Canterbury DHB

The adult patient requiring elective surgery who declines blood products– ‘bloodless surgery’

Bloodless surgery refers to the co-ordinated peri-operative care of patients aiming to avoid blood transfusion and improve patient outcomes [6]. The three pillars of bloodless surgery are maximising pre-operative haemoglobin, minimising blood loss and accepting post-operative anaemia.

The patient’s wishes need to be made clear to the surgeon and anaesthetist prior to any scheduling of surgery and a discussion regarding the potential complications of surgery including bleeding risk should take place. The surgical team can advise on available minimally invasive/traumatic techniques [6]. This discussion should be clearly documented in the patient's clinical notes.

Please refer to flowchart: Elective Surgery for Patients who Decline Blood Products.

The two major predictors of peri-operative blood transfusion that can be influenced are type of surgical procedure and pre-operative haemoglobin.

Generally, blood loss tends to be less with laparoscopic versus open surgery. Longer procedures result in more blood loss. See Estimating the maximum allowable blood loss (MABL).

Bloodless surgery: Maximising the pre-operative haemoglobin level

Early measurement of haemoglobin, investigation and treatment of underlying anaemia is crucial.

• In addition, if significant blood loss is expected the patient’s iron stores should be assessed by measuring a ferritin level and CRP. In the absence of inflammation (normal CRP), a ferritin of <100 mcg/L suggests inadequate iron stores [7] to be able to compensate for future blood loss and in this case pre-operative iron therapy is recommended. The presence of inflammation will elevate the ferritin independently of iron storage level – seek advice from a Haematologist.
• Consider use of recombinant erythropoietin (Epo). If acceptable to the patient, subcutaneous Epo can be used to attempt to increase red cell production pre-operatively [1]. In the absence of renal failure, high doses of Epo are needed to elevate Hb concentration. Current UK-licensed dose schedules include: Eprex 600U/kg weekly for 3 weeks plus day of surgery or 300 U/kg daily for 15 days starting 10 days before surgery [1]. Patients will require supplemental iron to increase response or maintain transferrin saturation to levels that will support erythropoiesis stimulated by Epo [8] Oral iron has been used effectively although a comparison of intravenous iron and oral iron for preoperative stimulation with Epo found a significantly increased haemopoietic effect with intravenous iron [8]. Side effects of erythropoietin include: hypertension, increased thrombotic risk, headaches and flu-like symptoms. Seek advice from a Haematologist.
• Evidence for chronic inflammation, infection or malignancy should be sought as these may predict a poor response to Epo [1] and oral iron therapy.

Bloodless surgery: Estimating the maximum allowable blood loss (MABL)

The estimated blood loss for the procedure in question, in conjunction with an estimation of the maximum allowable blood loss resulting in a post-operative haemoglobin level, can help with planning and influence the necessity of certain interventions e.g. need for erythropoietin. Please see Maximum Allowable Blood Loss Relating to Post-Operative Haemoglobin.

Bloodless surgery: Reducing blood loss

Pre-operative measures

• The patient should be questioned about any tendency for bleeding including family history.
• A drug history, including over the counter drugs and herbal substances, should be taken to identify increased bleeding risk and drugs discontinued if possible. Such drugs include aspirin, NSAIDs, warfarin, DOACs (dabigatran, rivaroxaban, apixaban), fluoxetine, garlic, gingko, ginseng, St John’s Wort.
• Hypertension should be adequately treated.

Intra-operative measures

• As is the case for any patient; operative procedures should be performed by the most experienced surgical team available who should use meticulous dissection, gentle handling of tissue and meticulous haemostasis [8].
• The use of intra-operative cell salvage using "cell saver" devices should be discussed. Cell salvage machines collect and filter blood removed by suction and in swabs, which can then be given back to the patient in a continuous circuit [6]. In Christchurch, there are 2 cell salvage machines in the public/women’s hospital site and one at Burwood Hospital. These are routinely used in cardiac surgery and major vascular procedures. Post-operative cell salvage can be used after knee replacement surgery. For more information, contact the Anaesthetic Department.
• Autologous blood collection and transfusion is possible here in Christchurch at a cost to the patient, although not usually acceptable to JWs and not generally recommended [7]. If patients wish for this to occur before elective surgery this should be discussed with the surgeon and the relevant NZBS form completed (Request for Autologous Blood Collection and Transfusion).
• Acute normovolaemic haemodilution (ANH) can be considered, however, it has limited efficacy in most scenarios. In this process whole blood is collected from the patient immediately before surgery (followed by intravenous fluids to maintain intravascular volume [6]) to be re-infused immediately after surgery or earlier if required [1]. Seek advice from an Anaesthetist.
• Systemic administration of antifibrinolytic agents e.g. tranexamic acid can also be considered, as well as the use of desmopressin [1].
• The use of fibrin glue should be discussed with the patient as these tend to be plasma fractionation products [1]. Tisseel fibrin sealant is available in Christchurch and stored in theatres. It comprises two frozen solutions: a "thrombin solution" (containing human-derived thrombin) and a "sealer protein solution" (containing fibrinogen, human factor XIII and bovine aprotinin). These pre-loaded syringes are thawed before use and their contents mixed together immediately before or during application [9].
• Deliberate controlled hypotension can be employed in operations with a large expected blood loss [8].

Bloodless surgery: Post operative anaemia

The haemoglobin threshold at which post-operative red cell transfusion is warranted is controversial. Multiple RCTs have demonstrated the non-inferiority of a restrictive transfusion strategy (with Hb trigger of 70-80) compared to more liberal strategies (Hb 90-100) with no mortality benefit and significantly more blood product use in the latter, in both cardiac and non-cardiac surgery settings.

Post-operative care:

• Limit phelobotomy to preserve blood volume and use paediatric bottles. Blood loss of just 2 mL daily can lead to iron deficiency[11].
• Vigilance for bleeding, which may require early surgical intervention.
• Close attention to fluid status to preserve cardiac output.
• Post-operative patients may have impaired oxygen delivery via a number of mechanisms and optimising respiratory functioning via chest physiotherapy and supplemental oxygen should be considered [6].
• Equally, reducing oxygen consumption can be aided by appropriate analgesia and preventing infection where possible [6].
• Iron supplementation should be considered if there is post-operative bleeding or the patient in being maintained on Epo [1].
• Post-operative folic acid should be considered when reduced oral intake is anticipated [1].
• Vitamin B12 should be adequately supplemented [6].
• In extreme circumstances post-operative sedation, paralysis and ventilation on intensive care can be used to reduce oxygen requirement and maximise delivery.

Topic Code: 47843