Transcription:
Bloodless Surgery

Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole and joining me today is Dr. Magdy Milad. He's the Chief of Minimally Invasive Gynecologic Surgery in the Department of Obstetrics and Gynecology. He's also the Medical Director for the Northwestern Medicine Center for Complex Gynecology, a multidisciplinary clinic for patients with complex gynecologic conditions. Dr. Milad is here today to discuss a unique type of surgery that Northwestern Medicine offers, which doesn't require a blood transfusion, a surgery without blood.

Dr. Milad, thank you so much for joining us today. So I'd like you to start right off, what is bloodless surgery?

Magdy Milad, MD, MS (Guest): Well, thank you for having me. Yeah. Bloodless surgery originally started back in the sixties as a method to avoid blood transfusion and blood products inter-operatively. But over the past 40 years, it has really grown more into a holistic approach to blood conservation, as well as new technologies that eliminate or minimize the need for transfusion during surgery.

Host: Isn't that interesting. I swear, this is the kind of thing that's the future of medicine. Now Dr. Milad, we've seen a dire need for blood resources in this country, but other than that, can you tell us about some of the benefits of having bloodless surgery?

Dr. Milad: Well, probably most importantly, there's a group of patients that really are opposed to receiving a blood transfusion. So, as a provider, we have a responsibility to take care of those patients and work within their rights of bodily autonomy. So, that's probably one of the most pressing things that we face.

If we think more globally though, blood and blood transfusions are a limited resource. And in fact, lately there's been a significant scarcity of blood available for patients that are trauma patients and such. And so as a result, we have to be very thoughtful about the need for transfusion and avoiding transfusion when we can.

Host: Well, along those lines, Dr. Milad, as we know, some people may not want a blood transfusion for religious, medical or personal reasons, but are only certain patients eligible for this type of surgery? I'd like you to speak about Jehovah's Witnesses, specifically the challenges they may face when seeking medical treatment and whether this type of surgery is eligible for a broad range of patients.

Dr. Milad: Well, and first of all, as you mentioned, patients from the Jehovah's Witness faith are often opposed to transfusion of blood and blood products and a common approach would be that they are opposed to red cells, white cells and platelets. And so they are at a unique disadvantage because, they have trouble finding providers that can live within that framework, to be able to respect their beliefs, and optimize their surgical outcomes.

So, they actually have a medical elders group that identifies providers that will be respectful of their wishes and direct those patients for care. However, other patients are also interested in this as well. I mean, blood transfusion, generally speaking, is a relatively low risk intervention, but it's not a zero risk. And if we can avoid blood transfusion and also save that blood for somebody that has a major trauma and won't survive unless they have a blood transfusion, I think that's important as providers.

Host: Well, then tell us how Northwestern Medicine is prioritizing Jehovah's Witness's religious beliefs, but also meeting their medical needs.

Dr. Milad: We approach this in a multidisciplinary fashion. So there's a codified approach to patients that are opposed to blood transfusion. And that way there's a seamless approach. It's not just me or my group and the center for a Complex Gynecology that is respectful of their wishes, but it's really the entire team from anesthesia to nursing, to the surgeons, to the ICU, to the emergency room. So we have a seamless approach to bloodless surgery and being respectful of patients that are opposed to blood transfusion.

Host: Are there certain guidelines, Dr. Milad, that patients need to follow before having a bloodless surgery when they're considering no blood treatment, and you're discussing this with them and seeking alternatives are lifestyle choices that better prepare the body for bloodless surgery or bloodless medicine in general?

Dr. Milad: Well, I think it's probably the most important recommendation for patients seeking bloodless surgery is first of all, to identify a provider that's respectful of their wishes. For surgery, again, it's important to find a team of providers, not just a surgeon who is open to and respectful of their wishes, finding a medical center that has developed this kind of cogent and seamless approach to blood transfusion is critical.

Another thing that's really important is that patients seek out a provider before it gets severe. I can't emphasize that enough. For example, in patients that have symptomatic fibroids, where they're really having a lot of vaginal bleeding to the point of anemia, there are medical and non-surgical ways to reduce the blood loss so that, the patient sort of isn't painted into a corner of being severely anemic, but really so anemic that surgery wouldn't be very safe. So, it's critical that you it's important to get those patients in early so that these other interventions can be effective.

Host: Let's talk about the techniques that you use, Dr. Milad. Can you describe some of the ones that you use during surgery to minimize blood loss?

Dr. Milad: When I teach my residents and fellows, I'd like to say, it's just like a relationship, but the little things are the big things. So in the example of symptomatic fibroids, like we mentioned a moment ago, there are a lot of little things that you can do that make a big difference in the outcome afterwards.

So for example, symptomatic fibroids, right from the beginning, before we make an incision, we can instill a agent that will reduce the bleeding at the level of the skin. That already you already are intervening proactively to reduce the amount of blood loss during the surgery. We can inject the fibroid with medications that will shrink the blood vessels and has been shown to be effective in reducing blood loss at surgery.

Another technique is to use a tourniquet, just like you would put a tourniquet on your wrist if you had a bleeding hand, we can put a tourniquet around the base of the uterus to compress the vessels during the removal of those fibroids. We can also use a thing called a Cell Saver which is a way to aspirate the blood inter-operatively and then if the patient does need it, we can give them back their own blood that's been rinsed and washed in the operating room at the same time. So all of these like little things make a big difference. Another thing that's really important is to really be, multimodal in your approach. So preoperative hormonal suppression has been shown to reduce the bleeding at surgery and also help build the blood count up before the surgery.

Also, we can do a thing like a uterine fibroid embolization before the surgery, again, to cut those blood vessels down to a smaller size and reduce the bleeding intraoperatively. So a multimodal approach like we have at the center is a great way to reduce the bleeding and lower the risk of severe anemia.

Host: Dr. Milad, how does this surgery differ from a surgery that uses blood transfusion? And I have to ask this, but why wouldn't everybody want this?

Dr. Milad: I think probably everybody would want this. I think it's probably a really good approach. It it makes a physician, a better steward of blood and blood products, even in the patient that isn't necessarily morally opposed to it. So I think it is becoming more common and you see national trends and academic medical centers that have a lot of interest in developing protocols and even naming out bloodless surgery centers as a resource for patients with or without a moral objection to it.

Host: What about after surgery? Are there any protocols that you're following that are different than a regular surgery?

Dr. Milad: Well, I mean, a simple thing would be not to keep drawing the patient's blood afterwards because every time you draw a test tube of blood from a patient it's no longer in their body and results in them being that much more at risk for further anemia. And it's never really been shown in a typical gynecologic case that drawing blood routinely postoperatively changes your approach to that patient. So I would strongly advise avoiding blood draws postoperatively, and really just monitor the patient's symptoms and vital signs and so on. If they are stable and feeling fine and walking and so on, it really isn't necessarily to monitor their hemoglobin. Obviously postoperatively, you can give iron transfusion either preoperatively or postoperatively is a great way to build up blood counts before or after surgery. So just these little things, again, make a big difference.

Host: These little things. That's certainly true. So do you see the use of bloodless surgeries growing in the future and becoming more common and you're speaking to other physicians, what would you like them to consider when they're planning a bloodless surgery and for providers that are apprehensive about taking care of those patients? What do you have to

Dr. Milad: Do think that bloodless surgery is becoming a national trend. It's been this way now for really many years, and it's just getting more and more common among both those that are morally opposed to it and also those that just would like to avoid blood transfusion. And now we have at Northwestern, a blood stewardship committee and they're very deliberate about how they recommend transfusion and in what settings and how much and so on again, just to be respectful of blood and how scarce a resource that is. So I would advise providers that are reluctant or hesitant to be in contact with those providers that do have some comfort level with it and be proactive about managing those patients as opposed to being reactive and fearful.

Host: Do you have any resources you'd like to recommend for physicians who want to know more about bloodless surgery and tell them just about your team at Northwestern, when you think it's good for them to refer.

Dr. Milad: Well, I think whenever a provider feels uncomfortable, they should certainly refer. Specifically, our center is designed to be for complex gynecology, so if it's just outside the wheelhouse of someone who doesn't manage patients on a regular basis with these kinds of issues, happy to take care of them. I mean, in, in our center, we actually have interventional radiologists seeing patients alongside of gynecologists and fellowship trained surgeons. So we work together pretty regularly. As far as overall resources, the Jehovah's witness website on bloodless surgery is quite good. It really is a JW.org.

But there are many articles in Pub Med, including cardiac surgery in patients that are Jehovah's Witnesses or, oncology patients that are Jehovah's witnesses. So there are many resources available to providers to better understand again, all these little things and how they make a big difference in outcomes avoiding blood transfusion.

Host: Thank you so much, Dr. Milad for joining us today. What an interesting topic we discussed. To refer your patient or for more information, visit our website at nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians and for updates on the latest medical advancements, breakthroughs and research, please follow us on your social channels. I'm Melanie Cole.