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Asian Tribune is published by World Institute For Asian Studies|Powered by WIAS Vol. 12 No. 2961

Focus on bloodless surgery

By Janaka Perera - Asian Tribune

Blood conservation and transfusion alternatives have become increasingly important in health care worldwide. Concerns about blood safety, periodic blood shortages, liability issues and consumer demand for are drawing attention to transfusion alternatives and bloodless surgery, according to the International Society of Hematology.

After the worldwide AIDS epidemic cast the spotlight on blood in the 1980s, efforts to eliminate its unseen threats intensified. The refusal of blood products by patients has led to greater awareness of blood conservation strategies. Increased awareness of the risks of transfusion including communicable diseases such as HIV has resulted in greater numbers of patients not accepting blood for non-religious reasons, while Jehovah's witnesses refuse blood transfusions on religious grounds.

We know the case of a leading Sri Lankan doctor who died of after a contaminated blood transfusion following injuries she received in a motor accident. Similar cases were having been reported from other countries too.

Peter Carolan, Senior Officer of the International Federation of Red Cross and Red Crescent Societies say: "Absolute guarantees on blood supplies can never be given." He adds, "There will always be new infections for which at the moment there is no test."

Collecting blood samples from the wrong patient, mislabeling samples and requesting blood for the wrong patient cost the lives of at least 440 people in the USA between 1995 and 2001, according to the Awake magazine August 2006.

Blood brings oxygen, nutrients and defensive help to our body cells and carries away junk such as toxic carbon dioxide, the contents of damaged and dying cells and other waste. And non one can guarantee that all of the junk in blood has been identified and removed before it given to someone else.

Says Dr. Prasad Krishnan of Apollo Hospital, Colombo, one of the few Cardiac Surgeons who have performed bloodless surgery in Sri Lanka:

"Giving someone else's blood has a certain risk for transmission of diseases although we have tests to check so many of the known diseases – there is still a small chance that something can be transmitted. There are also allergic reactions that can happen because our body always considers anything that is not our own as foreign and fights with it – that is nature's way."

While bloodless heart surgery eliminates the risks of blood transfusion; it does make cardiac surgery, especially in children complicated and difficult, due to the obligatory hemodilution of cardiopulmonary bypass.

As The Royal College of Surgeons of England notes, bloodless surgery requires a co-coordinated multidisciplinary approach. Senior surgical, unaesthetic and theatre staff is expected to discuss cases in advance, and the skill mix and number of support staff need to be modified to facilitate blood conservation strategies.

Dr. Krishnan stresses the need for the doctor to be confident in performing and the patient to be aware of the risks bloodless heart surgery. If properly done, the results are most gratifying.

"Basically when you have to operate inside the heart you have to stop it. When you have to stop the heart blood has to be kept continuously flowing to ensure that the rest of the body is alive."

"In other words the surgeon must take over the heart's functions to keep the blood flowing. Normally the right side of the heart gets blood without oxygen, which it pumps to the lungs, the blood takes up oxygen from the lungs and comes to the left side of the heart which than pumps the blood to the body. The surgeon has to take this blood before it comes to the heart, add oxygen to the blood outside the body and pump it back to the body."

"All forming a fluid filled closed loop circuit; so the body continues to get oxygen. At that point the doctor has to stop the heart and cut it open to do the operation, inside the heart (e.g. like closing a hole). When you have to connect a patient to a heart lung machine for the operation the tubing and everything in the machine has to be filled with fluid – not with air- because when blood comes you cannot have air bubbles in the system. When the blood mixes with this fluid it gets diluted. In blood you get hemoglobin, which carries oxygen. That is why blood is red. We need a certain level of hemoglobin to carry oxygen. You cannot dilute blood as much as you want and expect the patient to stay alive. So we have to be able to minimize the dilution. We are talking about operating inside the heart NOT on the coronary arteries, which are on the surface of the heart. The latter can sometimes be done without stopping the heart.

He emphasizes:

"These are the requirements for the operation, which is a very difficult in little children who have a smaller blood volume in their body resulting in a higher dilution, after connecting to the heart-lung machine. It leaves very little margin for error. Consequences can be very grave since this is a matter of life and death. In the case of other organs you can live without them functioning – without an eye or without a limb or with one kidney. But without a heart you have no chance of living at all."

Dr. Krishnan further says: "When the patient is put on a heart lung machine you have to insert pipes (cannulae) into the major blood vessels in the body. Even if you make a needle hole blood will flow profusely – because there is a large volume of blood flowing in these pipes sometimes at high pressure. So putting these cannulae and every little step has to be done meticulously – perfectly – leaving no room for errors. The quickness in which you do the surgery is vital – because the longer you do surgery the leakage of blood from within the blood vessels into the body. In the event of leakage you need more and more volume of blood, which means you, has to keep on adding fluid, which is will result in more dilution of blood. So it is important to do the surgery correctly and quickly. Very stringent conditions have to be met if bloodless heart surgery is to be successful, especially in children. You have no margin for error."

According to him, side effects of not giving blood occur if the patient ends up losing too much of blood or the blood ends up getting diluted too much. So surgeons make sure that the problem is avoided.

In the case of hole in the heart he notes: "When you have a hole in the heart you have too much blood flowing in your lungs. The pressure of the lung starts to go up and progressively keep increasing with age. And it reaches a certain point where you need that hole to be alive. If you close the hole you die because the pressure of the lung are is so high that the heart cannot pump all the blood through the lungs. If you are beyond that stage you die early. And closer you are to that stage the greater the risk in closing the hole."

At Apollo Hospital Colombo, bloodless surgery was performed successfully on two children – five years and 13 years- suffering from this disease.

The 5 year old had a tumor inside the heart that was obstructing the flow of blood and had to be removed. The 13 year old had a large hole in the heart, that had produced a very severe increase in the lung blood pressure, and she was told to be inoperable. After detailed tests at Apollo Hospital , we found she may still have a chance and after explaining the higher risk involved to the parents, she underwent closure of the hole successfully. Both the operations were performed without any blood transfusion whatsoever.

There is an increasing international recognition that one of the aims of good clinical care is to avoid blood transfusion wherever possible.

- Asian Tribune -

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