2016 Johns Hopkins Bloodless Medicine Seminar

Thank you so much for coming
out on this hot, hot, hot day. >> [LAUGH]
>> We do appreciate your support of our program. Want to welcome you to the third
annual Education Seminar for the Center of Bloodless Medicine and
Surgery at Johns Hopkins. And we really are happy to see
everyone attending today and we have a great program lined
up with terrific speakers. Now along with an overview of
our bloodless program by Dr. Steven Frank and Progress and
Successes with Bloodless Strategies by Dr. Lynn Legrasar,
we’re also privileged to have Dr. Stacey Scheib who will discuss
minimally invasive gynecological surgery as well as a live
demonstration of a cell saver system by Tim Boyle, a consultant with
the Hemomedics Corporation. First up is Dr.
Steven Frank, and Dr. Steven Frank is a professor of
Anesthesiology and Critical Care in Medicine at Johns Hopkins
University School of Medicine. His area of clinical expertise
is anesthesia for vascular, thoracic and transplant surgery. He’s an expert in blood
conservation methods. Dr. Frank serves as
a medical director for the Bloodless Medicine and
Surgery Program. He is also director of the Interdisciplinary
Blood Management Program and of Peri-operative Blood Management
Services at Johns Hopkins Hospital. And please welcome Dr. Steven Frank. >> [APPLAUSE]
>> Thank you Andy, for that fine introduction and
welcome everybody. I’m so glad that we can get
together to have this seminar and for the first time ever, we’re gonna try to do a live
cell saver demonstration. So we do have three speakers and
then Tim Boyle will be the fourth speaker and
he’ll do the demonstration. So this is our agenda today. I’ll start out with
an overview of our center. And then Tim will come up and
do the cell saver demonstration. Stacey Scheib and
Linda Resar will follow, like Andy said with
gynecologic surgery and recent advances in our field. So our primary goal as a center at
Johns Hopkins is to respect you and your family’s wishes
when it comes to avoiding transfusion and
the patient comes first. So we’ve been doing this for
four years now. So we know how to conserve blood and
I’m gonna show you the ten different ways that we use to
conserve blood so we can get patients through the hospital
without needing a transfusion. And we also like to treat our
patients as if they were family members, so we spend more time with the patients
than the typical patient. Cuz there’s a lot to talk about when
it comes to honoring your wishes. This is our website and this is
the front page of the Center for Bloodless Medicine and
Surgery at Johns Hopkins. And note that there’s a cell
saver on the front page of our website and
how does it work, it says. So we’re gonna see how it works. And I’ll tell you what a cell
saver is in just a minute. These are the methods that we use of blood conservation to
provide bloodless care. So I’d like to say that the best
transfusion is no transfusion. The second best transfusion
is to use your own blood for the transfusion because
it belongs to you. And this is how we
avoid transfusions. First of all,
if you have anemia before surgery, we’d like to diagnose it and
treat it. For example, $5 worth of iron pills
can avoid $500 worth of blood. So if we can simply treat your
anemia before you come in to the hospital, sometimes we
get intravenous iron for example or even the erythropoietin
and Linda will talk about that. Good surgery, for
example laparoscopic and robotic surgery are new ways that we use to reduce bleeding,
during surgery. And at first I thought robotic
surgery was just a marketing gimmick to be honest. And then I looked at the blood
loss in robotic surgeries like prostate surgeries, and
it was a fraction of the blood loss that we see with
the traditional open surgery. Blood Salvage or the Cell Saver has been called the
centerpiece of blood conservation. So, this is what
the Cell Saver looks like. Tim is gonna give you the whole
history and the background behind, how it came on
the scene back in 1970. And this is really the way we
collect your blood you lose during surgery and
give it back to you. It’s really your own blood. It’s fresh,
it hasn’t been sitting around. And it’s the best way to conserve
blood during the surgery. We minimized blood lost to lab test. We use special drugs like TXA and
Amicar that can reduce bleeding. We use point of care testing and
education like we’re doing today. So this is our first big article that came out as a review. Linda Resar is the first author
who’s gonna be one of our speakers today. And this is a review
article explaining the 15 different things
that we do special. So our goal is to educate
people around the world. That’s doctors and
nurses and patients. So these articles
are available on web and if you wanna learn more,
you can read what we. This is a study that we
published from our team in 2014, so two years ago. Showing how our patients do
better than patients who accept transfusion because they get
this special kind of care. For example, if you look at heart
attack, respiratory, renal, or thrombotic events, if you compare
the bloodless patients to the control patients, so that’s
everybody else in the hospital. So, the bloodless patients had less
infections and less deaths, so lower mortality than the patients who
take transfusion probably because there’s risk with transfusion
that comes from the bloodbank. And we also showed a lower cost and
charges in the bloodless patients. About 12 to 14%
decrease in costs and charges because blood coming from
the blood bank is expensive. It’s more expensive than
using the cell saver. Linda and
I wrote another article in 2014 on bloodless medicine what to
do when you can’t transfuse. So our goal here is to educate
doctors around the world on how to provide this type of care. So these articles are available for
anybody with web access. And Linda presented this at the
largest blood meeting in the world. The American society hematology, which had maybe 10,000 people,
something more than that. Okay, so Linda had the honor
presenting our work at that meeting. This is an editorial that I
wrote about the cell saver and who benefits from red cells salvage. I talked about when we should use
it and who we should use it on and then our article got written
up in the newspaper, both the New York Times and
the Washington Post. And we proved that recycled blood or cell saver blood was a higher
quality than the stuff that comes from the blood bank
because it’s fresh, okay. And the stuff in the blood
bank’s been sitting around for up to six weeks. So blood is like milk in
the grocery store, okay. It doesn’t get better
when it sits around and you would rather use it fresh
like from the cell saver. In fact,
we showed in this study that 2,3-DPG which is a good thing to have,
goes much higher in cell-saver blood than it was
in the blood bank blood. So that means the cell-saver
blood can deliver oxygen better. And I won’t bore you with
all the science here, but if you look at 2,3 DPG on
the left in the stored blood, in the light blue,
that’s banked blood. It was 95% depleted, but in the cell
saver blood, it was normal, okay? Same as fresh blood. And so this got written up
in the news media as well, and they talked about re
using a patient’s own blood which is exactly
what the cell-saver does. We do everything we can to minimize
blood loss due to lab testing. So we found that just by sending
labs on patients in the hospital, blood tests, that you can lose about 1% of your
blood every day just to lab test. And so
we started using these small tubes. You see the ones on the left? Those are neonatal tubes, so
we can use those on adults too to minimize the blood that
you lose just for lab tests. And our next article to come out
is called Bloodless Medicine and Surgery: Top 10 Things to Consider. So this comes out next month, this is a preview of the next
article that Linda and I wrote. And these are the ten methods
that we use, top ten things to consider when providing
bloodless care. I just wanna tell you that we
successfully did a 13 pound baby for open heart surgery at Johns Hopkins, that’s really tricky
to do without blood. Because the amount of blood in
a 13 pound baby is slightly more than what’s in a can of Coke,
okay? That’s how much blood the baby has. So you can imagine how
small the amount of blood that they can
afford to lose would be. And I just want to show a four
minute video, if you will, and then we’ll move on to
the Cell Saver demonstration. The video that we made
came out fabulously so. Give me one second. It’s on the front
page of our website if you want to show
it to other people. And here it is. >> My neck felt like
a bullfrog pumping. Have you ever seen like a bullfrog
in its throat, pumps like that? That’s what my neck looked like. All that blood was
regurgitating up there. These flowers are coming out pretty,
aren’t they? My name’s Tammy,
live in Christiansburg, Virginia. All my family’s for
most part has been really healthy. And I didn’t know I had
blood pressure problems. >> Tammy presented to us with a
large aortic aneurysm that you could see pulsating in the base of her
neck, right above her breastbone. And that’s a ballooning of
the artery in the chest. Her blood pressure,
when she presented, was 240 over 40. She had a leap in her aortic
valve in her heart, so the one way valve was
allowing two way blood flow. >> And here I was like, this blood
pressure was like, really, how, why are you still alive? People couldn’t believe you were
still alive with this blood pressure like that. We searched for
a place to go for six months, we found that Andy Pippa
was the coordinator for the bloodless surgery program
there at Johns Hopkins. >> Tammy called us because she
couldn’t find a doctor or a hospital that would operate on her without
resorting to a blood transfusion. >> I did not want to do this
no blood transfusion period, they said with such
a bloody surgery. But with my religion being
a Jehovah’s Witness, I wasn’t gonna take any blood but I also didn’t want to die on
the operating table either. >> The fact that she took her
stand for no blood transfusion and the courage that she showed,
was inspiration to me. >> Our bloodless program
is designed to care for patients who wish to get therapy for
their illnesses or to undergo a surgery without
receiving transfused blood products. And so our rule as a bloodless
program is to care for these patients, to get them ready
for surgery when they need surgery, to keep their blood
at a healthy level. >> Every time we
avoid a transfusion, we avoid potential
complications like hepatitis. There’s HIV, TACO and TRALI which are complications from
blood transfusion that can be fatal. >> Okay, so
this is a fresh blood sample. >> So by avoiding unnecessary
transfusions we’re actually saving lives. And I haven’t met a patient yet that
wouldn’t rather have their own blood back, as opposed to someone else’s
blood coming from the blood bank. >> Nobody plans to
go to the hospital. It’s really a scary place to be. The fact that I can
make a patient feel more at ease is key to their
having a good outcome. >> We had to be very careful
with Tammy because we wanted to be sure that her level of blood,
the strength of her blood, was at a safe level for
her to get through the surgery. >> We did several things
special in the operating room. First we did something called
ANH where we bank the patient’s own blood,
right before the surgery begins. Then we use a medication called
Amicar that reduces bleeding during surgery. And third, we use a device called a
Cell Saver, which collects the blood that patients lose during surgery,
cleans it, processes it, and then we can give them back their own blood
before the end of the procedure. In Tammy’s case, without the Cell
Saver, I’m not sure we could have brought her through
the surgery successfully. >> As our bloodless program has
grown over the years, we’ve gained a lot of experience and expertise
in caring for these patients. >> By providing care to
Jehovah’s Witness patients, for example, we’re perfecting methods of
blood conservation that will benefit all patients. >> The compassionate nature of
this team, everybody on it, makes the patients feel special. >> I’m very grateful for
Johns Hopkins, for the bloodless surgery team. I made it. And I did it without their blood. >> We were so pleased with
the way the video came out. I had to show it, sorry,
we love this video. [LAUGH] And with that, I’m gonna
introduce Tim Boyle who drove here all the way from Richmond, Virginia
and brought the Cell Saver with him. And so this is Tim and Tim’s gonna talk about
the history of the Cell Saver. And then we’ll do a demonstration
and we’ve never done this before, so I’m hoping that it works. >> Keep your fingers crossed.
>> [LAUGH] >> Good afternoon. As Dr. Frank shared,
my name’s Tim Boyle. I’m one of the blood management
consultants with Haemonetics. And I just wanted to give you
a little history of blood conservation. Where did we come from? Why do we do what we do? Back in the 1600s, a French
physician by the name of Jean Denys, performed transfusions
between animals and human. As you can expect,
it didn’t go well. And then in 1818, we have
an English surgeon by the name of James Blundell who actually
reported studies of doing human-to-human transfusions, again
the results were not favorable. One of the reasons is as we know
today, what is your blood type, if we give somebody the wrong type
of blood they’re gonna have negative reactions. So this is why James reported
the challenges that they had with the human-to-human transfusions
back in the early 1800s. And then we move forward
to the end of the century, with the first record and
report from Dr. James Highmore who advocated the utilization of doing
salvage blood return during surgery. In other words auto transfusion,
getting their own blood back. So then we come up
to our century and we come to the Vietnam War era. And an American military surgeon by
the name of Dr Klebanoff utilized an open heart pump to collect
the patient’s blood, the soldier. Collect that soldier’s blood,
anticoagulate it so we would not have coagulation
occur so we would process it. Then he filtered it and then we
reinfused blood during surgery. And then in the 70s, a company by
the name of Bentley Laboratories brought that device
to the marketplace. And then also, in concert with
all of these steps, a Dr. Cohn and a Dr. Jack Latham looked
at utilizing a centrifuge for separating blood components
because of the need for albumin in the battlefield for
our soldiers. And as you can see, in the slide, they literally got the idea
from dairy process separation. So we can thank our whole milk and
our cream and everything, >> [LAUGH] >> For autotransfusion. Then along comes Dr.
Latham where he improved upon Dr. Cohn’s stainless steel bowl and
for his Cohn Fractionator. He then developed it into a plastic
bowl, which we still use today. We use the exact same bowl and the
device that we have in front of you today that we used
back in the early 70s. I got into open heart
surgery running the pump, being the perfusionist. Actually in the early days,
the devices looked so different back then. Today, the device what we have
in here today to show you, just to do the demo, is the latest. And as they tease in marketing,
the latest and the greatest. And it makes it so much simpler for the clinician to operate and
separate the blood out, so you’re actually getting
back whole red blood cells. In 1975, Dr.
Latham in concert with other folks at Haemonetics brought the very
first Cell Saver to the market. And then in 78 is when I got my
hands on the For the very first time, I literally used the very
first one that was developed. This is a pictorial representation
of what the bowl looks like. And as you can see, in the center
here is a capillary tube. So, the blood is coming from the
surgical field, the blood comes into the cell saver, and
goes down to this capillary tube. And hits this plate right here
that Dr. Latham invented. And we still hold
the patents to this today. And as the blood comes in,
this bowl is spinning at 5,650 rpm. So, as you drive home today,
look down at your RPM and figure out how fast you’re
going down the highway. And then, consider if you had
Jack’s Bowl underneath your hood, you’d probably get there quicker. >> [LAUGH]
>> [LAUGH] >> To the side of the road with blue lights behind you, probably. >> [LAUGH]
>> But in our creator’s infinite wisdom, red blood cells
are the heaviest part of our blood. So, as this bowl is spinning,
the red blood cells are pushed out against the outside
the wall of the bowl. And then, all of the other
components of the blood, as you can see here,
represented in yellow, will then be pushed
out into a waste bag. And I’ll get through the process
a little bit deeper, but I wanted you to see exactly what
is going on inside the bowl. Because when we do the processing
and we do the live demo, you actually can’t see that because the
bowl sits down inside the device. So, what are the advantages of doing
autotransfusion or cell saving? You want to avoid
transfusion at all costs. Our blood supply is the best and the safest it ever has been and
anywhere in the world. But as Dr. Frank shared with you, you wanna get your own blood
back if at all possible. And the value to that is that you’re
not gonna have an allergic reaction to it because it literally
is a transplant. And then, also, you have your high
quality of fresh red blood cells. Dr. Frank shared with you 2,3-BPG,
which I affectionately call the key that releases that bond
between hemoglobin and oxygen, so, you get tissue oxygenation. Also, while blood is being stored. Well, it’s aging just
like we are all doing, sitting in this room right now. So, you will have a little bit
of hemolysis that occurs even in the bag. Getting your own blood back, you also reduce the chances of
having a transfusion error. And definitely,
when you get your own blood back, that’s not gonna happen. The other thing is also, it reduces the demand on
the blood bank inventory. I’m sure we’ve all seen in the news,
in the Internet, newspapers, are requests for people of a certain
blood type, to come in and donate blood cuz of a shortage. Platelets, which come out of
the blood and separated out, we’ve had a tremendous shortage of that in
the Richmond area, that, as of late. The other reason too for utilizing cell saving is for
the psychological benefits. I don’t want, no offense, I don’t
want anybody’s blood in this room. You don’t want mine either. And, so,
you wanna get your own blood back. The indications for
doing cell saving is the patient, you don’t wanna half of them. And with the Jehovah’s Witness
faith, definitely not. One of the things too is that
when with the hospital liaisons, with the videos, you actually
see one of our other devices, it’s called orthopath,
that’s represented in that video. It’s a very small cell saver. I teasingly call it cell saver on
a stick cuz it’s on an IV pole. So this is our Tootsie Roll,
and that was the Tootsie Pop. >> [LAUGH]
>> Then also, if you’re gonna have 15% to 20% percent of your
blood lost in surgery, you definitely wanna have a
consideration for doing cell saving. Also, if you’re gonna be transfusing
more than one unit of blood, you may wanna opt out of that and
then utilize the cell saver. Also, if you wanna have surgery and
it’s a surgery where normally will have transfusions done,
you definitely wanna do that. The other reasons too is because
people have had multiple transfusions or many, they literally
develop their own blood type and it becomes very difficult,
if not impossible. It’s like you’ve cross-matched them. I’ll give you an example. I had a knee replacement
done about six years ago. But when I was younger,
in fact, when Dr. Frank and I were in the Kansas City area,
I also used to race motorcycles. And I had quite a few transfusions
from hitting things that were not moving, and I was. >> [LAUGH]
>> So, it made it a little tough for me. I was not Evel Knievel. I figured that out pretty quick,
so, I got into healthcare. Types of procedures, as you can see
on the display, cardiac surgery, definitely. Transplants, liver transplants, orthopedics, trauma,
most definitely. And one of the things
that I hold near and dear to me is in pediatrics. One of the things that is unique
with the pediatric community is for scoliosis repair. So, you think about all the things
that we do with blood and giving blood to getting a transfusion
from someone else into your body, you definitely don’t wanna
start that at an early age. So, it’s great to keep children
from having to have a transfusion. The next thing I wanted
to share with you, and this is one of our older platforms. In fact, we just retired
manufacturing of the Cell Saver 5 Plus, which had been in
manufacturing for over 20 years. It is the cornerstone
of the industry. In fact, as Dr.
Frank shared with you, and I have so far is that we invented
the technology. We’re the industry leader in
the technology around the world. We manufacture around the world. And what we do is we collect
the blood from the surgical field. And then we do processing,
and there’s three steps. We’re gonna fill the bowl that
you saw the pictorial of. Then, we’re gonna express out or push out all the components
we don’t wanna have in there. And then, we’re gonna wash those
red blood cells with saline. So, it’s basically
a washing machine. It’s a rinse cycle of
a washing machine. And then, what we’re gonna do is
empty those healthy red blood cells in to a bag, and then,
transfuse that to the patient. Again, this is a picture of
the device to my right, and this is a screen,
just a quick little pictorial of it. Just to share with you, it’s exactly the way the screen
should look right now. And what it allows us
to do is to modify, change things as we’re going along
so you get a better product back. And what I’d like to do now is
go into the live demonstration. So, what we’re gonna do is
demonstrate to you exactly how the device works. It takes about ten minutes,
so, as we’re doing that, if it’s okay with you, I’d like
to continue the slides as well. Cuz you’re gonna be watching
the blood move from one location to another. But I just wanna share with
you exactly what’s going on at that time. So, let me just move over here. >> So, I’m an anesthesiologist,
but I’m gonna have to play a surgeon during this
>> [LAUGH] >> Demonstration because- >> I’m sorry [LAUGH] >> [LAUGH] >> What happens is we, first of all, I should say, accepting cell
saver blood is a personal choice. There are some
Jehovah’s Witnesses that choose not to accept
cell saver blood. >> So, we discuss the risk and
the benefits >> And then, we explain how it works, and
then, it’s a personal choice. So, don’t mistake us. We’re not telling you have to
accept it, it’s a personal choice. But if we use it, we can hook
it up in a continuous circle. So, it’s always
connected to the patient. For example, this would be
connected to the cervical field to suction the blood
that you’re losing, okay? And then, after it’s processed, the blood will end up
coming through here. And this is connected to your IV,
so, it’s a continuous circuit. And because this is
a saline-filled line, that will be soon filled
with cell saver blood. And that way,
there’s no interruption. So, should we start processing? >> Absolutely
>> Or sucking? >> Start sucking. >> Okay, so,
let’s say that losing blood. This is, by the way,
we bought this blood. It’s from a bovine source or
a cow, okay. >> Yeah. >> [LAUGH]
>> And that’s not me, I was driving [INAUDIBLE]
>> [LAUGH] >> So, this is how the suction works. >> So-
>> And it goes into the reservoir there. It’s working right? >> Yes, yep, absolutely. So, right now, what we’re doing now
is we’re doing a representation of an actual surgical event. So, the blood comes in
to the reservoir and it’s filtered by this
dark filter right here. It’s a gross particle filters,
so, we get large particles out. And now, what the machine is doing
is it is now bringing blood down into the reservoir or into the bowl, as I shared with you earlier,
that picture? And those of you that are closer,
and I’ll keep quiet in a second so you can hear it, it actually
sounds like a turbine spinning. That is the centrifuge in the center
of the device When we’re done, you can come up and look. But what’s happening now,
as the ball is spinning, and so, as the blood is coming down in,
it’s going to separate out all the healthy red blood cells, and
it’s gonna express out, or push out all of the unwanted particles,
so I’ll just put it to you that way. And it’ll go over here
to this waste bags, where it stays nice and closed. And even though we have the blanket
over here to protect this nice carpeting,
feel very comfortable with that, we’re not going to get
blood on the carpet. So what, and this takes a little
bit of while for it to happen, actually, with human blood,
usually it’s about seven minutes, so while this is processing. And filling those, we’ll come
back over to my slides, and we’ll discuss a few more things. So, as what Dr. Frank shared with
you is the collecting first. So, we have an anti-coagulant
that goes down to the very, this very tip of the tubing that Dr. Frank had to yank out our tip,
or the suction tip. And it mixes with the blood, so that the anticoagulant
keeps the blood from clotting. It travels back up into this
reservoir, and then goes into the device in the cell saver,
just as we were demonstrating. So, what it’s gonna do is it’s gonna
separate out this anticoagulant, and everything else that comes
from the search of the field. So, the blood again, leaves that
reservoir, comes down through that capillary tube that I shared with
you earlier, and hits down on this plate right here, which is what made
this even a more effective tool. Dr. Latham had the great
idea of putting little turban-things down here. So, it actually separates it out. Again, acts like an agitator we
have in our washing machines. So, right now the bowl is spinning, the blood is filling all
the way up to the top. And once it does, it’s pushing everything
else out to this waste bag, see the word supernatant right here,
that’s what we refer to as a plasma, your white blood cells, the saline
that we add, the that table, or the surgeon and the nurses may
add to wash up the surgical field. So, we’re gonna get everything out. And then what we do next, is you can
see the capillary tube now is blue. And you can see a bunch of numbers
over here that are really more for a clinician to study, and understand
how much volume we’re gonna use for washing. But what we’re doing now is
we’re bringing in saline, so we’re now doing the rinse cycle
as I shared with you earlier during the red cycle,
with those healthy red blood cells. So, any red blood cells that would
have hemolyzed through this process, they’re gonna be expressed out or
pushed out. So, what you’re gonna get back
is healthy red blood cells. And we use certain
volumes to make sure, and lead to the things presented
to the FDA to make sure that you have the best product coming
back to you, so that you’re not having concerns about any
contaminants coming back to you, and you want to have your healthy
red blood cells return to you. So, that third phase
that the machine will go into once it’s done washing
will be the empty phase. So, we’re going to take those
healthy red blood cells, and we’re gonna send those up
to the reinfusion bag. And then from there, as Dr. Frank shared with you,
would be it’s all primed. So, it’s a continuous closed loop,
and then from that reinfusion bag,
the blood, which is washed red blood cells,
you’re not getting whole blood back. And it’ll be 95 to 99% cleaned
of any of the contaminants and hematocrit, or
the amount of that volume, a known volume is
gonna be roughly 50%. It’ll vary depending upon of
the things that are going on in the field, and the device as well. And while the device is fading,
in fact, if you want to, why don’t we do this? You can actually come up if you want
to take a look and look down in, and see how the device is working,
and I can also answer any questions you may
have with regards to cell saving. >> How much longer do you think
it has to process [INAUDIBLE]? >> At least another six minutes. >> Okay. >> [INAUDIBLE]
>> We can entertain questions, or come up and check it out and
explain it. >> [INAUDIBLE]
>> Yes, this is the bowl in size, and you can see this infrared light. What we’re doing is we’re sending
a red light across the field, and whole red blood cells
absorb that light, and different rates that does
plasma free hemoglobin. So, once it hits that level, it knows to switch from
the fill mode to the wash mode. And as you can see now, the machine
is telling us what it’s doing. It should say empty right now. So, we finished the wash, so now. The red blood cells are gonna go to
set up to the reinfusion bag, okay? >> Yeah, to find the saline, so,
this is the phase that I when the laundry comes out of the washing
machine and into the basket, and your husband forgets
where the clothes line is. >> [LAUGH]
>> Okay, so right now, and since we have insufficient
volume in here, it’s actually gonna
continue the process. So, this continues going
on as long as your device, as long as in the reservoir, and it
will turn to you, the patient, okay? Your blood during this procedure? There’s the blood bank, what we do, let’s say I
donated blood today, okay? The blood in the blood bag is not,
okay. >> So there was a question
about the word banked. So, the cell saver
blood is never banked. So, it’s not put
into the blood bank. It stays in the operating room
connected to the patient. So, it’s really part
of your circulation, because it’s connected to your
vascular system with the IVs. So, banked is a term we use for the blood that comes
from the blood bank. Which is we don’t get
that with his patients. >> [INAUDIBLE]
>> That’s right. The first thing we do is suction,
well, we hand the suction to the surgeon. And they use that special suction to recover the blood
that you’re losing. So, when we don’t use a cell saver,
the suction blood gets wasted. It just ends up going in the trash,
basically. And so, it doesn’t make sense
to put your fresh blood that you lose in the trash, we’d rather
recover it and give it back to you. >> Can you talk more
about the priming? >> The priming, sure. >> Sure. >> So, one thing we like to do is
to prime the system with saline. Those are the clearer fluid
bags that you see, and that way,
there’s no air in the system. If you get air in someones IV,
it can be life threatening, so we definitely want to prime
the system with saline and that way that also provides a continuous
circulation with your body, because you have air between you and
the cell saver. It’s a safety issue and
a continuity issue. >> Thank you. >> Tim, it worked
>> [LAUGH] >> We’ve never done this outside of the operating room, so
we were a little bit nervous. >> [APPLAUSE]
>> And then the reinfusion bag is filling,
right? It’s filling?
>> Yes. >> So,
that would be the washed processed blood that you see
handing from the pole. >> Right. >> And then we can run that
straight into the patient’s IV, and basically recover all
the red cells that you lose. So, this technique has saved two
lives that I know of in the last three years at Johns Hopkins,
in Jehovah’s Witness patients. So, when we tell patients
the risk and the benefits if it’s a surgery with significant bleeding,
then we recommend this. Okay, now, if you have,
say, a thyroid surgery, where you’re gonna lose about
a teaspoon of blood, okay? We’re not gonna recommend
the cell saver, okay? So, don’t take home the message
that you always need this machine, because I can name 15 kinds
of surgery right now where the blood loss is minimal, okay? And if you come in and
ask for the cell saver, they’re gonna tell you that it’s
not necessary, because we’ve ranked all the surgeries on a scale for the
amount of blood loss that occurs. And so the prostate surgeries
we do nowadays with the robot, they lose maybe 30 ounces of blood,
okay. So the Cell Saver’s not gonna help. We may have it around as a backup,
just in case they get into bleeding. Sometimes we do that. We have a Cell Saver on standby
as a back-up maneuver, okay. For example, our next speaker,
Stacey Scheib, is gonna tell you about
gynecologic surgery. And hi, Stacey. And sometimes with her cases,
for example, we use a Cell Saver
in a back-up mode. Because she doesn’t lose hardly
any blood for some of the ovary or hysterectomy surgeries. So we’ll have the Cell Saver around, right in the room or
outside the room, ready to use. So I’m going to introduce Stacey, who’s one of our
favorite gyn doctors. And we refer her a lot of patients, and we’re privileged to
have her speak today. Welcome, Stacey. >> [APPLAUSE]
>> Hi, everyone. >> One more question? >> Sure.
>> Is that okay? >> Yeah. >> Okay. >> You might have to
speak up a little bit. >> Spinal surgery. >> Spinal surgery, yes. Spine surgery comes in small,
medium and large. I learned that over the years. So if you’re having a laminectomy,
for example, you’re gonna lose maybe
50 ccs of blood, okay. That’s 1% of all
the blood in your body. But if you have a five level fusion,
okay, that’s a large spine surgery, and you could lose half of
your blood volume, okay. So then we definitely want
to use the Cell Saver. So a laminectomy, no,
we probably won’t use it. A five level fusion? Yes, we’re gonna use it
>> I’m so appreciative, hi, I’m Stacey Scheib. I’m so appreciative for
being invited to speak. I think we’ve done a lot of good
work over the past few years collaborating together to really
push forward bloodless gyn surgery. There is a huge role for it here. I’ve worked a lot with Jehovah’s
Witnesses during my time in Philadelphia. There’s a huge Jehovah’s Witness
population up there. And so I have to really
embraced it and, I think, especially with what I do, I’m
a minimally invasive gynecologist. It’s a great pairing together. Actually, one of those
two patients of Dr. Andrew’s was one of my patients. [LAUGH] Unfortunately,
it was a very complex case, but that patient is doing great. Went back home to Texas and
is doing remarkably well, considering what happened. So we’re gonna talk about bloodless
gynecologic surgery today. I have no disclosures,
no conflict of interest. So the thing is, what I know first,
what are we treating? In my world,
this is not an exhaustive list. This is the most common things that
women come to my office regarding, the top one being uterine fibroids. If we look at this room right now,
if in terms of all women, this whole side has
fibroids and that side does not. That is the difference,
70% of all women have fibroids. And 80% of black females have
fibroids at some point during their lifetime. So that is probably the biggest
thing that I’ve seen. This can present as heavy bleeding,
but not all the time, which is why this is a particular
complement to bloodless medicine. The others you can
have are bulk symptoms, pressure on your bladder,
chronic pain, pain with sex, increase in abdominal girth,
urinary frequency urgency. You may have symptoms
of either diarrhea or constipation if the fibroids
are particularly large. Adenomyosis is a condition
of the uterus where the cells in the lining grow
into the muscle layer and can present very heavy bleeding or
painful periods. Endometriosis is also very common. Most of the time that’s
asymptomatic, but it can present as infertility or
as chronic pelvic pain. This is sort of a hot topic,
but pelvic pain, in general, we use minimally invasive surgery
to evaluate more and to correct. Ovarian cysts, there are a number
of different reasons why people get cysts on their ovaries,
but that’s another reason. Those menstrual
abnormalities that we don’t put into the whole common things
like fibroids or adenomyosis. We use surgery commonly
to evaluate for infertility that we can’t seem
to find other reasons for. And also for urinary incontinence or
pelvic organ prolapse. These are probably the most
common surgeries that I deal with in terms of
those common problems. Hysterectomy being the most common,
followed by myomectomy, a close second [LAUGH]. We also do surgeries on the ovaries,
both removal of the cyst or potential removal of the ovary
which is what an oophorectomy is. Salpingostomy or salpingectomy is surgery
regarding the fallopian tubes. Scar tissue or lysis of adhesions,
excision of endrometriosis and pelvic reconstruction. So the big question I always get
asked is why bother with a minimally invasive approach? Okay, why see a specialist that
does minimally invasive surgery? It’s not uncommon for me to see a patient who’s physician
said you’re not a candidate. I’m like, but you actually might
be if you went to an expert, and there are very big pros and
cons. And in this particular
patient population that we’re trying to avoid blood, this is all the more important for
you to see a specialist that does minimally invasive surgery because
there’s some huge benefits. The biggest one is activity. Of course, we get to go back to our
normal activities pretty quickly. Most of my patients actually go
home the same day from surgery. Even from a hysterectomy, which is amazing considering
where things were when I trained. And they can do stairs,
they can walk, they eat whatever they
want that same day. That’s pretty amazing. And because of that, we’re actually decreasing the risk
of postoperative complications. Things like a clot to your leg or
a clot to your lungs. Or a pneumonia or atelectasis, which are respiratory complications
initially after surgery. Postoperative pain. Clearly, if we’re going
through small incisions, that’s with minimally invasive,
either going through the vagina or through small,
tiny little incisions on your belly. Compared to a big incision,
of course, if you have a smaller incision,
you’re gonna have less pain. The added benefit of
that is guess what? You don’t need as
much pain medication. And in this day in age we’re hearing
all around the news about narcotic abuse and
what do we do with the drug issues. This is an added benefit of us
being able to move forward is that we’re having to use a lot
less pain medication. And this is the biggest
one is we clearly see, when we work with small incisions,
tiny, and we have a camera that gets to amplify what we get to see, we
tend to have much less blood loss. And also, clearly seen,
looking at your blood count, right? We don’t see the drops in it. So if we can do it minimally
invasively, we want to do it. With specific procedures,
specifically with myomectomy, we’ve sometimes also seen
less febrile morbidities and spike of fevers for unknown reasons. Which can affect your blood work and
evaluation because we’re trying to figure out the etiology
of why you’re having fevers. This one is another big one,
especially for the fibroid group and the
endometriosis group as well, is that we have less scar tissue when we
can do things minimally invasively. What that means is scar tissue pulls
things where they’re not supposed to be, and that can be a bad thing. So if it’s affecting
your fallopian tubes, that can cause infertility if you
get scar tissue after a surgery. And so
we know from a lot of studies. They did this great study in
Italy where they went back and looked after people
had open surgery and people who had laparoscopic
surgery in the past. And they clearly saw if you
had laparoscopic surgery, you had a much lower chance
of getting scar tissue. And that’s important, too, also
because of the downstream effects. If you have scar tissue
in your pelvis, too, because it pulls things where
it’s not supposed to be. If you have any subsequent surgery,
it can increase the risk of having other injuries or
having a greater blood loss. And so it has a downstream effect,
so it’s prevention as well. A topic that’s very near and dear is related to fertility cuz
I deal with a lot of fibroids. And a lot of women who are trying to
get pregnant because of fibroids or because of endometriosis. After laparoscopic surgery,
we clearly get a better outcome. In terms of getting pregnant sooner,
okay, and improving that outcome. So how does my team work with
the bloodless medicine group? Our goal is for you guys. We want to have
patient tailored care. We want to honor your wishes in
the best way that we can, okay? We want to increase the chances of
minimally invasive surgery for you, for all the reasons
I just talked about. And the last one is, we want to
make it work in a way that we keep you safe at all times, and minimize
risk to you as much as we can. And that really comes
from a team approach. That we are talking together,
that we work together. And when you have a team that
consistently works over and over together,
Things work better, okay. We have better outcomes. We know that through
all different fields. If we look at all fields, airline
industry, look at surgery outcomes, when we have set teams
that are dedicated and work together things work better. This is what I tell my residents
all the time and my fellows. An ounce of prevention
[LAUGH] goes a long way. And that’s where the team approach
really works is that we know what’s potentially coming. I’m gonna put all those things in
place to try to prevent bad things from happening. So the most common reason that I may
need to involve bloodless medicine, most commonly is because I have
a patient who is anemic and is also Jehovah’s Witness, or doesn’t accept
blood products for other reasons. And now they’re bleeding from their
vagina because of their fibroids or because of their adenomyosis,
or a polyp or whatnot. And so what we need to do is
get them to a better place. It’s always better to do some
preventative measures before we ever even get to the operating room. So maybe I won’t even need to even
consider this machine at all, okay? So the analogy I was using
with my residents is it’s like a leaky bucket. I need to plug the holes, okay, otherwise I’m never gonna
fill that bucket back up. I can give you all
the erythropoietin, all the iron, all folate, it doesn’t matter if
I don’t stop your bleeding, okay? And so because ideally, in
preparation for surgery, I want us to get to a point where blood
count is in a much better place. And ideally,
in the normal range, okay? And so this is what we’re gonna do. So I may try to stop your period for
a little while, so that I can plug that bucket, okay,
and allow things to come back up. Or I might need to do a uterine
artery embolization to try to secure that blood supply
a little bit more to optimize our chances of not needing
a blood transfusion or eating or
any other interventions, okay? So these were things that we do. Also one thing I didn’t put on
there, I realized in Carrie’s talk, I said, sometimes if they want
to auto donate, I say okay. Let’s auto donate, but then I may
delay your surgery for a little bit longer so that I can get your
blood count to a better spot so that we are as tip-top
position as possible. I like my little ducks in a row. I don’t like surprises, and
I don’t wanna surprise for my patients either, okay. And I’m very adamant with my
patients and I’m very forthright, because the bottom line
is I wanna keep you safe. I’m gonna give you some examples of
some of the cases that we’ve done over the years. This is case 1, she was
a 54-year-old who had had one child in the past,
long-standing history of fibroids. She had heavy bleeding, pelvic
pressure, fullness, low back pain, and leg pain. She was done with having kids,
so she was ready for definitive treatment
with a hysterectomy. She already has a history of anemia, which is clear because
her blood count is low. She had attempted to do more
conservative management in the past with a uterine artery
embolization to treat her fibroids, but it had failed,
which is not uncommon. About 30% of women who have had
an embolization need some other intervention within five years. And we knew she had a big
uterus walking in to this, so what this means, she has
a 20-week sized fibroid uterus. So that uterus is somewhere
between her belly button and the bottom of her rib cage. So it is going up into her upper
abdomen and she is, we’d call that someone who’s probably six or
seven months pregnant. That’s a big uterus,
not very comfortable. So we discussed it in our
Fibroid Conference, and we review all our images with
the interventional radiologist to see what options are on the table. We ultimately came to we
thought the best option for her would be to do a laparoscopic
hysterectomy, okay. But to do a uterine artery
embolization prior to the hysterectomy to try to get that
blood supply under control a little bit better prior to us going
to the operating room. I also postponed her surgery for
three months in order to get her blood count back up
to a normal range. Cuz I gave her a medication
called Aygestin, which is a progesterone hormone, to try to
suppress her period temporarily, and stop her period, and I also
gave her iron to bring it back up. So by the time we got to surgery,
her blood count was normal, she had minimal bleeding, and we actually
had a very successful hysterectomy. To give you a sense
of how big it was, a normal uterus is about 70 grams,
70, hers was 2006. And she went home the next day and was back to most of her normal
activities within three weeks. Another case that we did, this is a 42-year-old with an acute
episode of vaginal bleeding. She really didn’t want
a hysterectomy though. She was not ready, even though she had completed
having all of her children. And when I examined her,
her cervix was dilated and we had a big fibroid sort of
popping out through her cervix. By the way, that’s not normal. Not normal at all, okay. And when we looked at the MRI,
she had a cervical fibroid, which is actually a more difficult
fibroid to tackle because they usually have a big blood supply
from the main blood vessel, or the uterine artery, to the uterus. And so they tend to have
a much higher blood loss rate. Cuz we can’t give other
medications that we normally do during a myomectomy to try to
get that uterus to contract down or get it to slow down on the bleeding
cuz it doesn’t really work. Those medicines don’t
work with the cervix. And so
we also get a combined UAE, but I did myomectomy through
the vagina this time. And she went home the same day, lost
maybe a few tablespoons of blood, if that. >> [APPLAUSE]
>> Here’s another patient, so this one is a 30-year-old. She had never had children, and
she really, really wanted to have children but she had a really,
really large fibroid uterus. And she really wanted someone to
try to keep that uterus for her, because before she came to see me,
she had seen two other providers who would only offer her a hysterectomy
because she was a Jehovah’s Witness. But she was passing clots with her
period, constipation, bloating, pain with sex. And it was to the point that she
couldn’t have sex with her husband, okay. So unfortunately for someone who
wants to keep their fertility, we only have two
options on the table. One, go get pregnant, which clearly she can’t do cuz
she’s not having sex cuz it hurts. Or two, we need to proceed
with a myomectomy. So her uterus went all
the way up to her rib cage, all the way to her liver,
so it’s all the way up here like she was pregnant, so
we did something unusual. So we did a UAE as well, but we used
something that dissolves quickly, so something called gel foam, so that wouldn’t compromise
her fertility long term. And I did do an open myomectomy,
which I don’t usually do. But because of this I really
wanted to lay hands on it so I could keep her uterus
like I promised her. And I put a tourniquet around it,
sort of like when you give blood. They put a little rubber
band around your arm. So we did a similar thing on
the blood vessels to her uterus, and we got out 3,200
grams of fibroid. And she still has
a normal uterus now, and is getting ready to get pregnant. So the last case,
which I should have included, was the one patient that really
did need this machine right here. Is with a patient I did do
an open myomectomy on, and she came all the way
from Texas to see me. She had had two prior
myomectomies already, so two other surgeries
to remove her fibroids. That makes the surgery
very difficult. Like I said,
if you’ve had a myomectomy, that is a surgery notorious for
causing scar tissue. And scar tissue is bad, causes things to go where
they’re not supposed to be. So her bowels were attached
to her uterus, and her uterus was attached to
the main vessels to her leg. So when we tried to dissect it out,
and I ended up having another surgeon to come assist me because
of the complexity of the case. We ended up getting into
the vein of her Right leg, and had to call [INAUDIBLE]
surgery to come and assist. So we used the cell saver,
while doing the case, while we could repair her vein and
get her uterus out. And she felt great the next day, and she went home two
days after surgery. And is doing great in Texas, and is looking forward to
one day having children. So our goals here at Hopkins are to
really tailor our care to what your goals are. I don’t wanna dictate to
you what you should have. I’ll give my recommendations, but
it’s totally up to you what you want, and if it’s in our power,
we will try to accommodate. And we have a couple locations. Any questions? >> [APPLAUSE]
>> Great job, Stacy. Yes, Jerilyn might have
the first question. >> [LAUGH] What are some of the
factors that determine whether or not somebody’s a candidate for
the minimum invasive surgery? >> Well, take for example,
our fibroid cases. I evaluate them with a cadre
of my colleagues and with the interventional
radiologists. And we review every MRI of all of
our patients to determine are they a candidate for
minimally invasive surgery or not? And there’s different levels
of comfort level too, even within my colleagues. And we’ll say are you
comfortable with this? If not, they’ll pass it on to me cuz usually
I’ll take on more complex ones. But we try to fit that as best as
we can to offer someone a minimally invasive, okay,
within the group, okay? And then if not, then we are very
frank with the patient about what we can and cannot do. I’m always willing to try. I usually tell them that there
might be a risk of conversion. The risk of conversion in our
department, our division, is somewhere between around 2%, so it’s actually low if
we say that we tried. Most of the time we can do it. Yes? >> [INAUDIBLE]
>> What was that? >> Where you-
>> Are you at Johns Hopkins? >> I am at Johns Hopkins. [LAUGH] Yes? >> In a situation where there’s
a prolapse of the uterus, do you have to remove the uterus, or can you do other things that
will be lost, or remove, and/or remove the, Ovaries? >> Okay, so let me just repeat the
question, make sure I understand. So do I always have to take
the uterus out if there’s prolapse? That was the first question. Not all the time, okay? It’s dependent on the severity
of the situation and how big your uterus is, and whether
we think it’s a contributing factor. We will probably counsel
you about the risk and benefits of leaving
the cervix versus taking it. Because sometimes, if we leave it
in, it’s particularly large, and we think it’s contributing to
the prolapse, you’re at risk for recurrence. And the best surgery for prolapse
is usually the first surgery, so we try to weigh those things. Of course, you ultimately will make
that decision of what risk factors you’re willing to accept. The second question was do we
always have to take ovaries? So part of that is dependent
on whether someone is menopausal already or not, okay? So if someone is not menopausal,
and they look normal, and there’s nothing about the imaging
that is concerning, then absolutely, I’m wholeheartedly for
you keeping your ovaries. Let your body make those hormones. There’s no reason necessary
to take them, okay? If you’re post-menopausal, okay? That means you’ve already
gone through menopause, you’re no longer having
a period anymore, then they just become risks to you,
typically, okay? Because there’s no added benefit. Your ovaries are no longer making
any hormones that will provide you with benefit. They’re only providing you risk. Risk of ovarian cancer or cysts or
pain or along those lines. And so, typically if
someone is post-menopausal, we recommend removal. Cuz it doesn’t add anything more,
more time to the surgery or any additional risks, okay, yes? >> Does the type of
insurance you have factor into being able to
come to the bloodless unit? >> I have not had a problem with
insurance issues with signing patients [INAUDIBLE]. At least, up until now. >> I can try to answer that. Fabulous talk Stacy,
thank you, it’s really nice. I’ve learned a lot. >> [LAUGH]
>> So the only time we have problems with insurance is with
someone who has Medicaid and they’re from out of state, okay? Those are the challenging patients,
okay? Everything else that we do
seems to work out just fine. So that’s the short answer, and
Andy may know more about insurance than I do, but even in those cases,
we found a way around it. Because we have some special
strings we can pull to get it done. I have a question for
Stacy, so, historically, doctors compare tumors to
fruit in the grocery store. So is a 3,200 gram tumor, is that
like a cantaloupe or a watermelon? >> That is a watermelon. [LAUGH]
>> I’m serious. >> It’s a watermelon. >> When someone has
an apricot-size tumor, that’s how we describe it, so. >> We like fruit in medicine. >> Yeah, [LAUGH]. >> [LAUGH] We compare
everything to some food. [LAUGH] Any other questions? >> I do have a question. If a woman is about three
months pregnant, and she have tumors or fibroids, would that cause any
risk in her pregnancy? >> They can, it is dependent
on the location of those fibroids, and
the size of those fibroids. If you’re already
three months pregnant, you already know where
the placenta is already implanted. As long as it’s not overlying
a fibroid, one of those fibroids, it’s usually okay. Sometimes if it overlies one of
the thyroids, it can compromise the blood supply to the fetus
during course of a pregnancy, which can cause some birth
restrictions sometimes, okay? Depending on how much they
grow during during pregnancy, it can affect the risk
of pre-term labor, that means you go
into labor too soon. That the baby is mispositioned, so that you may need
a caesarean delivery. Or that it obstructs labor, so blocks the opening to
get to the vagina. Okay, so there are some things that
it can affect during pregnancy. At the time, if you need a cesarean
delivery, if they’re located in the areas that we need to do
the C-section on the uterus, that it can increase the risk of
bleeding during your C-section and the need for other interventions,
and potentially a hysterectomy. But usually, you will have some
inkling of that, cuz they’ll monitor them during pregnancy and
talk to you about those, yes? >> How do you handle patients who
have Medicare, but no GAP insurance? >> Medicare, but no GAP insurance. I think on a case-by-case basis, we have people in our department
that work with patients to figure that stuff out, and
it’s usually not the doctors. So I wish I could give
you better answer, but we have ways to work it out. Now I think we’re gonna
take one more question, cuz we promised Tim a break, okay,
so we can take down the cell saver. And so one more question, then we’ll
take a break, and then Linda Resar, who’s our hematology specialist,
she’s gonna give the last talk. Can we do one more question? Yes, Dionne? >> I don’t have a question for Dr.
Frank, but after we take a break, I can answer those questions
regarding her insurance. >> That’s right. You just joined
the radiology department. >> [LAUGH]
>> As an insurance expert, right? Okay, how about we can have
you answer after the break? After the break, cuz I promised Tim
we would take down the cell saver. >> I can answer a question
during the break. >> During the break, okay. Thank you, Stacy. >> [APPLAUSE]
>> Linda, welcome, and we’ll get
finished on time, I’m sure. Thank you, everybody. >> Well, first, I wanna thank
Steve and our bloodless group and all of you for coming today. It’s really a pleasure
to be here and to speak at this meeting every year. And it’s especially fun, because we
get to see our patients when they’re in the hospital, when they’re sick, when they’re coming to our clinic
because they have a medical problem, so it’s really fun to
just see everyone. One where they’re well,
and we’re having fun and talking about what we do. And so as Steve mentioned, our real
goal is to make sure that your blood is at a safe level, and
make sure that you’re healthy. And so in doing that, we come up
with a number of protocols and we have some exciting plans for the
future to make things even better. And another thing that I’m gonna
share with you in my talk today is how we teach other doctors
how to take care of you. And while we would love to take care
of every bloodless patient there is, that’s not always possible. So another very important goal of
our program is to educate other doctors and nurses about how to take
care of our bloodless patients. So as you heard earlier,
the general principles of our care are first to diagnose and
treat anemia and in doing. So we can get you safely
through surgery or through your medical illness and
keep your blood at a safe level. And also as you’ve heard about, another major goal of our program
is to minimize blood loss. So I think Dr.
Frank mentioned this but your average patient who’s in
an intensive care unit just from getting blood tests alone a patient
losses 1% of their blood volume. So you can imagine ten
days in a hospital, you can loss 10% of
your blood volume. So, we’re really careful. We make sure that all of our
patients are getting their blood drawn with pediatric tubes,
teeny, tiny tubes, so that you don’t have to lose
it just for a blood test. And the other thing we do is we make
sure that every blood test that gets ordered is absolutely needed. A lot of times,
things are just done by routine but really aren’t helpful to
the care of our patients. So we take extra care and caution to
make sure that when we need to draw blood, we’re taking the least
amount that’s necessary. And that every test is necessary,
that we’re drawing from your body. Another thing that we do is diagnose
and treat bleeding disorders. Many of us take aspirin so
if you took an aspirin a week ago, your platelets are still
affected by that aspirin. Platelets take about ten days to
circulate within our bodies, so even having taken an aspirin a week
ago affects your bleeding risk. So we try to find out what our
patients are taking, if they are going to surgery we counsel
them to stop those kinds of agents. And if they go through
an emergency surgery, it’s good to know what’s in their system, because
what could cause excess bleeding. And something I don’t have
time to talk about is, we also think about other
parts of your blood. I mean, we talked mostly about
blood strength and anemia today, but we also look at platelets
which are the part of our blood that helps
our bodies clot. And we’ve had a number of bloodless
GW patients with low platelets, and we find a way to treat that
without giving new transfusions. So what is anemia? Just so we’re all on the same page
and I apologize to those of you who can pronounce Greek
words better than me. But anemia actually comes
from the Greek word an-haima, which means without blood. So when somebody has anemia, they
have generally a decreased number of red cells and
decreased amount of hemoglobin. And hemoglobin is the protein in our
blood that makes our blood red and it’s primary job is to carry
oxygen to our tissues, so very important job. And this is what it looks like. When I look at your blood
under the microscope, so if you are a patient with and you’re
going to see Dr. Shy, she may say, check out this blood, it’s low,
how can we best treat it? So we’ll get it under the microscope
and you can see on the left, you see lots of these little
doughnut-shaped red cells. That’s what it should look like. If you’re anemic you have fewer red
cells and less amount of hemoglobin. And this is actually the real deal,
so you see on the left, this is a patients’ blood smear. You can see there are lots
of little red cells. They look like doughnuts, and like a good doughnut, you don’t
want it to have a big center. Only about a center third of
the whole diameter of the red cell should be pale. And then on the right you can
barely see those red cells. In fact we call those ghost cells. And for patients who have
severe iron deficiency anemia, their red cells are small. They have fewer red cells and
they have less hemoglobin so they look like a ghost and you can
also see some of them are misshapen. They’re shaped like hotdogs or
teardrops and that’s characteristic
of iron deficiency. So we look at your blood
under the microscope, it helps us tell why
you have the low blood. And then, how does one determine
whether you really have anemia? So we use two measures generally, they are usually a team
by a simple blood count, which I’m sure everybody in
the room has had at some point. It’s called a complete blood count,
a CBC, and in doing that we
calculate the hematocrit. And that’s actually, as you
heard in the really interesting talk about the cell saver,
the red cells are fairly heavy. So if you put them in a tube
like a straw and you spin them, the heavy cells go to the bottom,
and the percentage that are red
blood cells is your hematocrit. And I’ll show you a little
diagram of that to help you conceptualize that. We can also use a Coulter counter
machine to measure how much hemoglobin is there. And so those are the two numbers we
look at to determine whether you have anemia, okay? And so here you can see is a picture
of somebody’s hand with anemia. They’re pale and sometimes
when one has iron deficiency, you can actually get
flattening of the nail beds. We call it spooling. And if you see on
the left that tube, that’s one way to
measure the hematocrit. You take the blood,
you put it into a tiny tube. You up the end and
you spin it in the centrifuge, and then the amount that’s red cells,
that’s shown with dark marks in this tube, that’s the measure
of the hematocrit, okay? And for a normal adult male,
it’s somewhere between 42 and 45. For a normal adult female,
it’s somewhere between 37 and 42. And anemia’s been around
since the beginning of time. Here’s a beautiful painting
of somebody who I think looks a little pale and maybe a bit,
tired symptoms of anemia. And anemia however,
can be challenging to diagnose. One of these patients is one of our
bloodless patients, and in fact, last year during this presentation,
he was in the hospital, and today he’s doing well. The other picture is his sibling and so just looking at those two
picture, I think most of us will be able to pick out which of these
adorable little children has anemia. It turns out it a little boy and if
you’ll look closely at his gums and his lips,
their pale compared to his sister. Although she has lighter complexion,
her little tongue and lips are really rosy. So she’s the patient or the child
who does not have anemia and it’s her brother who has anemia. And he’s one of our bloodless
patients because he’s very severely alloimmunized, he
has sickle cell and he cannot accept transfused blood. So when he comes in,
we have to treat him very carefully, we use pediatric tubes and
we try to do everything we can for his body to maintain his
level of hemoglobin, okay? And why is it important? Why do we care about anemia? Why do we need our red cells? Well, in this picture I’m
showing the picture of the doughnut shaped cells,
the little sacks of hemoglobin, and they actually go to our lungs
where they pick up oxygen. And then the basic job of these
little sacks of hemoglobin is to deliver the oxygen to our
vital organs like our brain, our heart, our muscles. So it’s really an essential
life function. We need our red cells to deliver
oxygen to our tissues and organs, and our organs and
tissues need that to function. So when we are evaluating
a patient with anemia, what kinds of things do we look at? I showed you we’ll look at the blood
smear, we’ll measure the hematocrit. One of the most common causes for
anemia, around the word, in fact, is iron deficiency. So that’s usually one of the tests
we check on our patients. In older folks who are of
Eastern European ethnicity, B12 deficiency is pretty common. Folate deficiency is common in
parts of the world like Africa or in women who have
a hemolytic anemia, like the little boy I showed you,
he has sickle cell. Patients who have red cells that are
turning over faster are at risk for folate, so we will check for
those nutritional deficiencies. Many of our patients,
especially elderly patients, can have renal dysfunction or
renal insufficiency, and as I’ll share with you later, the
kidney is a really important organ. It makes a hormone called
erythropoietin and that hormone tells your
body to make blood. So if somebody’s kidney
is not working properly, they often will have low levels of
this hormone, and so they need more. So we determine whether they
have renal insufficiency. Another common cause for anemia in our patients is
anemia chronic disease. So things like rheumatoid arthritis,
diabetes, obesity, lung disease, these alone
can actually cause anemia. They cause underline inflammation,
which interferes with your body’s ability to use iron and
make new red blood cells. So it’s important for us to figure out why you have
anemia so we know how to manage it. For some patients, we look for hemoglobinopathy like sickle cell
in that little boy I showed you. And also we’re very careful to
ask our patients about bleeding diathesis. Do you have bad nose bleeds? For women, do you have fibrous? Do you have heavy
menstrual bleeding? We wanna know if this occurs and
why it occurs? So that if you’re going
through surgery or if you’re just managing
a medical illness. We can better hope you build up
your blood if we know why the low blood has occurred,
why the anemia has occurred? So how do we treat it
once we diagnose it? As I mentioned, iron, globally, worldwide is the most
common cause of anemia. And in order for
your bodies to make hemoglobin and red cells, you need iron. So we a supplement. And for those of you old enough
to remember Popeye, I think, we all learned that spinach
is a good source of iron. And that’s actually not true. For a vegetable it’s not bad,
but if you really need iron, you’re really not gonna
get it the way Popeye did. What you really need are meats,
and in particular red meats and some chicken and fish. Many of us are very health
conscious, a lot of people are cutting back on red meat, so
sometimes you just can not get enough from diet, and in that case
we will often go to supplementing. And the easiest way to supplement
for somebody who’s at home and just has a low level of
anemia is with iron pills and I’m showing you a picture there. Sometimes iron is not
easy to tolerate. For some of us, it can cause
a little bit of constipation or indigestion. Sometimes you just have a really
significant deficiency and we need to fix it fast. You need to have
your surgery soon or you just really can’t
tolerate the iron. So in that case we do IV iron and
we’ve been changing and improving our protocols
over the years. There are newer iron dextran
preparations which are very good sources of iron for
our patients who are outpatients. We can give them up to 1,000
milligrams in a single visit, so that’s wonderful for patients who
are traveling far to our center. You can come in for a single dose
and just restore your iron stores. For inpatients, we use
something called iron sucrose. It’s a slightly lower dose but it’s available through our hospital
pharmacy and that enables us to give you little doses every day
you’re in the hospital. So, we’re constantly looking for
the best and the safest iron preparations and our
practice has changed over the year. A few of those iron preparations
on the list we used before, and more recently we’re using the
ones that I circled there for you. And then what else can
we do to treat anemia? I think some of you are probably
familiar with Lance Armstrong and some of you have been reading about
the various blood doping practices of some of the athletes who have
been banned from the Olympics. So EPO is a drug that has been used
by athletes, in particular cyclists, because it’s the hormone that
our bodies normally make. Our kidneys in fact is what makes
EPO and they sense low oxygen. So when you have low blood, you have
low oxygen, the kidney’s say uh-oh, we need to make more blood. So the kidney makes erythropoietin
and that goes to our bone marrow and tells us to make more blood. Athletes who used it would
give themselves extra EPO. In people who have renal disease,
we will supplement with EPO. And what EPO does is, as I
mentioned, it’s made in the kidneys, it goes to the bone marrow, and it tells your bone marrow
to make more blood cells. Let’s just take a look
at what they looks like. So this is actually a picture
of a bone marrow from a patient. And those big blue cells
with the big purple centers, those are young blood cells. And those are the cells
on which EPO is acting. EPO is coming up to those cells and
saying make more blood cells. And then eventually you get
the donut shaped red cells that are carrying hemoglobin and
oxygen throughout our body. So how do we do that for
our patients? There are a number of
preparations that we use. We give typically to our
outpatients about 20,000 or 30,000 international units. We like to work with you. We wanna personalize your care so
that you’re getting the best care and it’s the most convenient for
your life. You’ve heard we treat patients
from more all over the country, even all over the world. So if you’re living in Virginia and
you need to build up your blood, we can contact your primary
care provider and say well, let’s have you come in once a week,
twice a week, get EPO, which can usually be given in a
primary care office subcutaneously. And then we’ll also
supplement you with iron and make sure your blood is at a safe
level, so that when you come in for your surgery, you’re at
a very safe and normal level. For our patients who are on
dialysis, we like to give IV EPO, you’re already getting IV access for
dialysis, so IV is great. You can get the medicine
right into your vein. It’s the fastest acting and
it’s a very safe approach. There are other EPO preps that
are sort of slow release preps and in some cases we use that, too. And one of those preparations
is called Darbepoietin. So when we started, we actually
relied very heavily on a study that was published out of Philadelphia on
how to manage bloodless patients. But since then we’ve really
advanced that practice and I just drew a circle around a number
of the papers that have come out of our program. And I think some of you were asking,
how can we access those papers and give them to our doctors? If you send an email, or contact
Andy, we can make sure you get those papers and that abstracts
are actually on the web-site. But the strategies that we use are,
first, a team evaluation. Many of you have met Andy,
our coordinator, we have a couple wonderful nurses. You’ve heard from Steve, our anesthesiologist and
I’m the hematologist. We manage anemia with iron,
as I mentioned, sometimes EPO. And we also come up with a target
hemoglobin with our surgeons like Stacy. What is the best number
that you feel comfortable that we can get this patient
through the surgery safely? It used to be patients’ surgeons
were afraid if a patient doesn’t accept blood, I just can’t do it. And now, that we’ve built a team and
we have lots of approaches to help our patients, many of our surgeons
are very comfortable with it. And they’re getting more
comfortable with lower levels, which is good for all of us. Because having too much hemoglobin
has risks as that having too little. In here, as I mentioned,
we treat bleeding diathesis, or a predisposition to bleeding,
and these are all of our papers where we’ve will be built
on this initial experience and I think have improved
it considerably. So, how are we doing? For those of you who were here
last year, I showed this slide. You can see that between 2013 and
2015, we prepared a number of
outpatients for surgery. And they were coming in
with low hemoglobins and our treatments were very effective. How are we doing this year? Even better. We have this really low p-value
which basically tells us the difference between
the starting hemoglobin and the subsequent hemoglobin. And this is actually not
the full number of patients, but we’ve had many, many patients
who are getting to surgeries. And you can see the hemoglobins
are in the normal range when our patients are going to surgery. And the other thing that’s kind of
interesting, the actual hemoglobin level is slightly lower when we
include all the recent patients. And I think that reflects the idea
that because we have this very supportive helpful team, our surgeons are feeling much more
comfortable with our patients. And so, it used to be
cardiac surgery patients, the surgeon would like hemoglobins
that were super normal. Now that we’ve had many patients
safely get through procedures, and they know there’s
a team to support them for anemia, they’re feeling more
comfortable with normal values. So the actual number, interestingly,
is slightly lower, but the patients are doing beautifully,
as you heard about. And this is just another example of
one of our patients, she actually has uterine fibroids and
I think she’ll be seeing you soon. She had anemia and like many of us, she was a very conscientious
employee, she wanted to take care of her anemia, but
she didn’t wanna miss work. So we actually treated her between
7:30 and 8:30 in the morning. She came in and got iron infusions,
started out quite anemic, 5.9 and I believe I told you
earlier the normal value for women is about 11 or
12, so really low. Came in early in the morning,
got iron infusions, and before not too long she
was completely normal. So, we really try to work with
you in terms of treatment. Is it better for you to get the iron
and EPO with your local doctor? Should you come here? What time of the day
can we treat you? We really wanna make this
an optimal experience, we wanna help you get better and
we want it to fit in with your life. In response to actually this
request from patients in meetings in the past, people asked
well what happens if iron and EPO aren’t an option? What if I’m in an accident? What if there’s a trauma and
I need blood fast? Well there are actually hemoglobin
substitutes and we’ve been able to work with the companies and
get protocols to our institutions. So we now actually have two of
these products available for our patients at all times. One of them is called Sanguinate and
it’s a cow, a bovine hemoglobin. And it’s specially processed, it’s called pegylated which
means it’s coated in sugar so that it can last for
a longer period time in your body. If we we’re just to give you
the naked cow hemoglobin, it would actually be destroyed
by enzymes that are normally circulating in your body. So by coating it with sugar,
it last longer. And we have this now available
all the time for our patients. We try not to use it because
it’s not as effective as your won hemoglobin, but we’re
very pleased that it’s available. We also have another
substance called Hemopure and that’s shown here. It’s also a bovine hemoglobin agent. It’s processed in a different way. It’s chemically cross-linked shown
here to enhance it’s stability. And if you look at it
in the blood stream, it’s much smaller than a red cell. A red cell has a large number
of hemoglobin molecules, these are just tiny
isolated molecules but they function in carrying
oxygen to your vital organs. So, over the next couple years, what
we’re hoping to do is to determine which of these is most effective and
safest. And to come with protocols so that we can see if we give
this to should you need it. Another area where our
program has really grown and where we have some really nice
outcomes is in cancer therapy. Probably everybody knows somebody
who’s had cancer chemotherapy. Oftentimes you lose your hair and
the reason for that is most of the drugs
that we have available to us, they target cells that
are rapidly growing and dividing. Cancer cells tend to
rapidly grow and divide, that’s why patients lose their hair. I need haircuts I guess about once
or twice every few months and so those are cells that are rapidly
growing in the body. A problem for our bloodless patients
then is that your blood cells are rapidly growing and dividing. So if you’ve got a drug that
effects that type of cycling cell, you can have toxicity
in getting anemic. And so we’re working to
personalize your therapy, so that you can hopefully
get treatment for the cancer without causing
toxicity to your bone marrow. And one example that has been in
a number of lung cancer patients, normally we could use a chemo
therapeutic agent called Cis-platinum. That not only kills rapidly
growing cancer cells but also turns off your blood
production [INAUDIBLE]. We’ve switched over to a [INAUDIBLE]
agent that can kill the cancer cells but won’t affect your marrow as much
and that’s called Carbo-platinum. And we’ve had a number of patients
get through their therapy without any need for even Epo. And in some of our cases, we’ve use Epo to help the patients
get through their therapy. Blood cancers, lymphoma and
leukemia is another area where it could be challenging if
transfusion is not an option. We’ve had a patient get through
successful lymphoma therapy with some Epo and iron. We also have other patients who
are getting currently treated at our institution and are doing very well. And in recent years we’ve had or
actually in recent months, we’ve had a couple of
patients with bladder cancer. And bladder cancer can be
associated with bleeding and so our patients can get anemic and
iron deficient. And we’ve been helping these
patients get through therapy with iron and in some cases Epo. Aand working with their oncologist
to come up with therapies that are the least toxic to the marrow, but the most beneficial
in treating the cancer. And why are we doing this? What’s the reason we’re all here? It’s really safe and successful
therapy, surgery outcomes for our patients. And this is just one of my
wonderful families that I’ve had the privilege to care for. The woman shown in the middle
is currently getting therapy for lung cancer. And I had the privilege of caring
for their little girl shown in the pink dress on the left,
who had low platelets. And we were able to keep her
platelets in a safe range. And another patient, one of my very favorites who’s
here today is Miss Hazel Skinner. And she is just, as you can see,
not only is she beautiful but she has one of the most sunniest
personalities you will ever meet. And she has been really courageously managing a long time history of
anemia and doing it beautifully. And I’m particularly proud that
[INAUDIBLE] comes to see us and see me, because she actually
lives in Philadelphia. And she used to go to the local
Bloodless Program which actually was around
longer than our program. But once she came here, she now
prefers to come here for therapy. And I think one of the things
we do really well is to work as a team with our patients. Nobody knows their body better
than the patient themselves and Hazel, when she knows that
something’s not right. She will either call or
text me or Liz or Andy and say, I can tell my bloods going
down, I’m getting anemic. So what we’ll do we’ll
call her doctors, we’ll find out what
the latest level is. We’ll find our what Epo dose is,
what her iron is and we’ll make sure we treat it
before it becomes a problem. So we really try to established
excellent teamwork and have very open communication. And I feel very privileged to work
with my team where there’s so many wonderful people can
reached out to our patients. Help them and keep them healthy and keep their blood levels safe
before they become a problem. So I wanted to show off
that beautiful picture and many of her beautiful
family members are here. I’ve gotten to meet lots
of sisters and nieces and it’s always a real pleasure. When I see he’s on my clinic list, I
get excited to go to clinic [LAUGH], because I know it’s gonna
be a wonderful day. And then here’s another patient that
I wanted to share her beautiful picture with you. She has a lymphoma,
had blood clots and anemia. And as you can see she’s
doing beautifully and then she also came from a number
of other hospitals in Virginia and Washington DC areas and
now comes to see us. And another really important goal
of our program is like I said we would love to take care of all the
bloodless patients in the world but that’s really not feasible. So we’re very dedicated to teaching
bloodless therapy, not only for doctors here but for
doctors in other parts of the world. And I was recently in China where
due to limited resources in some part of the country in very
dense patient populations. Medicine there is effectively
bloodless because there aren’t resources to provide blood for
the patients. And I had the opportunity to consult
on a little baby with a very serious blood disorder. And I’m showing you a picture of,
the babies so tiny, just a couple months old that
you really can’t see the baby. But here are the team of doctors
that I worked with and I just got an email yesterday actually, this
little baby is doing really well. And here’s just to show you
the outside of the hospital was in the high end
province of China in Hi ko. Which is in the south area and it’s a really big hospital
with lots of patients. So as I mentioned, one of our
really important goals of our programs is to teach other
doctors how to care for patients with bloodless medicine. And so what do we look for
in the future? What would we want to do better? We want to continue to improve our
therapies to build up your blood, so you can go and
see Doctor [INAUDIBLE] and come out with a wonderful
surgical outcome. We’d like to advanced the hemoglobin
substitute field because sometimes there are going to be instances
where people lose a lot of blood fast and we want to make sure
that we can treat you effectively. Certainly cell saver is
a real advance in our field. And we wanna be constantly
evaluating the hemoglobin substitutes to see what
will be best for you. We also want to look for
approaches to build blood cells and platelets when those parts
of your blood are low. And actually in my own lab we’re
looking at blood stem cells and trying to find ways to coax blood
stem cells to make blood better. To make platelets better,
to make white blood cells better and to make hemoglobin carrying
blood cells better. And then the other thing
that’s a big area, because it’s increasing as our
population ages is cancer therapy. And we’re looking for new agents and new approaches to kill cancer cells
without effecting your blood cells. And I was just actually
in Germany earlier this summer working with a company
just trying to develop drugs. That will kill the cancer cells
without killing your blood cells or suppressing the growth
of your blood cells. And they also have this
agent that blocks a pathway, it’s called hepsiden. Which for patients who have inflammation like
rheumatoid arthritis or diabetes and their bodies aren’t making blood
very well because they’re inflamed. They actually have an agent that
can block that [INAUDIBLE] pathway, so that their bodies can
start making blood better. So we’re constantly looking for
better ways to care for you, better ways to improve your blood
strain and new ways to treat cancer. And other problems that could
effect your level of hemoglobin in your anemia. So again, the real reason we’re
here is because of you and I always love to share the pictures
of our beautiful patients. And it also equally important
because not everybody can come here is to teach other
physicians and nurses and care providers throughout the world, how
to care for our bloodless patients. And I showed you
an example of China. Last year we had a student from
Saudi Arabia who was able to come to this conference session, fly in
to learn more bloodless medicine. And in closing I just want to extend
a very special thank you to all of you here, because you
are the reason we are here and hereby we do what we do. In this picture, I like to think
she is clapping for our program. >> [LAUGH]
>> [INAUDIBLE] And take time for some questions. >> [APPLAUSE]
>> And a special thank goes out to Hazel
and her wonderful family for coming all the way
from the Philadelphia. >> [APPLAUSE] >> Treatment for sickle cell. >> So treatment for sickle cell, so we have a number of bloodless sickle
cell patients in our program. And those patients
normally have anemia, so we want to prevent any
worsening in anemia. And there are some drugs out
there that can be beneficial, you may have heard of
hydroxyurea for instance. Which is a drug that actually helps
to turn on a kind of hemoglobin we all had when we were fetuses. It’s called fetal hemoglobin. And what happens is this drug
increases the production of fetal hemoglobin which normally
we make when we’re fetuses and during the first year of
life it gets turned off. So we turn it back on and it turns
out that this dilutes the sickle hemoglobin and it can also build
up the strength of the blood. So I think that’s one of
the more promising therapies that is available to our
sickle cell patients. There are newer drugs on horizon
that are being tested that could do the same thing and
that could potentially be safer. But I think for
our sickle cell patients, that’s the most promising area. Any questions? Thank you again for
coming to our program, it’s wonderful to see everybody. >> [APPLAUSE]
>> One more thing, there is a questionnaire
in the packet. It has ten questions. We would be so grateful if you
could turn in the questionnaire. And Andy has pens if you
need a pen by the door. And it’s just so we can know
better how to serve the community. And what you guys want to hear for
example, in our next seminar. So thank you so much for being here.

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