Cross-matched blood in colorectal surgery: a clinical waste?

Utility of routine type and cross for anterior cervical discectomy and fusion: A retrospective review

Background

Preoperative type and screen and type and cross are routinely obtained in patients undergoing elective cervical spine surgeries. This is despite low perioperative transfusion rates, particularly in patients undergoing anterior cervical discectomy and fusion (ACDF).

Methods

We conducted a retrospective cohort study at a single tertiary medical center of all patients 18 years of age or older undergoing elective ACDF for degenerative cervical spine disease between January 2016 and January 2021. Our primary outcome measures included the frequency of type and screen/crossmatch orders, rate of perioperative transfusion, and crossmatch to transfusion (C/T) ratio. Secondary outcomes included differences between preoperative and postoperative hemoglobin and hematocrit.

Results

In total, 1,162 patients were identified. There were no cases of intraoperative transfusion. The overall transfusion rate was less than 1%, with only 1 patient receiving a blood product transfusion during their hospital admission. This patient received 2 units of platelets for severe preoperative thrombocytopenia. Yet, 961 patients (83%) received ABO/Rh blood typing and screening and 647 patients (56%) had their blood typed and crossed. A total of 1,318 units of blood were crossmatched, with no units of packed red blood cells (pRBCs) transfused and only 2 units of platelets transfused, achieving a high crossmatch to transfusion (C/T) ratio of 659:1.

Conclusions

Among 1,162 patients who underwent elective ACDF at our institution, there were no patients who required an intraoperative or emergent blood transfusion. Furthermore, routine type and screen and crossmatch in patients undergoing elective ACDF at our insitution is associated with a high C/T ratio, suggestive of inefficient usage of blood products.

Blood ordering and utilization in patients undergoing elective general surgery procedures in a tertiary care hospital: A prospective audit

Background

Blood ordering is commonly done for patients undergoing major elective surgery. Excessive order of the blood for elective surgery leads to wastage of resources, time and workforce. Auditing preoperative blood ordering decreases the cost of medical care by avoiding unnecessary cross-match without compromising patient safety.

Methods

For this hospital-based audit, we collected data prospectively from July 2017 to June 2018 regarding the transfusion and transfusion indices, namely cross-match-totransfusion ratio (C/T ratio), transfusion probability (T%), transfusion index (TI) and maximum surgical blood ordering schedule (MSBOS) for elective surgeries done in the Department of Surgery.

Results

A total of 1151 patients were included in the study. A total of 160 units of blood were issued of which only 138 were transfused to 116 patients. Seventy-one procedures were included in the study. The C/T ratio was less than 2.5 for 16 procedures, T% was >50% for 9 procedures and MSBOS was more than 0.5 for 16 procedures.

Conclusion

Cross-matching is overused for elective surgical procedures. Only 16 of the 71 procedures had an ideal C/T ratio. Group and screen policy can be adopted for most of the commonly performed procedures, and cross-matching of blood may not be needed.

Forecasting the Amount of Blood Ordered in the Obstetrics and Gynaecology Ward with the Data Mining Approach

Preoperative blood ordering is frequently used in the obstetrics and gynecology ward of university hospitals in Iran, even for surgeries that rarely require blood transfusions. This routine procedure is an inefficient use of resources and rising costs, wasting time and cause shortage for essential patients. So this study was carried out to propose a new optimal system based on data mining techniques for ordering blood. This cross-sectional study examined the number of units cross-matched and transfused during surgery in the obstetrics and gynecology ward from 2013 to 2015. Data was collected for 1097 patients. Statistical analyzing was applied on data to prove that; the current blood ordering was not optimal. So with use of blood indices, C/T ratio, the new blood ordering variable was introduced. Then decision tree was applied on data with use of Rapid miner. Decision tree evaluation measures were rMSE and accuracy. A total of 1097 patients were examined for which 9747 units of blood were ordered. There was a significant difference between the number of cross-matched and transfused units according to all variables. The new method reduced the cross-matched units about 71.50%. The accuracy of proposed decision tree based on new blood ordering variable (according to C/T index) was 96.10%. The effective variables of blood ordered were type of surgery, blood group and amount of hemoglobin. The recent blood ordering variable prevent blood shortages, reduce costs. Excessive blood ordering is common in the obstetrics and gynecology department. According to proper results of new ordering variable, we suggest to apply this procedure in all hospitals in order to reduce extra costs and the optimal management of blood ordering.

An audit of perioperative blood transfusions in a regional hospital to rationalise a maximum surgical blood ordering schedule

Appropriate preoperative blood typing and cross-matching is an important quality improvement target to minimise costs and rationalise the use of blood bank resources. This can be facilitated using a maximum surgical blood ordering schedule (MSBOS) for specific operations. It is recommended that individual hospitals develop a site-specific MSBOS based on institutional data, but this is challenging in non-tertiary centres without electronic databases. Our aim was to audit our perioperative blood transfusions to develop a site-specific MSBOS. A retrospective audit of blood transfusions in surgical patients in our regional referral hospital was conducted using five years' coded administrative data. Procedures with higher transfusion rates warranting preoperative testing (type and screen with or without subsequent cross-matching) were identified. There were about 15,000 eligible surgical procedures performed in our institution over the audit period. The need for preoperative testing was identified for only a few procedures, namely laparotomy, bowel resection, major amputation, joint arthroplasty, hip/femur fracture and humerus surgery, and procedures for obstetric complications. We observed a reduction in transfusion rates over time for total joint arthroplasty. The use of coding data represents an efficient method by which centres without electronic anaesthesia information management systems can conduct large-scale audits to develop a site-specific MSBOS. This would represent a significant improvement for hospitals that currently base preoperative testing recommendations on expert opinion alone. As many procedures in regional centres have very low transfusion rates, hospitals with a similar case mix to ours could consider selectively auditing higher-risk operations where local data is most likely to alter testing recommendations.

Impact of preoperative laboratory investigation and blood cross-match on clinical management of pediatric neurosurgical patients

PURPOSE

Studies in the adult literature suggest that preoperative laboratory investigations and cross-match are performed unnecessarily and rarely lead to changes in clinical management. The purposes of this study were the following: (1) to explore whether preoperative laboratory investigations in neurosurgical children alter clinical management and (2) to determine the utilization of cross-matched blood perioperatively in elective pediatric neurosurgical cases.

METHODS

We reviewed pediatric patient charts for elective neurosurgery procedures (June 2010-June 2014) at out institution. Variables collected include preoperative complete blood count (CBC), electrolytes, coagulation, group and screen, and cross-match. A goal of the review was to identify instances of altered clinical management, as a consequence of preoperative blood work. The number of cross-matched blood units transfused perioperatively was also determined.

RESULTS

Four hundred seventy-seven electively scheduled pediatric neurosurgical patients were reviewed. Preoperative CBC was done on 294, and 39.8 % had at least one laboratory abnormality. Electrolytes (84 patients) and coagulation panels (241 patients) were abnormal in 23.8 and 24.5 %, respectively. The preoperative investigations led to a change in clinical management in three patients, two of which were associated with significant past medical history. Group and screen test was performed in 62.5 % of patients and 57.9 % had their blood cross-matched. Perioperative blood transfusions (71 % of these patients were under 3 years of age) were received by 3.6 % of patients (17/477). The cross-match to transfusion ratio was 16.

CONCLUSION

This study suggests that the results of preoperative laboratory exams have limited value, apart from cases with oncology and complex preexisting conditions. Additionally, cross-matching might be excessively conducted in elective pediatric neurosurgical cases.

Pediatric preoperative blood ordering: when is a type and screen or crossmatch really needed?

BACKGROUND

Unnecessary testing for and ordering of blood products adds to overall healthcare costs.

OBJECTIVES

Determine intraoperative red blood cell (RBC) product utilization for pediatric procedures and costs associated with perioperative testing and ordering.

METHODS

A retrospective chart review captured perioperative blood testing and intraoperative transfusion data for patients <19 years of age who underwent noncardiac surgery over a 13-month period at one tertiary care hospital. The main outcome measure was cost associated with testing for blood products in patients undergoing procedures that had a zero rate of transfusion.

RESULTS

The intraoperative transfusion rate for 8620 noncardiac pediatric procedures was 2.78%. Of 8380 nontransfused patients, 707 (8.4%) had type and screen, and of those, 420 (5%) were crossmatched for RBC products in preparation for surgery. The 10 surgical procedures that had the highest perioperative blood testing but no instances of transfusion were as follows: colostomy or ileostomy takedown, spinal cord untethering, tunneled catheter placement, laparoscopic Nissen fundoplication, elbow reduction and fixation, lumbar puncture, suboccipital craniectomy, hip arthrogram, percutaneous intravascular central line, and tonsillectomy and adenoidectomy. Procedures with low transfusion probability and high crossmatch testing were ventriculoperitoneal shunt revision and growing rod distraction. For all nontransfused patients, the cost of obtaining type and screen was $31,815, and the cost for crossmatch was $25,200.

CONCLUSION

Patients may undergo preoperative type and screen or crossmatch for procedures rarely associated with transfusion. Historic transfusion probability may be used to predict need for transfusion for specific surgical procedures and reduce unnecessary perioperative testing and associated costs.

Iliac crest autograft versus alternative constructs for anterior cervical spine surgery: Pros, cons, and costs

Background:

Grafting choices available for performing anterior cervical diskectomy/fusion (ACDF) procedures have become a major concern for spinal surgeons, and their institutions. The “gold standard”, iliac crest autograft, may still be the best and least expensive grafting option; it deserves to be reassessed along with the pros, cons, and costs for alternative grafts/spacers.

Methods:

Although single or multilevel ACDF have utilized iliac crest autograft for decades, the implant industry now offers multiple alternative grafting and spacer devices; (allografts, cages, polyether-etherketone (PEEK) amongst others). While most studies have focused on fusion rates and clinical outcomes following ACDF, few have analyzed the “value-added” of these various constructs (e.g. safety/efficacy, risks/complications, costs).

Results:

The majority of studies document 95%-100% fusion rates when iliac crest autograft is utilized to perform single level ACDF (X-ray or CT confirmed at 6-12 postoperative months). Although many allograft studies similarly quote 90%-100% fusion rates (X-ray alone confirmed at 6-12 postoperative months), a recent “post hoc analysis of data from a prospective multicenter trial” (Riew KD et. al., CSRS Abstract Dec. 2011; unpublished) revealed a much higher delayed fusion rate using allografts at one year 55.7%, 2 years 87%, and four years 92%.

Conclusion:

Iliac crest autograft utilized for single or multilevel ACDF is associated with the highest fusion, lowest complication rates, and significantly lower costs compared with allograft, cages, PEEK, or other grafts. As spinal surgeons and institutions become more cost conscious, we will have to account for the “value added” of these increasingly expensive graft constructs.

Is routine blood cross-matching necessary in elective laparoscopic colorectal surgery?

BACKGROUND

Routine pre-operative cross-matching of two units of packed red cells (PRC) is current practice in most hospitals for patients undergoing elective laparoscopic colorectal surgery (LCS).

AIMS

To determine the usage of PRC in patients undergoing elective LCS & its cost implications.

METHODS

Retrospective analysis of 116 consecutive laparoscopic colorectal resections under the care of 2 consultant surgeons.

RESULTS

Surgical procedures were anterior resection (31.9%; n = 37), right hemicolectomy (22.4%; n = 26), sigmoid colectomy (22.4%; n-26), subtotal colectomy (7.8%; n = 9), APR (4.3%; n = 5), panproctocolectomy (3.4%; n = 4), completion proctectomy (1.7%, n = 2), left hemicolectomy (0.9%, n = 1), total colectomy (0.9%; n = 1) & resection rectopexy (0.9%; n = 1). The median age was 65 years, 58% female. The median pre-operative haemoglobin was 131 g/L, median blood loss 100 ml and median post-operative haemoglobin 111.5 g/L. Eleven cases were converted. Three patients required perioperative blood transfusion, 2 of whom underwent open conversion. The cost of carrying out a group & save (G&S) in our hospital is £40.60 excluding laboratory staff labour cost. A 2 unit cross-match costs £294.60. There is potential for substantial cost savings with change of practice to G&S only.

CONCLUSION

G&S is sufficient to allow safe & cost-effective operative practice in laparoscopic colorectal surgery.