JANET, a Canadian woman, explained to her son why she had AIDS. She
had contracted the disease from her husband before he died. In turn,
her husband, a hemophiliac, had likely got AIDS through a blood
fraction. Nightmares like this are just one of the factors that have
prompted the medical community to reconsider giving blood transfusions
as standard practice. Indeed, a headline in The New York Times this
year declared: "'Bloodless' Surgery Gains New Acceptance."

Several medical conferences have highlighted the increased interest in
bloodless surgery. Among those held last year were two in the United
States (Boston and Atlanta), one in Canada (Winnipeg), and one in
Latvia (Riga), which was an international conference for Eastern
Europe.

After over 50 years of reliance on blood transfusions, why did more
than 1,400 professionals from 12 countries attend these four
conferences heralding bloodless surgery as "the way of the future," as
one newspaper headline expressed it? What did these conferences
highlight regarding new drugs, equipment, and techniques that can
affect treatment available to your family?

Why the Search for Alternatives?

A prime motivation is the inability to safeguard blood supplies. For
example, Toronto's Globe and Mail, of January 31, 1998, comments on
Canada's "tainted-blood tragedy" of the 1980's: "Hepatitis C is a
potentially debilitating liver disease for which there is no cure. . .
As many as 60,000 Canadians may have been infected with the virus
through tainted blood, which means as many as 12,000 could die as a
result of blood-borne hepatitis."

Although newer screening procedures have greatly lessened the threat,
Justice Horace Krever said to the conference held in Winnipeg:
"Canada's blood supply never was absolutely safe, and never can be.
The use of blood inevitably entails risks." And the risks of
transmitting disease or causing severe reaction increase with each
additional unit of blood given.

In Riga, Dr. Jean-Marc Debue, of the Clinique des Maussins, in Paris,
concluded: "We physicians had to reconsider our usual therapeutic
approach. . . . Blood transfusion has extended the lives of many
patients, but it has also poisoned the lives of others by giving them
an incurable disease."

Procedures for screening blood for contaminants tend to lag behind new
threats of disease and thus may not protect against them. For example,
Dr. Paul Gully, of Ottawa, Ontario, Canada, observed: "Hepatitis G is
a newly described RNA virus; transmission through transfusion has
occurred but the current risk is unknown."

An additional danger was reported in a special medical issue of Time
magazine: "Transfusions can suppress the immune system, . . . leaving
a patient open to infection, slower healing and a longer recovery
time."

Another factor is financial savings. In the United States, according
to Time magazine, each blood transfusion can cost $500. And in some
places, the blood supply is dwindling because there are fewer donors.

Further savings to patients who have bloodless surgery result from
lower infection rates and shorter hospital stays. Speaking in
Winnipeg, Durhane Wong-Rieger, of the Canadian Hemophilia Society,
said about bloodless surgery: "We feel it is essential. It's
cost-effective and would definitely improve the health of patients."

There is also an increased demand for bloodless surgery by a wider
constituency of patients. Dr. David Rosencrantz, of Legacy Portland
Hospitals (Oregon, U.S.A.), stated that initially "100% of those who
came to us did so on religious grounds." However, now at least 15
percent prefer medical alternatives to blood transfusions, but not
because of religious conscience.

A Variety of Views

At the four conferences, a major point of consensus was that using
one's own blood is far safer than using blood donated by other humans.
Because of this, some recommend storing one's own blood before an
operation. However, many noted that there is no time to store blood in
emergencies. Also, there is the religious objection of Jehovah's
Witnesses to using any stored blood.

Dr. Bruce Leone, of Duke University, North Carolina, U.S.A., told the
Canadian conference: "Preoperative donation [of one's own blood] is
expensive, labor intensive, does not eliminate the most common cause
of transfusion-associated morbidity [which is clerical—that is, office
or procedural—error] and requires significant time prior to surgery."

Many physicians advocate continuing to develop medications and
techniques that drastically reduce the use of transfused blood. They
contend that blood transfusion should be employed only in emergency
situations. On the other hand, others now essentially eliminate blood
transfusions altogether from their practice. They point to extremely
difficult operations—hip replacement, complex neurosurgery, open-heart
surgery on infants and adults—performed without transfusion, with
rapid patient recovery.

To date, there are over 100 hospitals worldwide with bloodless
programs, of which more than 70 are in the United States. In fact,
there are now more than 88,000 doctors worldwide who are cooperating
with patients who do not want blood.

New Techniques

At the Atlanta conference, speaker after speaker acknowledged having
developed a particular technique first when treating Jehovah's
Witnesses. Many reflected the sentiments of Dr. James Schick, of
Encino-Tarzana Regional Medical Center, Los Angeles, who noted that
because of new procedures developed while working with premature
babies of Jehovah's Witnesses, he now uses 50 percent less blood with
all his tiny patients. Of course, such new procedures have also proved
valuable with adults.

Dr. Jean-François Hardy, of the Montreal Heart Institute, noted:
"Bloodless surgery cannot be achieved with the help of any single
therapeutic intervention . . . Rather, this objective can only be
achieved by the combination of various strategies."

Among the new techniques are (1) preoperative preparation, (2)
prevention of blood loss during surgery, and (3) postoperative care.
Obviously, all surgical approaches are greatly affected by the time
factor, that is, whether there is time beforehand to build up a
patient for surgery or no time because emergency surgery must be
performed.

The ideal approach to bloodless surgery is preoperative treatment that
increases blood cell counts and improves general health. This includes
high-potency iron supplements and vitamins as well as, when
appropriate, doses of synthetic erythropoietin, a drug that stimulates
the patient's bone marrow to produce red blood cells at an accelerated
rate. Technology that permits microanalysis makes it possible to draw
less blood for testing and yet get more results from that which is
drawn. This is vital for premature infants and older patients who have
lost considerable blood.

Also helpful are volume expanders, fluids administered intravenously
to increase blood volume. The hyperbaric oxygen chamber too is used in
certain facilities to help supplement the oxygen needs of a patient
who has suffered severe blood loss. In Atlanta, Dr. Robert Bartlett
explained that the oxygen chamber is a powerful asset but must be used
carefully because oxygen in high doses is toxic.

For the second step, prevention of blood loss during the operation,
there is an array of new instruments and technologies. They help to
minimize blood loss; are less invasive, minimizing both blood loss and
trauma; or help immediately to capture and reuse the patient's own
blood that would have been lost during surgery. Consider just a few of
the new techniques.

· An electric cautery device uses heat to stop vessels from bleeding.

· The argon beam coagulator helps stop bleeding during surgery.

· The harmonic scalpel employs vibration and friction to cut and cause
blood clotting at about the same time.

· During certain types of surgery, such drugs as tranexamic acid and
desmopressin are often used to increase blood coagulation and lessen
bleeding.

· Hypotensive anesthesia reduces blood loss by lowering blood pressure.

Also significant is the improvement in intraoperative blood salvage
machines. During an operation, these recover and immediately reuse the
patient's own blood, without having to store it. Newer machines, while
remaining connected to the patient, can even separate blood into
components and reuse those that are needed.

After the conference in Riga and upon hearing of Latvia's need,
Jehovah's Witnesses in Sweden donated two cell-saver machines to
Latvia. The arrival of the first one and the benefits of bloodless
surgery created so much enthusiasm in Latvia that the event received
national television coverage there.

Postoperative care often includes many of the same blood-building
regimens used in preoperative preparation. However, care of
nontransfused patients after surgery is often easier than that of
those transfused. Why?

Striking Results

While techniques that eliminate the use of blood often require more
work prior to and during surgery, surgeons have noted that patients
benefit because of having shorter postoperative recovery times. They
do not suffer from complications that often accompany transfusions.
Reduced hospital stays for patients who have not been given blood have
been documented.

Dr. Todd Rosengart, of The New York Hospital-Cornell University
Medical Center, observed that their eight-step blood conservation
strategy permitted complex open-heart surgeries to be performed
confidently without blood. Dr. Manuel Estioko, of Good Samaritan
Hospital in Los Angeles, spoke of their "extensive experience with
hundreds of open-heart operations without blood." Dr. S. Subramanian
reported success with bloodless open-heart surgery on children at
Miami Children's Hospital.

Orthopedic surgery, particularly hip replacement, is a challenging
area. Yet, Dr. Olle Hägg, of Uddevalla Hospital in Sweden, reported in
Riga that combining "surgical strategy and precision" had allowed them
to reduce blood loss significantly for patients who are Jehovah's
Witnesses. Indeed, Mr. Richard R. R. H. Coombs, of Imperial College
School of Medicine, London, said that "99.9 percent of all orthopedic
surgery can be done without . . . blood transfusions."

The Future

The number of hospitals and doctors using bloodless methods continues
to increase. And conferences where such knowledge is exchanged have
been extremely helpful, as physicians learn of alternatives that have
been tested successfully and are being used regularly.

Dr. Richard Nalick, of the University of Southern California School of
Medicine, said: "There is an ever-increasing population that desires
medical and surgical treatment without blood . . . Bloodless medicine
and surgery represents a state-of-the-art approach and should not be
misunderstood as a less effective 'alternative therapy.'"

As the problems related to blood transfusions continue and public
demand for alternatives increases, the future of bloodless surgery
seems bright.