Questions & Answers

According to the World Health Organization (WHO) anemia is defined as the level of hemoglobin below 13.0 g/dL for men, below 12.0 g/dL for non-pregnant women and below 11.0 g/dL for pregnant women. In children the WHO defines anemia as the hemoglobin below 11.0 g/dL for the age of 6-60 months age, below 11.5 g/dL for the age of 5-12 years old, and below 12.0 g/dL for adolescents of 12-15 years old.

No. Fortunately, today we have several therapeutic options for saving the life of a patient with severe anemia. These involve clinical and surgical strategies for treating anemia and/or preventing blood loss. To achieve this it is required equipment, machinery, techniques and specific drugs.

Karl Landsteiner (Austrian physician and biologist, discoverer of Rh blood factor (1868-1943))

“The number of transfusions given is very great, and it may be that the use of this technique has gone too far”.

Doctor Denton Arthur Cooley (Johns Hopkins School of Medicine – JAMA 1977 vol. 238)

“Cardiovascular operations can be performed safely without blood transfusion”

Prof. Aryeh Shander (Chief of the Dept. of Anaesthesiology Englewood Hospital, New Jersey, EUA)

“As doctors we have learned key lessons. Even the most profound anemia can be controlled and quickly repaired without the use of allogeneic blood products. The perioperative blood loss, even in complex procedures, can be significantly reduced. Each bag of blood has its own risks and they are cumulative”.

Prof. James Isbister (Haematology & Transfussion Medicine, Royal North Shore Hospital, Sidney, Austrália)

“We really need to change transfusional practice, there is no other alternative. And there is a sense of urgency in doing this”. He adds, “This change will go from a focus in the transfusion to a focus on the patient.”

Prof. Donat Spahn (Charmain of the Dept. of Anesthesiology, Uni. Hospital Zurich, Switzerland)

“After evaluating all available evidence, all we have left to do is to conclude that transfusion is a great multiplier of morbidity and mortality.”

Doctor Bruce Spiess (Professor of Anestesiology Richmond, VA, EUA)

“Patients who were transfused have a higher incidence of cases such as, post-surgery infections, cancer recurrence, lung disease and pulmonary problems. This is cause and effect. ”

Doctor Danilo Kuizon (Interventional Cardiology, Quezon City, Philippines)

“I have seen many patients with hemoglobin as low as 5, 4, 3, up to 2 g/dL and they survive. Many things could be really understood in the light of human physiology.”

Prof. Hans Gombotz (Chief of the Dept. of Anesthesiology and Intensive Care, Linz, Austria)

“The transfusional practice is based more on custom than on evidence.”

Ludhmila Abrahão Hajjar (Coordenadora da UTI cirúrgica do InCor e da UTI cardiológica do Hospital Sírio-Libanês de São Paulo)
“We cannot keep doing medicine in 2011 based on a 1942”

Steve Rothman (Representante dos EUA de 1997 – 2013)

In 2010, he delivered the amount of 4.69 million dollars of federal funds to the Englewood Hospital Medical Center to provide US military and civilian doctors, and other health care providers with education and training on how to practice and perform a bloodless medicine and surgery. “The program will be especially important during natural disasters or conflicts when blood is often limited or unavailable,” Rothman said. The clinical staff of the Hospital Englewood has more than 200 doctors among more than 25 medical and surgical specialties, who have been specially trained to perform bloodless medical and surgical techniques.

Época journal 10/01/2011 (p. 94, 95)
The special reporter for Época journal, Cristiane Segatto, in an objective and logical way, summed up in three words, the material published: “Less blood, please”.

Dr. Doctor Antônio Alceu dos Santos (Specialist in Cardiology by the Brazilian Society of Cardiology, Doctor at the Hospital Beneficência Portuguesa of São Paulo and Hospital Vaz Monteiro in Minas Gerais)

“PHYSICIANS and physicians treat the patient’s anemia; the PHYSICIAN of all physicians treats the PATIENT who has got anemia.

The physician attention shall be the anemia’s patient, not the patient’s anemia”

He summed up in four words the main objective of the www.bloodless.com.br Web site.

“LESS BLOOD, MORE LIFE”.

The WHO recommends: “Reduce need for transfusion”. WHO adds: “Blood transfusions have the potential to lead to acute complications or delayed effect, and it can transmit infections. The risks associated with transmission of infections can be reduced by minimizing the number of unnecessary transfusions …”
Many researchers around the world have concluded this very fact that treatment of anemia through a blood transfusion has serious side effects, including risk of death.

See this WHO conclusion at the. SCIENTIFIC EVIDENCE section.

Have a better conversation with your doctor on this matter.

The WHO says: “… simple alternatives to transfusion are safer and cost-effective.”

Facing a misuse of blood, the WHO has guided the medical profession to make use of the therapeutic options to the allogeneic blood transfusion. Concerned about the risks related to traditional transfusion practice, performed through blood bags donation, the WHO strongly encourages the creation of a patient’s own blood conservation program (Patient Blood Management – PBM). It has been found in this last decade that the veracity of these facts is increasingly apparent in scientific research published by several researchers around the world.

See in the SCIENTIFIC EVIDENCE session an overview of the Global Forum for blood safety: Patient Blood Conservation, performed by the WHO.

Allogeneic transfusions (someone else’s blood) can result in multiple inflammatory and immune reactions (acute or delayed hemolytic reactions).

Thus, the more is the blood units transfused, the higher is the antigens load (foreign body) injected into the patient’s circulation. Hence, on one side we have hemolytic reactions and on the other, the most critical, the immunomodulation.

Immunomodulators are substances that act at the immune system giving increased organic response against certain microorganisms, including viruses, bacteria and protozoa, through the production of interferon and its inducers.

Therefore, before an infection, this immune response is vital for the patient. This situation can worsen greatly in the presence of a blood transfusion, because the immune system (immunomodulators) will have now to act not only against the infectious agent, but also against a new hemotoxin (a substance that has direct or indirect harmful effect on the human body), in this case the allogeneic blood. This partly explains the several deleterious complications associated to blood transfusions.

Medicine does not provide this answer. In 1942, Dr. John Lundy believed that a person with hemoglobin of 10 g/dL or less, would be at risk of death, therefore, he proposed blood transfusion to all patients who achieved such a hemoglobin level. Unfortunately, this idea lasted for over half a century. After year 2000, the risk of death came to be considered for patients with hemoglobin

below 8 g/dL.

Fortunately, medical knowledge evolved greatly over the past decade, and one of the major discoveries in transfusional practice was that human beings not just tolerate 8 g/dL of moglobin, but much lower levels than this. Recent researches show survival of patients even in severe anemia condition.

Dr. Graffeo reported that his patient reached level of 1.9 g/dL of hemoglobin and he did not die.

Dr. Liana Araújo reported that one of her patients survived even after target a hemoglobin level of 1.4 g/dL.

Another case described in abstracts published in the Brazilian Archives of Cardiology (January 2015) showed a patient who achieved 2.9 g/dL of hemoglobin and requiring hemodialysis.

For many doctors these values would be incompatible with life.

Nonetheless, all of these survived without the use of blood and blood components.

However, to highlight even more that there is an individual tolerance of every human being to critical levels of blood in the body JianQiang Dai has reported the survival of his patient after he has reached 0.7 g/dL of hemoglobin.

(Learn more on the SCIENTIFIC EVIDENCE section)

There are countless options. We going to quote the main options with the impact to reduce and/or prevent a blood transfusion.

1 – Tolerance to anemia.. The patient tolerates anemia, the doctor cooperates with the patient in tolerating anemia. This tolerance is individual. Learn more with the second question of this section.
2 – Medicines for treating anemia.. Ferrous sulphate, folic acid, vitamin B12, erythropoietin.

3 – Medicines of systemic usage (intravenous) to stop bleeding and prevent blood transfusion:: tranexamic acid, epsilon aminocaproic acid,vasopressin, desmopressin acetate, vitamin K, activated recombinant factor VII, coagulation factor VIII concentrated, prothrombin complex concentrated, human fibrinogen concentrated, human recombinant factor XIII. Dosages of
these drugs are found at the article “Therapeutic options to minimize allogeneic blood transfusions and their adverse events in cardiac surgery: Systematic review”.

4 – Topical usage medicines to stop the bleeding and avoid blood transfusion: oxidized cellulose hemostat for the wound’s compression; fibrin glue/sealant; fibrin or platelets gel; hemostatic collagen; gelatin foam/sponges; calcium alginate.

5 – Equipment that avoids blood transfusion (cell saver):: This equipment recovers the patient’s blood that otherwise would be lost during the surgery. The interesting fact to consider is that this recovered blood has the patient’s DNA. This blood can be reused and does not represent a hemotoxin (“foreign body”). This is a true blood’s “recycling”. This is the best blood that a patient could receive in a transfusion: HIS OWN BLOOD.

The intraoperative autotransfusion is an excellent alternative to allogeneic blood, primarily because the benefits such as: availability of fresh blood, decreased postoperative complications, reduction of number of days of hospitalization and associated infections, reduction of death and decreases the homologous blood demand (donated blood).

6 – Acute normovolemic hemodilution.. It consists of the withdrawing of one, two, three or more bags of the patient’s blood at the beginning of the surgery,

being replaced by crystalloid and/or colloid solutions such as plasma volume expanders, in order to maintain normovolemia. This blood will be at the surgeon’s disposal to be used in the appropriate time, usually at the end of surgery. In case of any bleeding in surgery, we will have less blood loss, as it will be diluted. This stored blood has the patient’s DNA without the risk of immunological reactions.

7 – Surgical techniques.. It is also a treatment option for reducing the use of blood transfusions. This strategy involves meticulous hemostasis, a hypotensive anesthesia and mild hypothermia to prevent loss of blood, and consequently, less consumption of blood. 

8 – Avoid excessive blood samples.. Withdrawing of blood three, four, five or more times in one day, from the same patient, only to follow a routine or some
arbitrary protocol of certain intensive care unit (ICU), for sure will cause an iatrogenic anemia and consequently result in an also iatrogenic blood transfusion.Therefore, excessive blood withdrawal causes anemia, and as most doctors will not tolerate anemia, the result is a transfusion.

Therefore, always ask your doctor if this withdrawal will change the conduct, that is, if it will guide further treatment. Otherwise, the withdrawn blood will only contribute to worsen the clinical condition.

9 – Use of pediatric tubes for collecting blood. The more blood is withdrawn from a patient, especially when he is hospitalized, the worse will be his health condition. What is proposed is to collect a minimum of blood needed to carry out essential laboratory tests. The objective of this strategy is to avoid unnecessary blood loss and hence avoid blood transfusions. Ask your doctor about this.

10 – Early oxygen therapy/Supplemental oxygen. Tolerance to anemia can be increased by ventilating the patient with a high fraction of inspired oxygen (FiO2). Ventilate with 100% oxygen results in rapid increase in arterial oxygen content, ensuring tissue oxygenation even with very low hemoglobin (severe anemia) and it proves to be an important strategy for reducing allogeneic transfusion.

11– Other therapeutic options are found in the article” Therapeutic options to minimize allogeneic blood transfusions and their adverse events in cardiac surgery: Systematic review “,, publicado na Rev Bras Cir Cardiovasc. published by Rev Bras Cir Cardiovasc. 2014;29(4):606-21, available in the following link: http://www.rbccv.org.br/article/2321/Therapeutic-options-to-minimize-allogeneic-blood-transfusions-and-their-adverse-effects-in-cardiac-surgery–a-systematic-review

We can say that all types of pathologies in any health center in the world have been treated using one or more therapeutic options to the blood transfusions. The more options and/or alternative we use to avoid the use of blood, the greater the possibility of saving the patient without the use of a blood transfusion.

Among serious and complex surgeries already performed with these strategies include: heart transplantation, heart retransplantation, bone marrow transplant, kidney transplant, liver transplant, aortic aneurysm repair surgery, heart surgeries (coronary artery bypass grafting, valve replacement, simple and complex congenital heart disease repairs), benign or malignant tumor resection surgeries (cancer), orthopedic surgery, neurological surgeries and several other surgeries.

Three main reasons:

I – Blood is an exhaustible resource and is in short supply worldwide. Most national and international blood banks are with its scarce stocks below of what would be the ideal.

According to a study conducted in 2007, the demand for blood in Brazil grows at a rate of 1% per year, while donations grow 0.5% to 0.7% per year, indicating that in the near future, we will have to get along with the possibility of not having blood available for all medical procedures. Fewer transfusions mean savings for blood banks.

II – Blood transfusion increases hospital costs as it increases patient’s length of stay in the hospital, especially higher ICU (Intensive Care Unit) length of stay. The longer the patient stay in hospital higher will be the hospital costs. Fewer transfusions mean lower hospital costs.

III – Treatment using transfusion of allogeneic blood (someone else’s blood) may result in myocardial infarction, cardiac arrhythmia, renal failure, stroke, multiple organ failure, and transmission of up to 68 (sixty eight) infectious agents (bacteria, viruses, protozoa, worms). The main side effect that the latest researches have shown is the higher risk of death after a blood transfusion. It has found further that this risk of patient death increases proportionally with the number of transfused units, that is, the more is someone else’s blood that the patient receives, the higher is the risk of dying.

LINK: “Mortality risk is dose-dependent on the number of packed red blood cell transfused after coronary artery bypass graft”

LINK: “Harms associated with single unit perioperative transfusion: retrospective population based analysis” This has caused great concern to all healthcare professionals who are directly or indirectly involved in transfusion practice. Fewer transfusions mean less complications, less death, more life