use of blood in elective surgery

8/14/2019 Use of blood in elective surgery

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Use of Blood in Elective SurgeryDeba P. Sarma, MD

A retrospective study of blood-ordering practices and blood use forelective surgical procedures at the Veterans Administration Medical Centerof New Orleans shows a cross match-to-transfusion ratio of 4.29. To reduce

this ratio, a guideline for ABO-Rh type andantibody screen(type andscreen)is implemented. This avoids routine cross matching for those surgicalprocedures where blood is seldom transfused.

(JAMA 243:1536-1538, 1980)

A PROFESSIONAL letter in 1976

from theDepartmentof Medicine andSurgery of the Veterans Administration raises concerns about ineffectiveuse of blood. Once blood is crossmatched for a specific recipient, it isheld in a reserved status for that

person and is not available to other

patients. If this blood is not used, itmay become outdated during thereserved period. In our hospital, thisreservedperiod isusually 24 hours.

A second aspect relates to the

growing realization that, for certainelectivesurgicalprocedures, the number of cross-matched units that areordered frequently exceeds considerablythe numberactually transfused. Ifthe cross match-to-transfusion (C-T)ratio is high, the blood bank is burdened with keeping a large bloodinventory, excessive personnel time,

andhighoutdatingof units.

The VA recommends thatthe bloodbank director of each local facilitystudy and analyze the pattern ofblood use and develop guidelines forordering blood for elective surgery.For theproceduresin which the average number of units transfused percase is 0.5 or less, determination ofABO-Rh type and a screen of thepatient's serum for unexpected antibodies (typing and screening) is suggested in lieu of type and crossmatching, provided ABO-Rhcompatible units are readily available.

This report willprovide our experience of blood use for elective surgicalprocedures in the VA Medical Centerat New Orleans.

METHOD

For a 12-month period from Jan 1, 1976,toDec31,1976, the electivesurgical procedures with blood ordered were tabulatedto show the number of units of blood

(whole blood and packed RBCs) crossmatched vs the number of units transfused for each case. The units used may

.

have been transfused in the operatingroom or within 24 hours postoperatively.This information was summed and aver

agedfor eachprocedure.Onlythose procedures performed five or more times arereported.

Fromthesedata aguideline fororderingtyping and screening was prepared forthoseproceduresusing anaverage of 0.5 orless units perpatient.

RESULTS

The results are shown in Table 1.The averages have been rounded offtothe nearest0.01 foreachprocedure,and the operations have been dividedintosubspecialties, Next to the nameofoperations,Table 1 showsthe number of patients who were crossmatched for that procedure vs thenumber ofpatientswho were actuallygiven transfusions. The next columnshows the total number of units ofblood cross matched vs the total number of units transfused. The number

of cross-matched unitsdividedby thenumber of transfused units gives theC-T ratio inthe parentheses. The lastcolumn shows the average number ofunits crossmatched perpatient vs theaverage number of units used perpatient cross matched.

Table 2 shows the list of surgicalprocedures under different subspecialties,wheretypingand screeningisrecommended. In all these cases, with

exception of laminectomy, the average number of units transfused per

From the Department of Pathology, VeteransAdministration Medical Center and LouisianaState University Medical Center, New Orleans.

Reprint requests to Department of Pathology,VA Medical Center, 1601 Perdido St, NewOrleans, LA 70146 ( Dr Sarma).

at Creighton University Med Ctr on November 22, 2009www.jama.comDownloaded from
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Table 1.Blood Data for Elective Surgical Procedures, 1976*

PatientsCross

Matched vs

Patients

GivenOperations

Units CrossMatched (C) vs

Units Transfused (T)

Transfusions (C-T Ratio)

AvN o. CrossMatched per

Patient vs AvN o.Used per Patient

CrossMatched

General surgeryGastrectomy 144/25(5.78) 4.65/0.80

Laparotomy 31/14 131/37(3.54)

Cholecystectomy 30/5

73/6(12.17)Colectomy 29/9(3.22)Vagotomy 17/1(17.0) 3.40/0.20

OrthopedicsHipprocedures 30/23 127/58(2.19)

Amputations 15/6 31/11(2.82)

Spinal fusions 27/3(9.0) 2.08/0.23

Open reduction 7/5 22/12(1.83)Total knee 17/4(4.25)Iliac crest bone graft 12/0(0) 2.00/0

UrologyProstatectomy, transurethral 319/28(11.39) 2.22/0.19

Prostatectomy (suprapubic, perineal) 16/6(2.67) 3.20/1.20

Nephrectomy 5/2 25/11(2.27) 5.00/2.20

Urethroplasty 22/4(5.50)Lithotomies (uretero-,

pyelo-) 12/2 30/2(15.0)

NeurosurgeryLaminectomy 54/15 130/29(4.48)

Cranlotomy 60/11(5.45) 4.29/0.79

OtolaryngologyLaryngectomy with or without

radical neck dissection 87/30(2.90) 4.14/1.43

Vascular surgeryAortofemoral bypass 136/62(2.19) 5.04/2.30

Arterlovenous fistula 25/0(0) 2.08/0

Endarterectomy 7/0 20/0(0) 2.86/0

Aneurysm resection orrepair 5/4 43/16(2.69)Thoracic surgery

Medlastinoscopy 64/3(21.33) 2.56/0.12

Thoracotomy 47/12(3.92)

Lobectomy 6/5 25/14(1.79)

Plastic surgerySkin flap 5/0 10/0(0)Total 546/168 1,689/394(4.29) 3.09/0.72

'Total number of procedures forwhich blood was ordered, 775.

patient cross matched is less than 0.5.Of 54 patients cross matched forlaminectomy, one patient used 4 unitsof blood, whereas others used 1 or 2units. After this particular patientwas excluded, the average number ofunits used perpatient cross matchedwas 0.47.

COMMENT

Table 1 shows that the types ofelective surgicalprocedures are fairlylimited in our institution, a 580-bed,general medical and surgical carefacility. The primary reason for thislimitation is that included in this

study were only the surgical procedures with a blood order performedfive or more times during the 12-month period. Many surgical procedures,such as hernia repair and liver

biopsy, were done five times or moreduring the period without an orderforblood, andthey are excluded fromthe study. The secondary reason isthatobstetric-gynecologic and pdiatrie surgical procedures are not performed in our hospital.Because of ourelderlypatientpopulation, there is an

unusually large number of certainprocedures such as transurethralprostatectomy, mediastinoscopy, laminectomy, and aortofemoral bypass.For below-knee amputations blood israrely required. Amputations in Table 1 consisted of primarily above-knee amputations.

Thehigh C-T ratios for such procedures as cholecystectomy, vagotomy,spinal fusions, total knee, transurethral prostatectomy, lithotomies,laminectomy, craniotomy, mediasti-

Table 2.Elective SurgicalProcedures forType and Screen

General surgeryCholecystectomyVagotomy

OrthopedicsSpinal fusionsIliac crest bone graft

UrologyProstatectemy, transurethralLithotomies, ureterollthotomy and

pelvlllthotomyNeurosurgery

LaminectomyVascular surgery

Arteriovenous fistula

EndarterectomyThoracic surgery

MediastinoscopyPlastic surgery

Skin flap

noscopy,andthoracotomyobservedinthis study have been also noted byother observers.13 An overall C-Tratioof 4.29 for our institutionin 1976is comparable to the C-T ratio of 4.1observed in the Los Angeles County-University of Southern CaliforniaMedical Center.2 This is unacceptablyhigh. Such a C-Tratio means thatthenumber of units cross matched ismore than four times the number ofunitsactually transfused.A C-Tratioof 2.5 or less is more acceptable in aninstitution like ours where most ofthe blood requests come from internsand residents. To reduce the C-T

ratio, one should implement typingandscreeningand not cross matchingon specimens from all the procedureswhere the average number of unitstransfused perpatient cross matchedis less than0.5. Table 2 shows thislistof procedures, which make up 313 of775 cases forwhichblood was orderedin 1976. In other words, 40% ofelective surgery cases with bloodordered in 1976 couldhave hadtypingand screening rather than crossmatching. In terms of blood, thismeans that 727 units of blood were

cross matched for these 313 cases, ofwhich only 72 units were transfused.Iftypingand screeninghad been usedfor these patients, the blood bankwould have been relievedof inventoryproblems and screening would alsohave helped to reduce outdating,allowed for more efficient allocationof technologists' time, and reducedthe overall cost of the blood bank's

operation.The safety of typing and screening

has been adequately studied.45 The



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medical director of the blood bankbears the full responsibility of disseminating the information and convincing the physicians of the importance and the purpose of typing andscreening. Most of the physicians stillbelieve in the traditional "routine 2unit type and cross match." Once theprocedure isexplained, ie, thattypedand

screened blood is 99.99% safe in

regard toavoiding the transfusion ofincompatible blood,45 and that bloodwillbe available on demand ifneededforpatients who havepreviously onlyhad typing and screening, then thephysicians are enthusiastically supportiveof thissubstitution.As ofthisdate, our guideline for typing andscreening has been fully implemented. Anadequate numberof unitsof bloodis beingkeptin the inventoryto cover the typing and screeningcases. If the screening uncovers anyirregular antibody, it is identified,and fewunits of blood thathave been

screened for the corresponding antigen for which the patient has theantibody are kept in the blood bank.Anytime a patient whose blood hasbeen typed and screened needs bloodin an emergency, it is immediatelydispatched, and cross matching isstarted at the same time. Physicianshave also been instructed that the

guideline is

only for routine cases.

For anyunusual orhigh-riskpatient,cross matching rather than a typingand screening procedure should berequested.

After the physicians accept theconcept of typing and screening, theindividual chiefs of different subspe-cialties of surgery are consulted. Bymutual discussionand understanding,additional guidelines for orderingblood for typing and cross matchingfor elective surgical procedures arethenprepared. The data from Table 1are used to formulate these guidelines.Many surgeons believe that it is

the responsibilityofthe primaryphysicians to decide how many units ofblood should be ordered for the

patients. Pathologists, who are notdirectly taking care of the patients,traditionallydo notset guidelines forprimary care physicians. To settlethis issue, the blood bank directormustopenlycommunicate and jointly

developthe

guidelinesfor the clinical

services. Otherwise, chances of successfulimplementation ofsuchguidelines are slim. The guidelines fortyping and cross matching for mostofthe subspecialtieshave beenpreparedand implemented; but, because theyare nottotallycomplete,they are notincluded in this report. Implementation of guidelines for typing andscreening and for typing and crossmatching, if done in two phases,seems to be more easily understoodandacceptedby thephysicians.

References

1. Mintz PD, Nordine RB, Henry JB, et al:Expected hemotherapy in elective surgery. NYStateJ Med 76:532-537,1976.

2. Rouault C, Gruenhagen J: Reorganizationof blood ordering practices. Transfusion 18:448\x=req-\453, 1978.

3. Boral LI, Dannemiller FJ, Stanford W, etal: A guideline for anticipated blood usageduring elective surgical procedures. Am J ClinPathol71:680-684, 1979.

4. BoralLI, Henry JB : Thetype and screen: Asafe alternative and supplement in selected

surgical procedures. Transfusion 17:165-170,1977.

5. Boral LI, Hill SS, Apollon CJ, et al: Thetype and screen, revisited. Am J Clin Pathol71:578-581,1979.

JAMA75YEARSAGOApril 15, 1905

SpecialTraining for Employeesin State Institutions

[Editorial, pp 1199-1200]

We pointed out. . .

the need of expert

knowledge and of special training for theadministrative work ofpublic institutionsand o fpublic boards. Sopalpable has beenthe deterioration of many public charitableinstitutions under the recurringpolitical changes of the last dozen years thatpublicopinion hascompelled the introduction into the present legislature of a billfor a state merit law. As theagitation hasbeen greatenough topledge both politicalparties and the governor of the state[Illinois] to such a measure, we mayassume that a law will be secured whichwill protect all the appointments to the

state public institutions from the control

of politicians. This goes further than our

suggestion, since it involves the 2,500 ormorepositions in thepenal a nd charitableinstitutions, most of which are not filledby physicians. It is plain, however, thatthefilling of theseplaces alsowithexpertswould be in the line of medical progress.How are we to obtain theseexperts? Thatis the question which another bill nowbefore the Illinois legislature undertakesto solve. This bill provides an appropriation of $15,000 yearly for the training ofstate employees in andby the State University.

Any training of experts for public ser

vice is still more or less experimental inthis country; butthis measure which actuallyprovides thatthe universityshall takea hand in thetraining of a prisonguard orof anasylum attendant is bold, indeed. Itwill seem to the Philistine foolishness andto the politician astumbling block, but tothe student of criminalpsychology and tothe alienist it will seem a welcome publicrecognition of a condition that should beremedied.Every one atallacquaintedwithhospitals for the insane knows that thephysician can only give the briefest personal attention to each patient and that

the wholesystemof treatmentdependsfor

itsefficacy on

the attendant. In

the same

way it is the prison guardthe shopforemanin whose hands, if anywhere,the reformation of the prisoner mustlie. Yet these positions are filled by people chosen haphazard or, worse, "pulled"in..

. .Thetrainingoughtcertainly to be prac

tical, the student should begiven a happybalance o fclinical work and o f theoretical

teaching. There should be enough theoryto make him understand the clinic and

respect his task. We judge that much ofthe instruction would necessarily begivenin the form of lectures by experts in the

institutions themselves. Whatever themethods which experience might developfor the suggested teaching, the very proposalputs a new face on the otherwisecoldand barren aspect of a civil-service law,whose more obvious virtues are merelynegative. To keep plundering and ignorance out ofpublic institutionsshould notbe sufficient to satisfy us. We must fillthese institutions with medical spirit andwith scientific ardor. We must demand forthebaffling task of restoring the mentallyandmorally sick the finestability and thebesttraining.


use of blood in elective surgery

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