AN INTERVIEW ON BLOODLESS MEDICINE AND SURGERY PROGRAM UCTH, First of its kind in Africa.

[An interview of Dr Nathaniel Usoro by Dede Oputamuno Gilbert]

Dr Nathaniel Usoro and Dede Oputamuno Gilbert after the interview
Dr Nathaniel Usoro and Dede Oputamuno Gilbert after the interview

Dede Oputamuno Gilbert: Good Evening Sir, I am Dede Oputamuno Gilbert, from kampusareablog can I meet you.
Dr Nataniel Usoro: Yes, Sure, You can. I am Dr Nathaniel Usoro the immediate past Head of Surgery in University Of Calabar Teaching Hospital {UCTH}, the current Head of Bloodless Surgery Programme (UCTH).
Dede Oputamuno Gilbert: Sir, like you earlier stated, that this was the final part of the event, sir could you kindly give us a rundown of the whole event.
Dr Nathaniel Usoro: Well the bloodless surgery movement started 9 years ago, and that was when the group was formed.

      The bloodless medicine and surgery programme for 2016 started on Sunday {15th of May} with arrivals.

      On Monday we had the opening ceremony, were we had 4 CPD talks {Continuous Professional Development Talks};  there was a talk on Anaemia by the Head of Haematology, there was a talk on Dietary prevention and treatment of anaemia by the head of Dietetics, there was a talk on Pharmacologic prevention and treatment of anaemia by the deputy director of Pharmacology, there was a talk by myself on how to access Bloodless surgery in UCTH.

On Tuesday we had video shows were we had educational videos, videos from the society for the advancement of blood management which is an international organisation, which promotes bloodless care {avoidance of blood transfusion}.

     On Wednesday we had 2 CPD talks, one by a Professor of Urology where he spoke on “blood transfusion avoidance as a current imperative in surgery” and then I spoke on “protocol for bloodless surgery in UCTH”.

On Thursday we had free haemoglobin checks for different people, we used machines donated by a company for the haemoglobin checks.

      On Friday we honoured the invitation of General Hospital and Navy Hospital, were we gave one hour talks each on “bloodless surgery as the current standard of care”.

On Saturday which is today, we had the last part of the programme, which was a novelty match between the Female Medical Students and the Female Nursing Students, were the Female Medical Students won by Two goals to Nothing. There was also a cultural display by the Department of Theatre and Media Art.
Dede Oputamuno Gilbert: So Sir I have been hearing about bloodless Medicine and Surgery, what’s it all about?

Dr Nathaniel Usoro: The group is a multi disciplinary group, made up of Professionals in different Medical Areas.  This multi disciplinary group is committed to advancing the science of the bloodless care and also the teaching of it. And by the bloodless Care we mean giving the patients quality medical care without the use of Allogeneic blood {blood from another individual, which is given during blood transfusion}.

      The aim is to improve the outcome of patient care and also to respect patient’s right. At this moment medical scientists, medical doctors and physicians all over the world is moving away from blood transfusion, because it came into medicine at the First and Second World War, it was never tried as a therapy before that time. But right now with evidence based medicine, there is a big question mark about the efficacy of Blood Transfusion, and also the safety of it is in doubt because it is not safe.

Now we know that blood transfusion doesn’t really do what we thought it did. Instead of it increasing tissue oxygenation, it rather cause tissue hypoxia {i.e reduce in supply of oxygen to tissues}.    And we came to discover that patients were better of when they used alternatives or substitutes of Blood Transfusion, even though these substitutes don’t contain Red Blood Cell {RBC}, they actually lead to improved oxygenation, by reducing the viscosity and improving the perfusion of the blood. So it has been found all over the world that there is reduced morbidity and Mortality when Blood Transfusion is avoided.

In Africa our centre in UCTH is the very first to have a bloodless program. There are so many in North America, in Europe; but in Africa, our centre is the very first. We have had training in bloodless centres in the US. Since we started practising with bloodless we have had Zero Mortality, our patients get home faster, wounds heal excellently and we always try to share the information we have by raising awareness like this one.
Dede Oputamuno Gilbert: But Sir in Class we are taught about blood transfusion, that before transfusion, the blood is tested to know the efficacy and compatibility of the blood; does it mean that this method is not effective or what?
Dr Nathaniel Usoro: What you are talking about is just the immunological aspect of Blood Transfusion. All that is done in blood banks all over the world is to check for ABO and Rh; however you need to know that Blood Transfusion is an organ transplant, and there is no organ transplant that is done with only ABO and Rh; that will be criminal, because there are so many antigens which are not tested for in blood transfusion, there are sophisticated laps that have to match Donor and Recipient, they do things like LHA antigens, and a battery of test which we don’t do locally and definitely no blood bank is able to do that.

      After all the LHA checks and the other battery of test on the transplanted organ (the blood), the blood could still be rejected by the recipients body. If you are taking blood as a liquid organ and transfusing it into another individual, with just ABO and Rh, do you think thats scientific?
Dede Oputamuno Gilbert: No Sir, because we have other antigens present too.
Dr Nathaniel Usoro: Exactly! And this accounts for the immunological issues associated with blood transfusion, which leads to Mortality and Morbidity in the transfused patients when compared with the non-transfused patients of the category.

Apart from the immunological issues we also have issues with storage lesions, because the blood used in blood transfusion were stored after collection, and this storage leads to deterioration, and within 24hours there would be no more platelets {for initiation of blood clotting, and this make patients to bleed when they are transfused}; within few hours there would be no Nitric Oxide needed to open up the capillaries, within 2weeks there would be no more 2,3 BPG needed to offload oxygen at the tissue level, and the cells become deformed physically {been swollen with spicules} therefore they block the blood capillary and this leads to hypoxia instead of improved tissue oxygenation.

      The National Institute of health challenged Medical Doctors all over the world in a consensus conference in 1988 to prove the benefits of blood transfusion, and virtually 30years later nobody has come out with the benefits of Blood Transfusion, instead news of harm has been reported.

There could also be transmission of infection during Blood Transfusion, because there are a host of viruses, parasites and prions; but only four test is done in the lab which is HIV, Hepatitis B, Hepatitis C and Syphilis; but the others are left untested, because most labs can’t afford that testing.

For all of these reasons and the fact that it is proven that patients who do not have blood transfusion do better, the World Health Organisation {WHO} and other respected bodies, societies of anaesthesiologists, society of surgeons and so on are trying to move away from Blood Transfusion to Bloodless Surgery.
Dede Oputamuno Gilbert: So Sir, what are the different steps taken in bloodless surgeries, and what is the principle used?

Dr Nathaniel Usoro: WHO has three pillars, but we have four. The pillars are:

  • Minimise blood loss, by doing simple manoeuvres. History of the patient is needed so you can know if the patient is having bleeding disorders; if the person is on anticoagulant or some other medications that prolongs bleeding, we need to be aware of it so we can stop it before surgery.
    In the surgery we have medications WHO have been promoting, like tranexamic acid (an anti fibrinolytic agent), it has been tested world wide and found to be very effective and so we use it. Vitamin K and others too are used. Positioning of patients, Diathermy and Topical Hemostat is also used to minimise blood loss.
  • Raise the hematocrit first, i.e you increase the haemoglobin level by administering Iron and adding other things like Vitamin C, Vitamin B12, Folic Acid e.t.c.
    Iron could be administered orally or by intravenous method. Erythropoietin too could be added.
  • Optimising Oxygen Tension, that’s increasing tissue oxygenation. In this pillar we give the patient oxygen, we don’t wait till the patient starts gasping. But we only give oxygen when the haemoglobin is either 6g/dl or less than that.
    We replace the lost blood. Blood is a colloid, so we replace the lost blood with another colloid; where there is bleeding, you replace the lost blood with crystalloids and colloids {although crystalloids are not used where there is so much bleeding, because they don’t have the thickness, but colloids are used instead because they have the tonicity} and this alternative is very cheap when compared to blood transfusion. And they are very effective, because when you put a pulse oxymeter you read 100 percent for our patients, but in the blood transfused patients it reads about 80 percent for them.We also make sure we remove pain in the patient, because pain leads to hypoxia too.
  • In the fourth step we try to lower our transfusion triggers. We try not to increase the haemoglobin count, if it is above 6g/dl, because it is not necessary and even WHO has recommended it too, even for those who believe in Blood Transfusion.

However for us we don’t have transfusion triggers, because the more sick the patient is, or the lower the haemoglobin level, the more important it is for us to avoid Blood Transfusion; because the patient is in a critical condition, and Blood Transfusion can lead to hypoxia, which can possibly lead to death.
That is why this discoveries were made in Critical Care Medicine, because their patients were in critical conditions, so they discovered that blood transfusion is bad, because their patients were transfused with blood, and their patients health deteriorated; but this wasn’t so for those who abstained from blood transfusion, because they did better. So they had to ask why? And they discovered the problems associated with blood transfusion, and so they discouraged blood transfusion, not only for those who refused Blood Transfusion from the onset, but also for all patients, just to improve the outcome of their health.
Dede Oputamuno Gilbert: Sir what if the person has lost a lot of blood, and you can’t just help the situation, don’t you think the best option would just be Blood Transfusion?
Dr Nathaniel Usoro: Transfusion is the best only if you want to cause hypoxia, morbidity and mortality; and that is not ethically correct for us as Medial Doctors because our job is to save lives.
What we are to do first is to first stop the bleeding, if the patient is still alive it means the patients haemoglobin is still compatible with life; so we make sure the patient doesn’t die, we replace the volume of blood lost by using colloids like Hetastarch, Isoplasm, gelofusine or hemacell. The Colloids are like blood in terms of tonicity. And these colloids improve tissue oxygenation, by reducing the viscosity of blood and increasing the perfusion of the blood.

You have stopped the bleeding, you have replaced the volume and the patient is still alive, don’t panic, don’t worry; all you have to do is to raise the patients haemoglobin level by giving iron, erythropoietin and the patient will be fine and sound. Just like the patient operated upon last week Thursday in UCTH, at the end of the surgery, the PCV {Pack Cell Volume} was 17, and the patient objected to Blood Transfusion, so he called us, and we came and gave intravenous iron and erythropoietin and the patient has been discharged with a PCV of 27, and that’s fine.
Dede Oputamuno Gilbert: Wow! I have really learnt a lot from you today, I am pleased that you granted us audience.
Dr Nathaniel Usoro: Me too, I am glad to associate with you and kampusareablog.
Dede Oputamuno Gilbert: Thank you sir, it’s my pleasure.

 

For more information about accucthturesessing the bloodless medicine and surgery programuctucthturesturesh.org

 

 

 

Pictures of The Novelty FOOTBALL MATCH BETWEEN FEMALE MEDICAL STUDENTS VS FEMALE NURSING STUDENTS

The game ended in a 2-0 win for the Female Medical Students Team.

Female Medical Students 2.   –   0 Female Nursing Team1

 

Female Nursing Team
Female Nursing Team
Female Medical Students Team
Female Medical Students Team
Both Teams and Organisers
Both Teams and Organisers
Cultural Display by Students of Department or Theatre and Media Arts
Cultural Display by Students of Department or Theatre and Media Arts
More beautiful display
More beautiful display

Bloodlesss medicine an surgery week UCTH nigeria

Vice President (Elect) CUMSA and some CUMSites
Vice President (Elect) CUMSA and some CUMSites

5 thoughts on “AN INTERVIEW ON BLOODLESS MEDICINE AND SURGERY PROGRAM UCTH, First of its kind in Africa.”

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  3. This is really educative. It marks a start-point to a new era of medicine and in fact a different dimension of surgery.

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