On this episode of Kentucky Health, host Dr. Wayne Tuckson speaks with Dr. Carolyn M. Burns, president of the Society for the Advancement of Patient Blood Management. Dr. Burns discusses protocols for giving blood transfusions to patients and new advances in the field.
New Ways of Thinking About Blood Management
Dr. Burns initially became interested in how and when to perform blood transfusions when she worked at Jewish Hospital in Louisville. She practiced what’s known as “bloodless medicine,” meaning that physicians and staff treated patients via a system that did not have blood transfusion as an option.
The patients in this program did not receive blood for a variety of reasons: Some of them refused due to their religious beliefs, some had rare blood types, and some had medical conditions that made it too risky. As a result, Burns says she and her colleagues had to be very creative in helping patients without giving them blood. Over time they realized that their patients’ outcomes were as good or even better than those of patients at other hospitals undergoing similar procedures who received blood.
“My experience at Jewish – and we had a lot of surgeons, internists, and hospitalists there that were a part of that bloodless program – we all agreed to handle those patients,” she says. “So it was a natural transition for many of us, including myself, to move toward global implementation of bloodless methods when possible.”
Furthermore, Burns says that by the late 1990s and early 2000s, a substantial amount of medical research had been published showing the risks of giving blood transfusions to patients. These studies revealed increased morbidity and mortality rates for patients who received blood transfusions.
Based on this advanced knowledge, Burns says a movement formed within the medical community to re-think the practice of blood transfusion and especially its frequency. She offers five instructions, or “rights,” to medical providers that can help guide this decision.
“First of all, do I have the right product, going to the right patient, at the right time, in the right dose, and most importantly, for the right reasons?” she asks. “I want people to, in a sense, stop, drop, and roll and think, ‘Must I use a transfusion for this?’”
One major shift in thinking concerned how to address anemia, Burns says. That condition occurs when a patient lacks enough red blood cells to carry oxygen to organs and tissues. The transmission occurs via protein called hemoglobin that exists inside red blood cells.
One third of patients admitted in the U.S. for elective surgery are anemic, and the leading cause of anemia worldwide, Burns notes, is iron deficiency. She explains that over the past 20 years or so, physicians have sought to alleviate this cause of anemia through iron supplements or infusions rather than giving blood to the patient.
In other cases, anemia may be caused by some chronic, progressive disease, such as internal bleeding from a cancerous colorectal tumor or severe inflammation due to rheumatoid arthritis. Burns says that the overarching goal for physicians should be to determine the root cause of blood loss and treat that rather than just performing a transfusion.
The Importance of Preserving Blood Health
“Blood’s an organ. It’s a liquid organ, but it’s an organ,” Burns says. “It has cells, it has proteins, it has fluids. Its business is to supply your body with oxygen, coagulation factors, anticoagulation factors, pH buffering.”
Blood that is donated may be used in whole for trauma patients, Burns says. Most often, however, blood is broken down in a centrifuge to extract components such as red blood cells, plasma, platelets, and cryoprecipitate. This last product is drawn from plasma that has been frozen and it is used for its fibrinogen, a glycoprotein that helps blood to clot. On the other end, patients who are given platelets will be good for five to seven days, Burns says, and red blood cells can circulate for three months.
“(Blood) supports all of your other organs,” Burns says. “None of your other organs can live without blood. So, what are you doing when you replace it? You’re transplanting.”
Transplant surgeries for tissue organs are some of the most dangerous and complex procedures in the field, and Burns says transfusing blood is no different. It requires modulating the recipient’s immune response because an entire liquid organ is being introduced from a foreign donor.
“That’s probably the reason we are seeing these adverse outcomes associated with transfusion,” she says. “So I would like people to start thinking about the concept of blood health the way we would heart health, colon health, brain health. Think of blood and its insufficiencies or failures, diagnose them, and treat them appropriately. Don’t reach for the replacement right out of the gate.”
As noted above, Burns believes that patients who present with anemia should be assessed thoroughly to determine the underlying cause, and given iron if needed. An elderly patient coming in for a knee or hip replacement, for example, will often have multiple co-morbid conditions such as diabetes or hypertension that are associated with inflammation. Since inflammation suppresses the release of iron into the blood, the deficiency can be ameliorated by iron supplements or infusions. These will replenish red blood cells and thus negate the need for a transfusion so that the surgery can be performed.
Burns advises patients who are set to receive iron replenishment to check with their insurance provider to see what is covered and when. Some patients may need to start with oral supplements in order to receive coverage. If those don’t bring levels back to normal or the side effects are too severe (the main one being stomach upset), an infusion may be recommended.
“Now, cancer patients that have chemotherapy or stem cell transplants, they absolutely will go through periods right after the treatments where their blood counts will hit their nadir, and you may need to support with transfusion,” she continues. “But that’s when you can get into these ideas of, why do we always feel we need to give two units? Why don’t we just give one, and see how the patient does? Can we get rid of their symptoms and keep their counts at a reasonable level during those tough times?”
For patients who are hemorrhaging blood rapidly due to a major trauma, Burns says a transfusion is necessary – they need that lost blood replaced as soon as possible. But she notes that the majority of blood transfusions are done in medically stable patients.
“We react to a laboratory value and we say, ‘Oh my goodness, we’ve got to do something and we’ve got to do it now,’” she says.
For these medically stable patients, all of their conditions should be assessed before considering a transfusion, Burns says, as alternative methods for treating the blood loss during a procedure may be preferable. Patients who are on anti-coagulant medications (to keep blood from clotting) may need those drugs suspended to reduce bleeding. Other patients may benefit from what’s called a cell salvage device. This machine is used during surgery to collect batches of a patient’s expended blood, which is then “washed” and re-introduced back into the patient.
“You could initiate an anemia work-up while (the patient is) in the hospital, and ,with good communication after the episode of care, continue that with their primary physician or their advanced practice clinician,” Burns says. “I think that’s another place where we’ve dropped the ball a bit. We tend to work in our silos, and we don’t close the loop on that continuity of care.”
