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.