Search for solutions for blood shortages

  • by: By Michelle Henderson, AAP National Medical Writer
  • From: AAP
  • August 10, 2012 12:21PM

FACED with a critically injured patient refusing a blood transfusion, but bleeding profusely after a car accident, trauma surgeon Dr Sudhakar Rao needed a solution – fast.

The patient’s heart and brain were starting to shut down as the blood loss starved his organs of much-needed oxygen.

The head of trauma at Royal Perth Hospital recalled a similar situation in Victoria in 2010, involving a 33-year-old woman who was given a lifesaving dose of a synthetic blood product following a horrific car crash.

Tamara Coakley was unable to accept a blood transfusion because of her religious beliefs, but Jehovah’s Witnesses do allow some blood products and substitutes.

Dr Rao contacted The Alfred hospital in Melbourne, where the woman was treated, and requested a batch of a lifesaving synthetic oxygen-carrying blood product called Hemopure.

Further stocks of the product were immediately ordered from the United States and arrived at Royal Perth Hospital within 24 hours.

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The male patient was treated with Hemopure, or HBOC-201, while physicians boosted his own blood-making capacity by priming his system with iron and other chemicals.

Hemopure contains oxygen-carrying haemoglobin extracted from the red blood cells of cows.

While it can be a lifesaver in critical situations for people who reject blood transfusions, the product is not licensed for use in Australia and is only available on a compassionate basis.

Physicians stress it is not the answer to blood shortages, which reached a critical low in Australia in June, but could play a role in remote locations in vast states such as Western Australia because of its long shelf life.

But careful monitoring of a patient’s blood supply before surgery by boosting the body’s ability to make more blood, and reducing the risk of blood loss during operations, could lessen demand on stretched blood supplies.

“With better planning, we can get the body to make more blood prior to surgery or after injury,” Dr Rao told AAP.

“For elective surgery, that involves priming the system with iron and other chemicals.”

While Dr Rao is keen to have Hemopure stocked at remote locations around Western Australia where it could be used in critical situations to keep people alive until they arrive at hospital, he is a keen advocate of managing patient’s blood to minimise the need for transfusions.

This approach, enshrined in the state’s health policy, is mirrored by similar policies in other Australian states including Queensland, South Australia, Victoria and NSW. Some individual hospitals also have their own patient blood management guidelines.

Australia leads the world in these blood conservation strategies.

It is the first country to develop evidence-based national guidelines for patient blood management, drafted by the National Blood Authority, with the UK and parts of the US looking to Australia to adopt similar models.

The same techniques that have been used for decades to treat Jehovah’s Witnesses are now being advocated more widely to the general community as blood supplies become increasingly precious.

But as Queensland intensive care specialist Dr Anne-Marie Welsh recently pointed out, limiting blood transfusions can also be in the patient’s best health interests.

In a chapter devoted to the critical care of Jehovah’s Witness patients published in Australian Anaesthesia, Dr Welsh says the risk of infection is higher in patients who receive blood transfusions, as the transplant suppresses the immune system.

The ideal circumstances for managing a patient’s blood without the need for a transfusion occur during elective surgery, she says.

This involves priming a patient’s system with a good diet and nutritional supplements including vitamin C, iron, folic acid and the hormone erythropoietin, which improves blood cell count, one month before surgery.

Non-Jehovah’s Witnesses can also donate their own blood several months before the operation for their own use, or their blood can be collected, washed, filtered and returned as needed during the procedure.

Treating patients without a transfusion for blood loss in an emergency is trickier.

Dr Welsh says sedating a patient and connecting them to a life support system can reduce their oxygen requirements until their haemoglobin levels rise, but vitamins and hormones are less effective in a limited timeframe.

Dr Welsh says patient blood management is best suited to elective surgery but can’t be the only solution to ongoing blood shortages.

“We’re always going to need blood,” Dr Welsh tells AAP.

“Without it, lots of our patients would die.

“This is really suited to the elective situation, whereas the majority of the blood use is probably in the emergency situation, such as when someone comes in after a motor vehicle accident.

“I don’t think it eliminates or solves the problem, I think it just could help to ease the problem if, in the elective situation, we were more careful and worked with our patients more thoroughly.”

Dr Rao says oxygen-carriers such as Hemopure will not replace the need for blood either but it could be play an important role in meeting the challenges faced by physicians in Western Australia.

The product can be kept for up to three years without refrigeration.

Storing it at key sites around the state could help improve the survival of critically ill patients.

“Being in Perth, our patients come from all parts of the state and sometimes they take 12 to 14 hours to get here, 24 hours sometimes.

“If they were critically ill they wouldn’t survive that trip.

“Our biggest push here is patient blood management to reduce the usage of blood.

“This (Hemopure) is just for the very, very occasional case where someone cannot have blood for many reasons and this should just be there for a backup.

“The best way forward is to manage our blood usage by preparing patients well. That is the actual solution, not expensive drugs like this which could have potential side effects.”

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