Key learning points

Introduction

Anemia frequently complicates the treatment of surgical patients. The high vascularity of the head and neck can foster significant blood loss during surgery. For example, allogenic blood transfusion (ABT) rates are quoted as high as 84% in head and neck cancer patients perioperatively. Noteworthy factors that may predict the need for blood transfusion in head and neck oncologic surgery include the preoperative hemoglobin (Hb) level, patient age, the site and extent of the primary tumor, the need for flap reconstruction, and prior chemotherapy. In addition to tumor location and stage, anemia of chronic disease, nutritional factors, and chemotherapy are all major contributors to preoperative anemia and should be monitored and corrected when possible. The effects of anemia on the surgical patient are wide-ranging and serve not only as a major risk factor for transfusion, but also as an independent predictor of morbidity and mortality.

Traditionally, correction of anemia took place via ABTs. However, for a variety of reasons there remain populations unable to receive this option. For example, religious beliefs (Jehovah’s Witnesses), fear of the risks and complications of transfusion, medical contraindications (ie, presence of autoantibodies), or logistical issues (ie, rare blood groups, unavailability of blood components) may preclude a patient from accepting a blood transfusion. Additionally, ABTs are not without complication, and may result in transfusion reactions, fever, hemolysis, lung injury, and immunodeficiency.

Bloodless medicine and surgery programs have developed out of a need to find alternative means to treat acute and chronic anemia in patients who cannot receive ABTs. The goal of this article is to acquaint the otolaryngologist with alternative methods of managing blood loss and anemia in their surgical patients who cannot or should not receive ABTs.

Jehovah’s witnesses

The Jehovah’s Witness faith began in Philadelphia, Pennsylvania, in the 1870s as a Bible study group. A cornerstone of this religion is the literal interpretation of Bible passages. Passages such as “Every moving animal that is, alive may serve as food for you…Only flesh with its soul—its blood—you must not eat” from Genesis 9:3,4 are taken literally as a ban of blood via any route. As such, a refusal of blood transfusions is a core value of their faith. Disobeying this ban taints the recipient’s immortal soul leading to shunning by friends, family, and the entire Jehovah’s Witness community.

Over the last 20 years, the Jehovah’s Witness faith and prohibitions have evolved with a broader interpretation of what components, techniques, and kinds of blood and blood products are acceptable. As a rule, Jehovah’s Witnesses refuse transfusion of allogenic blood and its major components—red cells, white cells, platelets, and plasma. However, acceptance of “minor” fractions such as albumin, immunoglobulin, vaccines, clotting factors, and prothrombin complex concentrates are considered a “matter of conscience” and is often left to be decided by the individual ( Table 1 ).

With regard to perioperative planning, banking of the patient’s own blood for later reinfusion (ie, preoperative autologous donation [PAD]) is not allowed; however, blood left connected to the patient as in cell salvage, hemodialysis, or cardiopulmonary bypass is acceptable for reinfusion. Additionally, acute normovolemic hemodilution (see “Intraoperative Techniques: Acute Normovolemic Hemodilution”) and many of the pharmaceutical agents that promote hematopoiesis or hemostasis (ie, iron, topical hemostatic agents, antifibrinolytics, and erythropoiesis stimulating agents) are also accepted by most Jehovah’s Witnesses.

It was the refusal of ABTs in this population that served as one of the impetuses to develop alternative means for treating anemia and decreasing surgical blood loss, which can be applied to a plethora of other populations and medical and surgical conditions.

Introduction

Anemia frequently complicates the treatment of surgical patients. The high vascularity of the head and neck can foster significant blood loss during surgery. For example, allogenic blood transfusion (ABT) rates are quoted as high as 84% in head and neck cancer patients perioperatively. Noteworthy factors that may predict the need for blood transfusion in head and neck oncologic surgery include the preoperative hemoglobin (Hb) level, patient age, the site and extent of the primary tumor, the need for flap reconstruction, and prior chemotherapy. In addition to tumor location and stage, anemia of chronic disease, nutritional factors, and chemotherapy are all major contributors to preoperative anemia and should be monitored and corrected when possible. The effects of anemia on the surgical patient are wide-ranging and serve not only as a major risk factor for transfusion, but also as an independent predictor of morbidity and mortality.

Traditionally, correction of anemia took place via ABTs. However, for a variety of reasons there remain populations unable to receive this option. For example, religious beliefs (Jehovah’s Witnesses), fear of the risks and complications of transfusion, medical contraindications (ie, presence of autoantibodies), or logistical issues (ie, rare blood groups, unavailability of blood components) may preclude a patient from accepting a blood transfusion. Additionally, ABTs are not without complication, and may result in transfusion reactions, fever, hemolysis, lung injury, and immunodeficiency.

Bloodless medicine and surgery programs have developed out of a need to find alternative means to treat acute and chronic anemia in patients who cannot receive ABTs. The goal of this article is to acquaint the otolaryngologist with alternative methods of managing blood loss and anemia in their surgical patients who cannot or should not receive ABTs.

Jehovah’s witnesses

The Jehovah’s Witness faith began in Philadelphia, Pennsylvania, in the 1870s as a Bible study group. A cornerstone of this religion is the literal interpretation of Bible passages. Passages such as “Every moving animal that is, alive may serve as food for you…Only flesh with its soul—its blood—you must not eat” from Genesis 9:3,4 are taken literally as a ban of blood via any route. As such, a refusal of blood transfusions is a core value of their faith. Disobeying this ban taints the recipient’s immortal soul leading to shunning by friends, family, and the entire Jehovah’s Witness community.

Over the last 20 years, the Jehovah’s Witness faith and prohibitions have evolved with a broader interpretation of what components, techniques, and kinds of blood and blood products are acceptable. As a rule, Jehovah’s Witnesses refuse transfusion of allogenic blood and its major components—red cells, white cells, platelets, and plasma. However, acceptance of “minor” fractions such as albumin, immunoglobulin, vaccines, clotting factors, and prothrombin complex concentrates are considered a “matter of conscience” and is often left to be decided by the individual ( Table 1 ).

With regard to perioperative planning, banking of the patient’s own blood for later reinfusion (ie, preoperative autologous donation [PAD]) is not allowed; however, blood left connected to the patient as in cell salvage, hemodialysis, or cardiopulmonary bypass is acceptable for reinfusion. Additionally, acute normovolemic hemodilution (see “Intraoperative Techniques: Acute Normovolemic Hemodilution”) and many of the pharmaceutical agents that promote hematopoiesis or hemostasis (ie, iron, topical hemostatic agents, antifibrinolytics, and erythropoiesis stimulating agents) are also accepted by most Jehovah’s Witnesses.

It was the refusal of ABTs in this population that served as one of the impetuses to develop alternative means for treating anemia and decreasing surgical blood loss, which can be applied to a plethora of other populations and medical and surgical conditions.

Complications of blood transfusions

Although safer than ever before, ABT is not without risk. Although infectious complications, such as human immunodeficiency virus and hepatitis B and C are dwindling in number owing to better screening techniques, risks of ABT remain. Furthermore, new threats, such as variants of Creutzfeldt-Jakob disease and West Nile virus have been reported in the blood supply.

Human error may lead to acute hemolytic reactions, often owing to ABO incompatibility, which is characterized by fevers, chills, nausea, vomiting, hypotension, renal failure, disseminated intravascular coagulation, and death in up to 40% of cases. Delayed hemolytic reactions, owing to extravascular hemolysis caused by antibodies to red blood cells (RBCs), occur about 3 days to 2 weeks after a transfusion and display symptoms of inability to maintain Hb levels, fever, chills, dyspnea, and jaundice. These hemolytic reactions are particularly problematic in the surgical patient where it may be difficult to parse out whether these symptoms are related to infection or the transfusion.

Transfusion-related acute lung injury is another well-recognized complication of ABT. The underlying mechanism is poorly understood but it seems to involve localization of antibody-coated leukocytes to the pulmonary vasculature resulting in increased permeability and edema. Usually during or shortly after transfusion, patients present with dyspnea, hypotension, fever, and bilateral pulmonary infiltrates without evidence of cardiac compromise or fluid overload. It develops fully within 1 to 6 hours of transfusion and is fatal in 5% to 10% of cases. Treatment of transfusion-related acute lung injury includes prompt recognition, cessation of the ABT, and oxygen therapy. The blood in question should be returned to the blood center for testing.

Finally, another untoward result of ABT is immunosuppression. The immunosuppressive effects of ABT were first noted in 1978 when renal transplant patients undergoing multiple ABT showed improved graft survival. McRae and colleagues examined the immune profiles of 20 head and neck cancer patients treated with surgery, one-half of whom received blood transfusions. In patients who received transfused blood, total lymphocyte, T cell, helper T4 cells, and interleukin-2 receptor–positive T4 cell counts were significantly decreased. This immunosuppressive effect leads some to fear the risk of cancer recurrence in those patients who undergo multiple transfusions. However, some authors have failed to find this relationship and counter that patients with advanced disease require more extensive surgery and have a worse prognosis regardless of the number of transfusions. Nonetheless, a possible immunosuppressive effect and therefore increased risk of recurrence should at least be considered when treating perioperative anemia, particularly in oncologic patients.