The Divine Law and blood X

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. 

Outcome of Patients Who Refuse Transfusion After Cardiac Surgery: A Natural Experiment With Severe Blood Conservation FREE

Gregory Pattakos, MD, MS; Colleen G. Koch, MD, MS, MBA; Mariano E. Brizzio, MD; Lillian H. Batizy, MS; Joseph F. Sabik III, MD; Eugene H. Blackstone, MD; Michael S. Lauer, MD

ABSTRACT

ABSTRACT | METHODS | RESULTS | COMMENT | ARTICLE INFORMATION |REFERENCES

Background Jehovah's Witness patients (Witnesses) who undergo cardiac surgery provide a unique natural experiment in severe blood conservation because anemia, transfusion, erythropoietin, and antifibrinolytics have attendant risks. Our objective was to compare morbidity and long-term survival of Witnesses undergoing cardiac surgery with a similarly matched group of patients who received transfusions.

Methods A total of 322 Witnesses and 87 453 non-Witnesses underwent cardiac surgery at our center from January 1, 1983, to January 1, 2011. All Witnesses prospectively refused blood transfusions. Among non-Witnesses, 38 467 did not receive blood transfusions and 48 986 did. We used propensity methods to match patient groups and parametric multiphase hazard methods to assess long-term survival. Our main outcome measures were postoperative morbidity complications, in-hospital mortality, and long-term survival.

Results Witnesses had fewer acute complications and shorter length of stay than matched patients who received transfusions: myocardial infarction, 0.31% vs 2.8% (P = . 01); additional operation for bleeding, 3.7% vs 7.1% (P = . 03); prolonged ventilation, 6% vs 16% (P < . 001); intensive care unit length of stay (15th, 50th, and 85th percentiles), 24, 25, and 72 vs 24, 48, and 162 hours (P < . 001); and hospital length of stay (15th, 50th, and 85th percentiles), 5, 7, and 11 vs 6, 8, and 16 days (P < . 001). Witnesses had better 1-year survival (95%; 95% CI, 93%-96%; vs 89%; 95% CI, 87%-90%; P = . 007) but similar 20-year survival (34%; 95% CI, 31%-38%; vs 32% 95% CI, 28%-35%; P = . 90).

Conclusions Witnesses do not appear to be at increased risk for surgical complications or long-term mortality when comparisons are properly made by transfusion status. Thus, current extreme blood management strategies do not appear to place patients at heightened risk for reduced long-term survival.

Red blood cells (RBCs) not only are in short supply but are also associated with increased morbidity and reduced survival after cardiac surgery.1- 3 Jehovah's Witness patients (Witnesses) hold beliefs that disallow blood product transfusion and therefore offer a natural experiment in severe blood conservation. Their beliefs encourage the use of a number of blood conservation practices, including preoperative use of erythropoietin and iron and B-complex vitamins, hemoconcentration, and minimal crystalloid use; intraoperative use of antifibrinolytics and cell-saver and smaller cardiopulmonary bypass circuits; and postoperative liberal use of additional operation for bleeding along with tolerance of low hematocrit levels postoperatively. Although some of these practices may be beneficial to all cardiac surgical patients, others are associated with well-documented morbidity,4- 6 and their effect on long-term survival is uncertain.

Although prior investigators compared immediate postoperative outcomes between Witnesses and non-Witnesses,7- 16 comparisons of long-term survival are lacking. Comparison is hampered, however, by impossibility of randomization to religious preference or blood transfusion, typical of any natural experiment. We have therefore used propensity-based comparative effectiveness tools17- 19 to compare morbidity and long-term survival of Witnesses undergoing cardiac surgery with a propensity-matched group of patients who received transfusions.

Outcomes in cardiac surgery in 500 consecutive Jehovah's Witness patients: 21 year experience.

Vaislic CD1, Dalibon N, Ponzio O, Ba M, Jugan E, Lagneau F, Abbas P, Olliver Y, Gaillard D, Baget F, Sportiche M, Chedid A, Chaoul G, Maribas P, Dupuy C, Robine B, Kasanin N, Michon H, Ruat JM, Habis M, Bouharaoua T.
Author information
Abstract
BACKGROUND:
Refusal of heterogenic blood products can be for religious reasons as in Jehovah's Witnesses or otherwise or as requested by an increasing number of patients. Furthermore blood reserves are under continuous demand with increasing costs. Therefore, transfusion avoidance strategies are desirable. We describe a historic comparison and current results of blood saving protocols in Jehovah's Witnesses patients.
METHODS:
Data on 250 Jehovah's Witness patients operated upon between 1991 and 2003 (group A) were reviewed and compared with a second population of 250 patients treated from 2003 to 2012 (group B).
RESULTS:
In group A, mean age was 51 years of age compared to 68 years in group B. An iterative procedure was performed in 13% of patients in group B. Thirty days mortality was 3% in group A and 1% in group B despite greater operative risk factors, with more redo, and lower ejection fraction in group B. Several factors contributed to the low morbidity-mortality in group B, namely: preoperative erythropoietin to attain a minimal hemoglobin value of 14 g/dl, warm blood cardioplegia, the implementation of the Cornell University protocol and fast track extubation.
CONCLUSIONS:
Cardiac surgery without transfusion in high-risk patients such as Jehovah Witnesses can be carried out with results equivalent to those of low risk patients. Recent advances in surgical techniques and blood conservation protocols are main contributing factors.

PMID: 23013647 [PubMed - indexed for MEDLINE] PMCID: PMC3487917 Free PMC Article

Comparisons of cardiac surgery outcomes in Jehovah's versus Non-Jehovah's Witnesses.

Stamou SC1, White T, Barnett S, Boyce SW, Corso PJ, Lefrak EA.

Author information

Abstract

Jehovah's Witnesses is a Christian faith whose members will not accept blood or blood products under any circumstances on the basis of religious grounds. To date, no comparative studies have evaluated the outcome of open heart surgery in Jehovah's Witnesses compared with patients who accept the transfusion of blood products. The present study was conducted to systematically compare the operative mortality and early clinical outcome after open cardiac surgery in Jehovah's Witnesses versus non-Jehovah's Witnesses. From January 1990 to July 2004, 49 Jehovah's Witness patients underwent cardiac surgery, and their data were compared with those of a contemporaneous control group of 196 non-Jehovah's Witnesses. Logistic regression analysis was used to compare operative mortality, postoperative intensive care unit care, and hospital length of stay between the 2 groups, controlling for preoperative risk factors. The Jehovah's Witnesses were matched in a 1:4 ratio to the non-Jehovah's Witnesses using propensity scores. No significant differences were identified in unadjusted stroke (p = 0.5), acute myocardial infarction (p = 0.6), new-onset atrial fibrillation (p = 0.106), prolonged ventilation (p = 0.82), acute renal failure (p = 0.70), and hemorrhage-related reexploration (p = 0.59) rates between the 2 groups. On multivariate analysis, Jehovah's Witnesses had operative mortality (odds ratio 0.66, 95% confidence interval 0.12 to 3.59, p = 0.63), intensive care unit stay (odds ratio 1.36, 95% confidence interval 0.46 to 3.97, p = 0.58), and postoperative length of stay (odds ratio 1.43, 95% confidence interval 0.92 to 2.20, p = 0.16) comparable to those of the non-Jehovah's Witnesses, after controlling for preoperative risk factors through matching. In conclusion, cardiac surgery in Jehovah's Witnesses is associated with clinical outcomes comparable to those of non-Jehovah's Witnesses by adhering to blood conservation protocols.

PMID:

 

17056333

 

[PubMed - indexed for MEDLINE]

Safety of cardiac surgery without blood transfusion: a retrospective study in Jehovah's Witness patients.

El Azab SR1, Vrakking R, Verhage G, Rosseel PM.

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Retraction in

• Notice of retraction. [Anaesthesia. 2010]

Abstract

The aim of this retrospective study was to compare the utilisation of blood products and outcomes following cardiac surgery for 123 Jehovah's Witnesses and 4219 non-Jehovah's Witness patient controls. The study took place over a 7-year period at the Amphia Hospital in Breda, the Netherlands. A specific protocol was used in the management of Jehovah's Witness patients, while the control group received blood without restriction according to their needs. Patients' characteristics were comparable in both groups. Pre-operatively, the mean (SD) Euro Score was higher in the Jehovah's Witness group (3.2 (2.6) vs 2.7 (2.5), respectively; p < 0.02). Pre-operative haemoglobin concentration was higher in the Jehovah's Witness group (8.9 (0.7) vs 8.6 (0.9) g.dl(-1), respectively; p < 0.001). The total cardiopulmonary bypass time did not differ between groups. The requirement for allogenic blood transfusion was 0% in the Jehovah's Witness group compared to 65% in the control group. Postoperatively, there was a lower incidence of Q-wave myocardial infarction (2 (1.8%) vs 323 (7.7%), respectively; p < 0.02), and non Q-wave infarction (11 (9.8%) vs 559 (13.2%), respectively; p < 0.02) in the Jehovah's Witness group compared with controls. Mean (SD) length of stay in the intensive care unit (2.3 (3.2) vs 2.6 (4.2) days; p = 0.26), re-admission rate to the intensive care unit (5 (4.5%) vs 114 (2.7%); p = 0.163), and mortality (3 (2.7%) vs 65 (1.5%); p = 0.59), did not differ between the Jehovah's Witness and control groups, respectively.

Comment in

• Safety of cardiac surgery without blood transfusion: a retrospective study in Jehovah's Witness patients. [Anaesthesia. 2010]

PMID:

 

20402872

 

[PubMed - indexed for MEDLINE]

Comparison of outcome in Jehovah's Witness patients in cardiac surgery: an Australian experience.

Bhaskar B1, Jack RK, Mullany D, Fraser J.

Author information

Abstract

INTRODUCTION:

Despite the advances in modern medicine, cardiac surgery remains associated with significant amounts of blood transfusion and is responsible for nearly 20% of all transfusions in Australasia. Progressive advances in perfusion technology and perioperative supportive management have made it possible for members of the Jehovah's Witnesses (JW) religious group to undergo open cardiac operations with remarkable safety. This study systematically compares the operative mortality and early clinical outcome after cardiac surgery in JWs.

METHODS AND MATERIALS:

Data was obtained from the cardiac surgery and intensive care unit databases from January 2002 to December 2005. A total of 5353 patients who underwent cardiac surgical procedures including coronary artery bypass grafting with cardiopulmonary bypass (n=4041) and valvular heart surgery (n=2287) were assessed in this study. Of the 5353 patients 49 patients refused blood and blood products because of their religious beliefs. Models were constructed to determine the association between JWs and non-JWs and three outcomes: (1) operative mortality, (2) postoperative variables and (3) length of stay in intensive care unit. Propensity scores were computed from these models and used to match JWs with non-JWs.

RESULTS:

There were minimal differences in the baseline patient demographic characteristics between the two groups. Haemoglobin and haematocrit levels were higher in JWs both before (13.7g/dL vs 12.8g/dL; P=0.01, and 40.0% vs 39.2%; P=0.08) and after (10.8g/dL vs 9.9g/dL; P=.003, and 34.0% vs 30.9%; P=.001) surgery. Jehovah's Witnesses experienced significantly less bleeding, almost half compared to the control group, with 

CONCLUSION:

This study concurs with the international published data that outcomes for JW patients who undergo cardiac surgery are similar to those who receive transfusion. Every appropriate opportunity to reduce the use of allogeneic blood products.

Copyright © 2010 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. All rights reserved.

PMID: