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Up to now, Jehovah's Witnesses, who have long demanded equal medical care without having to compromise their religious beliefs, have made up some 90% of those who seek the bloodless techniques. But increasing numbers of other patients today refuse transfusions out of fear of blood-borne diseases such as AIDS and hepatitis, not to mention unidentified viruses.
Their concern is not always misplaced. Blood transfusions, while safer today than in the past, are not risk free. The chance of contracting AIDS from a unit of blood, for instance, is 1 in 500,000, and 1 in 103,000 for hepatitis C, according to the National Institutes of Health. The risk becomes greater as more units are transfused. "If you get 10 units of blood, the risk of HIV infection becomes 1 in 50,000," says George Nemo, leader of a group investigating transfusion medicine at the National Heart, Lung and Blood Institute. "If you're in an automobile accident, and you need 100 units, you're down to one in 5,000." Even when donor blood is deemed safe, if blood of the wrong group is transfused by mistake, recipients may suffer kidney failure, shock and clotting difficulties. Differences between donor and recipient platelets, white cells and plasma proteins can also cause reactions. Even donating one's own blood for use during surgery can be hazardous if the blood is mishandled.
Other factors make bloodless surgery increasingly attractive. Transfusions can suppress the immune system, for example, leaving a patient open to infection, slower healing and a longer recovery time. "Also, banked blood, after it's cooled and stored, doesn't have the capability of fresh blood to transport oxygen," says Shander. "We're just beginning to understand what it is we do when we give a transfusion." Finally, there is the cost: at around $500 for each transfusion, plus administrative add-ons, the total bill comes to between $1 billion and $2 billion annually, more than enough incentive to consider alternatives. Already, Englewood Hospital's managers claim, they have cut blood usage 20% and racked up savings in labor costs by lowering infection rates and shortening hospital stays.
But for surgeons who are queasy about operating without a transfusion backup, the operating field is not black and white. The jury is still out on whether it is safe to withhold blood, and large-scale clinical trials have yet to be performed. Last year an nih-funded study tried to get some answers. Dr. Jeffrey Carson, chief of the division of general internal medicine at the Robert Wood Johnson Medical School in New Brunswick, N.J., studied records of 1,950 bloodless-surgery patients in an effort to determine the relationship between patients' hemoglobin levels and the risk of dying or developing complications after surgery.
The results were mixed. The mortality rate was an encouragingly low 3.2%, but Carson also discovered that the risk of complications or death was higher in people with heart disease. "In some circumstances," he says, "blood is lifesaving. When people get very low blood levels, their risk of running into trouble is substantial, and if you're old or have cardiovascular disease, that risk may be even greater. So I recommend caution."