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With less blood shed

As techniques, tools and attitudes change, transfusion-free surgery goes mainstream.

January 31, 2005|Valerie Reitman | Times Staff Writer

Steve and Jane Hewitt searched far and wide for a surgeon who could straighten their teenage daughter's severely curving spine which had hunched her over at a 105-degree angle. The extremely long and difficult surgery involves exposing and separating the muscles from the entire spinal column and installing cadaver bones attached with screws and metal rods for support.

The Hewitts had an additional requirement that made their search even more difficult: The surgery had to be done without blood transfusions. As Jehovah's Witnesses, they adhere to a biblical admonition against receiving blood.

Surgeons in Kansas City, Kansas, near their hometown, refused to take the case, warning that Sarah, 17, would die during the operation without blood. A Dallas surgeon concurred. But without the procedure, they warned, the condition known as Scheuermann's kyphosis would likely paralyze and kill her within a decade.

"When they said 'transfusion,' our hearts were in our stomachs," recalled Steve Hewitt. "We cried every night."

Their church came to the rescue. The Jehovah's Witnesses' hospital liaison committee directed the Hewitts to Dr. Ram Mudiyam at the 600-bed Fountain Valley Regional Hospital and Medical Center in Orange County, which has one of the nation's oldest "bloodless medicine" programs.

Wearing the hospital's special purple "no blood" tag around her wrist, Sarah emerged from the surgery 11 1/2 hours later in good shape -- with no transfusions -- and was walking a few days later. Her spine is now close to normal.

What makes sense religiously for the Jehovah's Witnesses, a growing number of physicians and researchers are finding, is in fact good medicine for the rest of the population, for health as well as economic reasons.

Building on knowledge gained from performing thousands of complex surgeries on patients who refuse transfusions for religious reasons, doctors now are using the technique on other patients, performing open-heart and lung surgeries, replacing knees and hips, removing prostates and treating cancer patients -- often with little or no transfused blood. Their experience and studies documenting results are encouraging growing numbers of physicians -- and now large academic centers -- to implement their techniques.

About 100 hospitals across the country, including about a dozen in Southern California, have created bloodless programs.

The Witnesses' aggressive push, which began in the 1980s to encourage surgeons and hospitals to attempt bloodless procedures, dovetailed with the concern over HIV and hepatitis C viruses tainting the blood supply, which highlighted the risks of using donated blood.

"Once we saw that we could do it, we started seeing it as an opportunity because there is a benefit to everybody," said Dr. Nicolas Jabbour, a USC Medical Center surgeon who performed his first bloodless liver transplant in 1999. In a small study published last summer in the Annals of Surgery, Jabbour and his USC liver-transplant team compared results for 38 patients -- eight Jehovah's Witnesses who did not receive transfusions, and 30 other patients who did receive blood -- in surgeries performed from 1998 to 2001. All eight Witnesses survived, contrasted with 27 survivors among the 30 other patients, who received about 4.5 pints of blood on average.

Englewood Hospital and Medical Center in Englewood, N.J., which operates one of the most extensive bloodless management programs for all patients, not just Witnesses, has the lowest cardiac-surgery mortality rate in New Jersey, according to state statistics. Dr. Aryeh Shander, chief of anesthesiology and critical care, says the cardiac unit probably uses "the lowest amount of blood in the world" after the hospital implemented an aggressive campaign to teach all of its physicians how to avoid transfusions.

Blood conservation is among the primary goals of a group of doctors who forged the Society for the Advancement of Blood Management a few years ago. Already, periodic blood shortages have forced hospitals to cancel elective surgeries, and more critical shortages are forecast. Fewer people are eligible to donate blood because of potential exposure to ailments such as mad cow disease. Blood banks, meanwhile, have hiked prices to as much as $500 a pint, giving hospitals an incentive to use blood more judiciously.

Yet, hospitals are vampires, draining at least a pint from each intensive-care patient per week just for testing, substantially raising the odds of a future transfusion. There is even a medical term for this: "iatrogenic" -- that is, doctor-induced anemia. Many bloodless programs have reduced routine daily testing and now take samples in pediatric vials one-fifth the adult size.

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