Blood Saver

A wide range of treatment options, from powerful drug therapies and diet modification to surgical options and heart transplantation, are rapidly changing how chronic heart failure is treated.

by Monika Guttman

Angelica Garcia was told she had less than three months to live if she did not have surgery to remove the cancer on her duodenum.

But as a Jehovah's Witness, the 81-year-old grandmother would not undergo any surgical procedure that involved blood transfusions. Since the surgery she needed often results in significant blood loss, the hospitals she approached refused to try the surgery without transfusions.

With her health rapidly deteriorating, Garcia was referred to Dilip Parekh, M.D., chief of the division of tumor and endocrine surgery at the USC School of Medicine and a participant in the USC Transfusion-Free Medicine and Surgery Program-a program that studies and implements surgical techniques that minimize blood loss and reduce the need for transfusion.

Parekh understood immediately why so many facilities had refused to do the operation. "She had three previous abdominal surgeries, so just entering the abdominal cavity in that situation, you run the risk of bleeding. Secondly, the tumor was in a difficult place. The blood vessels that take blood from the small intestines to the liver and the main artery supplying blood to the small intestine were tented over the tumor. Under those circumstances, if you're not meticulous, you can have a considerable amount of bleeding."

Last spring, Parekh and a team at the USC/Norris Comprehensive Cancer Center and Hospital that included Duraiyah Thangathurai, M.D., professor of anesthesiology, conducted a novel nine-hour operation known as a Whipple procedure to remove the cancer. Miraculously, they were able to do the surgery without the need for transfusion.

Up to 4 million patients receive blood transfusions each year in the U.S., according to the American Association of Blood Banks. But thanks to advances in surgical and medical techniques and technology, more and more patients who request transfusion-free surgery are being accommodated at USC, says Randy Henderson, coordinator of the Transfusion-Free Medicine and Surgery Program at USC University Hospital and USC/Norris. In addition to those whose religious beliefs prohibit transfusions, he says, there are increasing numbers of patients who want to avoid any of the even minimal risks associated with blood transfusions.

At USC, more than 100 physicians in a wide variety of disciplines-from neurosurgery and orthopaedics to otolaryngology and oncology-have signed on with the Transfusion-Free Medicine and Surgery Program. That means they will, at a patient's request, use techniques to minimize blood loss, including:

When patients come to the Transfusion-Free Medicine and Surgery Program, says Henderson, they receive counseling in the various methods used to minimize blood loss and then consent to the specific procedures with which they and their physicians feel comfortable. They can refuse the alternatives they dislike. To assure that a patient's wishes are respected, upon admission several security measures are put into place to help identify them as participants in the Transfusion-Free Program, including yellow-colored identification bands and flags on all charts and computerized patient lists.

In the past two years, more than 300 patients have participated in the Transfusion-Free Medicine and Surgery program. Transfusion-free procedures have included liver resections, hip revision and replacement surgery, cancer biopsies and vascular procedures. Technological advances have helped the Transfusion-Free Program become a more realistic possibility for many patients in the past few years, says anesthesiologist Thangathurai. He notes that the drugs used in Mrs. Garcia's case have only been available for the past four or five years. In addition, fairly new monitoring technology allows anesthesiologists to fine-tune blood pressure and oxygen levels.

Because of their role as researchers at the USC School of Medicine, many of the participating physicians are trying new procedures to minimize blood loss that are not yet available in most hospitals. For example, when Robbin Cohen, M.D., assistant professor of surgery, was brought in on the case of Marie Jackson, there weren't many options: the 59-year-old Pasadena resident needed open heart surgery to replace a faulty mitral valve. But as a Jehovah's Witness, she had religious objections to receiving donor blood.

Since 30 to 40 percent of patients undergoing open heart surgery need transfusions, the best alternative Cohen could offer was a relatively new procedure called port access surgery-where the valve could be replaced through a small four inch incision, or "port," on the side of the chest between the ribs. No sawing through the breastbone, no spreading the rib cage to reach the heart, and, most importantly for Jackson, no blood transfusion. The grandmother of 16 and great-grandmother of two opted for this minimally invasive procedure, which was a success.

Parekh attributed the success of the Garcia procedure to the team approach routinely used in the Transfusion-Free Program, including the anesthesia techniques of Thangathurai and preoperative management of the patient. For instance, Thangathurai used two different medications - one to lower blood pressure and one to prevent bleeding - to avert significant blood loss in patients where normally they would bleed a lot. "It requires working very closely with the surgeon throughout the surgery," says Thangathurai.

The preoperative management of the case involved making the patient physically strong enough to undergo the procedure. "When I first saw her she had only eight grams of hemoglobin [a healthy person generally has about 14 grams of hemoglobin per 100 milliliters of blood], because she was bleeding from the tumor," Parekh recalls. "I couldn't operate in those conditions." So Garcia was referred to Howard Liebman, M.D., associate professor of hematology, who was able to bring her hemoglobin up to 12 grams using the drug Epogen, intravenous iron and nutritional supplements. "After a period of nutritional buildup, she was ready to handle the operation, "says Parekh.

New technology on the horizon, such as efforts to develop artificial blood substitutes and ways to sterilize blood, may dampen the demand for transfusion-free medicine among those who choose it in order to avoid the risks. But for those like Garcia, whose religion makes any transfusion unacceptable, the advances in transfusion-free techniques have already made life better. "My family is most grateful," she says. "Where before I thought I might have only days left, I may yet live a long time."

Back