Alternatives to Blood Transfusion
The use of alternative treatments to blood transfusion is widely
discussed within the clinical literature. It is especially noted within
a number of case reports and case series specific to Witness patients.
One such example is a case report by Robblee et al , which
describes the novel use of prothrombin complex concentrate and
cryoprecipitate in a Witness patient undergoing a redo aortic valve
replacement and bypass graft25. Additionally, many
authors within the literature offer protocols from their own centres for
the conservation of blood products and management of patients who refuse
these pre, post and peri-operatively16,26,27.
In addition to these protocols, guidelines and recommendations exist,
produced by the National Institute of Health and Clinical Excellence
(NICE), the Royal College of Surgeons of England and the Joint United
Kingdom (UK) Blood Transfusion and Tissue Transplantation Services
Professional Advisory Committee22,28,11. These provide
further clarification on the alternatives to blood transfusions and the
key information from these has been summarised in Table 1.
One key factor, which is referenced frequently throughout the clinical
literature and within guideline criteria, is the importance of
discussion of various therapeutic options with the
patient10,11,22. This is in order to establish which
therapy is most suitable for the patient, however, evidence of direct
comparisons between therapies in Witness patients appears to be lacking.
One such example of a comparison comes from a study comparing
anti-fibrinolytics in 59 Witness patients (aprotinin, TXA and no
anti-fibrinolytic use), which found that aprotinin reduced median drain
output compared to TXA or no agent used (330 vs 500 vs 440ml,
respectively), but that the agent used made no difference to mortality,
morbidity or LOS29. However, the study stated that due
to possible bias within the selection of patients, these results were
not fully conclusive29. Aprotinin was removed from the
market in 2008 and is now only utilised in those with heavy
bleeding11,30.
Overall, clinicians must establish the level of acceptable use of blood
products with the patient pre-operatively and additionally discuss the
risks of lack of use in emergency
situations5,10,11,22. Furthermore, the utilisation of
a multidisciplinary team (MDT) approach is highlighted frequently within
the literature as being central to the establishment of a bloodless
protocol for Witness patients31-33. This is especially
important given that blood transfusions themselves have associated risks
and consequences, and that in some circumstances a bloodless regime may
in fact be a good treatment approach10,34.