Bloodless Medicine  – Caring Effectively for Patients Who Decline Blood Transfusions Michael J. Columbus Administrative Di...
What is Bloodless Medicine and Surgery? It is the safe and effective practice of medicine and surgery without the use of… ...
Why Bloodless? <ul><li>Individuals refuse for religious  reasons </li></ul><ul><ul><ul><li>Jehovah’s Witnesses </li></ul><...
A lesson learned from the history of blood’s use in medicine
History of Blood and Medicine <ul><li>2500 B.C. </li></ul><ul><ul><li>Egyptians practiced bleeding </li></ul></ul><ul><ul>...
History of Blood and Medicine During medieval times, phlebotomy was by far the most expedient way to rid the body of exces...
History of Blood and Medicine December 14, 1799
History of Blood and Medicine December 14, 1799 Benjamin Rush
1900 - Dr. Karl Landsteiner discovers blood groups During World war II blood was mobilized and its constituent parts used ...
Comment:  So, the first president of our country was the victim of the traditional medical paradigm of his time.  His phys...
The History of Blood use in medicine compels us to further explore alternatives
Preoperative Autologous Donation (PAD) RBCs Change Shape During Storage Day 1 Day 21 Day 35
Fundamental procedures  for Bloodless Medicine
Bloodless Program <ul><ul><ul><ul><li>Pediatric tubes </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Limited blood sampling ...
CELL SAVER / HEART LUNG MACHINE
Acute Normovolemic Hemodilution (ANH) In the operating room blood is collected before the operation begins Blood volume is...
ACUTE NORMOVOLEMIC HEMODILUTION
Factors Influencing Decision  to Correct Anemia Factors HemoglobinLevel Chronicity of Anemia Metabolic Needs Ongoing Blood...
Change in Transfusion Practice
I direct that no blood transfusions (whole blood, red cells, white cells, platelets, or blood plasma) are to be given to m...
I release Pennsylvania Hospital and all physicians involved in my care, and their respective employees, agents and represe...
 Tissue Adhesives (Cryoprecipitates) Fibrinogen  Organ transplants and donations  Other surgical procedures, medical te...
Patient Identification
Bloodless Medicine and Surgery is at its root an educational program, devised to educate and support physicians, staff and...
The Future of Bloodless Medicine and  Surgery
Oxygen Therapeutics <ul><li>Perfluorocarbons </li></ul><ul><ul><li>Oxygent®;  AANH® </li></ul></ul><ul><li>Human hemoglobi...
PFC liquids first studied as biologic gas carriers in the 1960s   <ul><ul><li>Mouse  breathing  when totally immersed in a...
Room Temperature Stable  Hemopure  ®  and Oxyglobin  ®  Approvals Hemopure and oxyglobin are registered trademarks of  Bio...
Mechanism of Action Normal blood flow Hemopure Anemic blood flow <ul><li>Biopure’s stabilized hemoglobin circulates in pla...
Is Bloodless Medicine safe?
1962 – Dr. Denton Cooley 1962 - Denton Cooley made history by performing the first &quot;bloodless&quot; heart surgery 196...
“Several methods are available to the surgeon who wishes to perform bloodless surgery… Alone, each of these techniques can...
Conclusion <ul><li>Blood supply and safety issues necessitate further exploration of nonblood alternatives </li></ul><ul><...
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Bloodless Medicine Caring Effectively For Patients Who Decline Blood Transfusions

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  • Blood is collected in standard blood bags containing citrate as the anticoagulant. Hemodilution kits are available, that contain 2 blood bags, a Y-type connector with a Luer lock adapter and a patient identification bracelet, which simplifies the ANH process. Vascular access for the collection of blood may be obtained from an artery,usually the radial, or a large vein. The blood should be gently and intermittently agitated to ensure adequate mixing with the anticoagulant. Approximately 7 - 10 minutes is required for the withdrawal of a unit of blood, and adequate time should be available to withdraw 3-4 units from anesthesia induction until major surgical blood loss occurs.
  • Hemopure causes the body’s circulatory system to oxygenate tissues more efficiently -- a huge help to circulation compromised by too few red blood cells. Hemopure’s mechanism is different from that of red blood cells. Hemopure sends oxygen swiftly to all parts of the body through the plasma. Talk about chart.
  • Bloodless Medicine Caring Effectively For Patients Who Decline Blood Transfusions

    1. 1. Bloodless Medicine – Caring Effectively for Patients Who Decline Blood Transfusions Michael J. Columbus Administrative Director, Center For Bloodless Medicine and Surgery at Pennsylvania Hospital HUP Nursing Cultural Competence Committee Presentation – September 10, 2009
    2. 2. What is Bloodless Medicine and Surgery? It is the safe and effective practice of medicine and surgery without the use of… Whole Blood Red Cells White Cells Platelets Plasma Allogeneic
    3. 3. Why Bloodless? <ul><li>Individuals refuse for religious reasons </li></ul><ul><ul><ul><li>Jehovah’s Witnesses </li></ul></ul></ul><ul><li>Cost of blood </li></ul><ul><li>Dangers of blood </li></ul><ul><li>Better patient outcomes </li></ul>
    4. 4. A lesson learned from the history of blood’s use in medicine
    5. 5. History of Blood and Medicine <ul><li>2500 B.C. </li></ul><ul><ul><li>Egyptians practiced bleeding </li></ul></ul><ul><ul><ul><li>Not known why or what they thought it would accomplish </li></ul></ul></ul><ul><li>Fourth and fifth centuries </li></ul><ul><ul><li>Hippocrates </li></ul></ul><ul><ul><ul><li>“ Since all sickness results from an imbalance of humours, the cure involves restoring the equilibrium by…bleeding” </li></ul></ul></ul><ul><li>Aristotle </li></ul><ul><ul><li>Continued the practice of bloodletting </li></ul></ul>
    6. 6. History of Blood and Medicine During medieval times, phlebotomy was by far the most expedient way to rid the body of excess humours which caused ill health.
    7. 7. History of Blood and Medicine December 14, 1799
    8. 8. History of Blood and Medicine December 14, 1799 Benjamin Rush
    9. 9. 1900 - Dr. Karl Landsteiner discovers blood groups During World war II blood was mobilized and its constituent parts used in an industrial scale. History of Blood and Medicine
    10. 10. Comment: So, the first president of our country was the victim of the traditional medical paradigm of his time. His physicians got away with it, but had to go to court to defend their actions. It is absolutely amazing what a few hundred years will do for one’s perspective. I cannot help but think of how equally barbaric the next story will appear in the future to even traditional medical doctors. The New England Journal of Medicine 1999; 341:1845-1849 What does this brief examination of the history of blood and medicine teach us?
    11. 11. The History of Blood use in medicine compels us to further explore alternatives
    12. 12. Preoperative Autologous Donation (PAD) RBCs Change Shape During Storage Day 1 Day 21 Day 35
    13. 13. Fundamental procedures for Bloodless Medicine
    14. 14. Bloodless Program <ul><ul><ul><ul><li>Pediatric tubes </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Limited blood sampling </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pharmaceuticals </li></ul></ul></ul></ul>Meticulous Blood Conservation
    15. 15. CELL SAVER / HEART LUNG MACHINE
    16. 16. Acute Normovolemic Hemodilution (ANH) In the operating room blood is collected before the operation begins Blood volume is simultaneously restored using volume expanders The patient’s withdrawn blood is returned when major bleeding has ceased. In a closed circuit set up, all tubing remains connected at all times.
    17. 17. ACUTE NORMOVOLEMIC HEMODILUTION
    18. 18. Factors Influencing Decision to Correct Anemia Factors HemoglobinLevel Chronicity of Anemia Metabolic Needs Ongoing Blood Loss Cost Cause Age Comorbid Diseases
    19. 19. Change in Transfusion Practice
    20. 20. I direct that no blood transfusions (whole blood, red cells, white cells, platelets, or blood plasma) are to be given to me. Legal protection for PAH and the patient
    21. 21. I release Pennsylvania Hospital and all physicians involved in my care, and their respective employees, agents and representatives from liability for any damages that might be caused by my refusal of blood, despite their otherwise competent care.
    22. 22.  Tissue Adhesives (Cryoprecipitates) Fibrinogen  Organ transplants and donations  Other surgical procedures, medical test or current therapy: Identify  Platelet cell fractions: Identify  White cell fractions: Identify  Red cell fractions: Identify  Hypervolemic Hemodilution (no blood storage)  Intraoperative Hemodilution where extracorporeal circulation is a closed circuit without blood storage  Intraoperative Blood Salvage (Cell-Saver) where extracorporeal circulation is a closed circuit without blood storage  Heart –Lung Equipment (non-blood primed)  Hemodialysis Equipment (non-blood primed)  Hemophiliac Preparations (clotting factors)  Immune Globulins (blood fraction, Rhogam  Erythropoietin (contains albumin)  Albumin (blood fraction) Refuse Accept Product / Treatment
    23. 23. Patient Identification
    24. 24. Bloodless Medicine and Surgery is at its root an educational program, devised to educate and support physicians, staff and the patient. Coordinators are available 24 hours a day, 7 days a week to provide information regarding our program, to facilitate a transfer from another hospital, or to locate a participating physician to meet the patient’s medical needs. Currently we have more then 160 physicians, representing virtually every specialty, registered with our program. much more than “a promise not to give transfusions.”
    25. 25. The Future of Bloodless Medicine and Surgery
    26. 26. Oxygen Therapeutics <ul><li>Perfluorocarbons </li></ul><ul><ul><li>Oxygent®; AANH® </li></ul></ul><ul><li>Human hemoglobin </li></ul><ul><ul><li>Polyheme®; trauma/GS </li></ul></ul><ul><ul><li>HemoLink®; trauma/CABG </li></ul></ul><ul><li>Bovine hemoglobin </li></ul><ul><ul><li>Hemopure® (Biopure); GS/CABG </li></ul></ul>“ Blood Substitutes”
    27. 27. PFC liquids first studied as biologic gas carriers in the 1960s <ul><ul><li>Mouse breathing when totally immersed in an oxygen saturated perfluorocarbon (FC-80, butyltetrahydrofuran) liquid (photograph courtesy Professor Leland Clark). </li></ul></ul><ul><ul><li>This pioneering experiment stimulated great interest in the development of fluorocarbons as respiratory gas carriers in biological systems. </li></ul></ul>
    28. 28. Room Temperature Stable Hemopure ® and Oxyglobin ® Approvals Hemopure and oxyglobin are registered trademarks of Biopure Corporation Hemopure (Human) Approved 2001 So. Africa Oxyglobin (Veterinary) Approved 1998 U.S.A. 1999 Europe
    29. 29. Mechanism of Action Normal blood flow Hemopure Anemic blood flow <ul><li>Biopure’s stabilized hemoglobin circulates in plasma </li></ul><ul><li>Greater distribution throughout the body than RBCs </li></ul>
    30. 30. Is Bloodless Medicine safe?
    31. 31. 1962 – Dr. Denton Cooley 1962 - Denton Cooley made history by performing the first &quot;bloodless&quot; heart surgery 1964 - Reported case He concluded that &quot;the risk of surgery in patients of the Jehovah's Witness group has not been substantially higher that for others.&quot; (D A Ott, D A Cooley, &quot;Cardiovascular surgery in Jehovah's Witnesses: Report of 542 operations without blood transfusion.&quot; Journal of the American Medical Association 238 (September 1977) 1256-1258) Thus emerged a new frontier of endless possibilities.
    32. 32. “Several methods are available to the surgeon who wishes to perform bloodless surgery… Alone, each of these techniques can successfully reduce the need for homologous [donor] blood transfusions by 50% to 70%. By combining these strategies, the surgeon can achieve the goal of performing bloodless surgery for most patients.” -Spence RK, et al. Transfusion and Surgery. Current Problems in Surgery, December 1993, pp. 1103-1180. 1993 – Dr. Richard K. Spence
    33. 33. Conclusion <ul><li>Blood supply and safety issues necessitate further exploration of nonblood alternatives </li></ul><ul><li>Progressive Non-Blood Centers of Excellence will bring Bloodless Medicine and Surgery into the mainstream of medicine </li></ul>

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