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Bloodless Medicine and Surgery Unit
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Technological and pharmacological resources

Technological and pharmacological resources

They offer medical care using techniques that represent the best option

The Bloodless Medicine and Surgery Unit promotes and utilises a range of technological and pharmacological resources to achieve its objectives of providing medical care using surgical techniques and procedures that are currently widely used and represent the best option for patients who reject or wish to minimise the use of blood components, whether due to their needs, values or beliefs. These resources include a series of techniques that are characterised by being as minimally invasive as possible, recovering or minimising blood from the surgical site and/or promoting haemostasis.

Surgical or diagnostic techniques
The use of one surgical technique or another is determined by the patient's condition, recommended by the surgeon, and accepted by the patient.

Among these, we can highlight:
- Endoscopic techniques
  They tend to be minimally invasive. These are surgical techniques used as the first choice that minimise blood loss. The following are particularly prominent:
  
  Laparoscopy. This technique involves inserting a flexible optical system into the skin and tissues of the abdominal cavity, which uses light to capture images of the area to be diagnosed. When displayed on the monitor, these images enable our specialists to ensure highly precise diagnostic and therapeutic procedures. The procedures may vary widely in terms of complexity. These include diagnostic techniques to determine abdominal or pelvic-gynaecological problems (exploratory laparoscopies), appendicitis, biopsies, gallbladder resection, hysterectomies or colon surgery, etc.
  
  Arthroscopy. Similar to laparoscopy, which uses an optical system, arthroscopy is a medical procedure that uses a similar but smaller optical system to observe the inside of the joints. As a surgical technique, it allows certain joint problems to be resolved without the need to open the joint, reducing risks and enabling much faster patient recovery. Arthroscopy is indicated as a complementary test in the diagnostic process for joint problems and as a therapeutic technique or procedure. It is commonly used on the knee, shoulder, elbow, wrist, hip, foot, and ankle.
  
  Spinal endoscopy. Endoscopic spine surgery allows for the effective treatment of herniated discs, with or without neurological involvement, conditions such as lumbar canal stenosis, or simple pathological protrusion of part of the vertebral disc that can cause discomfort to the patient when moving around.
  
  Digestive endoscopy. This approach involves the placement of an optical system in the area so that specialists can view the digestive tract (gastroscopy or fibrogastroscopy) or colon (colonoscopy). The images captured enable a more accurate diagnosis to be made in cases where there is a digestive problem (tumours, malformations, suspected ulcers, etc.) and therapeutic techniques to be performed.
- Laser
  Lasers use light amplification through stimulated emission of radiation. The distinct characteristics of this technique enables surgeons to make neat, low-bleeding, and highly precise incisions.
  
  A range of procedures currently leverage this technique, including prostate surgery, haemorrhoidectomy, varicose vein removal, and gynaecological procedures.
- Robotic Surgery
  The Da Vinci surgical system is an innovative surgical system that combines the effectiveness of open surgery with all the benefits of a minimally invasive approach. This technique allows complex procedures to be performed with maximum precision using the Da Vinci robot, which has four arms, two of which reproduce the surgeon's movements in real time, allowing for greater precision and optimal results. Another arm contains a camera that provides images of the area to be operated on, and the fourth arm supports the operating arms.
  
  This system provides minimally invasive procedures, lower risk of complications, shorter hospital stay, and shorter recovery time than conventional surgery.
- Novalis
  The Novalis radiosurgery and radiotherapy system provides precise treatment of tumours by integrating advanced technologies. The Novalis radiosurgery platform enables specialists to provide non-invasive treatment for a wide range of malignant tumours, without damaging nearby healthy tissue or involving traditional surgery.
- Interventional radiology
  Haemodynamics, angiography and neurointerventional procedures. Haemodynamics facilitates a structural and operational analysis of the heart, focusing on the dynamics and mechanical aspects of blood movement through the circulatory system. This study is performed by inserting thin catheters through the arteries (cardiac catheterisation) and allows for accurate assessment of the condition of the blood vessels throughout the body and heart. It also allows for intervention through the placement of meshes or stents (angioplasty) to restore or improve cardiac blood flow. Catheterisation procedures enable accurate diagnosis and treatment of various diseases, not only of cardiac origin, but also of vascular origin (angiography). Angiography is a method for studying the vascular network (arteries and veins) through either invasive or non-invasive methods, determined by the particular technique utilised. Likewise, in the case of vascular pathology, it can be repaired by placing endoprostheses (stents) and intra-arterial inflatable balloons (angioplasties), all without the need for surgery or blood transfusions.
  
  FNA (Fine-Needle Aspiration) There are other procedures that minimise blood loss and have led to significant advances in the diagnosis and treatment of diseases. These are referred to as FNA (Fine-Needle Aspiration) procedures. It is a percutaneous procedure performed through the skin, in which a fine needle is used to perform biopsies, drain abscesses, etc., guided by various radiological techniques: CT scan, mammography, ultrasound. It is used for procedures on the chest, abdomen and bones.
  
  Percutaneous ablation. Percutaneous ablation of tumours is another innovative technique that can be performed within the Bloodless Medicine and Surgery Unit. It consists of a technique in which primary or metastatic tumours in the liver, lung or kidney are ‘burned’. Using CT-guidance, a thin probe or needle is inserted into the core of the tumour, destroying it using radiofrequency or microwaves.
  
  Your doctor will advise you on the best option depending on the condition or planned procedure.
Intraoperative phase
- Prevention of temperature drop. In the operating theatre, it is common for the patient's body temperature to drop. A drop in temperature below 36º affects the ability of platelets to stop bleeding in small blood vessels. It is therefore important to maintain patients' temperature at normal levels during surgery to avoid this harmful effect. This can be achieved by using thermal blankets and pre-warming the fluids administered to the patient.
- Patient positioning. The anaesthetist takes special care when positioning the patient on the operating table to avoid compression causing areas of venous congestion, which would lead to increased bleeding during the operation.
- Intraoperative blood salvage. In procedures where there is a higher risk of bleeding, intraoperative blood salvage (IOS) devices will be available for use. These devices work by sucking up the blood produced within the surgical field and directing it to a special reservoir, where it is washed and centrifuged to separate it from any elements that cannot subsequently be administered intravenously (fat globules, small fragments of bone or tissue). The blood that is collected, washed, and centrifuged is reinfused into the patient, always maintaining the continuity of the circuit. The system allows blood to be recovered during surgery and immediately after surgery, with the recovered blood being reinfused up to a maximum amount after the procedure. This technique is therefore accepted by patients who refuse blood transfusions for religious reasons. There are various models of intraoperative salvage units, adapted to the type of surgery to be performed. Intraoperative salvage systems cannot be used in every case, e.g., when surgery is performed on an infected area.
- Administration of intraoperative drugs. In orthopaedic surgery procedures involving significant intraoperative bleeding (knee and hip replacements, etc.), it has been shown that administering a drug called tranexamic acid reduces surgical bleeding by 30%. Tranexamic acid acts by inhibiting the destruction of the clot that forms physiologically to stop bleeding.
- Acute normovolemic haemodilution. Normovolaemic haemodilution is a simple and safe technique performed at our centre. The technique consists of extracting 1 to 3 units of blood from the patient, through an arterial or venous line, into blood collection bags before or after anaesthetic induction, while replenishing or restoring the circulating volume with colloids or crystalloids in the same amount as the volume extracted. The extracted blood units remain connected to another of the patient's veins without interruption, so people who refuse blood transfusions for religious reasons can use this technique. Normovolaemic haemodilution is only considered in surgical procedures where the estimated blood loss is close to or may exceed 1000–2000 ml. It requires certain preconditions on the part of the patient and preoperative haemoglobin levels of at least 14 grams/litre.
Postoperative phase
In the postoperative phase of some surgical procedures, your surgeon may recommend the use of recovery drains if they anticipate that bleeding in the first 6 hours after surgery will exceed approximately 500 ml.

Recovery drains allow the bleeding that occurs at the surgical site to be aspirated, filtered, and collected in a special bag containing an anticoagulant. Within the first 5 hours after surgery, according to the Unit's internal protocols, this filtered blood can be administered to the patient to help reduce the degree of post-operative anaemia. The system is designed as a closed circuit with no contact with the patient, so its use is generally accepted by patients who, for religious reasons, do not accept autologous blood transfusions.

Additional bleeding-reduction measures:
- Blood pressure control. Hypertension is a factor that will lead to increased post-operative bleeding, so it is important that the patient is given the necessary medication immediately after surgery to keep their blood pressure within normal ranges.
- Analgesia. Pain is a stress-inducing factor and, therefore, through direct and indirect action (raising blood pressure), it is also a factor that increases bleeding. The medical team will be responsible for adjusting an appropriate analgesic regimen to achieve proper control of post-operative pain.
- Nausea. Nausea, through increased pressure in the venous territory, is another factor that can increase post-operative bleeding. Therefore, as a matter of protocol, all patients undergoing major surgery receive pharmacological treatment to prevent nausea and vomiting.
What is anaemia?
Haemoglobin is a protein in red blood cells (a component of red blood cells) that carries oxygen to all parts of the body. Anaemia is a condition that occurs when haemoglobin (Hb) levels are low or lower than normal, specifically when levels are below 13 g/dL in men and 12 g/dL in women.

The symptoms of anaemia are fatigue, exercise intolerance, headache, breathing difficulties, tachycardia, dizziness, nausea, weight loss, decreased libido, and difficulty maintaining attention.

Likewise, anaemia can be a symptom, in other words, a temporary condition resulting from other health conditions; or it can be a chronic problem, resulting from a permanent disorder that causes this deficiency.

-Iron deficiency anaemia-

The most common type of anaemia is iron deficiency anaemia, which occurs when there is a deficiency of iron (Fe). The main causes of the deficit may be an increase in demand (periods of rapid growth – childhood and adolescence), an increase in losses (women of childbearing age) or inadequate intake (malnutrition, malabsorption secondary to various pathologies such as inflammatory bowel disease or Helicobacter pylori infection, gastric resections or drug interactions - e.g. antacids).

In these cases, anaemia may be:
- Mild anaemia. People with mild anaemia may have no symptoms or only mild symptoms.
- Severe anaemia. People with severe anaemia may have problems that prevent them from carrying out normal activities, feel tired or, depending on the severity, may have difficulty breathing.
Studies have shown that anaemia is present in a very high percentage of patients prior to surgery. After surgery, anaemia increases, especially in patients who are more fragile or who have undergone high-risk or trauma surgery.
- What causes anaemia in surgery patients?
  Anaemia may be present before surgery, especially in people with chronic or oncological diseases, or who suffer from poor food absorption, significant metrorrhagia, nutritional deficiencies (elderly people), gastric ulcers, etc.
  
  In patients who have previously undergone surgery, intraoperative bleeding during the surgical procedure, blood collected by drains, and repeated extractions (in critically ill patients) can exacerbate this level of anaemia.
- Even if I do not have anaemia, is it possible for me to be treated with an anti-anaemic treatment?
  Yes, at the Unit we assess which medical, interventional or surgical procedure should be performed and whether it carries a low, medium or high risk of bleeding. Depending on your personal characteristics, your condition, your medical history, and whether you are undergoing any medical treatment, we may offer you a pharmacological supplement to raise your haemoglobin level.
  
  For this reason, it is important to contact the Unit at least 3-4 weeks before the procedure in order to diagnose and ensure an optimal haemoglobin level prior to surgery.
- What are the effects of untreated anaemia in surgical patients?
  Anaemia after surgery has been linked to an increased risk of infection, difficulty in suturing the surgical wound, a greater need for ventilator support, and a higher number of complications compared to people who do not suffer from it. Patients with severe anaemia are usually candidates for blood transfusions, which in some cases can prolong their hospital stay. That is why it is considered very important to treat and correct anaemia before performing surgery.
- What treatments are available to assist me?
  There are various possible treatments:
  
  Medications that stimulate red blood cell production (EPO or erythropoietin) have been approved to correct anaemia prior to surgery and have been shown to be useful in reducing transfusions in anaemic patients whose surgery involves large amounts of blood loss.
  
  Iron, intravenous or oral. Depending on the patient’s haemoglobin level, the underlying condition and the procedure to be performed, one or the other will be prescribed.
  
  In some cases, patients may be prescribed vitamin supplements (folic acid or vitamins B6 or B12) to provide additional amounts of these vitamins, which are necessary for the production of red blood cells. Likewise, an extra intake of vitamin C will contribute to greater absorption of the iron supplement administered.
  
  These medicines are most effective when administered three or four weeks before surgery, so it is important to find out whether you have anaemia as soon as possible. Your doctor will help you find the most appropriate treatment for you, taking into account the causes of your anaemia and its severity.

Technological and pharmacological resources

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