New “Gold Standard” Improves Outcomes for Elective Surgery Patients

by Larry Rondeau

Reviewed in June, 2013 by Dr. Joseph Sweeney, Director, Transfusion Medicine and Coagulation at Lifespan Academic Medical Center and Professor of Medicine at Brown University’s Warren Alpert Medical School.

The Cleveland Clinic – photo by HealthMonitor

Research carried on for decades in the U.S. and Europe has resulted in a new “gold standard” for elective surgery that significantly improves patient care, lowers costs and saves lives.  It is practiced regularly in leading medical centers across America, including Massachusetts General Hospital, The Johns Hopkins Hospital and The Cleveland Clinic, as well regional teaching hospitals like Rhode Island Hospital, Pennsylvania Hospital, Hartford Hospital and New Jersey’s Englewood Hospital, which pioneered its use.  It has become the official standard of treatment of the U.S. military for elective surgery.[i]

This new “gold standard” is actually an updated and improved version of a nineteenth century practice:  bloodless medicine and surgery.  According to surgeon Nathaniel Usoro, MD:

Kocher, MDVirtually all surgeries prior to the 20th century were essentially ‘bloodless.’ And some were remarkably successful.  Theodore Kocher, for instance, did his first thyroidectomy in 1872, and by the end of his career he had done 5000 thyroidectomies with only 1% mortality.  Kocher never transfused any patient and he won a Nobel Prize.[ii]

Dr. Kocher’s procedures were safe and successful because he meticulously avoided unnecessary bleeding.  The new bloodless surgery does that as well using up to date technology. In addition, it often makes use of the patient’s own blood, which at one time was thrown away during surgery.  It is “bloodless” because it avoids costly transfusions of donated blood that actually produce lower success rates than procedures that salvage the patient’s own blood.  As Dr. Usoro continues, “Many clinicians are surprised to learn that blood transfusion is based on tradition and associated with a poorer outcome (unrelated to infectious hazards) in a wide variety of patients.”[iii]

But isn’t blood “The Gift of Life?”

gift of lifeMarketing campaigns have trained most Americans to believe that “blood is the gift of life.”  And for some patients with massive traumatic blood loss, transfusions of donated blood can indeed prove to be lifesaving.  Around the time of World War I, when medical researchers learned how to safely store blood for weeks and match it correctly to patients, a new era in medicine was born.  Bloodless surgical techniques were set aside as transfusions became an automatic feature of modern surgery.  It appeared to be a genuine improvement.

surgeryBut then physicians conducted studies to compare outcomes of those who underwent what had become traditional surgery including transfusions with those who had the same procedures without blood.  This crucial body of research revealed that bloodless surgery patients experience substantially fewer complications, shorter hospital stays and faster recoveries.

Speaking at a medical conference Dr. Joseph Sweeney, Professor of Pathology and Laboratory Medicine at Brown University and Director, Coagulation and Transfusion Services for the Lifespan hospital group made these important points:

  • Studies show that patients who are anemic at the time of surgery have poorer outcomes.
  • Blood transfusions do not improve the prognosis for most anemic patients, as once widely believed.
  • Research has revealed a previously unknown transfusion risk that bloodless surgical techniques can eliminate. [iv]

capillaryBlood banks have worked hard to reduce the chance of transmitting blood borne infections through transfusions, with varying degrees of success.  But research has uncovered another risk that is hard to avoid without using bloodless surgery.  Dr. Sweeney explained that red blood cells stored for just six days become rigid.  Transfusions can hinder circulation through a patient’s capillaries, the tiny blood vessels that bring oxygenated blood to sustain individual cells.

The Journal of the American Medical Association stated, “Some studies actually indicate no increase in tissue oxygenation with blood transfusion.”[v] Rigid red cells can stop up tiny capillaries, actually starving the cells they were transfused to nourish.

Cleveland ClinicA major research study of patients who underwent heart bypass surgery at The Cleveland Clinic supports this conclusion. Those whose doctors used bloodless surgical methods were much less likely to suffer serious complications than those who had traditional bypass surgery with transfusions of packed red blood cells.  Summing up their detailed findings, researchers wrote:

Our results suggest that transfusions should be avoided to the extent possible.[vi]

Finding a better way

It has now become clear that transfusions of donated blood, even carefully screened and washed red cells, increase the risk of serious complications. New surgical methods are needed.  Fortunately, these were developed over the years by innovative surgeons and anesthesiologists.  They were willing to take on the challenge of operating on patients who refused blood transfusions, often for religious reasons.

dr-denton-cooley-cPatients whose beliefs required that they refuse blood transfusions formed a pool of experimental subjects, “human guinea pigs” who permitted doctors to try new procedures so that they could have the surgery they needed without violating their consciences.  One willing surgeon was Dr. Denton Cooley, who performed the world’s first heart transplant in 1968.  He also pioneered bloodless open heart surgery.  The outcomes were so much better that soon Dr. Cooley was employing this method for all his patients.

How the new gold standard is carried out

Speaking at a medical conference, Dr. Sweeney outlined a simple procedure for the new gold standard, bloodless elective surgery.  Since anemia (low blood count) reduces the likelihood of a successful procedure, it’s important to check and, if needed, build up patients’ blood 4-5 weeks before surgery.

Blood counts can be raised by administering iron supplements, either in pill form or intravenously.  In some cases, patients receive erythropoietin (EPO), a medication that speeds up their natural red blood cell production.  Surgery will be scheduled when blood counts reach the acceptable range.

Cell SaverDuring the procedure, doctors will employ equipment that minimizes blood loss.  This includes cell salvage equipment that suctions up blood leaking from the wound, cleans it, and returns it to the patient’s circulation.  Instead of throwing away the patient’s blood, as done for years, the medical staff cleanses and reinfuses it.  There is nothing better for a patient than their own fresh red blood cells.  They’re far safer than donated blood (or even the patient’s own stored blood).

If the patient’s blood count is still low, EPO administration will begin to raise it within a few days.


leaving hospitalBloodless medicine and surgery provides many advantages to both patients and the healthcare system.  It significantly improves outcomes, reducing the risk of complications.  It shortens hospital stays and promotes quicker recoveries.  Further, it saves healthcare dollars, an important consideration as baby boomers retire and Medicare membership grows.

Major medical centers, regional teaching hospitals and the U.S. military have all embraced the new gold standard.  If you’re considering elective surgery it might well pay dividends to ask your doctor if it’s appropriate to use bloodless medicine and surgery in your case.

[i] “U.S Military Doctors Learn Bloodless Surgery Methods,” New Jersey News Channel

[ii] Bloodless Medicine and Surgery by Nathaniel I. Usoro, MD

[iii] ibid

[iv] “Is Thrombosis a Complication of Stored Red Blood Cell Transfusion?” presentation by Joseph Sweeney, MD

[v] “Relationship of Blood Transfusion and Clinical Outcomes in Patients with Acute Coronary Syndromes” by SV Rao, MD et al.  Journal of the American Medical Association October 6, 2004

[vi] “Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting” by Colleen Gorman Koch et al. Critical Care Medicine, June 2006

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