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Another Key to Successful Surgery:
Obtain Hemoglobin Counts Pre-Operatively

May/June 2007

Annually, about 27 million units of blood are needed to sustain the needs of surgical patients in the United States. Unfortunately, blood donation often falls short of this, and there are also many risks associated with blood transfusion. A 1999 Institute of Medicine report found that transfusion errors are considerable. These mistakes include patient identification problems (37 percent of errors), testing (18 percent), and phlebotomy (13 percent). In fact, more than half of these errors occur outside the hospital blood bank.

“When it comes to blood transfusions, the biggest problem hospitals and surgeons face is human error,” says Patricia Ford, MD, medical director of the Center for Bloodless Medicine and Surgery at Pennsylvania Hospital. “And, that doesn't change with autologous transfusions.”

Autologous donation, the process by which patients donate their own blood prior to surgery in the event a blood transfusion is required, is often perceived as 100 percent safe. In reality, errors can still occur. “As the science about blood and blood transfusion has progressed, we've learned more about what happens when blood is stored outside of the body,” says Dr. Ford. “We now know that storage disease can occur. In blood that has been stored, we can see that the cells are not as healthy as they are when they've been in the body. They often don't release oxygen as well and this can lead to problems if this blood is transfused into a patient.”

For these reasons, blood conservation is an important consideration for a patient preparing for surgery. “For Jehovah's Witnesses and other patients who refuse blood products, I cannot think of any surgery that cannot be performed bloodlessly,” says Dr. Ford. In fact, at Penn, even surgeries that can involve significant blood loss, such as orthopaedic, obstetric/gynecologic, and vascular surgeries are performed bloodlessly.

For other surgical patients, blood management and conservation are key aspects. “Our surgeons work very hard to ensure every surgery is performed as transfusion-free as possible, often using advanced cell-salvage techniques to conserve a patient's blood,” says Dr. Ford. Although it is more difficult to perform emergent surgery bloodlessly, planned surgeries can often easily be performed using advanced blood conservation techniques – which is perhaps, according to Dr. Ford, one of the most important messages a primary care physician can pass on to his/her patients. “Every patient who is about to go in for surgery should be advised to have a hemoglobin count in hand,” she says.

At the Center for Bloodless Medicine and Surgery, patients' hemoglobin counts are evaluated pre-operatively, then, based on the patient's history and type of anticipated surgery, a plan is formulated to increase the hemoglobin count in vivo prior to surgery. “For example, a bilateral hip replacement can decrease a patient's hemoglobin count by four or five points. By targeting a specific hemoglobin count necessary for surgery and using iron to increase the hemoglobin in the body, we can raise a patient's hemoglobin count by one point per week. A surgery date can then be scheduled based on an optimal time for the patient,” says Dr. Ford.

This process enables the production of healthy blood cells, which are stored within the patient's own body – the best possible storage vessel for blood. “It also helps our surgeons because they are able to focus on the surgery. We monitor the patients postoperatively as well for any sign of anemia and treat it accordingly. A hematologist reviews the patient's blood work every day,” says Dr. Ford.

“The most important thing we can do as physicians is educate our pre-operative patients about the potential for blood loss and the availability of bloodless and blood conservation techniques,” continues Dr. Ford. “It makes the surgeon's job easier and reduces the likelihood of complications associated with blood transfusions.”

For more information about bloodless medicine or for a patient consult, call Penn's physician referral line, PENNHealth, at 1-800-789-PENN.

	Referring Physicians: To speak with a Penn physician or refer a patient, contact PennHealth through the secure online referral form or by calling 1-800-789-PENN (7366).