A guideline for anticipated blood usage during elective surgical procedures

Blood Ordering Habits for Elective Surgery: Time for Change

A prospective study was carried out for 6 months to determine the efficacy of blood ordering routines for elective surgery. It was found that only 23% of procedures needed preoperative crossmatching of blood (transfusion index ‘IT’ >0.5). There was an excessive over-ordering of blood for 77% of the operations (crossmatch/transfusion ratio >2.5). In addition, the transfusion index for the latter group showed that there was no need to prepare blood preoperatively (TI <0.5).

A transfusion tariff is worked out which abandons crossmatching for the majority of procedures (cholecystectomy, thyroidectomy and surgery for duodenal ulcer excluding gastrectomy). Instead a ‘group and screen’ policy is suggested.

Use of blood bank services in a burn unit

Burn patients may need transfusions, especially during surgery. The purpose of the study was to determine blood bank services utilization at an urban burn center. This was a retrospective review (March 1999 to May 2004) of burn patient data on blood utilization. There were 1615 admissions; 800 (49.5%) of the patients had a type and screen (T and S); 180 of 1615 (11%) were transfused with 1691 red blood cell (RBC) units; 616 units of fresh- frozen plasma (FFP), 399 units of pooled platelets, and 38 units of apheresis platelets. Of the 180 transfused patients, 140 (79%) received RBCs, 11 (6%) received RBCs plus FFP, 23 (13%) received RBCs plus FFP plus platelets, and 3 (2%) each received RBCs plus platelets and FFP. Overall, 3393 red cell units were cross-matched, and 1691 units were transfused for a cross-match/transfused unit (C/T) ratio of 2.01. Seventy-three (5.7%) of 1282 of patients with 0% to 10% TBSA required transfusions; 42 (21%) of 193 with 11% to 20% TBSA; 24 (39%) of 61 with 21% to 30% TBSA; and 62% of patients with 31% or greater TBSA required transfusion (P = .001). As %TBSA increased, more of the cross-matched units were transfused: 37% in the 0% to 10% TBSA to 59% in the 30% or greater TBSA burn. The C/T ratio in the 0% to 10% TBSA was 2.69; only 18% of patients with a T&S received blood. Although most patients who underwent transfusion were in the less than 30% TBSA group, more of the red cell units were used in patients with a 30% or greater TBSA burn. Elimination of admission T&S and cross matches in burn patients with less than 20% TBSA may improve the C/T ratio in this cohort.

Blood transfusion during aneurysm surgery

INTRODUCTION

Increasing costs and concerns about blood supply safety have led to a reevaluation of blood transfusion practices. This study was undertaken to examine blood use during aneurysm surgery.

METHODS

We performed a retrospective analysis of hospital records including operative, anesthetic, and nursing notes, computed tomographic scans, and four-vessel angiographic films of 547 patients undergoing surgery for ruptured and unruptured cerebral aneurysms at Harborview Medical Center in Seattle. During the review period, the transfusion threshold was not altered.

RESULTS

A total of 134 patients (24.5%) received an intraoperative blood transfusion (median number of units, 2; range, 1-17). Preoperative factors associated with intraoperative blood use included older patient age (P < 0.001), lower hematocrit level on admission (P = 0.007), ruptured rather than unruptured aneurysm (P = 0.004), severe intraventricular hemorrhage (P = 0.03), and larger aneurysm size (P = 0.004). Factors not associated with intraoperative blood transfusion included past medical history (including cardiac or pulmonary disease), admission clinical grade after aneurysm rupture, findings such as hydrocephalus on computed tomographic scanning, and aneurysm location and aneurysm neck-to-fundus ratio. Also associated with blood transfusion during surgery were intraoperative aneurysm rupture (P < 0.0001), intracerebral hematoma evacuation (P = 0.02), and obliteration of multiple aneurysms (P = 0.002). Among patients who received an intraoperative transfusion, those who experienced an aneurysm rupture required an average of 3.6 +/- 0.35 units, whereas patients who did not have a rupture required 1.9 +/- 0.12 units (P = 0.001). Postoperatively, a total of 244 patients (44.6%), including 77 who received blood intraoperatively, required a blood transfusion (median number of units, 2; range, 1-31). Postoperative blood transfusion was associated with the treatment of patients with subarachnoid hemorrhage (P < 0.0001), particularly among poor-grade patients who developed medical complications.

CONCLUSION

Blood transfusion can be expected in one in five patients undergoing aneurysm surgery. Reducing intraoperative rupture may reduce the need for blood products.

Autologous blood pre-deposit and cell salvage in orthopedic surgery

A successful autologous blood program should enrol all appropriate patients, conserve homologous blood and minimize the exposure to the risks of donor blood. A program of autotransfusion and proper use of blood has been implemented since 1980 with the objectives of including all eligible patients and to transfuse autologous blood only. The following strategies were adopted: critical review of transfusion indications; control of over-transfusion; avoidance of waste; systematic and integrated use of all autotransfusion techniques currently available. Results in 1992 in elective surgery: 98% enrolment, 75% blood conservation. Exposure to homologous blood was completely avoided in 53% of the cases.

The Organization of the Autotransfusion-perioperative Blood Salvage at San Martino Hospital

Autologous transfusion is playing an important role in modern transfusion medicine. At San Martino hospital we use a combination of manual and mechanical techniques in order to improve autotransfusion procedures, control the hypertransfusion and avoid waste.

Our autotransfusion program has determined a 55% reduction in the red cell concentrates used (from 42,000 in 1985 down to 19,400 in 1992). Proper training, cultural improvements and new applications on autotransfusion procedures will permit a better use of blood with less transfusion related complications, until a suitable substitute for blood will be available.

Audit of the use of packed red blood cells in association with seven common surgical procedures

The risks and costs associated with the transfusion of blood and its components have led to increasing demands for evidence of the appropriate use of blood components. We have examined the use of packed red blood cells (PRBC) in association with seven common, surgical procedures performed in 1987 and 1988 to establish patterns of use. The information has formed the basis for surgical blood order schedules and autologous donation targets for these procedures. It has also been used to determine appropriate audit 'triggers' and the results of an audit using these 'triggers' are reported.

Current issues in transfusion therapy. 2. Indications for use of blood components

Many factors have stimulated a recent renewal of interest in indications for and use of blood components, including red blood cells, platelets, fresh-frozen plasma, cryoprecipitate, and granulocyte concentrates. Laboratory test results often provide helpful guidelines for the decision to use blood components. In this era of cost consciousness, the most important consideration still is to treat the patient in the most expedient and beneficial way. A conservative approach with an emphasis on high-quality medical practice is to choose and use blood components with consideration of both clinical information and laboratory findings.

A rational blood-ordering policy for urology

A retrospective study of blood-ordering patterns and blood use for elective urologic procedures was done. Only in a few surgical procedures, such as cystectomies, open prostatectomies, and nephrectomies, do the patients commonly receive blood transfusions. Blood is rarely used for a large number of other procedures. In such cases routine crossmatching of blood can be safely substituted by "type and screen." A guideline for preoperative blood-ordering is proposed that may substantially improve utilization of blood without jeopardizing patient care.

Optimal blood use in genitourinary surgery

The most commonly performed urologic surgical procedure is transurethral resection of the prostate. We reviewed the crossmatching and transfusion records of 226 patients who had undergone transurethral prostatectomy at our hospital from 1977 through 1979. Only 13 patients (5.8 per cent) received a transfusion. The crossmatched-to-transfused ratio was 21.5. Preoperative ABO-Rh typing and antibody screen are safe and cost-effective alternatives to preoperative crossmatching of blood for uncomplicated transurethral prostatectomy.

Is routine crossmatching for two units of blood necessary in elective surgery?

The usual preparation for many elective procedures calls for typing and crossmatching for 2 units of blood. Most of the blood prepared is not used. Every unit of blood kept for a specific patient is removed from the blood bank pool, thereby reducing its resources. Fourteen hundred of the most frequent elective operations were examined with regard to their blood utilization. A transfusion index was developed to determine whether preoperative crossmatching was justified. Applying the index to 1,400 elective procedures, it was found that only vascular procedures justified preoperative crossmatching. The safety of transfusion (elective and emergency) based on type and antibody screening is explained. The constant increase in blood consumption (as for open heart surgery) and the small increase in blood donations has created a blood shortage. It is suggested that surgeons stop requesting crossmatching for 2 units for those elective procedures in which blood is rarely used. This would decrease the workload in the blood bank and increase the blood bank pool without compromising patients' safety.