Bloodless Medicine and Surgery Strategies

This module discusses the primary pillars of bloodless medicine and surgery and outlines strategies that ensure patient safety and well-being.

These Continuing Education (CE) accredited introductory modules walk learners through the history of bloodless medicine and surgery (BMS); identify key factors that led to the growth of the bloodless approach; outline strategies that ensure patient safety and well-being; and discuss legal and ethical concerns related to BMS. The intended audience for these modules are healthcare providers and administrators throughout the world who are interested in learning about the care of patients who decline blood transfusion.

Bloodless Medicine and Surgery Strategies
Bloodless medicine and surgery has been shown to not only provide a safe and effective alternative to blood transfusion but to hold the promise of a higher standard of care for all patients. And that standard is achieved when we adhere to clinically proven bloodless methods. Let’s take a look at some of them.

Pillars of Bloodless Medicine

• Minimize Blood Loss: Ensure that a patient loses as little blood as possible during the course of their treatment
  
• Optimize Tissue Oxygenation: Use techniques that help deliver oxygen to vital organs and help body efficiently utilize oxygen it already has
  
• Manage Anemia: Address clinical symptoms associated with low hemoglobin levels before, during, and after surgery
  The Royal College of Surgeons, the World Health Organization, and many other hospital-based bloodless medicine programs
  During the course of their treatment, patients can be at risk for blood loss and for complications resulting from inadequate oxygenation and anemia. This is where the three pillars of bloodless medicine come in.

The first pillar, minimizing blood loss, entails strategies to ensure that a patient loses as little blood as possible during the course of their treatment.  The second pillar, optimizing tissue oxygenation, encompasses techniques that help deliver oxygen to vital organs, and help the body efficiently utilize the oxygen it already has. The third pillar, managing anemia, involves strategies to address clinical symptoms associated with low hemoglobin levels before, during, and after surgery.

First formulated in the video Transfusion Alternative Strategies—Simple, Safe, Effective, the three-pillar concept, and comparable formulations, have been used by the Royal College of Surgeons, the World Health Organization, and many other hospital-based bloodless medicine programs.

Let’s see how the techniques contained in these strategies are applied in the surgical setting during the preoperative, intraoperative, and postoperative stages.

Pillars: Preoperative Stage

Prepare patient for physiological stress of surgery

Patient Info, Clinical History

• Age: 52
• Procedure: Total abdominal hysterectomy
• Fibroid tumors
• Anemia
• Coronary artery disease
• IV iron therapy
• Erythropoiesis-stimulating agents (ESAs)
• Oral iron
• Various blood draws to test for hematological pathology

CBC results

• Low MCV
• High RDW

What’s the best method to optimize this patient (Surgery 3 weeks out)?

Pillars: Preoperative Stage

During the preoperative stage, the goal is to prepare the patient for the physiological stress of surgery. Say you have a 52-year-old Witness patient undergoing a total abdominal hysterectomy. She has a history of fibroid tumors, anemia, and coronary artery disease. Her CBC indicates a low MCV and high RDW. Her surgery is scheduled for three weeks out. What’s the best way to optimize this patient?

• Identify patients who are anemic or at higher risk for bleeding (medical history and physical exam, clinical assessment of coagulation status)
• Limit phlebotomy (frequency and quantity) to necessary diagnostic testing and use microsampling when possible
  
• When medically indicated, stop medications that inhibit hemostasis, including anticoagulants, antiplatelet agents, ASA, NSAIDs, antibiotics, and herbal agents that increase intraoperative bleeding

Manage coagulation disorders

• Consider cell salvage (if acceptable to the patient) and prepare accordingly  
• Consider hemodilution (if acceptable to the patient) and prepare accordingly  
  

Optimize Tissue Oxygenation

• If available, employ hyperbaric oxygen therapy for severely anemic patients
• Minimize oxygen consumption through appropriate interventions such as adequate analgesia, the use of neuromuscular blocking agents, and treatment of sepsis and causes of tissue hypoxia promptly

Manage Anemia

• Diagnose anemia early (CBC and other laboratory assessments) and create an anemia management plan
• Identify iron deficiency and treat with oral iron or IV iron therapy
• Administer erythropoiesis-stimulating agents (ESAs), if indicated
• Optimize hemoglobin and hematocrit, if possible
• Boost HGB/HCT for patients at risk, e.g., those at greater risk of bleeding due to past surgery/scar tissue

Pillars: Intraoperative Stage

Practice meticulous hemostasis, and be cautious and exact in approach

Minimize Blood Loss

Optimize Tissue Oxygenation

Manage Anemia

• Monitor patient for anemia, and keep patient hemodynamically stable

Pillars: Intraoperative Stage

Once the patient is in surgery, it’s crucial for the surgical team to practice meticulous hemostasis and to be cautious and exact in their approach, as giving blood or major blood components is not an option. The team must also actively monitor the patient for anemia and ensure adequate tissue oxygenation by keeping the patient hemodynamically stable. Click the icons to see additional strategies.

Minimize Blood Loss

• Practice meticulous surgical technique and hemostasis, and administer hemostatic agents
• Use hemostatic surgical devices such as electrosurgical and ultrasonic devices

Optimize patient positioning

• Use cell salvage for any high-risk surgical technique
• Administer regional anesthesia and epidurals
• Maintain normothermia, which minimizes coagulopathy and blood loss
• Administer agents to enhance hemostasis, e.g., tranexamic acid, rFVIIa (if patient accepts)
• Allow for permissive hypotension
• Perform point-of-care testing in the OR by checking some labs right at the bedside
• Employ acute normovolemic hemodilution (ANH) if patient has adequate starting hemoglobin and accepts this procedure
• Angiographic embolization (for postpartum hemorrhage)
• Employ minimally invasive surgical techniques such as laparoscopy and robotics

Optimize Tissue Oxygenation

• Maintain circulating volume through the use of colloids or crystalloids
• Control factors responsible for hemoglobin affinity for oxygen (pH, pCO2, temperature)
• Minimize oxygen demand (mechanical ventilation, consider controlled hypothermia for some specific surgeries)

Manage Anemia

• Carefully monitor and manage anemia throughout procedure

Pillars: Intraoperative Stage

• Note maximal allowable blood loss
• Use cell salvage for any high-risk surgical technique
• Employ acute normovolemic hemodilution (ANH) if patient has adequate starting hemoglobin and accepts this procedure
• Recognize potentially misleading effects of crystalloids and colloids on HCT

Pillars: Postoperative Stage

Patients are at risk for active bleeding, increased oxygen consumption, and other complications arising from stress of surgery

Minimize Blood Loss

Optimize Tissue Oxygenation

Manage Anemia

There must be low threshold for return to OR since transfusion is not an option

When the patient is out of surgery, they’re at risk for active bleeding, increased oxygen consumption, and other complications arising from the stress of surgery. All surgical patients are monitored for postoperative bleeding. If excessive bleeding is present in a bloodless patient, there must be a low threshold for return to the OR since transfusion is not an option. Click the icons to see additional strategies. 

• Closely monitor patient for blood loss, and promptly arrest any bleeding
• Maintain patient normothermia
• Avoid hypertension
• Administer hemostatic agents
• Use postoperative cell salvage, if acceptable to the patient
• Determine optimal restart dates for medications that inhibit hemostasis
• Limit phlebotomy to necessary diagnostic testing

Optimize Tissue Oxygenation

• Put patients in hyperbaric oxygen chambers to increase blood oxygenation
• Minimize oxygen consumption through appropriate interventions, such as sedation and analgesia
• Manage blood volume with judicious use of non-blood expanders
• Administer IV iron therapy
• Administer ESAs
• Limit blood draws and use low-volume phlebotomy tubes
• Consider single blood draw versus multiple draws
• If available, utilize real-time noninvasive hemoglobin monitoring to limit blood draws

Recap: Pillars of BMS

We’ve seen the perioperative steps that need to be taken for bloodless patients and how the pillars factor into those steps. Let’s now listen to Dr. Hiep Dao, assistant professor in the Department of Anesthesia at Georgetown University Hospital, about why these pillars are so important and why it’s vital to factor them in early on in the course of a patient’s treatment.

Dr. Hiep Dao
Assistant Professor, Department of Anesthesia
MedStar Georgetown University Hospital

I think the whole idea of managing a bloodless patient encompasses everyone that interacts with this patient and their care. Whether it’s the nursing staff, the anesthesiologist, the surgical team, the resident, the intern, the nurse that will be taking care of the patient postoperatively, we all have a hand in the care of this patient. We talk to the intern or the surgeon that’s going to be taking care of the patient and say, “Well, let’s get this patient in our preoperative clinic a month ahead of time so we can start this iron therapy.” So the day they come in for surgery, the surgical team, the anesthesia team, we’re all on the same page.

It’s nice to have known this patient before because you get in the operating room and again we tell the surgeon, “Strict hemostasis, use electrocautery.” From an anesthesia standpoint, can we lower the blood pressure a little bit in order to decrease the risk of bleeding? Should we have cell salvage? Should we do normovolemic hemodilution? Postoperatively, keeping these patients warm, doing other things that optimize their hemoglobin and optimize their care.
I love it myself—working with these patients—because a lot of times they come in very frustrated. They’ve been to other institutions, been with other providers, who have not seen the data, really. Having a provider that understands where they’re coming from and their goals of care and a listening ear, I think is the best thing.

As a practicing anesthesiologist, transfusion medicine is a part of our practice. But even as a young physician, we weren’t taught about, “What’s the alternative to giving blood?” And really it’s educating the next generation of providers. Educating the new interns that come in, educating the new surgeons—or even the older surgeons who have this thought of transfusion as always the best thing for patients.

Identifying a subset population, too, has been a unique part of my practice now. We never had that in training and now we’re looking at bloodless medicine patients as a subset patient population and developing ways to better manage their care.