Can minimally invasive surgery help avoid a blood transfusion?

Today, there are increasing numbers of procedures offering new options for those who wish to refrain from blood transfusions.  This article will investigate two procedures:

1. Laparascopic Surgery
2. Robotic Surgery

First, we will take a look at what the benefits are of  minimally invasive surgery.

Benefits of minimally invasive surgery

Minimally invasive surgery offers many benefits in addition to decreasing the need for a blood transfusion:

1. Minimal or no blood loss.

2. Shortens hospital stay dramatically.  Some procedures are even being performed on a "Same Day   Surgery" basis.
3.Less time in the hospital means less hospital acquired infections - a high cause of morbidity.
4. Less time in the hospital also means less possiblity of medication errors.
5.Less surgical trauma to other organs and tissues.
6. Less need for pain medication, which can be a cause of other complications, such as constipation.
7. Smaller scars.

Laparascopic Surgery

Laparascopic surgery is a surgical approach where the surgeon makes several small incisions to the abdomen.  A long, slender camera with a light source in then threaded through the incision.  Surgery is performed through a port inserted into the abdomen.

Robotic Surgery

Robotic surgery (daVinci) offers a minimally invasive option for complex surgical procedures.  Some of the major features are thatthere are smaller incisions, more precision, less blood loss, less pain and quicker discharge.

Sources:

Uchai, Miro, MD "Minimally invasive surgeryand the bloodless patient" http://www.bloodlessmedicine.org/

What is VZig?

Remember the days when everyone got chicken pox? The worst thing that you used to expect (if you were a kid) was to have some scars after your bout with the infection was over.  Now, many adults, and those who are immune compromised, can suffer complications or even death as a result of the disease.  As a result, the CDC has made recommendations  that those who are not immune and at high risk for serious disease.(Keep in mind that many are concerned as well over the safety of the vaccination).

This article will review VZig (Varicella immune globulin), who should get it? And, if it is safe to use for those who wish to refrain from blood.

What is VZig?

The varicella-zoster virus causes chicken pox (varicella) and shingles (herpes zoster). VZig is used primarily by patients at high risk for severe disease who have been recently exposed to the Varicess-zoster virus.

Please note the following detailed excerpt from the CDC.gov website regarding indications for use of the immune globulin.

What are the indications for VAig use?

The Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) indicate that the decision to administer VZIG to a person exposed to varicella-zoster virus (VZV) should be based on whether a) the patient lacks evidence of immunity (either by having no evidence of prior infection or by lacking documentation of vaccination), b) the exposure is likely to result in infection, and c) the patient is at increased risk for severe disease and complications compared to the general population.

Both healthy and immunocompromised children and adults who have verified positive histories of varicella (except for bone-marrow transplant recipients) can be considered immune (see evidence of immunity). Persons who have received bone-marrow transplants should be considered non-immune, regardless of prior history of varicella or varicella vaccination in themselves or in their donors. However, bone-marrow recipients who develop varicella or herpes zoster following transplantation should subsequently be considered immune.

VZIG is not indicated for persons who received 2 dose of varicella vaccine and became immunocompromised due to disease or treatment later in life. These persons should be closely monitored, and, if disease develops, treatment with acyclovir should be instituted at the earliest signs or symptoms.

Several types of exposure can place susceptible persons at risk for varicella. Direct contact exposure is defined as more than 1 hour of direct contact with an infectious person while indoors; substantial exposure for hospital contacts consists of sharing the same hospital room with an infectious patient or having prolonged, direct, face-to-face contact with an infectious person (e.g., healthcare workers). Brief contacts with an infectious person (e.g., contact with x-ray technicians or housekeeping personnel) are less likely to result in VZV transmission than are more prolonged contacts.

Persons at greater risk for severe varicella who have contraindications for vaccination and for whom VZIG is recommended include:

• Immunocompromised persons, including persons who have primary and acquired immunodeficiency disorders, neoplastic diseases, and are receiving immunosuppressive treatment. Patients receiving monthly high-dose immune globulin intravenous (IGIV) (400 mg/kg or greater) are likely to be protected and probably do not require VZIG, if the last dose of IGIV was given less than 3 weeks before exposure (Red Book, American Academy of Pediatrics)
• Neonates whose mothers have signs and symptoms of varicella from 5 days before to 2 days after delivery
• Premature neonates exposed to varicella postnatally
  • Those born at or after 28 weeks of gestation whose mothers do not have evidence of immunity should receive VZIG because the infant’s immune system may not be fully functional.
  • Those who are less than 28 weeks gestation or who weigh 1,000g or less at birth should receive VZIG regardless of maternal history because such infants may have not acquired maternal antibodies.
• Pregnant women without evidence of immunity

"VZig" http://www.cdc.org/

Immunoglobulin - a blood fraction?

Those wishing to refrain from blood want to know if immunoglobulins are blood fractions, please note the definition of immunoglobulins:

Immunoglobulin (Ig) is a sterilized solution obtained from pooled human blood plasma, which contains the immunoglobulins (or antibodies) to protect against the infectious agents that cause various diseases. Antibodies are substances in the blood plasma that fight infections. Our bodies create antibodies (or immunity) against disease-causing agents when infections occur. These antibodies can protect us from becoming ill if we are exposed to the same infectious agents sometime in the future. When someone is given IG, that person is using other people's antibodies to help fight off or prevent an illness from occurring. This protection is temporary and should not be confused with getting an immunization, which provides longer-term protection. Special IG formulations are produced from donors with high levels of antibodies against hepatitis B (Hepatitis B Immune Globulin-HBIG), rabies (Rabies Immune Globulin-RIG), tetanus (Tetanus Immune Globulin-TIG) and varicella (chickenpox)(Varicella Zoster Immune Globulin-VZIG). Immunoglobulins are sometimes called gamma globulins or immune serum globulins.

"What sre immunoglobulins?" http://www.noblood.org/

So, therefore, immunglobulins are considered blood fractions.  In the case of Jehovah's Witnesses it would be an individual conscious matter if these medications are taken.

Sources:

"VZig" http://www.cdc.org/
"What sre immunoglobulins?" http://www.noblood.org/

Boosting your nutrition for surgery

Building oneself up for elective surgery is a situation in which an interdisciplinary approach should be taken and should be well supervised by the physician and /or nutritionist.

Included in this article are recommendations in five important areas to fortify your body for bloodless procedure.

Protein

Proteins are important in cell formation and maintenance.  Adequate protein levels are important in wound healing, as well. The RDA is 63 gramss per day for men amd 50 grams per day for women. You can obtain protein by eating nuts, beans, meats, fish, tofu, eggs and poultry.

One serving of protein is two to three ounces of any of the above.

Iron

In preparation for surgery, it is recommended to consume   the RDA amount of 10 milligrams per day for men and 15 milligrans per day for women (due to menstrual blood loss).

Sources of iron are organ meats such as liver, kidneys, egg yolks.  If a deficieny exists check with your physician or nutritionist for supplements.

Vitamins

Folic acid and B12 are important in building red blood cell, which carry oxygen.  Some sources are mets, beans, green vegetables, nuts and cantaloupes.

Also important are zinc and vitamin C for wound healting.  Vitamin C also helps control amount of blood lost. Vitamin C may be obtained in citrus fruits such as oranges, grapefruits and lemons.  Zinc is found in green leafy vegetables.  Check with your physician about supplements before taking them.

Vitamins and medicines that are contraindicated

Certain supplements are contraindicated prior to surgery, as they promote bleeding.  Check with your physician or nutritionist regarding their ingestion. The foods include, garlic,soy, flax, fish oil, and omega 3's. 

Blood thinners, aspirin and anti-inflammatories are contraindicated before surgery.  Check with your physician for specific instructions for discontinuance.

Source:

Winkler, Mary, RD, "How to prepare nutritionally for surgery" http://www.bloodlessmedicine.org/

What is Hemodilution?

Hemodilution is one of the techniques used to eliminate the needs for a blood transfusion.  Many Jehovah's Witnesses have accepted this procedure - under strict guidelines , to uphold their belief in the sanctity of blood. Others, for fear of blood transmitted diseases, have likewise requested and accepted this blood conservation technique.

In this article we will take a look at what this procedure is and what is involved.


What is hemodilution?

Acute normovolemic hemodilution, ANH, is a blood conservation technique that was introduced in the 1970's.  This procedure entails removing blood from a patient either before or immediately after the induction of anesthesia during surgery. The procedure involves the maintenance of isovolemia using a crystalloid and/or colloid replacement.  The amount of blood removed is usually is one to three units (450 ml approximately is one unit. Or about one half a liter bottle of soda.) 

The blood is then anticoagulated and maintained in the operation room for up to eight hours.  Is is then reinfused into the patient as needed during the surgical procedure. (Please note that Jehovah's Witnesses will not allow the blood to be saved for a later procedure, due to their belief in the sanctity of blood.  The blood must  remain part of a continuous closed circuit.)

Who can accept this procedure?

ANH should be used by patients with a good hematocrit and who are expected to lose more than two units (900ml) of blood during surgery.  It is better tolerated in young, healthy people but has been used in the elderly, depening on the procedure.

Hemodilution would be contraindicated in the following procedures:

Cardiac disease
Impaired renal function
Baseline Hgb less than 11g/dl
Low concentration of coagulation proteins
Inadequate vascular access
Absence of adequate monitoring

Finally, hemodilution may be used alone, or in combination with other blood conservation techniques.

Vocabulary

Anticoagulant - A substance that prevents the blood from clotting.
Colloid - A substance microscopically dispersed evenly throughout another.
Crystalloid - A substance that can pass through a semi-permeable membrance and crystallize.
Hematocrit - Ratio of volume occupied by packed red blood cells to volume of whole blood.
Isovolemia - Maintaining the same volume.  In this situation, the volume of fluid in the body.


Sources:

Silverglied, Arthur, MD "Acute normovolemic intraoperative hemodilution" http://www.uptodate.com/