Bloodless surgery is a term that has evolved from describing a protocol of merely avoiding the use of transfused blood to describing a concept that incorporates the use of advanced technologies, specific institutional policies, and changes in the knowledge and attitudes of staff members. In the past, bloodless surgery was performed on patients who refused blood transfusions, typically Jehovah's Witnesses whose religion forbids the transfusion of blood and many blood products. Patients' choices often were not respected because it was believed that these patients were at risk of dying unless they received blood. Coercion often was used to convince patients that transfusions were essential. The burden of responsibility and concern for patients' well-being usually was limited to the perioperative team.
Bloodless surgery has moved beyond the OR, and the current concept of bloodless surgery has no resemblance to that of the past. Now patients proactively enroll in bloodless medicine and surgery programs at their local hospital or medical center for services ranging from elective surgery or obstetrical care to cancer treatment. A wide array of technologies and procedures are available, and a variety of personnel from many departments are involved. The evolution of bloodless medicine and surgery programs has increased the complexity of care, mandating flawless communication among health care personnel throughout an institution.
Although perioperative personnel are those most involved in bloodless medicine and surgery programs, personnel in other departments also need to be informed and knowledgeable because not all patients who wish to have bloodless surgery are admitted through a bloodless program. They might be admitted for surgical procedures via the emergency department. Staff members beyond the OR can become involved in the care of patients desiring bloodless surgery (see "The nurse as patient advocate" on page 832). Departments caring for patients in the postoperative period also need to be informed because a bloodless program is administered along a continuum. This article discusses the development of the field of bloodless medicine and surgery and the interventions used in the care of patients along the continuum. The ethical implications for nurses also are discussed.
INCREASE FEAR LEAD TO INCREASED DEMAND
Most patients who refuse blood are of the Jehovah's Witness religion, which prohibits its members from receiving blood and many blood products. The interest in bloodless surgery, however, has expanded to people outside this group, and non-Witnesses now comprise 25% to 30% of patients undergoing bloodless surgery. (1) There now are more than 70 hospitals in the United States with bloodless surgery programs, (2) and hospitals throughout the world have them as well. A list of hospitals and medical centers with bloodless programs can be found on the Bloodless Surgery and Medicine Institute web site at http://www.bmsi.net/list_hospital.htm. For people without religious reasons for avoiding blood and blood products, concerns about allogenic transfusions center on four issues:
* contraction of possible infections, including those known and yet to be discovered;
* transfusion reactions;
* medical errors; and
* possible unavailability.
The risk of infection is the most commonly voiced concern about allogenic transfusions. Some people fear being infected with hepatitis or HIV due to inadequate blood screening. One author notes that the chance of dying from HIV after receiving one pint of blood is one in 600,000 and the risk of dying from receiving the wrong blood type is about one in 100,000; yet the risks, although small, are not absent. (3) Some fear transfusions because they believe blood might contain infections that are not yet known and, therefore, cannot be detected. Another concern is that even with thorough and appropriate laboratory analysis, transfusion reactions still are a possibility.
Concerns about receiving the wrong blood are not new, but the recent report from the Institute of Medicine on the excessively high rate of medical errors in hospitals may mean that transfusion concerns will increase. Questions even have been raised regarding the banking of one's own blood. Although the risks of infection and transfusion reaction no longer would be a concern, a 100% certainty of receiving the correct blood is not possible because after the blood is drawn and sent to be banked, there is a potential for human error in testing, labeling, and administering.
The demand for blood is impressive. Approximately three million pints of blood are used annually in the United States just for elective surgery. (4) The possibility that blood will not be available when it is needed is a valid concern. Some blood types are more rare than others and are not always readily available. Additionally, shortages of common blood types can occur because of an increase in demand or seasonal variations that result in fewer donations.