Interviews

Weighing the Risks and Benefits of Blood Transfusion

Sumner Gerald Sandler, MD |
MedStar Georgetown University Hospital

Summary

Blood transfusions may not always be necessary, and in some cases, they may cause harm. In this video, Dr. Sumner Gerald Sandler, medical director of Transfusion Service, Department of Pathology and Laboratory Medicine, at MedStar Georgetown University Hospital, describes how bloodless medicine and surgery has improved quality and safety at MedStar Health.

Transcript

I was really very pleased when I heard there was going to be bloodless medicine and surgery here, because it was part of the venue that I had, it was sort of, “over here,” and it wasn’t something I had a lot of experience with, and really wasn’t focusing on. It’s come here, and it’s clearly increased the quality of our transfusion service in the hospital, by making it more complete. It’s more complete when we go to a patient here, and if that person has for religious reasons, for scientific reasons, for whatever reason, a preference not to receive blood, we now have a team of informed professionals who can deal with that, and that has increased the quality of my overview of all of transfusion medicine. That segment now is very well cared for.

Well, the main impact on that is that we’ve been able to focus and increase the quality of our informed consent. We can now talk to people who have an aversion to being transfused and have that conversation with top professionals, informed; they network well beyond the hospital, which is an important aspect of this, and I think that we have made this hospital more suitable for a lot of people in this community. People in the community would like to come to Georgetown University and have the benefit of being at an academic center. But without an informed, professional staff that can focus on their focus on, “I don’t want blood – it’s not part of the way of the way I’m doing things. It’s greatly improved  the way that we can approach the community and say, “Come on in, we’ve got people who think the way you think.”

We’re talking about a trigger – that’s really the key – a trigger, at which a person should be transfused, and when I was trained, and that was back in the 50’s and the 60’s we would transfuse at this level here… if someone came down to here, you had to be transfused. That number was probably, let’s say, 10 grams per deciliter, 10…and then we would go 9, 8, we’re now safely transfusing at 7.

There’s a person right in the hospital now, it’s a lady, she’s on Bless 2; her hemoglobin is below 6; we’re having a great difficulty matching her. Years ago, if she was at 6 – that’s a lot less than 10 – we probably would have felt compelled to transfuse her with blood that wasn’t perfectly matched,…that’s what our problem is right now. I am perfectly comfortable sitting here now, knowing that she’s at that low level, I saw her last night, I saw her early this morning – she’s fine. And I’ve learned to be comfortable with that and not to feel compelled to give her something less than optimal.

Where does that come from? It comes from decades of experience and publications that have come out of the Jehovah’s Witness community globally, world wide, in fact, turns out that the particular resources that I used in the 60’s came out of Brazil, but they were publications, they were quality publications, and I became informed about the fact that you don’t have to transfuse here, you can go down here, you can go down here, in fact, you can just not transfuse…

And that basis has now come into what we call patient blood management. In this hospital, by the way, we use the term patient-centered blood management to bring attention to the fact that we’re focusing on “what does that patient personally need,” personalized medicine, that’s what we’re focusing on, adjusting the totality of the transfusion medical focus on that person…sort of a match the medical side to the person and we do that through the Bloodless Medicine and Surgery Program for those people who have a reason for not wanting to be transfused.

I spent 6 years heading a transfusion service in Jerusalem, Israel, and I can tell you that they have a very good national blood program, but the inventories of blood in the Middle East for a variety of reasons aren’t as adequate as they are here, there were times when I would have been very anxious about having a lower supply, but and I knew that we could go down safely, not compromise the treatment of anyone, and actually improve the quality of the transfusion experience by giving less blood.

You can’t get a complication from a blood transfusion if you didn’t get one. That is a very key part of this new focus, and it comes from the Jehovah’s Witness experience.

I’ve had open heart surgery, and I was faced with, do I want to get someone else’s blood if I don’t really really need it? And the surgeon didn’t know my specialty, and he came in and he said, “you know, we’ve asked you to sign the informed consent for blood, and I said, you know, I’m a specialist in transfusion medicine, and I’ve been there for decades, but I came face to face with the reality that I talk about in the abstract to people. And when it really came to me, do I want to get someone else’s blood, only unless I’m as white as my white lab coat would I want to get a transfusion, only if I was in a life-threatening situation, and that is where I come from, and where the contemporary specialization of transfusion medicine is, and of course, that’s where Bloodless Medicine and Surgery is.

None of us want to give a unit of blood if it’s not necessary, because if it’s not going to make things better, and it could make things worse, that’s not good medicine. So it’s the drive to do the best medicine that’s possible with the least amount of blood that’s possible. [discussion of patient-centered blood management and the life-threatening complications from blood, or maybe a life-long infection…senior physicians have seen more complications]

I’m relying on my older colleagues to convey to my younger colleagues the reality of their experience of having given a unit of blood that caused…maybe it was HIV, maybe it was Hepatitis c, and then questioning, “ Did I really need to give Mrs. Smith that unit of blood that’s caused her to have this complication?” And I want that message coming down from our more experienced physicians to the ones who are learning.

What I’m really happy about is that MedStar Georgetown University Hospital has from our leadership all the way through the hospital accepted, supported, and very enthusiastically encouraging us to go forward with patient-centered blood management through the bloodless medicine and surgery program. It’s working very well…

The patient-centered blood management program is bringing into focus the interplay between: ‘We have to give a transfusion because the person needs to have that support, versus, we don’t want to give a transfusion because that transfusion could cause a life-long or a life-threatening complication. What we want to communicate to our physicians who are placing the order is this: your patient can’t have a lifelong complication or a life-threatening complication if they haven’t had a blood transfusion. You have to balance the seriousness of complications of a blood transfusion with the transitory benefit of raising the hemoglobin over a few days, and that balance is the focus of decision-making for a transfusion.  

I’ve had fair experience in countries in Africa, I helped develop a large blood center in China, I’ve been in most of the countries in the Middle East. In those countries, the supply of blood isn’t as adequate as it is here in the United States. In a way, we’re learning a lot from their experience, because they don’t transfuse at numbers as high as we have, and they’re finding out they can do just fine. So as we move to help our colleagues in Africa…the level of transfusion, the volume of transfusion in these countries can be met with greater security, and greater understanding, because we know we don’t need to transfuse as much blood as we used to.

We’re learning from them and their experience, that you can do surgeries, and manage a lot of illness with less transfusions than we’ve been doing in this country. We’re learning to separate out, this is the normal amount of blood you need, but this is good enough, good enough is where we want to be, because extra, the difference between this, has the potential for very serious complications.

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