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Blood utilisation in elective general surgery cases: requirements, ordering and transfusion practices. M Vibhute, SK Kamath, A ShettyDepartment of Anaesthesia, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India., India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 0010855071
AIMS: For elective surgeries, over ordering of blood is a common practice. This can be decreased by simple means of changing the blood cross matching and ordering schedule depending upon the type of surgery performed. The principle aim of the study was to improve the efficacy of ordering system for maximum utilisation of blood and formulation of maximum surgical blood order schedule (MSBOS) for procedures where a complete cross-match appears mandatory. MATERIAL AND METHODS: We evaluated blood ordering and transfusion practices in 500 elective general surgical procedures at our institute. With the help of different indices such as cross-match to transfusion ratio (C/T ratio), transfusion probability (% T) and transfusion index (TI), blood ordering pattern was changed in the next 150 patients. RESULTS: Out of 1145 units of blood crossmatched for the first 500 patients only 265 were transfused with non-utilisation of 76.86% of ordered blood. With the help of the indices the wastage was reduced in next 150 patients, i.e. from 76.86% to 25.26% and improved the utilisation of blood, i.e. from 23.14% to 74.74%. CONCLUSIONS: Change of blood ordering patterns with use of MSBOS can avoid the over ordering of blood. Keywords: Blood Grouping and Crossmatching, Blood Transfusion, statistics &numerical data,utilization,Efficiency, Organizational, Hospitals, General, Human, Surgical Procedures, Elective,
The ready availability of blood and blood components has resulted in liberal use of blood transfusions. The increasing demand for blood and blood products together with rising costs and transfusion associated morbidity led to a number of studies in late 1970s reviewing blood ordering and transfusion practices[1]. These studies showed gross over ordering of blood much in excess of actual or anticipated needs. Many units of blood routinely ordered by surgeons are not utilised but are held in reserve and thus are unavailable for other needy patients. This can impose inventory problems for blood bank, loss of shelf life and wastage of blood. Hence we conducted a study in our general hospital to improve the efficacy of ordering system for maximum blood utilisation and formulation of Maximum Surgical Blood Order Schedule (MSBOS)[1],[2],[3],[4],[5]. The principle aim of study was to improve efficacy of ordering system for maximum utilisation of blood and formulation of MSBOS for common procedures where a complete cross-match appears mandatory.
Five hundred patients were included in this study over a period of six months. All these patients were posted for elective general surgical procedures for which intraoperative and/or postoperative transfusion was anticipated and preoperative grouping and cross-matching was requested. The preoperative data included haemoglobin, blood group and number of units cross-matched. The intra-operative data included duration of surgery, blood loss and blood units and/or colloids replaced These 500 patients were grouped under 30 separate procedures. Under each procedure the number of patients, units of blood cross-matched and number of units transfused were recorded and the following indices were calculated for each procedure. Cross-match to Transfusion ratio(C/T ratio) = No. of units cross-matched ----------------------------------- No. of units transfused A ratio of ? 2.5 is considered indicative of significant blood usage. Transfusion Probability (%T) = No. of patients transfused x 100 ----------------------------------- No. of patients cross-matched A value of ? 30 was considered indicative of significant blood usage. Transfusion Index (TI) = No. of units transfused ----------------------------------- No. of patients cross-matched A value of ? 0.5 was considered indicative of significant blood utilisation. MSBOS for the procedures showing significant blood usage based on above 3 indices, MSBOS was calculated by Mead’s criterion. MSBOS = 1.5 x TI where, TI = No. of units transfused ----------------------------------- No. of patients transfused In next 150 patients, blood was made available in the operation theatre only in surgeries in which all three indices showed significant blood utilisation and blood ordering and transfusion practices were noted. The % of blood utilisation was also calculated.
Out of these 500 cases in 50 patients, supra-major surgeries like devascularisation, lienorenal shunt, Whipple’s procedure and oesophagectomy were performed and in remaining 450 cases major surgeries like cholecystectomy, exploratory laparotomy, thyroidectomy, ureterolithotomy, pyelolithotomy, modified radical mastectomy, parotidectomy, etc. were performed. For these 500 patients, 1145 units of blood were cross-matched. Out of these only 265 units were transfused i.e. Only 23.14 % of blood was utilised while remaining 880 units of blood i.e. 76.86 % of blood was not utilised. In supra-major surgeries like devascularisation, lineo renal shunt, Whipple’s procedure, oesophagectomy, Hemimandibulectomy and major surgeries like colonic and ileal surgeries, gastrectomy, splenectomy, exploratory laparotomy for retroperitoneal mass, amputation and parotidectomy; all three indices i.e. C/T Ratio, % T and Ti showed significant blood utilisation (i.e. 50-100 %). While in surgeries like Puestow’s / Partington’s surgery, biliary-enteric bypass, prostatectomy, pyelolithotomy, modified radical mastectomy, two or one out of three indices showed significant blood utilisation and percentage of blood utilisation varied from 20-25 %. The surgeries where none of the three indices showed significant blood utilisation were cholecystectomy (open / laparoscopic), thyroidectomy, ureterolithotomy, gastro - / cysto-jejunostomy, vagotomy / pyloroplasty, incisional hernia repair, varicose vein surgery and omentopexy. After analysing 500 cases, we changed our blood ordering schedule. Blood was made available in the operation theatre only in surgeries in which all three indices showed significant blood usage in next 150 patients. Thus, only 31.33 % of blood was issued from the blood bank as compared to 100 % as in the earlier routine practice. Thus percentage of blood utilised also increased from 23.14 to 74.74. This new ordering schedule thus reduced the percentage of unutilised units from 76.76 to 25.26. For these 150 patients, 316 units of blood were cross-matched but only 99 units were issued from the blood bank. Out of these only 25 units were not utilised and remaining 74 units were transfused to the patients. Of these 25 units unutilised, 20 units were issued for exploratory laparotomy, which turned out to be inoperable. Of these 150 patients, eight patients who were posted for exploratory laparotomy, which turned out to be inoperable, were not transfused blood but rest all i.e. 142 patients were transfused blood.
Recently there has been a growing demand for blood and blood products. This demand has often exceeded the resources of local blood bank and thereby disrupted both the planning and nature of surgical lists. Elective surgery by demanding large quantities of blood each day, of which little is ultimately used commits valuable supplies and resources both in technician time and reagents. The criteria for ordering blood are often vague and established policies where they exist may be outdated since the amount transfused for a given procedure has fallen since 1950. Therefore, it is necessary to streamline blood ordering and transfusion practices. Preoperative over ordering of blood has been documented since 1973, when Friedman et al[2] published their findings. Subsequently, a number of studies also showed over ordering of blood by surgeons in most of the countries. The percentage of cross-match patients receiving transfusion for general surgical procedures ranged from 5-40% as compared to 28% of utilisation in our hospital. The use of the C/T ratio was first suggested by Boral Henry in 1975[1]. Subsequently a number of authors used the C/T ratio for evaluating blood transfusion practices and C/T ratio of ? 2.5 was suggested to be indicative of significant blood usage. A C/T ratio of > 2.5 means that less than 40% of cross-matches are transfused. The probability of a transfusion for the given procedure is denoted by %T and was suggested by Mead et al in 1980[4]. A value of ? 30 has been suggested as significant. The average number of units used per patient cross-matched is indicated by TI and signifies the appropriateness of number of units ordered. Boral and Henry[1] suggested that a procedure which uses <0.5 units of blood per procedure does not require a preoperative cross-match. A value of ? 0.5 is indicative of significant blood usage. All 3 indices were studied in 500 cases to obiviate the fallacy of using single index. The surgeries where all 3 indices showed significant blood utilisation were, Supramajor surgeries like, * Linorenal Shunt * Transhiatal oesophagectomy * Devascularisation * Whipple’s * Hemimandibulectomy Major surgeries like, * Colonic and Ileal surgeries * Gastrectomy * Splenectomy * Exploratory laparotomy for retroperitoneal mass * Above knee/ below knee amputation * Parotidectomy The surgeries where 2 or 1 out of 3 indices showed significant blood utilisation were: * Puestow’s/Partington’s surgery * Biliary Enteric Bypass * Prostatectomy * Pyelolithotomy * Modified Radical Mastectomy The surgeries where none of the indices showed significant blood utilisation were, * Cholecystectomy (open/laparoscopic) * Ureterolithotomy * Thyroidectomy * Gastro/Cystojejunostomy * Vagotomy/Pyloroplasty * Incisional Hernia repair * Varicose Vein Surgery * Omentopexy In the surgeries which have insignificant blood loss, only blood grouping of the patient should be done and cross matching can be avoided. However, one must confirm the availability of blood for emergency situation before starting the surgery. MSBOS: This may vary from institute to institute, as there is patient and surgeon variability. This can be done in surgeries where significant blood utilisation is seen and number of units to be grouped and cross-matched and to be kept ready for particular surgery can be decided.
1. Over ordering of blood has to be minimised. 2. Blood ordering pattern needs a definite change. 3. In view of fear of transmitting HIV, hepatitis and other transfusion hazards, single unit transfusion of blood should be avoided. 4. In surgeries with insignificant blood loss, only blood grouping of the patient should be done, but one must confirm the availability of blood for emergency situation before starting surgery. 5. In exploratory laparotomy especially in malignancy, blood should be made available only after the final surgery is planned.
[Table - 1], [Table - 2], [Table - 3]
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