also help patients before surgery. The once-promising practise of donating some of one’s own blood has fallen out of favour, he says, because most of it was never used.
During surgery, it’s also possible to administer medications such as tranexamic acid to stop blood clots from breaking apart. Or recycle a patients blood through a “cell saver” which reduced VGH’s use of red blood cells by about 3,000 units, or 10 per cent, this year.
Dr. Dana Devine, chief medical officer at the Canadian Blood Services and a professor of pathology and laboratory medicine at the University of British Columbia, says blood management in hospitals has been evolving for years, but has picked up speed as a number of factors converge. It began in the 1980s with Canada’s tainted blood scandal and the realization that the “gift of life” could also harbour diseases like HIV/AIDS and hepatitis C. Restrictive rules for blood donation that followed caused shortages as donors stayed home. Now Canada’s aging population is expected to turn a large portion of blood donors into blood users.
As a result, Canada has already reduced its per capita use of blood to below countries such as Germany and Denmark, she says.
“We used to think blood was a pure, natural product,” says Devine. “If you were to talk to anesthesiologists who have been practising for 25 or 30 years, they’ll all tell you how little blood is transfused today compared to 30 years ago.”
The idea that no patient should be anemic at any time, for instance, has gone by the wayside. Now they might be given intravenous fluids rather than whole blood after surgery to keep up the volume of liquid in their bodies.
“If someone is lying in bed recovering from surgery, they don’t need the same level of red blood cells that you or I might if we’re going to run 10 k.”
Despite advances, demand for blood products is still driven by car crashes, most heart surgery and chemotherapy, says Devine.
And because blood is discarded after 42 days of storage, a constant supply is needed.
“We try to keep the balance between supply and demand as close as we can,” she says. “These changes don’t mean that we’re no longer in need of blood donors.
I want to know with in five or 10 minutes what exactly the patient needs in the operating room when they’re critically ill. These new cutting edge tests allow us to deliver the right product to the right patient at the right time for the right reason DR. SUKH BARR ANESTHESIOLOGIST AT ROYAL COLUMBIAN HOSPITAL