Appendix Cancer Symptoms

thank you so much for comingout on this hot, hot, hot day. >> [laugh]>> we do appreciate your support of our program. want to welcome you to the thirdannual education seminar for the center of bloodless medicine andsurgery at johns hopkins. and we really are happy to seeeveryone attending today and we have a great program linedup with terrific speakers. now along with an overview ofour bloodless program by dr. steven frank and progress andsuccesses with bloodless strategies

by dr. lynn legrasar,we're also privileged to have dr. stacey scheib who will discussminimally invasive gynecological surgery as well as a livedemonstration of a cell saver system by tim boyle, a consultant withthe hemomedics corporation. first up is dr.steven frank, and dr. steven frank is a professor ofanesthesiology and critical care in medicine at johns hopkinsuniversity school of medicine. his area of clinical expertiseis anesthesia for vascular, thoracic and transplant surgery.

he’s an expert in bloodconservation methods. dr. frank serves asa medical director for the bloodless medicine andsurgery program. he is also director of the interdisciplinaryblood management program and of peri-operative blood managementservices at johns hopkins hospital. and please welcome dr. steven frank. >> [applause]>> thank you andy, for that fine introduction andwelcome everybody.

i'm so glad that we can gettogether to have this seminar and for the first time ever, we're gonna try to do a livecell saver demonstration. so we do have three speakers andthen tim boyle will be the fourth speaker andhe'll do the demonstration. so this is our agenda today. i'll start out withan overview of our center. and then tim will come up anddo the cell saver demonstration. stacey scheib andlinda resar will follow,

like andy said withgynecologic surgery and recent advances in our field. so our primary goal as a center atjohns hopkins is to respect you and your family's wisheswhen it comes to avoiding transfusion andthe patient comes first. so we've been doing this forfour years now. so we know how to conserve blood andi'm gonna show you the ten different ways that we use toconserve blood so we can get patients through the hospitalwithout needing a transfusion.

and we also like to treat ourpatients as if they were family members, so we spend more time with the patientsthan the typical patient. cuz there's a lot to talk about whenit comes to honoring your wishes. this is our website and this isthe front page of the center for bloodless medicine andsurgery at johns hopkins. and note that there's a cellsaver on the front page of our website andhow does it work, it says. so we're gonna see how it works.

and i'll tell you what a cellsaver is in just a minute. these are the methods that we use of blood conservation toprovide bloodless care. so i'd like to say that the besttransfusion is no transfusion. the second best transfusionis to use your own blood for the transfusion becauseit belongs to you. and this is how weavoid transfusions. first of all,if you have anemia before surgery, we'd like to diagnose it andtreat it.

for example, $5 worth of iron pillscan avoid $500 worth of blood. so if we can simply treat youranemia before you come in to the hospital, sometimes weget intravenous iron for example or even the erythropoietinand linda will talk about that. good surgery, forexample laparoscopic and robotic surgery are new ways that we use to reduce bleeding,during surgery. and at first i thought roboticsurgery was just a marketing gimmick to be honest.

and then i looked at the bloodloss in robotic surgeries like prostate surgeries, andit was a fraction of the blood loss that we see withthe traditional open surgery. blood salvage or the cell saver has been called thecenterpiece of blood conservation. so, this is whatthe cell saver looks like. tim is gonna give you the wholehistory and the background behind, how it came onthe scene back in 1970. and this is really the way wecollect your blood you lose

during surgery andgive 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 conserveblood during the surgery. we minimized blood lost to lab test. we use special drugs like txa andamicar that can reduce bleeding. we use point of care testing andeducation like we're doing today. so this is our first big article that came out as a review.

linda resar is the first authorwho's gonna be one of our speakers today. and this is a reviewarticle explaining the 15 different thingsthat we do special. so our goal is to educatepeople around the world. that's doctors andnurses and patients. so these articlesare available on web and if you wanna learn more,you can read what we. this is a study that wepublished from our team in 2014,

so two years ago. showing how our patients dobetter than patients who accept transfusion because they getthis special kind of care. for example, if you look at heartattack, respiratory, renal, or thrombotic events, if you comparethe bloodless patients to the control patients, so that'severybody else in the hospital. so, the bloodless patients had lessinfections and less deaths, so lower mortality than the patients whotake transfusion probably because there's risk with transfusionthat comes from the bloodbank.

and we also showed a lower cost andcharges in the bloodless patients. about 12 to 14%decrease in costs and charges because blood coming fromthe blood bank is expensive. it's more expensive thanusing the cell saver. linda andi wrote another article in 2014 on bloodless medicine what todo when you can't transfuse. so our goal here is to educatedoctors around the world on how to provide this type of care. so these articles are available foranybody with web access.

and linda presented this at thelargest blood meeting in the world. the american society hematology, which had maybe 10,000 people,something more than that. okay, so linda had the honorpresenting our work at that meeting. this is an editorial that iwrote about the cell saver and who benefits from red cells salvage. i talked about when we should useit and who we should use it on and then our article got writtenup in the newspaper, both the new york times andthe washington post.

and we proved that recycled blood or cell saver blood was a higherquality than the stuff that comes from the blood bankbecause it's fresh, okay. and the stuff in the bloodbank's been sitting around for up to six weeks. so blood is like milk inthe grocery store, okay. it doesn't get betterwhen it sits around and you would rather use it freshlike 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 wasin the blood bank blood. so that means the cell-saverblood can deliver oxygen better. and i won't bore you withall the science here, but if you look at 2,3 dpg onthe left in the stored blood, in the light blue,that's banked blood. it was 95% depleted, but in the cellsaver blood, it was normal, okay? same as fresh blood. and so this got written upin the news media as well,

and they talked about reusing a patient's own blood which is exactlywhat the cell-saver does. we do everything we can to minimizeblood loss due to lab testing. so we found that just by sendinglabs on patients in the hospital, blood tests, that you can lose about 1% of yourblood every day just to lab test. and sowe started using these small tubes. you see the ones on the left? those are neonatal tubes, sowe can use those on adults too

to minimize the blood thatyou lose just for lab tests. and our next article to come outis called bloodless medicine and surgery: top 10 things to consider. so this comes out next month, this is a preview of the nextarticle that linda and i wrote. and these are the ten methodsthat we use, top ten things to consider when providingbloodless care. i just wanna tell you that wesuccessfully did a 13 pound baby for open heart surgery at johns hopkins,

that's really trickyto do without blood. because the amount of blood ina 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 howsmall the amount of blood that they canafford to lose would be. and i just want to show a fourminute video, if you will, and then we'll move on tothe cell saver demonstration. the video that we madecame out fabulously so.

give me one second. it's on the frontpage of our website if you want to showit to other people. and here it is. >> my neck felt likea bullfrog pumping. have you ever seen like a bullfrogin its throat, pumps like that? that's what my neck looked like. all that blood wasregurgitating up there. these flowers are coming out pretty,aren't they?

my name's tammy,live in christiansburg, virginia. all my family's formost part has been really healthy. and i didn't know i hadblood pressure problems. >> tammy presented to us with alarge aortic aneurysm that you could see pulsating in the base of herneck, right above her breastbone. and that's a ballooning ofthe artery in the chest. her blood pressure,when she presented, was 240 over 40. she had a leap in her aorticvalve in her heart, so the one way valve wasallowing two way blood flow.

>> and here i was like, this bloodpressure was like, really, how, why are you still alive? people couldn't believe you werestill alive with this blood pressure like that. we searched fora place to go for six months, we found that andy pippawas the coordinator for the bloodless surgery programthere at johns hopkins. >> tammy called us because shecouldn't find a doctor or a hospital that would operate on her withoutresorting to a blood transfusion.

>> i did not want to do thisno blood transfusion period, they said with sucha bloody surgery. but with my religion beinga jehovah's witness, i wasn't gonna take any blood but i also didn't want to die onthe operating table either. >> the fact that she took herstand for no blood transfusion and the courage that she showed,was inspiration to me. >> our bloodless programis designed to care for patients who wish to get therapy fortheir illnesses or

to undergo a surgery withoutreceiving transfused blood products. and so our rule as a bloodlessprogram is to care for these patients, to get them readyfor surgery when they need surgery, to keep their bloodat a healthy level. >> every time weavoid a transfusion, we avoid potentialcomplications like hepatitis. there's hiv, taco and trali which are complications fromblood transfusion that can be fatal. >> okay, sothis is a fresh blood sample.

>> so by avoiding unnecessarytransfusions we're actually saving lives. and i haven't met a patient yet thatwouldn't rather have their own blood back, as opposed to someone else'sblood coming from the blood bank. >> nobody plans togo to the hospital. it's really a scary place to be. the fact that i canmake a patient feel more at ease is key to theirhaving a good outcome. >> we had to be very carefulwith tammy because we wanted

to be sure that her level of blood,the strength of her blood, was at a safe level forher to get through the surgery. >> we did several thingsspecial in the operating room. first we did something calledanh where we bank the patient's own blood,right before the surgery begins. then we use a medication calledamicar that reduces bleeding during surgery. and third, we use a device called acell saver, which collects the blood that patients lose during surgery,cleans it, processes it, and then we

can give them back their own bloodbefore the end of the procedure. in tammy's case, without the cellsaver, i'm not sure we could have brought her throughthe surgery successfully. >> as our bloodless program hasgrown over the years, we've gained a lot of experience and expertisein caring for these patients. >> by providing care tojehovah's witness patients, for example, we're perfecting methods ofblood conservation that will benefit all patients. >> the compassionate nature ofthis team, everybody on it,

makes the patients feel special. >> i'm very grateful forjohns hopkins, for the bloodless surgery team. i made it. and i did it without their blood. >> we were so pleased withthe way the video came out. i had to show it, sorry,we love this video. [laugh] and with that, i'm gonnaintroduce tim boyle who drove here all the way from richmond, virginiaand brought the cell saver with him.

and so this is tim and tim's gonna talk aboutthe history of the cell saver. and then we'll do a demonstrationand 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 managementconsultants with haemonetics. and i just wanted to give youa little history of blood

conservation. where did we come from? why do we do what we do? back in the 1600s, a frenchphysician by the name of jean denys, performed transfusionsbetween animals and human. as you can expect,it didn't go well. and then in 1818, we havean english surgeon by the name of james blundell who actuallyreported studies of doing human-to-human transfusions, againthe results were not favorable.

one of the reasons is as we knowtoday, what is your blood type, if we give somebody the wrong typeof blood they're gonna have negative reactions. so this is why james reportedthe challenges that they had with the human-to-human transfusionsback in the early 1800s. and then we move forwardto the end of the century, with the first record andreport from dr. james highmore who advocated the utilization of doingsalvage blood return during surgery. in other words auto transfusion,getting their own blood back.

so then we come upto our century and we come to the vietnam war era. and an american military surgeon bythe name of dr klebanoff utilized an open heart pump to collectthe patient's blood, the soldier. collect that soldier's blood,anticoagulate it so we would not have coagulationoccur so we would process it. then he filtered it and then wereinfused blood during surgery. and then in the 70s, a company bythe name of bentley laboratories brought that deviceto the marketplace.

and then also, in concert withall of these steps, a dr. cohn and a dr. jack latham lookedat utilizing a centrifuge for separating blood componentsbecause of the need for albumin in the battlefield forour soldiers. and as you can see, in the slide, they literally got the ideafrom dairy process separation. so we can thank our whole milk andour cream and everything, >> [laugh] >> for autotransfusion.

then along comes dr.latham where he improved upon dr. cohn's stainless steel bowl andfor his cohn fractionator. he then developed it into a plasticbowl, which we still use today. we use the exact same bowl and thedevice that we have in front of you today that we usedback in the early 70s. i got into open heartsurgery running the pump, being the perfusionist. actually in the early days,the devices looked so different back then.

today, the device what we havein 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 andseparate the blood out, so you're actually gettingback whole red blood cells. in 1975, dr.latham in concert with other folks at haemonetics brought the veryfirst cell saver to the market. and then in 78 is when i got myhands on the for the very first

time, i literally used the veryfirst one that was developed. this is a pictorial representationof what the bowl looks like. and as you can see, in the centerhere is a capillary tube. so, the blood is coming from thesurgical field, the blood comes into the cell saver, andgoes down to this capillary tube. and hits this plate right herethat dr. latham invented. and we still holdthe 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'regoing down the highway. and then, consider if you hadjack'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 cellsare the heaviest part of our blood. so, as this bowl is spinning,the red blood cells are pushed out

against the outsidethe wall of the bowl. and then, all of the othercomponents of the blood, as you can see here,represented in yellow, will then be pushedout into a waste bag. and i'll get through the processa little bit deeper, but i wanted you to see exactly whatis going on inside the bowl. because when we do the processingand we do the live demo, you actually can't see that because thebowl sits down inside the device. so, what are the advantages of doingautotransfusion or cell saving?

you want to avoidtransfusion at all costs. our blood supply is the best and the safest it ever has been andanywhere in the world. but as dr. frank shared with you, you wanna get your own bloodback if at all possible. and the value to that is that you'renot gonna have an allergic reaction to it because it literallyis a transplant. and then, also, you have your highquality of fresh red blood cells. dr. frank shared with you 2,3-bpg,which i affectionately call

the key that releases that bondbetween hemoglobin and oxygen, so, you get tissue oxygenation. also, while blood is being stored. well, it's aging justlike we are all doing, sitting in this room right now. so, you will have a little bitof hemolysis that occurs even in the bag. getting your own blood back, you also reduce the chances ofhaving 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 onthe blood bank inventory. i'm sure we've all seen in the news,in the internet, newspapers, are requests for people of a certainblood type, to come in and donate blood cuz of a shortage. platelets, which come out ofthe blood and separated out, we've had a tremendous shortage of that inthe richmond area, that, as of late.

the other reason too for utilizing cell saving is forthe psychological benefits. i don't want, no offense, i don'twant anybody's blood in this room. you don't want mine either. and, so,you wanna get your own blood back. the indications fordoing cell saving is the patient, you don't wanna half of them. and with the jehovah's witnessfaith, definitely not. one of the things too is thatwhen with the hospital liaisons,

with the videos, you actuallysee 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 ona 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 yourblood lost in surgery, you definitely wanna have aconsideration for doing cell saving. also, if you're gonna be transfusingmore than one unit of blood,

you may wanna opt out of that andthen utilize the cell saver. also, if you wanna have surgery andit's a surgery where normally will have transfusions done,you definitely wanna do that. the other reasons too is becausepeople have had multiple transfusions or many, they literallydevelop 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 replacementdone 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 transfusionsfrom 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 seeon the display, cardiac surgery,

definitely. transplants, liver transplants, orthopedics, trauma,most definitely. and one of the thingsthat i hold near and dear to me is in pediatrics. one of the things that is uniquewith the pediatric community is for scoliosis repair. so, you think about all the thingsthat we do with blood and giving blood to getting a transfusionfrom someone else into your body,

you definitely don't wannastart that at an early age. so, it's great to keep childrenfrom having to have a transfusion. the next thing i wantedto share with you, and this is one of our older platforms. in fact, we just retiredmanufacturing of the cell saver 5 plus, which had been inmanufacturing for over 20 years. it is the cornerstoneof the industry. in fact, as dr.frank shared with you, and i have so far is that we inventedthe technology.

we're the industry leader inthe technology around the world. we manufacture around the world. and what we do is we collectthe blood from the surgical field. and then we do processing,and there's three steps. we're gonna fill the bowl thatyou saw the pictorial of. then, we're gonna express out or push out all the componentswe don't wanna have in there. and then, we're gonna wash thosered blood cells with saline. so, it's basicallya washing machine.

it's a rinse cycle ofa washing machine. and then, what we're gonna do isempty those healthy red blood cells in to a bag, and then,transfuse that to the patient. again, this is a picture ofthe 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 screenshould look right now. and what it allows usto do is to modify, change things as we're going alongso you get a better product back.

and what i'd like to do now isgo into the live demonstration. so, what we're gonna do isdemonstrate 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 liketo continue the slides as well. cuz you're gonna be watchingthe blood move from one location to another. but i just wanna share withyou 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] >> what happens is we, first of all, i should say, accepting cellsaver blood is a personal choice. there are somejehovah's witnesses that choose not to acceptcell saver blood.

>> so, we discuss the risk andthe benefits >> and then, we explain how it works, andthen, it's a personal choice. so, don't mistake us. we're not telling you have toaccept it, it's a personal choice. but if we use it, we can hookit up in a continuous circle. so, it's alwaysconnected to the patient. for example, this would beconnected to the cervical field to suction the bloodthat you're losing, okay?

and then, after it's processed, the blood will end upcoming through here. and this is connected to your iv,so, it's a continuous circuit. and because this isa saline-filled line, that will be soon filledwith 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 ora 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 nowis we're doing a representation of an actual surgical event. so, the blood comes into the reservoir and it's filtered by thisdark filter right here. it's a gross particle filters,so, we get large particles out. and now, what the machine is doingis 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 actuallysounds like a turbine spinning. that is the centrifuge in the centerof 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, andit'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 hereto this waste bags, where it stays nice and closed. and even though we have the blanketover here to protect this nice carpeting,feel very comfortable with that, we're not going to getblood on the carpet. so what, and this takes a littlebit 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 comeback over to my slides, and we'll discuss a few more things. so, as what dr. frank shared withyou is the collecting first. so, we have an anti-coagulantthat 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 anticoagulantkeeps the blood from clotting. it travels back up into thisreservoir, and then goes

into the device in the cell saver,just as we were demonstrating. so, what it's gonna do is it's gonnaseparate out this anticoagulant, and everything else that comesfrom the search of the field. so, the blood again, leaves thatreservoir, comes down through that capillary tube that i shared withyou earlier, and hits down on this plate right here, which is what madethis even a more effective tool. dr. latham had the greatidea of putting little turban-things down here. so, it actually separates it out.

again, acts like an agitator wehave in our washing machines. so, right now the bowl is spinning, the blood is filling allthe way up to the top. and once it does, it's pushing everythingelse 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 salinethat we add, the that table, or the surgeon and the nurses mayadd to wash up the surgical field. so, we're gonna get everything out.

and then what we do next, is you cansee the capillary tube now is blue. and you can see a bunch of numbersover here that are really more for a clinician to study, and understandhow much volume we're gonna use for washing. but what we're doing now iswe're bringing in saline, so we're now doing the rinse cycleas i shared with you earlier during the red cycle,with those healthy red blood cells. so, any red blood cells that wouldhave hemolyzed through this process, they're gonna be expressed out orpushed out.

so, what you're gonna get backis healthy red blood cells. and we use certainvolumes to make sure, and lead to the things presentedto the fda to make sure that you have the best product comingback to you, so that you're not having concerns about anycontaminants coming back to you, and you want to have your healthyred blood cells return to you. so, that third phasethat the machine will go into once it's done washingwill be the empty phase. so, we're going to take thosehealthy red blood cells, and

we're gonna send those upto 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% cleanedof any of the contaminants and hematocrit, orthe amount of that volume, a known volume isgonna be roughly 50%.

it'll vary depending upon ofthe 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 wantto take a look and look down in, and see how the device is working,and i can also answer any questions you mayhave with regards to cell saving. >> how much longer do you thinkit has to process [inaudible]? >> at least another six minutes.

>> okay. >> [inaudible]>> we can entertain questions, or come up and check it out andexplain it. >> [inaudible]>> yes, this is the bowl in size, and you can see this infrared light. what we're doing is we're sendinga red light across the field, and whole red blood cellsabsorb that light, and different rates that doesplasma free hemoglobin. so, once it hits that level,

it knows to switch fromthe fill mode to the wash mode. and as you can see now, the machineis 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 toset 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 washingmachine and into the basket, and your husband forgetswhere the clothes line is. >> [laugh]>> okay, so right now, and

since we have insufficientvolume in here, it's actually gonnacontinue the process. so, this continues goingon as long as your device, as long as in the reservoir, and itwill turn to you, the patient, okay? your blood during this procedure? there's the blood bank, what we do, let's say idonated blood today, okay? the blood in the blood bag is not,okay. >> so there was a questionabout the word banked.

so, the cell saverblood is never banked. so, it's not putinto the blood bank. it stays in the operating roomconnected to the patient. so, it's really partof your circulation, because it's connected to yourvascular system with the ivs. so, banked is a term we use for the blood that comesfrom the blood bank. which is we don't getthat 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 bloodthat 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 senseto put your fresh blood that you lose in the trash, we'd ratherrecover it and give it back to you. >> can you talk moreabout the priming?

>> the priming, sure. >> sure. >> so, one thing we like to do isto prime the system with saline. those are the clearer fluidbags 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 primethe system with saline and that way that also provides a continuouscirculation with your body, because you have air between you andthe cell saver.

it's a safety issue anda continuity issue. >> thank you. >> tim, it worked>> [laugh] >> we've never done this outside of the operating room, sowe 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 seehanding from the pole. >> right. >> and then we can run thatstraight into the patient's iv, and basically recover allthe red cells that you lose. so, this technique has saved twolives that i know of in the last three years at johns hopkins,in jehovah's witness patients. so, when we tell patientsthe 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 abouta teaspoon of blood, okay? we're not gonna recommendthe cell saver, okay? so, don't take home the messagethat you always need this machine, because i can name 15 kindsof surgery right now where the blood loss is minimal, okay? and if you come in andask for the cell saver, they're gonna tell you that it'snot necessary, because we've ranked all the surgeries on a scale for theamount of blood loss that occurs. and so the prostate surgerieswe 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 standbyas a back-up maneuver, okay. for example, our next speaker,stacey scheib, is gonna tell you aboutgynecologic surgery. and hi, stacey. and sometimes with her cases,for example,

we use a cell saverin a back-up mode. because she doesn't lose hardlyany blood for some of the ovary or hysterectomy surgeries. so we'll have the cell saver around, right in the room oroutside the room, ready to use. so i'm going to introduce stacey, who's one of ourfavorite gyn doctors. and we refer her a lot of patients, and we're privileged tohave her speak today.

welcome, stacey. >> [applause]>> hi, everyone. >> one more question? >> sure.>> is that okay? >> you might have tospeak 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 maybe50 ccs of blood, okay. that's 1% of allthe blood in your body. but if you have a five level fusion,okay, that's a large spine surgery, and you could lose half ofyour blood volume, okay. so then we definitely wantto 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 forbeing invited to speak. i think we've done a lot of goodwork over the past few years collaborating together to reallypush forward bloodless gyn surgery. there is a huge role for it here. i've worked a lot with jehovah'switnesses during my time in philadelphia. there's a huge jehovah's witnesspopulation up there. and so i have to reallyembraced it and, i think,

especially with what i do, i'ma minimally invasive gynecologist. it's a great pairing together. actually, one of thosetwo 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 andis doing remarkably well, considering what happened. so we're gonna talk about bloodlessgynecologic 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 thatwomen 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 hasfibroids and that side does not. that is the difference,70% of all women have fibroids. and 80% of black females havefibroids at some point during their

lifetime. so that is probably the biggestthing that i've seen. this can present as heavy bleeding,but not all the time, which is why this is a particularcomplement to bloodless medicine. the others you canhave are bulk symptoms, pressure on your bladder,chronic pain, pain with sex, increase in abdominal girth,urinary frequency urgency. you may have symptomsof either diarrhea or constipation if the fibroidsare particularly large.

adenomyosis is a conditionof the uterus where the cells in the lining growinto the muscle layer and can present very heavy bleeding orpainful periods. endometriosis is also very common. most of the time that'sasymptomatic, but it can present as infertility oras chronic pelvic pain. this is sort of a hot topic,but pelvic pain, in general, we use minimally invasive surgeryto evaluate more and to correct. ovarian cysts, there are a numberof different reasons why

people get cysts on their ovaries,but that's another reason. those menstrualabnormalities that we don't put into the whole common thingslike fibroids or adenomyosis. we use surgery commonlyto evaluate for infertility that we can't seemto find other reasons for. and also for urinary incontinence orpelvic organ prolapse. these are probably the mostcommon surgeries that i deal with in terms ofthose 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 ovarywhich is what an oophorectomy is. salpingostomy or salpingectomy is surgeryregarding the fallopian tubes. scar tissue or lysis of adhesions,excision of endrometriosis and pelvic reconstruction. so the big question i always getasked is why bother with a minimally invasive approach?

okay, why see a specialist thatdoes minimally invasive surgery? it's not uncommon for me to see a patient who's physiciansaid you're not a candidate. i'm like, but you actually mightbe if you went to an expert, and there are very big pros andcons. and in this particularpatient population that we're trying to avoid blood, this is all the more important foryou to see a specialist that does minimally invasive surgery becausethere's some huge benefits.

the biggest one is activity. of course, we get to go back to ournormal activities pretty quickly. most of my patients actually gohome the same day from surgery. even from a hysterectomy, which is amazing consideringwhere things were when i trained. and they can do stairs,they can walk, they eat whatever theywant that same day. that's pretty amazing. and because of that,

we're actually decreasing the riskof postoperative complications. things like a clot to your leg ora clot to your lungs. or a pneumonia or atelectasis, which are respiratory complicationsinitially after surgery. postoperative pain. clearly, if we're goingthrough 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 ofthat is guess what? you don't need asmuch pain medication. and in this day in age we're hearingall around the news about narcotic abuse andwhat do we do with the drug issues. this is an added benefit of usbeing able to move forward is that we're having to use a lotless pain medication. and this is the biggestone 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, wetend 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 minimallyinvasively, we want to do it. with specific procedures,specifically with myomectomy, we've sometimes also seenless febrile morbidities and spike of fevers for unknown reasons. which can affect your blood work andevaluation because we're trying to figure out the etiologyof why you're having fevers.

this one is another big one,especially for the fibroid group and theendometriosis group as well, is that we have less scar tissue when wecan do things minimally invasively. what that means is scar tissue pullsthings where they're not supposed to be, and that can be a bad thing. so if it's affectingyour fallopian tubes, that can cause infertility if youget scar tissue after a surgery. and sowe know from a lot of studies. they did this great study initaly where they went back and

looked after peoplehad open surgery and people who had laparoscopicsurgery in the past. and they clearly saw if youhad laparoscopic surgery, you had a much lower chanceof getting scar tissue. and that's important, too, alsobecause of the downstream effects. if you have scar tissuein your pelvis, too, because it pulls things whereit's not supposed to be. if you have any subsequent surgery,it can increase the risk of having other injuries orhaving 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 cuzi deal with a lot of fibroids. and a lot of women who are trying toget 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 withthe bloodless medicine group? our goal is for you guys.

we want to havepatient tailored care. we want to honor your wishes inthe best way that we can, okay? we want to increase the chances ofminimally invasive surgery for you, for all the reasonsi just talked about. and the last one is, we want tomake it work in a way that we keep you safe at all times, and minimizerisk to you as much as we can. and that really comesfrom a team approach. that we are talking together,that we work together. and when you have a team thatconsistently works over and

over together,things work better, okay. we have better outcomes. we know that throughall different fields. if we look at all fields, airlineindustry, look at surgery outcomes, when we have set teamsthat are dedicated and work together things work better. this is what i tell my residentsall the time and my fellows. an ounce of prevention[laugh] goes a long way. and that's where the team approachreally works is that we know what's

potentially coming. i'm gonna put all those things inplace to try to prevent bad things from happening. so the most common reason that i mayneed to involve bloodless medicine, most commonly is because i havea patient who is anemic and is also jehovah's witness, or doesn't acceptblood products for other reasons. and now they're bleeding from theirvagina because of their fibroids or because of their adenomyosis,or a polyp or whatnot. and so what we need to do isget them to a better place.

it's always better to do somepreventative measures before we ever even get to the operating room. so maybe i won't even need to evenconsider this machine at all, okay? so the analogy i was usingwith my residents is it's like a leaky bucket. i need to plug the holes, okay, otherwise i'm never gonnafill that bucket back up. i can give you allthe erythropoietin, all the iron, all folate, it doesn't matter ifi don't stop your bleeding, okay?

and so because ideally, inpreparation for surgery, i want us to get to a point where bloodcount 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 fora little while, so that i can plug that bucket, okay,and allow things to come back up. or i might need to do a uterineartery embolization to try to secure that blood supplya little bit more to optimize our chances of not needinga blood transfusion or

eating orany other interventions, okay? so these were things that we do. also one thing i didn't put onthere, i realized in carrie's talk, i said, sometimes if they wantto auto donate, i say okay. let's auto donate, but then i maydelay your surgery for a little bit longer so that i can get yourblood count to a better spot so that we are as tip-topposition as possible. i like my little ducks in a row. i don't like surprises, andi don't wanna surprise for

my patients either, okay. and i'm very adamant with mypatients and i'm very forthright, because the bottom lineis i wanna keep you safe. i'm gonna give you some examples ofsome of the cases that we've done over the years. this is case 1, she wasa 54-year-old who had had one child in the past,long-standing history of fibroids. she had heavy bleeding, pelvicpressure, fullness, low back pain, and leg pain.

she was done with having kids,so she was ready for definitive treatmentwith a hysterectomy. she already has a history of anemia, which is clear becauseher blood count is low. she had attempted to do moreconservative management in the past with a uterine arteryembolization to treat her fibroids, but it had failed,which is not uncommon. about 30% of women who have hadan embolization need some other intervention within five years.

and we knew she had a biguterus walking in to this, so what this means, she hasa 20-week sized fibroid uterus. so that uterus is somewherebetween her belly button and the bottom of her rib cage. so it is going up into her upperabdomen and she is, we'd call that someone who's probably six orseven months pregnant. that's a big uterus,not very comfortable. so we discussed it in ourfibroid conference, and we review all our images withthe interventional radiologist to

see what options are on the table. we ultimately came to wethought the best option for her would be to do a laparoscopichysterectomy, okay. but to do a uterine arteryembolization prior to the hysterectomy to try to get thatblood supply under control a little bit better prior to us goingto the operating room. i also postponed her surgery forthree months in order to get her blood count back upto a normal range. cuz i gave her a medicationcalled aygestin, which is

a progesterone hormone, to try tosuppress her period temporarily, and stop her period, and i alsogave 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 actuallyhad a very successful hysterectomy. to give you a senseof 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 normalactivities within three weeks. another case that we did,

this is a 42-year-old with an acuteepisode of vaginal bleeding. she really didn't wanta hysterectomy though. she was not ready, even though she had completedhaving all of her children. and when i examined her,her cervix was dilated and we had a big fibroid sort ofpopping 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 difficultfibroid to tackle because they usually have a big blood supplyfrom the main blood vessel, or the uterine artery, to the uterus. and so they tend to havea much higher blood loss rate. cuz we can't give othermedications that we normally do during a myomectomy to try toget that uterus to contract down or get it to slow down on the bleedingcuz it doesn't really work. those medicines don'twork with the cervix. and sowe also get a combined uae, but

i did myomectomy throughthe vagina this time. and she went home the same day, lostmaybe 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, andshe really, really wanted to have children but she had a really,really large fibroid uterus. and she really wanted someone totry 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 hysterectomybecause she was a jehovah's witness. but she was passing clots with herperiod, constipation, bloating, pain with sex. and it was to the point that shecouldn't have sex with her husband, okay. so unfortunately for someone whowants to keep their fertility, we only have twooptions on the table. one, go get pregnant, which clearly she can't do cuzshe's not having sex cuz it hurts.

or two, we need to proceedwith a myomectomy. so her uterus went allthe way up to her rib cage, all the way to her liver,so it's all the way up here like she was pregnant, sowe did something unusual. so we did a uae as well, but we usedsomething that dissolves quickly, so something called gel foam, so that wouldn't compromiseher fertility long term. and i did do an open myomectomy,which i don't usually do. but because of this i reallywanted to lay hands on it so

i could keep her uteruslike i promised her. and i put a tourniquet around it,sort of like when you give blood. they put a little rubberband around your arm. so we did a similar thing onthe blood vessels to her uterus, and we got out 3,200grams of fibroid. and she still hasa normal uterus now, and is getting ready to get pregnant. so the last case,which i should have included, was the one patient that reallydid need this machine right here.

is with a patient i did doan open myomectomy on, and she came all the wayfrom texas to see me. she had had two priormyomectomies already, so two other surgeriesto remove her fibroids. that makes the surgeryvery difficult. like i said,if you've had a myomectomy, that is a surgery notorious forcausing scar tissue. and scar tissue is bad, causes things to go wherethey're not supposed to be.

so her bowels were attachedto her uterus, and her uterus was attached tothe main vessels to her leg. so when we tried to dissect it out,and i ended up having another surgeon to come assist me becauseof the complexity of the case. we ended up getting intothe 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 andget her uterus out. and she felt great the next day, and

she went home twodays after surgery. and is doing great in texas, and is looking forward toone day having children. so our goals here at hopkins are toreally tailor our care to what your goals are. i don't wanna dictate toyou what you should have. i'll give my recommendations, butit'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 havethe first question. >> [laugh] what are some of thefactors that determine whether or not somebody's a candidate forthe minimum invasive surgery? >> well, take for example,our fibroid cases. i evaluate them with a cadreof my colleagues and with the interventionalradiologists. and we review every mri of all ofour patients to determine are they

a candidate forminimally invasive surgery or not? and there's different levelsof comfort level too, even within my colleagues. and we'll say are youcomfortable with this? if not, they'll pass it on to me cuz usuallyi'll take on more complex ones. but we try to fit that as best aswe can to offer someone a minimally invasive, okay,within the group, okay? and then if not, then we are veryfrank with the patient about

what we can and cannot do. i'm always willing to try. i usually tell them that theremight be a risk of conversion. the risk of conversion in ourdepartment, our division, is somewhere between around 2%, so it's actually low ifwe 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'sa prolapse of the uterus, do you have to remove the uterus, or can you do other things thatwill be lost, or remove, and/or remove the, ovaries? >> okay, so let me just repeat thequestion, make sure i understand. so do i always have to takethe uterus out if there's prolapse?

that was the first question. not all the time, okay? it's dependent on the severityof the situation and how big your uterus is, and whetherwe think it's a contributing factor. we will probably counselyou about the risk and benefits of leavingthe cervix versus taking it. because sometimes, if we leave itin, it's particularly large, and we think it's contributing tothe prolapse, you're at risk for recurrence.

and the best surgery for prolapseis usually the first surgery, so we try to weigh those things. of course, you ultimately will makethat decision of what risk factors you're willing to accept. the second question was do wealways have to take ovaries? so part of that is dependenton whether someone is menopausal already or not, okay? so if someone is not menopausal,and they look normal, and there's nothing about the imagingthat is concerning, then absolutely,

i'm wholeheartedly foryou keeping your ovaries. let your body make those hormones. there's no reason necessaryto take them, okay? if you're post-menopausal, okay? that means you've alreadygone through menopause, you're no longer havinga period anymore, then they just become risks to you,typically, okay? because there's no added benefit. your ovaries are no longer makingany hormones that will provide you

with benefit. they're only providing you risk. risk of ovarian cancer or cysts orpain or along those lines. and so, typically ifsomeone 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 ofinsurance you have factor into being able tocome to the bloodless unit?

>> i have not had a problem withinsurance 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 withsomeone who has medicaid and they're from out of state, okay?

those are the challenging patients,okay? everything else that we doseems to work out just fine. so that's the short answer, andandy may know more about insurance than i do, but even in those cases,we found a way around it. because we have some specialstrings we can pull to get it done. i have a question forstacy, so, historically, doctors compare tumors tofruit in the grocery store. so is a 3,200 gram tumor, is thatlike a cantaloupe or a watermelon? >> that is a watermelon.

[laugh]>> i'm serious. >> it's a watermelon. >> when someone hasan apricot-size tumor, that's how we describe it, so. >> we like fruit in medicine. >> yeah, [laugh]. >> [laugh] we compareeverything to some food. [laugh] any other questions? >> i do have a question.

if a woman is about threemonths pregnant, and she have tumors or fibroids, would that cause anyrisk in her pregnancy? >> they can, it is dependenton the location of those fibroids, andthe size of those fibroids. if you're alreadythree months pregnant, you already know wherethe placenta is already implanted. as long as it's not overlyinga fibroid, one of those fibroids, it's usually okay.

sometimes if it overlies one ofthe thyroids, it can compromise the blood supply to the fetusduring course of a pregnancy, which can cause some birthrestrictions sometimes, okay? depending on how much theygrow during during pregnancy, it can affect the riskof pre-term labor, that means you gointo labor too soon. that the baby is mispositioned, so that you may needa caesarean delivery. or that it obstructs labor, so

blocks the opening toget to the vagina. okay, so there are some things thatit can affect during pregnancy. at the time, if you need a cesareandelivery, if they're located in the areas that we need to dothe c-section on the uterus, that it can increase the risk ofbleeding during your c-section and the need for other interventions,and potentially a hysterectomy. but usually, you will have someinkling of that, cuz they'll monitor them during pregnancy andtalk to you about those, yes? >> how do you handle patients whohave medicare, but no gap insurance?

>> medicare, but no gap insurance. i think on a case-by-case basis, we have people in our departmentthat work with patients to figure that stuff out, andit's usually not the doctors. so i wish i could giveyou better answer, but we have ways to work it out. now i think we're gonnatake 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'lltake 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 questionsregarding her insurance. >> that's right. you just joinedthe radiology department. >> [laugh]>> as an insurance expert, right? okay, how about we can haveyou answer after the break?

after the break, cuz i promised timwe would take down the cell saver. >> i can answer a questionduring the break. >> during the break, okay. thank you, stacy. >> [applause]>> linda, welcome, and we'll getfinished on time, i'm sure. thank you, everybody. >> well, first, i wanna thanksteve and our bloodless group and all of you for coming today.

it's really a pleasureto be here and to speak at this meeting every year. and it's especially fun, because weget to see our patients when they're in the hospital, when they're sick, when they're coming to our clinicbecause they have a medical problem, so it's really fun tojust see everyone. one where they're well,and we're having fun and talking about what we do. and so as steve mentioned, our realgoal is to make sure that your blood

is at a safe level, andmake sure that you're healthy. and so in doing that, we come upwith a number of protocols and we have some exciting plans for thefuture to make things even better. and another thing that i'm gonnashare with you in my talk today is how we teach other doctorshow to take care of you. and while we would love to take careof every bloodless patient there is, that's not always possible. so another very important goal ofour program is to educate other doctors and nurses about how to takecare of our bloodless patients.

so as you heard earlier,the general principles of our care are first to diagnose andtreat anemia and in doing. so we can get you safelythrough surgery or through your medical illness andkeep your blood at a safe level. and also as you've heard about, another major goal of our programis to minimize blood loss. so i think dr.frank mentioned this but your average patient who's inan intensive care unit just from getting blood tests alone a patientlosses 1% of their blood volume.

so you can imagine tendays in a hospital, you can loss 10% ofyour blood volume. so, we're really careful. we make sure that all of ourpatients are getting their blood drawn with pediatric tubes,teeny, tiny tubes, so that you don't have to loseit just for a blood test. and the other thing we do is we makesure 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 tothe care of our patients. so we take extra care and caution tomake sure that when we need to draw blood, we're taking the leastamount that's necessary. and that every test is necessary,that we're drawing from your body. another thing that we do is diagnoseand treat bleeding disorders. many of us take aspirin soif you took an aspirin a week ago, your platelets are stillaffected by that aspirin. platelets take about ten days tocirculate within our bodies, so even having taken an aspirin a weekago affects your bleeding risk.

so we try to find out what ourpatients are taking, if they are going to surgery we counselthem to stop those kinds of agents. and if they go throughan emergency surgery, it's good to know what's in their system, becausewhat could cause excess bleeding. and something i don't havetime to talk about is, we also think about otherparts of your blood. i mean, we talked mostly aboutblood strength and anemia today, but we also look at plateletswhich are the part of our blood that helpsour bodies clot.

and we've had a number of bloodlessgw patients with low platelets, and we find a way to treat thatwithout giving new transfusions. so what is anemia? just so we're all on the same pageand i apologize to those of you who can pronounce greekwords better than me. but anemia actually comesfrom the greek word an-haima, which means without blood. so when somebody has anemia, theyhave generally a decreased number of red cells anddecreased amount of hemoglobin.

and hemoglobin is the protein in ourblood that makes our blood red and it's primary job is to carryoxygen to our tissues, so very important job. and this is what it looks like. when i look at your bloodunder the microscope, so if you are a patient with and you'regoing 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 microscopeand you can see on the left, you see lots of these littledoughnut-shaped red cells.

that's what it should look like. if you're anemic you have fewer redcells 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 lotsof little red cells. they look like doughnuts, and like a good doughnut, you don'twant it to have a big center. only about a center third ofthe whole diameter of the red cell should be pale.

and then on the right you canbarely see those red cells. in fact we call those ghost cells. and for patients who havesevere iron deficiency anemia, their red cells are small. they have fewer red cells andthey have less hemoglobin so they look like a ghost and you canalso see some of them are misshapen. they're shaped like hotdogs orteardrops and that's characteristicof iron deficiency. so we look at your bloodunder the microscope,

it helps us tell whyyou have the low blood. and then, how does one determinewhether you really have anemia? so we use two measures generally, they are usually a teamby a simple blood count, which i'm sure everybody inthe room has had at some point. it's called a complete blood count,a cbc, and in doing that wecalculate the hematocrit. and that's actually, as youheard in the really interesting talk about the cell saver,the red cells are fairly heavy.

so if you put them in a tubelike a straw and you spin them, the heavy cells go to the bottom,and the percentage that are redblood cells is your hematocrit. and i'll show you a littlediagram of that to help you conceptualize that. we can also use a coulter countermachine to measure how much hemoglobin is there. and so those are the two numbers welook at to determine whether you have anemia, okay?

and so here you can see is a pictureof somebody's hand with anemia. they're pale and sometimeswhen one has iron deficiency, you can actually getflattening of the nail beds. we call it spooling. and if you see onthe left that tube, that's one way tomeasure the hematocrit. you take the blood,you put it into a tiny tube. you up the end andyou 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 measureof 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 aroundsince the beginning of time. here's a beautiful paintingof 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 ourbloodless 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 twopicture, i think most of us will be able to pick out which of theseadorable little children has anemia. it turns out it a little boy and ifyou'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 childwho does not have anemia and

it's her brother who has anemia. and he's one of our bloodlesspatients because he's very severely alloimmunized, hehas sickle cell and he cannot accept transfused blood. so when he comes in,we have to treat him very carefully, we use pediatric tubes andwe try to do everything we can for his body to maintain hislevel 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'mshowing the picture of the doughnut shaped cells,the little sacks of hemoglobin, and they actually go to our lungswhere they pick up oxygen. and then the basic job of theselittle sacks of hemoglobin is to deliver the oxygen to ourvital organs like our brain, our heart, our muscles. so it's really an essentiallife function. we need our red cells to deliveroxygen to our tissues and organs,

and our organs andtissues need that to function. so when we are evaluatinga patient with anemia, what kinds of things do we look at? i showed you we'll look at the bloodsmear, we'll measure the hematocrit. one of the most common causes foranemia, around the word, in fact, is iron deficiency. so that's usually one of the testswe check on our patients. in older folks who are ofeastern european ethnicity, b12 deficiency is pretty common.

folate deficiency is common inparts of the world like africa or in women who havea hemolytic anemia, like the little boy i showed you,he has sickle cell. patients who have red cells that areturning over faster are at risk for folate, so we will check forthose nutritional deficiencies. many of our patients,especially elderly patients, can have renal dysfunction orrenal insufficiency, and as i'll share with you later, thekidney is a really important organ. it makes a hormone callederythropoietin and

that hormone tells yourbody to make blood. so if somebody's kidneyis not working properly, they often will have low levels ofthis hormone, and so they need more. so we determine whether theyhave renal insufficiency. another common cause for anemia in our patients isanemia chronic disease. so things like rheumatoid arthritis,diabetes, obesity, lung disease, these alonecan actually cause anemia. they cause underline inflammation,which interferes with your body's

ability to use iron andmake new red blood cells. so it's important for us to figure out why you haveanemia so we know how to manage it. for some patients, we look for hemoglobinopathy like sickle cellin that little boy i showed you. and also we're very careful toask our patients about bleeding diathesis. do you have bad nose bleeds? for women, do you have fibrous?

do you have heavymenstrual bleeding? we wanna know if this occurs andwhy it occurs? so that if you're goingthrough surgery or if you're just managinga medical illness. we can better hope you build upyour blood if we know why the low blood has occurred,why the anemia has occurred? so how do we treat itonce we diagnose it? as i mentioned, iron, globally, worldwide is the mostcommon cause of anemia.

and in order foryour bodies to make hemoglobin and red cells, you need iron. so we a supplement. and for those of you old enoughto remember popeye, i think, we all learned that spinachis 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 gonnaget 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 healthconscious, a lot of people are cutting back on red meat, sosometimes you just can not get enough from diet, and in that casewe will often go to supplementing. and the easiest way to supplementfor somebody who's at home and just has a low level ofanemia is with iron pills and i'm showing you a picture there. sometimes iron is noteasy to tolerate. for some of us, it can causea little bit of constipation or

indigestion. sometimes you just have a reallysignificant deficiency and we need to fix it fast. you need to haveyour surgery soon or you just really can'ttolerate the iron. so in that case we do iv iron andwe've been changing and improving our protocolsover the years. there are newer iron dextranpreparations which are very good sources of iron forour patients who are outpatients.

we can give them up to 1,000milligrams in a single visit, so that's wonderful for patients whoare traveling far to our center. you can come in for a single doseand just restore your iron stores. for inpatients, we usesomething called iron sucrose. it's a slightly lower dose but it's available through our hospitalpharmacy and that enables us to give you little doses every dayyou're in the hospital. so, we're constantly looking forthe best and the safest iron preparations and ourpractice has changed over the year.

a few of those iron preparationson the list we used before, and more recently we're using theones that i circled there for you. and then what else canwe do to treat anemia? i think some of you are probablyfamiliar with lance armstrong and some of you have been reading aboutthe various blood doping practices of some of the athletes who havebeen banned from the olympics. so epo is a drug that has been usedby athletes, in particular cyclists, because it's the hormone thatour bodies normally make. our kidneys in fact is what makesepo and they sense low oxygen.

so when you have low blood, you havelow oxygen, the kidney's say uh-oh, we need to make more blood. so the kidney makes erythropoietinand that goes to our bone marrow and tells us to make more blood. athletes who used it wouldgive themselves extra epo. in people who have renal disease,we will supplement with epo. and what epo does is, as imentioned, it's made in the kidneys, it goes to the bone marrow, and it tells your bone marrowto make more blood cells.

let's just take a lookat what they looks like. so this is actually a pictureof a bone marrow from a patient. and those big blue cellswith the big purple centers, those are young blood cells. and those are the cellson which epo is acting. epo is coming up to those cells andsaying make more blood cells. and then eventually you getthe donut shaped red cells that are carrying hemoglobin andoxygen throughout our body. so how do we do that forour patients?

there are a number ofpreparations that we use. we give typically to ouroutpatients about 20,000 or 30,000 international units. we like to work with you. we wanna personalize your care sothat you're getting the best care and it's the most convenient foryour life. you've heard we treat patientsfrom more all over the country, even all over the world. so if you're living in virginia andyou need to build up your blood,

we can contact your primarycare provider and say well, let's have you come in once a week,twice a week, get epo, which can usually be given in aprimary care office subcutaneously. and then we'll alsosupplement you with iron and make sure your blood is at a safelevel, so that when you come in for your surgery, you're ata very safe and normal level. for our patients who are ondialysis, we like to give iv epo, you're already getting iv access fordialysis, so iv is great. you can get the medicineright into your vein.

it's the fastest acting andit's a very safe approach. there are other epo preps thatare sort of slow release preps and in some cases we use that, too. and one of those preparationsis called darbepoietin. so when we started, we actuallyrelied very heavily on a study that was published out of philadelphia onhow to manage bloodless patients. but since then we've reallyadvanced that practice and i just drew a circle around a numberof the papers that have come out of 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 contactandy, we can make sure you get those papers and that abstractsare 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 andi'm the hematologist. we manage anemia with iron,as i mentioned, sometimes epo.

and we also come up with a targethemoglobin with our surgeons like stacy. what is the best numberthat you feel comfortable that we can get this patientthrough the surgery safely? it used to be patients' surgeonswere afraid if a patient doesn't accept blood, i just can't do it. and now, that we've built a team andwe have lots of approaches to help our patients, many of our surgeonsare very comfortable with it. and they're getting morecomfortable with lower levels,

which is good for all of us. because having too much hemoglobinhas 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 builton this initial experience and i think have improvedit considerably. so, how are we doing? for those of you who were herelast year, i showed this slide. you can see that between 2013 and2015,

we prepared a number ofoutpatients for surgery. and they were coming inwith low hemoglobins and our treatments were very effective. how are we doing this year? even better. we have this really low p-valuewhich basically tells us the difference betweenthe starting hemoglobin and the subsequent hemoglobin. and this is actually notthe full number of patients, but

we've had many, many patientswho are getting to surgeries. and you can see the hemoglobinsare in the normal range when our patients are going to surgery. and the other thing that's kind ofinteresting, the actual hemoglobin level is slightly lower when weinclude all the recent patients. and i think that reflects the ideathat because we have this very supportive helpful team, our surgeons are feeling much morecomfortable with our patients. and so, it used to becardiac surgery patients,

the surgeon would like hemoglobinsthat were super normal. now that we've had many patientssafely get through procedures, and they know there'sa team to support them for anemia, they're feeling morecomfortable 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 ofone of our patients, she actually has uterine fibroids andi think she'll be seeing you soon. she had anemia and like many of us,

she was a very conscientiousemployee, she wanted to take care of her anemia, butshe didn't wanna miss work. so we actually treated her between7:30 and 8:30 in the morning. she came in and got iron infusions,started out quite anemic, 5.9 and i believe i told youearlier the normal value for women is about 11 or12, so really low. came in early in the morning,got iron infusions, and before not too long shewas completely normal. so, we really try to work withyou in terms of treatment.

is it better for you to get the ironand epo with your local doctor? should you come here? what time of the daycan we treat you? we really wanna make thisan optimal experience, we wanna help you get better andwe want it to fit in with your life. in response to actually thisrequest from patients in meetings in the past, people askedwell what happens if iron and epo aren't an option? what if i'm in an accident?

what if there's a trauma andi need blood fast? well there are actually hemoglobinsubstitutes and we've been able to work with the companies andget protocols to our institutions. so we now actually have two ofthese products available for our patients at all times. one of them is called sanguinate andit's a cow, a bovine hemoglobin. and it's specially processed, it's called pegylated whichmeans it's coated in sugar so that it can last fora longer period time in your body.

if we we're just to give youthe naked cow hemoglobin, it would actually be destroyedby enzymes that are normally circulating in your body. so by coating it with sugar,it last longer. and we have this now availableall the time for our patients. we try not to use it becauseit's not as effective as your won hemoglobin, but we'revery pleased that it's available. we also have anothersubstance 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 shownhere to enhance it's stability. and if you look at itin the blood stream, it's much smaller than a red cell. a red cell has a large numberof hemoglobin molecules, these are just tinyisolated molecules but they function in carryingoxygen to your vital organs. so, over the next couple years, whatwe're hoping to do is to determine

which of these is most effective andsafest. and to come with protocols so that we can see if we givethis to should you need it. another area where ourprogram has really grown and where we have some really niceoutcomes is in cancer therapy. probably everybody knows somebodywho's had cancer chemotherapy. oftentimes you lose your hair andthe reason for that is most of the drugsthat we have available to us, they target cells thatare rapidly growing and dividing.

cancer cells tend torapidly grow and divide, that's why patients lose their hair. i need haircuts i guess about onceor twice every few months and so those are cells that are rapidlygrowing in the body. a problem for our bloodless patientsthen is that your blood cells are rapidly growing and dividing. so if you've got a drug thateffects that type of cycling cell, you can have toxicityin getting anemic. and so we're working topersonalize your therapy,

so that you can hopefullyget treatment for the cancer without causingtoxicity to your bone marrow. and one example that has been ina number of lung cancer patients, normally we could use a chemotherapeutic agent called cis-platinum. that not only kills rapidlygrowing cancer cells but also turns off your bloodproduction [inaudible]. we've switched over to a [inaudible]agent that can kill the cancer cells but won't affect your marrow as muchand that's called carbo-platinum.

and we've had a number of patientsget through their therapy without any need for even epo. and in some of our cases, we've use epo to help the patientsget through their therapy. blood cancers, lymphoma andleukemia is another area where it could be challenging iftransfusion is not an option. we've had a patient get throughsuccessful lymphoma therapy with some epo and iron. we also have other patients whoare getting currently treated at our

institution and are doing very well. and in recent years we've had oractually in recent months, we've had a couple ofpatients with bladder cancer. and bladder cancer can beassociated with bleeding and so our patients can get anemic andiron deficient. and we've been helping thesepatients get through therapy with iron and in some cases epo. aand working with their oncologistto come up with therapies that are the least toxic to the marrow,

but the most beneficialin treating the cancer. and why are we doing this? what's the reason we're all here? it's really safe and successfultherapy, surgery outcomes for our patients. and this is just one of mywonderful families that i've had the privilege to care for. the woman shown in the middleis currently getting therapy for lung cancer.

and i had the privilege of caringfor their little girl shown in the pink dress on the left,who had low platelets. and we were able to keep herplatelets in a safe range. and another patient, one of my very favorites who'shere 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 sunniestpersonalities you will ever meet. and she has been really courageously managing a long time history ofanemia and doing it beautifully.

and i'm particularly proud that[inaudible] comes to see us and see me, because she actuallylives in philadelphia. and she used to go to the localbloodless program which actually was aroundlonger than our program. but once she came here, she nowprefers to come here for therapy. and i think one of the thingswe do really well is to work as a team with our patients. nobody knows their body betterthan the patient themselves and hazel, when she knows thatsomething's not right.

she will either call ortext me or liz or andy and say, i can tell my bloods goingdown, i'm getting anemic. so what we'll do we'llcall her doctors, we'll find out whatthe latest level is. we'll find our what epo dose is,what her iron is and we'll make sure we treat itbefore it becomes a problem. so we really try to establishedexcellent teamwork and have very open communication. and i feel very privileged to workwith my team where there's so

many wonderful people canreached out to our patients. help them and keep them healthy and keep their blood levels safebefore they become a problem. so i wanted to show offthat beautiful picture and many of her beautifulfamily members are here. i've gotten to meet lotsof sisters and nieces and it's always a real pleasure. when i see he's on my clinic list, iget excited to go to clinic [laugh], because i know it's gonnabe a wonderful day.

and then here's another patient thati wanted to share her beautiful picture with you. she has a lymphoma,had blood clots and anemia. and as you can see she'sdoing beautifully and then she also came from a numberof other hospitals in virginia and washington dc areas andnow comes to see us. and another really important goalof our program is like i said we would love to take care of all thebloodless patients in the world but that's really not feasible.

so we're very dedicated to teachingbloodless therapy, not only for doctors here but fordoctors in other parts of the world. and i was recently in china wheredue to limited resources in some part of the country in verydense patient populations. medicine there is effectivelybloodless because there aren't resources to provide blood forthe patients. and i had the opportunity to consulton 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 thatyou really can't see the baby. but here are the team of doctorsthat i worked with and i just got an email yesterday actually, thislittle baby is doing really well. and here's just to show youthe outside of the hospital was in the high endprovince of china in hi ko. which is in the south area and it's a really big hospitalwith lots of patients. so as i mentioned, one of ourreally important goals of our programs is to teach otherdoctors how to care for

patients with bloodless medicine. and so what do we look forin the future? what would we want to do better? we want to continue to improve ourtherapies to build up your blood, so you can go andsee doctor [inaudible] and come out with a wonderfulsurgical outcome. we'd like to advanced the hemoglobinsubstitute field because sometimes there are going to be instanceswhere people lose a lot of blood fast and we want to make surethat we can treat you effectively.

certainly cell saver isa real advance in our field. and we wanna be constantlyevaluating the hemoglobin substitutes to see whatwill be best for you. we also want to look forapproaches to build blood cells and platelets when those partsof your blood are low. and actually in my own lab we'relooking at blood stem cells and trying to find ways to coax bloodstem cells to make blood better. to make platelets better,to make white blood cells better and to make hemoglobin carryingblood cells better.

and then the other thingthat's a big area, because it's increasing as ourpopulation ages is cancer therapy. and we're looking for new agents and new approaches to kill cancer cellswithout effecting your blood cells. and i was just actuallyin germany earlier this summer working with a companyjust trying to develop drugs. that will kill the cancer cellswithout killing your blood cells or suppressing the growthof your blood cells. and they also have thisagent that blocks a pathway,

it's called hepsiden. which for patients who have inflammation likerheumatoid arthritis or diabetes and their bodies aren't making bloodvery well because they're inflamed. they actually have an agent thatcan block that [inaudible] pathway, so that their bodies canstart making blood better. so we're constantly looking forbetter ways to care for you, better ways to improve your bloodstrain and new ways to treat cancer. and other problems that couldeffect your level of hemoglobin in

your anemia. so again, the real reason we'rehere is because of you and i always love to share the picturesof our beautiful patients. and it also equally importantbecause not everybody can come here is to teach otherphysicians and nurses and care providers throughout the world, howto care for our bloodless patients. and i showed youan example of china. last year we had a student fromsaudi arabia who was able to come to this conference session, fly into learn more bloodless medicine.

and in closing i just want to extenda very special thank you to all of you here, because youare the reason we are here and hereby we do what we do. in this picture, i like to thinkshe is clapping for our program. >> [laugh]>> [inaudible] and take time for some questions. a special thank goes out to hazeland her wonderful family for coming all the wayfrom the philadelphia. >> [applause]

>> treatment for sickle cell. >> so treatment for sickle cell, so we have a number of bloodless sicklecell patients in our program. and those patientsnormally have anemia, so we want to prevent anyworsening in anemia. and there are some drugs outthere that can be beneficial, you may have heard ofhydroxyurea for instance. which is a drug that actually helpsto turn on a kind of hemoglobin we all had when we were fetuses.

it's called fetal hemoglobin. and what happens is this drugincreases the production of fetal hemoglobin which normallywe make when we're fetuses and during the first year oflife it gets turned off. so we turn it back on and it turnsout that this dilutes the sickle hemoglobin and it can also buildup the strength of the blood. so i think that's one ofthe more promising therapies that is available to oursickle cell patients. there are newer drugs on horizonthat are being tested that could do

the same thing andthat could potentially be safer. but i think forour sickle cell patients, that's the most promising area. thank you again forcoming to our program, it's wonderful to see everybody. >> [applause]>> one more thing, there is a questionnairein the packet. it has ten questions. we would be so grateful if youcould turn in the questionnaire.

and andy has pens if youneed a pen by the door. and it's just so we can knowbetter how to serve the community. and what you guys want to hear forexample, in our next seminar. so thank you so much for being here.