More surgery patients banking their own blood
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Patients, surgeons utilizing alternatives
Kerry Fehr-Snyder
The Arizona Republic
Sept. 16, 2004 12:00 AM
Before she scooted onto the operating table last week, Patricia Rasmussen banked on one thing: her own blood.
Rather than taking a transfusion from a stranger, the 53-year-old Phoenix resident pre-donated two units of her own blood to replace what was lost during her three-hour back surgery at St. Joseph's Hospital and Medical Center.
"Like that poor person who got West Nile, I didn't want donated blood. I don't think anything's 100 percent safe," she said.
In August, health officials said a 43-year-old Navajo County man died of meningitis after receiving blood carrying the mosquito-borne West Nile virus.
Although United Blood Systems now tests each donation for the virus, at the time, it was screening donated blood in batches, which made the virus more difficult to detect.
Even before the incident, doctors had been recommending that patients bank their own blood for a variety of reasons.
First and foremost is safety.
Hospitals have instituted blood-conservation programs that boost a patient's own blood reserves to reduce anemia in the case of blood loss.
They also are using blood-cleaning and -recycling equipment, which returns a patient's own blood during surgery so a transfusion isn't needed.
In addition, they are encouraging surgeons to minimize the amount of bleeding so transfusions are unnecessary.
Together, the measures reduce the reliance on dwindling community blood supplies, which frequently are at dangerously low levels.
"The safest transfusion is no transfusion at all," said Lawrence Rodriguez, blood bank supervisor at St. Joseph's.
Even a patient's own pre-donated blood can result in an immune reaction once it is returned to a patient, especially if the patient recently had been infected with a virus, Rodriguez noted. Add to that the remote possibility of a mix-up that could result in a patient receiving someone else's pre-donated blood or it being delivered to the wrong hospital.
"There's certainly human error, and you could conceivably give an A (donated blood type) to an O (patient). Always in medicine, never assume anything," Rodriguez said.
Those instances are rare, he said, adding, "In 25 years in the field, I've seen it happen once."
Rodriguez estimated the use of autologous, or the donation of blood for a patient's own use, has grown at his hospital tenfold during the past dozen years.
"It's going to continue to increase, especially with the huge demand for blood and the limited supply of it," he said.
United Blood Services, which collects and tests most banked blood in the Valley, estimates that about 5 percent of the blood it collected in 2003 was for the donor's use. The percentage has been steady for four years. Data before that is impossible to obtain, because the service tracked autologous donations with "directed donations," those given for specific family members or friends, said United Blood Services spokeswoman Sue Thew.
Doctors are required to tell patients they can donate their own blood before elective surgery or a medical procedure so they can avoid having to accept donated blood.
But banking blood is not always an option for patients limited by volume and time. Patients can donate up to five units before an elective surgery for a handling fee of about $65 per unit, which often is paid by insurance companies. Patients typically donate one unit a week leading up to surgery. The shelf life of blood is 42 days.
An alternative to autologous blood donations is Cell Saver, which drains red blood cells from a patient and returns them during surgery. But even that technology isn't without risks. Red blood cells can erupt during the procedure or not get adequately washed.
"There are certain safeguards to prevent it, but those can fail," Rodriguez said.
University Medical Center in Tucson has been using the Cell Saver machine for about eight years, especially during lung and heart transplant surgeries, back and knee operations and prostate removal.
"Whenever there's a patient that we anticipate a lot of blood loss," said Tina Ontiveros, the hospital's supervisor of blood recovery services.
The machine returns up to one unit of blood to a patient in about five minutes and is a good alternative for patients who can't pre-donate before surgery because they have a low blood count, she said.
Ontiveros prefers the technology over banked blood because of the risk of human error and new research showing red blood cells lose their ability to oxygenate tissues after seven days in storage.
"If I were going to have surgery and knew there would be significant blood loss, I would never pre-donate - ever," she said, citing the potential for mix-ups, reactions and problems with red blood cells getting old.
The use of Cell Savers in surgery at University Medical Center has grown about 19 percent in the past five years, to 823 patients last fiscal year, which ended June 30. That compares with 689 patients in the fiscal year that ended June 30, 1999.
"The thing is, the surgery has to meet certain criteria," she said. "We don't do it on every surgery."
That leaves patients with still other options, from "bloodless surgeries," in which surgeons minimize blood loss, to giving patients blood-fortifying drugs before surgery.
Banner Good Samaritan Medical Center in Phoenix is among those hospitals that have pioneered ways to eliminate or reduce the need for blood transfusions during or after surgery.
The hospital, the largest in the Valley, prefers to give patients iron, vitamin C and folate intravenously before surgery.
"They're in a much better position to tolerate surgery," said Richard Melseth, director of the hospital's blood conservation medicine program.
Autologous donations seem to be declining, he said, because they increase anemia in patients.
"We don't discourage pre-donation if you want to do it; we just don't encourage it," Melseth said. "If your body doesn't compensate for that blood loss, what have you gained?"
Blood conservation measures are ideal for elective surgeries and medical-management cases, he said.
"Eighty percent of blood products are used for elective surgeries and chronic medical conditions," he added. "That's a myth that more blood is used for trauma (cases)."
Although Melseth favors blood-recycling technology, he is most supportive of surgical techniques that reduce the amount of blood lost during surgery.
"Again, the key is if you don't lose it, you don't have to use it. Meticulous surgery is the cornerstone to blood conservation," Melseth said.
For certain faiths, there is little choice. Jehovah's Witnesses, for example, refuse donated blood and even their own blood once it has left their bodies. Even the Cell Saver can cause a problem for the strictest Jehovah's Witnesses unless the machine's tubing is considered an extension of the patient's own circulatory system.
Half of the patients in Melseth's program are Jehovah's Witnesses.
"Generally, (Jehovah's) Witnesses have been the driving force behind blood conservation measures," Melseth said.
Among them is Stephen Beller, a 57-year-old welder who lives in Black Canyon City and recently underwent back surgery to remove a cyst growing on his spine.
"When it comes to taking blood, it's non-negotiable," Beller said. "I will not take blood and not blood fractions."
It's a life-or-death choice for Beller, whose doctor minimized blood loss during the 2½-hour surgery at Banner Good Samaritan.
"I'm not rushing out to die, but if I'm faced with a decision where it's obedience to God's law or death, I would choose God's law," he said.
For Rasmussen, her choice to refuse a blood transfusion and instead bank her own blood was rooted in personal experience.
In the 1970s, her mother contracted hepatitis C in a transfusion during a hip-replacement surgery. She eventually died of liver failure.
Although Rasmussen considers the blood supply relatively safe, there are no guarantees.
"With West Nile virus, it really hadn't dawned on me," she said. "When they have a new disease come out, they have to come up with a new test." http://www.azcentral.com/arizonarepublic/local/articles/0916blood.html# Watchtower News http://www.watchtowernews.org