Download PDF
Semin Thromb Hemost 2013; 39(02): 182-190
DOI: 10.1055/s-0032-1333541
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Approach to Patients with Bleeding Disorders Who Do Not Accept Blood-Derived Products

Aryeh Shander
1   Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey
2   Departments of Anesthesiology, Medicine, and Surgery, Mount Sinai School of Medicine, New York, New York
,
Mazyar Javidroozi
1   Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey
› Author Affiliations
Further Information

Publication History

Publication Date:
08 February 2013 (online)

    Permissions and Reprints

Abstract

Despite the widespread use of allogeneic blood components in clinical practice, there are patients in whom transfusion cannot be carried out for various reasons, including refusal of transfusions because of religious beliefs. The refusal of transfusion is not equivalent to refusal of medical treatment, and numerous options are available to effectively manage care without transfusions. The strategies are collectively called Bloodless Medicine and Surgery and share many similarities with Patient Blood Management, that is, application of evidence-based medical and surgical concepts designed to preserve patient's own blood to improve the outcomes of patients. The strategies involve obtaining advance directive and consent to determine what components and procedures are acceptable to the patient; preoptimizing the patient for early correction of treatable deficiencies (e.g., anemia, coagulopathy); minimizing blood loss (e.g., hemostatic agents, blood salvage); and improving physiologic responses to anemia. Using these approaches, it is possible to effectively manage patients, with outcomes comparable to patients who accept transfusions.

Keywords

blood transfusion - Bloodless Medicine - Patient Blood Management - anemia - hemoglobin
 

  • References

  • 1 Tsai AG, Hofmann A, Cabrales P, Intaglietta M. Perfusion vs. oxygen delivery in transfusion with “fresh” and “old” red blood cells: the experimental evidence. Transfus Apheresis Sci 2010; 43 (1) 69-78
    CrossrefPubMedGoogle Scholar
  • 2 Bolliger D, Görlinger K, Tanaka KA. Pathophysiology and treatment of coagulopathy in massive hemorrhage and hemodilution. Anesthesiology 2010; 113 (5) 1205-1219
    CrossrefPubMedGoogle Scholar
  • 3 Goodnough LT, Shander A, Spence R. Bloodless medicine: clinical care without allogeneic blood transfusion. Transfusion 2003; 43 (5) 668-676
    CrossrefPubMedGoogle Scholar
  • 4 Mackenzie CF, Moon-Massat PF, Shander A, Javidroozi M, Greenburg AG. When blood is not an option: factors affecting survival after the use of a hemoglobin-based oxygen carrier in 54 patients with life-threatening anemia. Anesth Analg 2010; 110 (3) 685-693
    CrossrefPubMedGoogle Scholar
  • 5 Ott DA, Cooley DA. Cardiovascular surgery in Jehovah's Witnesses. Report of 542 operations without blood transfusion. JAMA 1977; 238 (12) 1256-1258
    CrossrefPubMedGoogle Scholar
  • 6 Watchtower Bible and Tract Society. Jehovah's Witnesses and the question of blood. Brooklyn, New York: Watchtower Bible and Tract Society; 1977
    Google Scholar
  • 7 Shander A, Goodnough LT. Objectives and limitations of bloodless medical care. Curr Opin Hematol 2006; 13 (6) 462-470
    CrossrefPubMedGoogle Scholar
  • 8 Carson JL, Noveck H, Berlin JA, Gould SA. Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion. Transfusion 2002; 42 (7) 812-818
    CrossrefPubMedGoogle Scholar
  • 9 Martyn V, Farmer SL, Wren MN , et al. The theory and practice of bloodless surgery. Transfus Apheresis Sci 2002; 27 (1) 29-43
    CrossrefPubMedGoogle Scholar
  • 10 Moskowitz DM, Perelman SI, Cousineau KM , et al. Multidisciplinary management of a Jehovah's Witness patient for the removal of a renal cell carcinoma extending into the right atrium. Can J Anaesth 2002; 49 (4) 402-408
    PubMedGoogle Scholar
  • 11 Donahue LL, Shapira I, Shander A, Kolitz J, Allen S, Greenburg G. Management of acute anemia in a Jehovah's Witness patient with acute lymphoblastic leukemia with polymerized bovine hemoglobin-based oxygen carrier: a case report and review of literature. Transfusion 2010; 50 (7) 1561-1567
    CrossrefPubMedGoogle Scholar
  • 12 Nagarsheth NP, Shander A, Malovany R, Tzeng J, Ibrahim I. Bloodless surgery in a Jehovah's Witness patient with a 12.7-kg uterine leiomyosarcoma. J Surg Educ 2007; 64 (4) 212-219
    CrossrefPubMedGoogle Scholar
  • 13 Shander A, Javidroozi M, Ozawa S, Hare GM. What is really dangerous: anaemia or transfusion?. Br J Anaesth 2011; 107 (Suppl. 01) i41-i59
    CrossrefPubMedGoogle Scholar
  • 14 Hofmann A, Farmer S, Shander A. Five drivers shifting the paradigm from product-focused transfusion practice to patient blood management. Oncologist 2011; 16 (Suppl. 03) 3-11
    CrossrefPubMedGoogle Scholar
  • 15 Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR. Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion 2010; 50 (4) 753-765
    CrossrefPubMedGoogle Scholar
  • 16 Ghiglione M. Blood management: a model of excellence. Clin Leadersh Manag Rev 2007; 21 (2) E2
    PubMedGoogle Scholar
  • 17 Be guided by the living God. Watchtower 2004; June 15;19–24
    PubMedGoogle Scholar
  • 18 Questions from readers. Watchtower 2000; June 15;29–31
    PubMedGoogle Scholar
  • 19 Naftalovich R, Javidroozi M, Ozawa S, Shander A. Acceptance of minor blood fractions, procedures and organ donation and transplantation among Jehovah's Witness patients. Society for the Advancement of Blood Management (SABM) Annual Meeting. Hollywood, CA. 2007
    PubMed
  • 20 Van Norman GA, Jackson S, Rosenbaum SH, Palmer SK. Clinical Ethics in Anesthesiology: A Case-Based Textbook. Cambridge, United Kingdom: Cambridge University Press; 2010
    CrossrefGoogle Scholar
  • 21 Gombotz H, Rehak PH, Shander A, Hofmann A. Blood use in elective surgery: the Austrian benchmark study. Transfusion 2007; 47 (8) 1468-1480
    CrossrefPubMedGoogle Scholar
  • 22 Shander A, Javidroozi M, Perelman S, Puzio T, Lobel G. From bloodless surgery to patient blood management. Mt Sinai J Med 2012; 79 (1) 56-65
    CrossrefPubMedGoogle Scholar
  • 23 Goodnough LT, Shander A. Patient blood management. Anesthesiology 2012; 116 (6) 1367-1376
    CrossrefPubMedGoogle Scholar
  • 24 Shander A, Moskowitz DM, Javidroozi M. Blood conservation in practice: an overview. Br J Hosp Med (Lond) 2009; 70 (1) 16-21
    PubMedGoogle Scholar
  • 25 Goodnough LT, Maniatis A, Earnshaw P , et al. Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth 2011; 106 (1) 13-22
    CrossrefPubMedGoogle Scholar
  • 26 Gammon HM, Waters JH, Watt A, Loeb JM, Donini-Lenhoff A. Developing performance measures for patient blood management. Transfusion 2011; 51 (11) 2500-2509
    CrossrefPubMedGoogle Scholar
  • 27 Ferraris VA, Brown JR, Despotis GJ , et al. Society of Thoracic Surgeons Blood Conservation Guideline Task Force; Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion; International Consortium for Evidence Based Perfusion. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91 (3) 944-982
    CrossrefPubMedGoogle Scholar
  • 28 Goodnough LT, Shander A. Blood management. Arch Pathol Lab Med 2007; 131 (5) 695-701
    PubMedGoogle Scholar
  • 29 Buresly K, Eisenberg MJ, Zhang X, Pilote L. Bleeding complications associated with combinations of aspirin, thienopyridine derivatives, and warfarin in elderly patients following acute myocardial infarction. Arch Intern Med 2005; 165 (7) 784-789
    CrossrefPubMedGoogle Scholar
  • 30 Radovanovic I, Queally J, Bahari S, Sproule J, McElwain J. Anticoagulant use and its effect on bleeding and complications in total knee arthroplasty. Acta Orthop Belg 2012; 78 (2) 187-191
    PubMedGoogle Scholar
  • 31 Goodnough LT, Shander A. How I treat warfarin-associated coagulopathy in patients with intracerebral hemorrhage. Blood 2011; 117 (23) 6091-6099
    CrossrefPubMedGoogle Scholar
  • 32 He SW, Wang LX. The impact of anemia on the prognosis of chronic heart failure: a meta-analysis and systemic review. Congest Heart Fail 2009; 15 (3) 123-130
    CrossrefPubMedGoogle Scholar
  • 33 Harper P, Littlewood T. Anaemia of cancer: impact on patient fatigue and long-term outcome. Oncology 2005; 69 (Suppl. 02) 2-7
    CrossrefPubMedGoogle Scholar
  • 34 Moscucci M. Anemia and blood transfusion: prognostic implications in patients undergoing contemporary percutaneous coronary intervention. Curr Cardiol Rep 2009; 11 (5) 363-368
    CrossrefPubMedGoogle Scholar
  • 35 Goodnough LT, Shander A, Spivak JL , et al. Detection, evaluation, and management of anemia in the elective surgical patient. Anesth Analg 2005; 101 (6) 1858-1861
    PubMedGoogle Scholar
  • 36 Bennett CL, Silver SM, Djulbegovic B , et al. Venous thromboembolism and mortality associated with recombinant erythropoietin and darbepoetin administration for the treatment of cancer-associated anemia. JAMA 2008; 299 (8) 914-924
    CrossrefPubMedGoogle Scholar
  • 37 Auerbach M, Ballard H. Clinical use of intravenous iron: administration, efficacy, and safety. Hematology (Am Soc Hematol Educ Program) 2010; 2010: 338-347
    CrossrefPubMedGoogle Scholar
  • 38 Shander A, Spence RK, Auerbach M. Can intravenous iron therapy meet the unmet needs created by the new restrictions on erythropoietic stimulating agents?. Transfusion 2010; 50 (3) 719-732
    PubMedGoogle Scholar
  • 39 Savoia HF, Metz J, Maxwell EL, Hauesler MN, Mellor J, Kiely S. Utilization of preoperative autologous blood donation in elective surgery. ANZ J Surg 2002; 72 (8) 557-560
    CrossrefPubMedGoogle Scholar
  • 40 Doctor A, Spinella P. Effect of processing and storage on red blood cell function in vivo. Semin Perinatol 2012; 36 (4) 248-259
    CrossrefPubMedGoogle Scholar
  • 41 Spinella PC, Doctor A, Blumberg N, Holcomb JB. Does the storage duration of blood products affect outcomes in critically ill patients?. Transfusion 2011; 51 (8) 1644-1650
    CrossrefPubMedGoogle Scholar
  • 42 Martin K, Keller E, Gertler R, Tassani P, Wiesner G. Efficiency and safety of preoperative autologous blood donation in cardiac surgery: a matched-pair analysis in 432 patients. Eur J Cardiothorac Surg 2010; 37 (6) 1396-1401
    CrossrefPubMedGoogle Scholar
  • 43 Gurusamy KS, Samraj K, Fusai G, Davidson BR. Robot assistant versus human or another robot assistant in patients undergoing laparoscopic cholecystectomy. Cochrane Database Syst Rev 2012; 9: CD006578
    PubMedGoogle Scholar
  • 44 Willaert WI, Aggarwal R, Daruwalla F , et al. European Virtual Reality Endovascular Research Team EVEResT. Simulated procedure rehearsal is more effective than a preoperative generic warm-up for endovascular procedures. Ann Surg 2012; 255 (6) 1184-1189
    CrossrefPubMedGoogle Scholar
  • 45 Sculco TP, Baldini A, Keating EM. Blood management in total joint arthroplasty. Instr Course Lect 2005; 54: 51-66
    PubMedGoogle Scholar
  • 46 Degoute CS. Controlled hypotension: a guide to drug choice. Drugs 2007; 67 (7) 1053-1076
    CrossrefPubMedGoogle Scholar
  • 47 Achneck HE, Sileshi B, Jamiolkowski RM, Albala DM, Shapiro ML, Lawson JH. A comprehensive review of topical hemostatic agents: efficacy and recommendations for use. Ann Surg 2010; 251 (2) 217-228
    CrossrefPubMedGoogle Scholar
  • 48 Shakur H, Roberts I, Bautista R , et al. CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376 (9734) 23-32
    CrossrefPubMedGoogle Scholar
  • 49 Henry DA, Carless PA, Moxey AJ , et al. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2011; 3 (3) CD001886
    PubMedGoogle Scholar
  • 50 Simpson E, Lin Y, Stanworth S, Birchall J, Doree C, Hyde C. Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia. Cochrane Database Syst Rev 2012; 3: CD005011
    PubMedGoogle Scholar
  • 51 Warmuth M, Mad P, Wild C. Systematic review of the efficacy and safety of fibrinogen concentrate substitution in adults. Acta Anaesthesiol Scand 2012; 56 (5) 539-548
    CrossrefPubMedGoogle Scholar
  • 52 Levi M, Cromheecke ME, de Jonge E , et al. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet 1999; 354 (9194) 1940-1947
    CrossrefPubMedGoogle Scholar
  • 53 Shander A, Perelman S. The long and winding road of acute normovolemic hemodilution. Transfusion 2006; 46 (7) 1075-1079
    CrossrefPubMedGoogle Scholar
  • 54 Bennett J, Haynes S, Torella F, Grainger H, McCollum C. Acute normovolemic hemodilution in moderate blood loss surgery: a randomized controlled trial. Transfusion 2006; 46 (7) 1097-1103
    CrossrefPubMedGoogle Scholar
  • 55 Jarnagin WR, Gonen M, Maithel SK , et al. A prospective randomized trial of acute normovolemic hemodilution compared to standard intraoperative management in patients undergoing major hepatic resection. Ann Surg 2008; 248 (3) 360-369
    PubMedGoogle Scholar
  • 56 Wang G, Bainbridge D, Martin J, Cheng D. The efficacy of an intraoperative cell saver during cardiac surgery: a meta-analysis of randomized trials. Anesth Analg 2009; 109 (2) 320-330
    CrossrefPubMedGoogle Scholar
  • 57 Carless PA, Henry DA, Moxey AJ, O'Connell D, Brown T, Fergusson DA. Cell salvage for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2010; 4 (4) CD001888
    PubMedGoogle Scholar
  • 58 Esper SA, Waters JH. Intra-operative cell salvage: a fresh look at the indications and contraindications. Blood Transfus 2011; 9 (2) 139-147
    PubMedGoogle Scholar
  • 59 Waters JH. Indications and contraindications of cell salvage. Transfusion 2004; 44 (12, Suppl) 40S-44S
    CrossrefPubMedGoogle Scholar
  • 60 MacIvor D, Nelson J, Triulzi D. Impact of intraoperative red blood cell salvage on transfusion requirements and outcomes in radical prostatectomy. Transfusion 2009; 49 (7) 1431-1434
    CrossrefPubMedGoogle Scholar
  • 61 King M, Wrench I, Galimberti A, Spray R. Introduction of cell salvage to a large obstetric unit: the first six months. Int J Obstet Anesth 2009; 18 (2) 111-117
    CrossrefPubMedGoogle Scholar
  • 62 Nieder AM, Manoharan M, Yang Y, Soloway MS. Intraoperative cell salvage during radical cystectomy does not affect long-term survival. Urology 2007; 69 (5) 881-884
    CrossrefPubMedGoogle Scholar
  • 63 Waters JH, Yazer M, Chen YF, Kloke J. Blood salvage and cancer surgery: a meta-analysis of available studies. Transfusion 2012; 52 (10) 2167-2173
    CrossrefPubMedGoogle Scholar
  • 64 Branco BC, Inaba K, Doughty R , et al. The increasing burden of phlebotomy in the development of anaemia and need for blood transfusion amongst trauma patients. Injury 2012; 43 (1) 78-83
    CrossrefPubMedGoogle Scholar
  • 65 Rosebraugh MR, Widness JA, Nalbant D, Veng-Pedersen P. A mathematical modeling approach to quantify the role of phlebotomy losses and need for transfusions in neonatal anemia (epub ahead of print). Transfusion 2012; DOI: 10.1111/j.1537-2995.2012.03908.x.
    PubMedGoogle Scholar
  • 66 Rezaeian F, Wettstein R, Amon M , et al. Erythropoietin protects critically perfused flap tissue. Ann Surg 2008; 248 (6) 919-929
    CrossrefPubMedGoogle Scholar
  • 67 Kawasaki T, Chaudry IH. The effects of estrogen on various organs: therapeutic approach for sepsis, trauma, and reperfusion injury. Part 2: liver, intestine, spleen, and kidney. J Anesth 2012; 26 (6) 892-899
    CrossrefPubMedGoogle Scholar
  • 68 Kawasaki T, Chaudry IH. The effects of estrogen on various organs: therapeutic approach for sepsis, trauma, and reperfusion injury. Part 1: central nervous system, lung, and heart. J Anesth 2012; 26 (6) 883-891
    CrossrefPubMedGoogle Scholar
  • 69 Villela NR, Tsai AG, Cabrales P, Intaglietta M. Improved resuscitation from hemorrhagic shock with Ringer's lactate with increased viscosity in the hamster window chamber model. J Trauma 2011; 71 (2) 418-424
    CrossrefPubMedGoogle Scholar
  • 70 Salazar Vázquez BY, Wettstein R, Cabrales P, Tsai AG, Intaglietta M. Microvascular experimental evidence on the relative significance of restoring oxygen carrying capacity vs. blood viscosity in shock resuscitation. Biochim Biophys Acta 2008; 1784 (10) 1421-1427
    CrossrefPubMedGoogle Scholar
  • 71 Shander A, Goodnough LT. Why an alternative to blood transfusion?. Crit Care Clin 2009; 25 (2) 261-277
    CrossrefPubMedGoogle Scholar
  • 72 Van Meter KW. The effect of hyperbaric oxygen on severe anemia. Undersea Hyperb Med 2012; 39 (5) 937-942
    PubMedGoogle Scholar
  • 73 Shander A, Javidroozi M, Thompson G. Hemoglobin-based blood substitutes and risk of myocardial infarction and death. JAMA 2008; 300 (11) 1296-1297 , author reply 1298–1299
    PubMedGoogle Scholar
  • 74 Natanson C, Kern SJ, Lurie P, Banks SM, Wolfe SM. Cell-free hemoglobin-based blood substitutes and risk of myocardial infarction and death: a meta-analysis. JAMA 2008; 299 (19) 2304-2312
    CrossrefPubMedGoogle Scholar