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Dr. Vivek Rao, Chief, Division of Cardiovascular Surgery with the Peter Munk Cardiac Centre, prepares an aortic valve replacement during open heart surgery on a sixty nine year old Michael Joseph Towns on April 10 2014. The patient was having an aortic valve replaced during the 3 + hour operation. (Fred Lum/The Globe and Mail)
Dr. Vivek Rao, Chief, Division of Cardiovascular Surgery with the Peter Munk Cardiac Centre, prepares an aortic valve replacement during open heart surgery on a sixty nine year old Michael Joseph Towns on April 10 2014. The patient was having an aortic valve replaced during the 3 + hour operation. (Fred Lum/The Globe and Mail)

How doctors are using a simple test in surgery to save blood – and money Add to ...

Globe and Mail Update Apr. 21 2014, 12:18 PM EDT

Video: How a new blood test is reducing unnecessary blood transfusions

But, more importantly, there has been a concerted, if quiet, effort to conserve blood – particularly in Ontario. The head of the province’s successful blood-management program, which has saved the province at least $15-million in the cost of red blood cells alone since 2002, is urging other jurisdictions to follow suit.

“What we need to do is change the culture in hospitals. This isn’t easy,” said John Freedman, director of transfusion medicine at St. Michael’s Hospital in Toronto and head of the Ontario Transfusion Co-ordinators (ONTraC) program.

Blood transfusions, which are generally safe but carry some health risks, are most often given for reasons that might surprise people outside the medical world. The typical recipient is not the car-crash victim rushed to the emergency room with a bleeding wound; it is the presurgical patient with low levels of hemoglobin in his or her blood, a condition that can be dangerous during an operation.

Hospitals regularly pump fresh blood into patients before elective surgeries because it swiftly boosts red blood cell counts. It seems cheap, too, because neither hospitals nor patients pay for blood.

But there are alternatives to transfusions if anemic patients are flagged early. The blood-boosting drug EPO, best known as Lance Armstrong’s doping agent, can increase hemoglobin levels, as can iron supplements or drugs.

“The fact that blood is free to hospital patients in Canada makes it more difficult for us,” Dr. Freedman said. “Whereas the drugs, the hospital has to pay for them. The patient has to pay for them.”

The ONTraC program, started at St. Michael’s and now in place at 25 Ontario hospitals, dispatches nurses to guide elective-surgery patients in raising their hemoglobin levels without a transfusion before going under the knife.

Transfusions rates at participating hospitals have plummeted. Rates dropped 64.3 per cent for coronary artery bypass surgeries and 86.9 per cent for knee surgeries between 2002 and 2013; they fell 59.6 per cent for prostate surgeries and 62.2 per cent for hip surgeries between 2005 and 2013.

“Programs like this make the requirement for blood less and this plays a major role in the reduction in shortages,” said Dr. Freedman, noting hospitals can also take less blood for testing and use a machine called a “cell saver” to wash the blood patients lose during surgeries and return it to them.

The new bedside testing regime at Peter Munk Cardiac Centre takes blood conservation a step further. Its goal is to use rapid tests at the end of a surgery to pinpoint as much as possible what kind of blood product a patient might need – platelets? plasma? red blood cells? – to make blood clot as quickly as possible.

In the case of Mr. Towns, the results were good news. “Already I have enough information to tell us this guy isn’t going to have any clotting problems,” Keyvan Karkouti, deputy chief of anesthesia at Toronto General Hospital, said as he watched the results roll in on computer screen in a tiny lab down the hall from the operating room.

Sure enough, when Mr. Towns came off the heart-lung machine that kept him alive while surgeons sewed a new equine tissue valve into his stopped heart, he did not bleed enough to require red blood cells, platelets or plasma – even though he initially seemed to be “wet” (still bleeding) before doctors closed his chest.

Before the new testing protocol, “chances are 60 to 70 per cent he would have received a transfusion,” Dr. Karkouti said.

But now the surgical team is mindful of conserving a precious resource.

“We’re not claiming the tests alone have made all the difference,” Dr. Karkouti said. “It’s the awareness, the whole package.”

How it works

The testing protocol used on Mike Towns was born in a Dragon’s Den.

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