Originally published Monday, February 12, 2007

BLOODLESS MEDICINE GOES WITH THE FLOW

By Lee Petersen
DAILY BREEZE STAFF WRITER

The mind-set has changed when it comes to blood transfusions.

Amid ongoing shortages and concerns about the health risks of blood transfusions, bloodless medicine and surgery is quietly gaining wide acceptance in the United States beyond its roots in one religious minority's philosophy.

While supply and quality issues have certainly played a role, the idea has largely been moved by Jehovah's Witnesses, a Christian denomination that does not readily accept blood transfusions -- even with a patient's own blood.

And as hospitals have started "bloodless" programs to cater to people trying to avoid transfusions for religious or nonreligious reasons, the medical community in general also has tried to rely less on the safety net of transfusions and moved more toward the philosophy of conserving blood.

"There was a time 30 years ago, the idea of doing heart surgery without the option of transfusion was unthinkable," said Dr. James McPherson, associate director of cardiothoracic surgery at Centinela Freeman Regional Medical Center's Tommy Lasorda Heart Institute. "Certainly the culture has changed."

Jose Bretones, manager of the Bloodless Medicine & Surgery Program at Centinela in Inglewood since 1999, said about 175 patients a month seek to participate in the program at Centinela. Most are Jehovah's Witnesses, but some are looking for blood-free hospitalization or surgery for secular, health reasons.

Though the perception is that transfusions are usually done in the operating room, Bretones said most transfusions in a hospital are in the medical ward, for chronic anemia or other disorders.

So Bretones looks at bloodless or transfusion-free care as a total hospital package and tries to instill the message among everyone working there, whether they are directly working in the transfusion-free program or not.

For example, phlebotomists are trained to draw only the blood they need, to reduce the draining, vampirelike effect of repeated hospital tests. And new guidelines are used that allow a blood count to go lower before the blood bank is called.

Overall, Bretones said, the use of transfusions since he's started has fallen by 30 percent.

These days, it's not only transfusion-free patients with anemia who can be treated with iron and other methods to boost their blood counts more naturally.

Blood conservation techniques, such as donor-directed programs, where a patient gives blood in advance of his own surgery, have spread throughout the medical community, and not just at centers with bloodless programs.

In part, these changes have come about, Bretones said, because of efforts by the Jehovah's Witnesses community. That community comes from a biblical perspective, but also presents the health arguments as well.

In surgery, McPherson said, "One thing that is important to note is that we don't give transfusions lightly, even in those who are not in the transfusion-free program."

McPherson said the typical coronary artery bypass surgery is performed without transfusion.

But with a formal transfusion-free program, he is routinely faced with doing major operations without having that option at all.

Patients are educated and then selected based upon their desires and medical conditions. There are times when he feels it's too risky to do the procedure -- bypass, heart valve replacement or lung cancer surgery -- without the option of transfusions. Usually, in those cases, McPherson said, the patient decides against having the surgery.

Another important part of the bloodless program is the education of the staff, McPherson said. "Nurses, respiratory therapists, technicians ... everyone who comes into contact with the patient has to recognize that they are transfusion-free patients."

Finally, the operation has to be technically perfect to minimize the loss of blood, from the moment the first incision is made until the sutures are sewn, McPherson said.

Though Bretones said he'd like to see the transfusion-free program used to an even greater extent by those who are doing it for nonreligious reasons, he said that's not that easy to do, considering the limits of HMO insurance coverage, which generally preassigns hospitals.

"Our endeavor is to try to get it out to anyone who may benefit from it," Bretones said.