Dr. Kenichi Tanaka received his doctor of medicine degree from Keio University in Tokyo, Japan. He completed the Anesthesiology residency at University of Pittsburgh Medical Center (1995-1998). He subsequently pursued a clinical fellowship at the Department of Anesthesiology at Emory University School of Medicine (1998-2000). He holds a diplomate of the American Board of Anesthesiology since 1999. He completed the Masters program in the Science of Clinical Research at Emory University (2006); in the same year, he was promoted to Associate Professor of Anesthesiology at Emory University School of Medicine. In 2012, Dr. Tanaka left Emory and joined the faculty of University of Pittsburgh as Professor of Anesthesiology. In 2014, he was recruited to become the Section Chief of Adult Cardiac Anesthesiology and Professor of Anesthesiology at University of Maryland School of Medicine. In 2021, Dr. Tanaka joined the faculty of University of Oklahoma Health Sciences Center as John Plewes Chair and Professor of Anesthesiology. Dr. Tanaka’s clinical expertise is cardiovascular anesthesiology with a special focus on perioperative coagulation management and patient blood management. Dr. Tanaka’s has written more than 260 peer-reviewed articles including 50 review papers as well as 15 book chapters, primarily in the areas of: 1) Clinical coagulation monitoring; 2) Perioperative hemostatic intervention, and 3) Transfusion-related outcomes.
In this podcast, Dr. Kenichi Tanaka talks with Helen Osborne about:
- Bloodless surgery years ago, before there was anesthesia.
- Bloodless surgery today, especially with patients who are Jehovah’s Witnesses.
- Challenges and ethical concerns about bloodless surgery.
- Thoughts for practicing hematologists; scientists, medical students, and health professionals newer in their careers; recommendations for those of us who are simply curious about blood.
Producer and audio editor: Adam Weiss, Relativistic Media
Transcript:
HELEN: Welcome to Talking About Blood. I’m Helen Osborne, host of this podcast series and a member of the advisory board for The Blood Project. I also produce and host my own podcast series about health communication, and it’s called Health Literacy Out Loud. Today, I’m talking with Dr. Kenichi Tanaka, who is the John Plews Chair and Professor of Anesthesiology at the University of Oklahoma Health Sciences Center. Ken is a cardiac anesthesiologist by training and has worked at several major U.S. medical centers. He also is a well-published author of more than 260 peer-reviewed articles, 50 review papers, and 15 book chapters on topics that include clinical coagulation monitoring, perioperative hemostatic intervention, and transfusion-related outcomes. Bill Aird, who is the head of The Blood Project, suggested that I interview Ken about a topic that has fascinated Bill and me about bloodless surgery. Ken, welcome to Talking About Blood.
KEN: Thank you, Helen. It’s my pleasure to be here.
HELEN: Bloodless surgery. I need to get my kind of brain around that. Tell us, kind of, is this something new? Is this something old? Put in context, what do you mean by bloodless surgery, and how in the world does that happen?
KEN: Yes, I do say bloodless surgery is old. So, in the beginning of surgery, you understand there was no IV fluid, no IV catheter, so the surgeons had to cut patients’ tumor, you know, typically on the surface of the skin, very quickly, and stop the bleeding, so that, you know, patient doesn’t lose too much blood. So, I would call all the surgery in the beginning of the history were bloodless.
HELEN: Oh, really? Bloodless? So, you mean, well, there’s a little bit of blood, but you mean they never put any blood back, right?
KEN: We couldn’t do it. So, over time, I think surgical skill was more advanced, and the surgeons started to work on internal organs. As IV fluids and IV catheters became available, we were able to manage blood loss by replacing intravascular fluid.
HELEN: Okay.
KEN: I think that really enabled more advanced surgery to be performed on patients.
HELEN: So, in the history of surgery and medicine, this is a fairly recent development, that you’re able to replace blood fluids?
KEN: Yes. IV catheter was only developed in late 1800s. So, you know, early 1900s, I think our approach to the care of surgical patients were rather primitive, and we always had a lot of blood loss, and I think we ended up giving lots of blood to the patient, and, you know, blood transfusion from other, you know, healthy volunteer donors. These were basically given to the patient to, you know, fill the intravascular space.
HELEN: So, if you don’t do that, they’re not going to survive the procedure, correct?
KEN: When patients lose a lot of blood and without transfusion, it’s very difficult to keep the patient alive, even when the surgery was successful.
HELEN: Okay. So, bring us into more contemporary issues, and I think what fascinates Bill Aird, it fascinates me, is just our times and certain cultures or religions, and I’m thinking particularly of Jehovah’s Witnesses, and perhaps other groups who are not accepting of blood products. Is that correct?
KEN: Yes, that is correct. And, you know, I was listening to one of your previous podcasts, and I think the topic was on religion and the blood. And I do think, you know, the same concept applies to these patients. They understand the Old and New Testaments in their own way, and that’s how they see the medical treatment in their own views. So, we do provide care to these patients who refuse blood transfusion on religious grounds. So, with that, we have to devise a better way to reduce the blood loss. So, this technique called acute normovolemic hemodilution, we use this approach so that patients lose fewer red cells and clotting factors during the surgery. So, how we do this acute normovoelmic hemodilution, so-called ANH.
HELEN: ANH, okay.
KEN: Yes, ANH. This is actually very similar to what vampire bats do.
HELEN: We have a podcast on that one, too.
KEN: Yes, I heard it on your podcast as well. But we anesthesiologists can go to the patient who is already under general anesthesia, and we actually take the blood from the patient, you know, his or her own blood, from existing intravenous catheter into a plastic bag. So, the plastic bag, we put some anticoagulant so that blood doesn’t clot off inside the bag. So, this is very similar to vampire bats, too, because vampire bats carry anticoagulant in their saliva, right? So, we actually use a very similar concept. While they are asleep, we take the blood off. We keep the blood, patients own blood, maybe one pint or two pints inside the bag. And we have the surgeon start the surgery. So, with less blood in the patient, you know, IV fluid is given to the patient to keep the blood pressure from falling. So, this means that during the surgery, when the surgeon cuts the tissue and patient bleeds, it’s much more diluted blood and fewer red cells and clotting factors.
HELEN: That’s fascinating. And what are the outcomes like?
KEN: Yeah. So, at the end of the surgery, we give the blood back. So, that means compared to those who did not get this ANH protocol, usually patients need one pint less blood transfusion when you just compare the data in heart surgery patients. So, you know, we are not really testing this technique in patients who refuse blood transfusion on religious grounds. But we do test this technique in the general surgical population. And generally speaking, we are able to reduce the total requirement for blood transfusion. So, I think we learned a lot from patients who actually refuse blood transfusion because we make our approach more advanced and safer for the patient.
HELEN: So, I feel like we’re kind of, as you’re telling me about this, and I’m really fascinated with it, you’re talking about what happens right before surgery, during surgery, a little bit later. Can we take us back to the beginning? So, you’re not the surgeon, you’re the anesthesiologist. You’re part of that team, correct?
KEN: Yes.
HELEN: I want to kind of make this pretty vivid there. So, a patient needs this surgery. When do you start talking with the patient? When does the issue about being a Jehovah’s Witness come in? And what’s that conversation and preparation even before surgery?
KEN: Yes. So, when Jehovah’s Witness patients come to us, you know, we have to know what procedures they are having. If the procedure doesn’t lose much blood, of course, you know, we can easily perform these procedures without transfusion. But if someone comes to your center for heart surgery or big aortic or big, say, pancreatic surgery, there’s a potential for large blood loss. So, for these patients, we look at their laboratory data. If patients are anemic, we try to correct and increase the red cell volume inside the patient. So, we can use different approaches such as irons or erythropoietins that increase the red cell production in the body. And after that process, we, you know, estimate intraoperative blood loss. And we decide whether we can implement acute normal hemodilution for that patient. There are also other techniques such as cell saver that sometimes is called autotransfusion. So, that is a technique. We have a special suction, you know, sterile suction that is placed in a surgical field and basically recovers shed blood from the field. And we put it into the special machine to spin it off.
HELEN: Oh.
KEN: And we collect shed red blood cells from the patients so we can actually give back patients own red blood cells from the surgical field, clean that, and into the blood vessels. So, that is a good way to keep the patient’s red cell volume steady during the surgery.
HELEN: You’ve practiced in major medical centers. I live in Boston, major medical centers around here too. Are these advanced techniques available across the U.S. and around the world? Or do you have to go to a specialty place for this?
KEN: So, a lot of centers do implement combinations of these approaches. Maybe ANH is not widely performed. I think maybe a much fewer centers compared to cell salvage or autotransfusion, which is implemented in almost all medical centers around the globe.
HELEN: So, tell me about this from the patient’s perspective. My background, and I shared that with you before, is about health communication and health literacy. So, communicating in ways people can understand and accept and act on. There must be a beginning place in this conversation when somebody already has a bad enough disease that they need surgery. For all that entails of being scared and frightened and everything else. They also have their strong belief system. How do you begin this conversation with somebody? And you’re talking about advanced principles too. I appreciate you’ve tried to explain it to me in ways I can understand. You’re doing a great job. I’m getting it. But how do you explain that to the patient and family who needs this procedure?
KEN: Yes, for patients who could accept blood transfusion or start explaining about how surgery and anesthesia goes, how much blood loss you might expect. And we discuss about the possibility of transfusion. Of course, most of our blood products are very safe, checked for any known infectious agents inside the bag. But, you know, there’s a potential for allergic reactions when you give, you know, say red cells or even platelet concentrates to the patient. So, reducing blood transfusion that is from somebody else is very important because we never know. If you give next blood unit, you know, patient may develop a severe allergic reaction and (blood) pressure might go down. So, there is an always risk associated with blood transfusion. So, from that point of view, I think it’s really important to discuss overall benefit of blood transfusion. So, when it comes to a Jehovah’s Witness patient who most likely refused, you know, donated red blood cells, plasma, platelet transfusion, we discuss alternatives. So, we discuss the risk of not receiving blood transfusion. And then we discuss potential alternatives and how we might be able to help these patients understanding how the surgery goes and how the postoperative cause might go following the surgery.
HELEN: Sounds like that’s fairly time-consuming. You have a lot to explain there. Are you doing this alone? Are you dealing with the patient and family? Are you bringing in religious leaders or advocates? Are there other people who are part of this? Not to persuade the patient necessarily, but to inform in a clear way so they can make a reasoned choice.
KEN: Yes, I do have previously worked with Jehovah’s Witness hospital liaison.
HELEN: Oh, a liaison. Okay.
KEN: Yes. So, that person usually has very good medical knowledge and aware of other Jehovah’s Witness groups’ experience from the literature or from the church communication. So, they know a lot about bloodless surgery. So, usually they are aware of the names of the surgeons who can perform bloodless surgery in town. So, oftentimes I meet with Jehovah’s Witness liaison person and discuss the risks of not having blood transfusion and how we could help this particular patient for this particular surgery. So, then, you know, he or she, this liaison person might go to the patient and discuss the situation. Sometimes the patient, he or she might directly communicate with me or sometimes, you know, once they come in, we meet in the hospital room and then discuss again the options.
HELEN: That’s fascinating. The Blood Project, I don’t know if you know much about this website that Bill has created. It really brings together humanity and science or medicine. And what you’re talking about does that. You are respecting that individual, their humanity, their preferences, their values, their traditions, you know, all of that. And you’re putting that together with the science and the medicine and, you know, looking ahead to new ways of doing that. I am just, thank you. Thank you for all you’re doing in that.
KEN: My pleasure. So, personally, I call this modern bloodletting.
HELEN: Modern bloodletting.
KEN: Yeah.
HELEN: Really?
KEN: Yes.
HELEN: You explain that some more.
KEN: So, in the old times, I do think bloodletting was used to take out bad blood or potential cause for disease, right? So, the sick patient had to bleed out. So, sometimes that actually made patients feel worse. And a lot of times, you know, we know from the history that barber surgeons, the old, you know, school surgeons practiced this for a long time from 16th century into, you know, early 19th century. But historically, that goes to, like, you know, 1,000 years BC. And, you know, Egyptians were already doing it. So, I think the purpose at that time was to take the bad blood out. But in modern bloodletting, we actually take something good out of the patient, keep it in the bag, and after the surgery is done, we return that to the patient. And, you know, that will do something good for the patient. So, again, you know, we are different from those older, you know, physicians who practice phlebotomy even from vampire bats, you know, which don’t return the blood to the subjects.
HELEN: Well, I certainly would believe you when I’d follow anything you tell me to be doing about this because you’re so kind and thoughtful about it. A few different directions and questions I have about it. What are the challenges about doing this? The ethical challenges, the everyday challenges? I mean, it sounds good as you’re quickly describing this. What are you facing as a physician? What’s the whole team facing? What’s the patient facing?
KEN: Yes. I think the most difficult challenge is the timing of the surgery. So, some patient might come to you with anemia. And then, you know, we really have to do this surgery rather quickly for, say, cancer. And we don’t really have good, you know, enough time to fix, you know, correct this anemia before surgery.
HELEN: Okay.
KEN: And if somebody comes in with anemia, it’s very difficult to induce dilution because then blood cell count goes so low and then it goes into very unsafe zone for tissue oxygenation. So, we really have to think about, you know, how anemic the patient is before we do this ANH technique. So, when you have an elective surgery, we can give patient iron, erythropoietin, and we can fix anemia that really help us to do ANH for the patient. Another difficulty might be related to patient himself or herself. You know, if patients are very small, of course, including children, it’s more difficult to do, you know, one-pint blood collection. You know, again, the blood might, you know, red blood cell might get too thin to safely conduct surgery. So, we always have to think about patient size before we can safely do ANH.
HELEN: And are there times patients will just go, no, I’m not doing it. It’s not my values.
KEN: That is possible, yes. ANH, we have to keep the blood in the bags, and we can keep the tubing connected to the patient. But some of the Jehovah’s Witnesses might say, no, you know, the blood is outside my body. I do not want that procedure.
HELEN: A lot of you’re facing there. You talked beginning about this new procedure and you’re learning by it. I’m thinking about the upside of this beyond that individual case that you’re working on then. Are you, as a scientist and a physician, learning skills or techniques that might be applied more universally in the future?
KEN: Yes. We share the knowledge of doing ANH, you know, based on the clinical study or just case reporting. And we also have many different blood-derived products, such as factor concentrates in the powder. And we always try to combine these old, you know, relatively old techniques with new technology. So, if we have qualified, you know, clotting factor concentrates, we actually combine ANH with clotting factor concentrates. And we can even make this bloodless surgery more feasible. So, you know, we always think about, you know, implementing newer technologies alongside the older techniques such as ANH.
HELEN: I love that. I imagine. So, let me tell you about the listeners to this podcast. They might be seasoned hematologists, senior physicians, people who’ve been practicing medicine or at a high level of their science careers for a while. It sounds like they could very much use this information in their practices. Our listeners also, a large group of them, seem to be those earlier in their careers. Whether they’re thinking about going into medicine or science, they’re in school for it, early in their residency. And another group of listeners are people like me who just want to know all about blood. We are just curious. What would you like each group to know about this bloodless surgery?
KEN: Yes, I think it’s really important to strive for bloodless surgery because blood transfusion is a very safe technique. But sometimes it causes multiple complications. And, you know, those are not trivial. You know, if you look at the literature, those who get transfused tend to have more complicated or sometimes worse postoperative outcomes. So, you know, some people call blood transfusion transplantation. Giving somebody else’s blood to, you know, a different person is considered transplantation. So, we still don’t know many things about blood products and blood transfusions. So, I think it’s really great to have more, you know, young people get interested in, you know, the surgical, medical, you know, bloodless techniques and help advance science.
HELEN: I can hear that, to do that to the advanced science. And you’re putting together, as I referenced before, the humanity and the science together. And you’re opening up all these possibilities. Ken, thank you so much for all you’re doing, for sharing with us, for explaining it so clearly. I am delighted you agreed to be a guest on Talking About Blood.
KEN: It’s my honor. Thank you, Helen.
HELEN: As we just heard from Dr. Kenichi Tanaka, bloodless surgery is a factor to consider, too. It’s been a factor for centuries when they’re doing surgery, and now we’re figuring out how to do that again. As he referred to this as modern-day bloodletting. There’s so much to be learning about this. To learn more about The Blood Project and explore its many resources for professionals, for trainees, for trainees and patients, go to thebloodproject.com. I invite you to also listen to my podcast series about health communication at healthliteracyoutloud.com. Please help spread the word about this podcast series and The Blood Project. Thank you for listening. Thank you for listening. Until next time, I’m Helen Osborne.