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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 ...

When Mike Towns went in for cardiac surgery recently, doctors hoped to save two things: his heart, and a few units of blood.

The 69-year-old retired owner of a general store in Duoro, a small town outside Peterborough, Ont., was having his aortic valve replaced at Toronto’s Peter Munk Cardiac Centre, where doctors have piloted an innovative bedside-testing regime to reduce the amount of blood and blood products pumped into patients at the end of heart surgery.

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

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

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The new protocol has driven down the cardiac centre’s use of red blood cells by 20 per cent and blood products by 40 per cent, saving the hospital more than $1-million so far.

The pilot project, which is set to expand to a dozen other Canadian hospitals beginning in September, is part of a larger movement toward conserving blood in this country.

Experts say that movement will be critical to prevent blood shortages as the population ages. The older the baby boomers get, the more they are expected to require complex treatments that include transfusions and the less they are expected to roll up their sleeves and donate blood.

It’s a looming demographic development that could begin to drain the country’s blood banks and drive up the cost of a system that already costs more than $465-million a year in provincial and territorial funding to operate.

“There are calculations that suggest now that our blood has run out … we only produce just enough to support cancer patients and surgical patients right now. Just enough,” said Stuart McCluskey, medical director of the blood-conservation program at Peter Munk Cardiac Centre, which is located at Toronto General Hospital.

“There’s a finite amount of donors. This is such an important initiative because the only way to make the balance sheet work is to reduce the utilization of blood when it’s not needed.”

A 2012 study in the journal Transfusion projected that demand for blood could begin exceeding supply the same year the paper was published.

The researchers dug into the 2008 figures for blood donation and blood use in Ontario – a province they considered a fair proxy for supply and demand rates in the rest of the country – and then extrapolated out to the year 2036. If the trends hold, red blood cell “demand is forecasted to outstrip supply as soon as 2012,” the study concluded.

The researchers calculated that, thanks to the grey wave, the gap would widen to a chasm by 2036, when red-blood cell transfusions to the over-70 set would make up 68 per cent of all transfusions, up from 53 per cent in 2008.

So far, the study’s early predictions have not come to pass.

Canadian Blood Services, which manages the blood system in every province and territory but Quebec, says there has not been a national blood shortage – defined as less than two days’ supply on CBS’s shelves – since the agency was founded in 1998 in the wake of the tainted blood scandal.

There have been occasional shortfalls of platelets, the cells in blood that clot to keep people from bleeding, around the Christmas holidays. Those have typically been resolved in a day or two, CBS said. (Maintaining platelet supplies can be tricky because platelets are only good for five days. Red blood cells keep for 42 days and plasma, which can be frozen, keeps for years.)

CBS says donation rates have not budged in a decade, with fewer than 4 per cent of eligible donors rolling up their sleeves every year.

That suggests the lack of shortages is thanks mostly to less demand, not more supply.

“We’ve actually seen blood demand decrease in the last five years,” said Kathryn Webert, medical director of utilization management for CBS. “That wasn’t necessarily predicted.”

Some of the drop is due to changes in medical technology, Dr. Webert said. For instance, a pleasant side effect of the rise of minimally invasive surgeries has been a reduction in blood use.

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.

Loosely modelled on the CBC-TV reality show, the cardiac centre’s innovation committee in 2012 awarded $150,000 in philanthropic funds to a blood-saving experiment pitched by Keyvan Karkouti and his colleagues. Their goal was to adopt a point-of-care testing system that some European hospitals had used to better predict what kind of blood product a patient might need at the end of a major surgery, when it is tricky to assess which patients will not clot well and why.

Some need platelets, others plasma or other blood products. If doctors give the wrong one, the patient won’t suffer serious problems, but the blood product will have been wasted.

“There’s risks associated with blood transfusions, even though they’re small,” said Barry Rubin, medical director of Toronto’s Peter Munk Cardiac Centre. “Now, rather than just making a decision in the operating room based on, ‘Hmmm, I think that there’s a significant amount of blood, we should do something in terms of transfusing,’ now we actually have a process in place. By following the process, that allows you to make clinical decisions in a much more rigorous way.”

On the day of Mr. Towns’s procedure, a nurse withdrew a vial of his blood from the heart-lung machine toward the end of the surgery, then walked it down the hall to a lab containing two machines that insert a rod into the vial and spin it to see how quickly clotting begins in the blood sample.

A graph crawled across the screen, which Dr. Karkouti interpreted to mean that Mr. Towns was unlikely to bleed enough to require a transfusion of any kind.

After restarting Mr. Towns’s heart and unhooking him from the heart-lung machine, the surgeons packed his heart with two sponges and observed a “five-minute rule,” an aspect of the new regime that helps the surgical team assess just how much the patient is bleeding.

When five minutes had elapsed, the sponges were placed on a scale. If they weighed more than 60 grams, it could be a sign the patient would bleed more than expected. The sponges weighed 83 grams.

Rather than rush to transfuse, the surgical team waited a few more minutes, reassured by the earlier test results. Mr. Towns’s bleeding soon stopped on its own and the surgical team closed his chest. No transfusion necessary.

The pilot project, which began with cardiac surgeries in January of 2013, has now been expanded to lung and liver transplants at Toronto General Hospital, which is part of the University Health Network. The work is now funded permanently by the hospital.

Dr. Karkouti and his colleagues, meantime, have received a grant to run a formal clinical trial of the regime at 12 hospitals, which is set to begin in September.

“I don’t think that there’s a better strategy than what we’ve done here because the blood that you save, that you end up not having to transfuse during cardiac surgery cases and now during lung transplants and liver transplants, which by their very nature are significant blood loss cases, occasionally, that blood is now available for somebody else to use,” Dr. Rubin said.

Follow me on Twitter: @kellygrant1

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