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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 1  |  Issue : 2  |  Page : 51-56

Blood utilization practices in elective surgical patients in a Tertiary Care Hospital of Uttarakhand


1 Himalayan Institute of Medical Sciences, SRHU University, Dehradun, Uttarakhand, India
2 Department of Pathology, Himalayan Institute of Medical Sciences, SRHU University, Dehradun, Uttarakhand, India

Date of Web Publication6-Sep-2016

Correspondence Address:
Gita Negi
Department of Pathology, Himalayan Institute of Medical Sciences, SRHU University, Dehradun, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-8893.189843

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  Abstract 


Background: Ordering of blood is a common practice in elective surgical procedures. Unnecessary blood orders need to be waived to reduce both workload and financial expenditure. We need to optimize the quantity of blood being cross-matched, by assigning each surgical procedure, a tariff of transfusion. To this effect, the maximum surgical blood ordering schedule(MSBOS) is one such approach. The study was performed with the aim of evaluating whether preoperative blood cross-matching in our hospital is well adjusted to the actual intraoperative blood usage.
Materials and Methods: A hospital-based retrospective cross-sectional study was conducted in those patients who underwent elective surgeries in Himalayan Institute Hospital Trust hospital over a period of 1year. Blood requisitions and transfusions were compiled and reviewed. The number of units requested, cross-matched and transfused along with number of patients cross-matched and transfused were collected. The blood bank requisition forms, databases, old surgical records, and discharge sheets were reviewed. Following indices were calculated: (i) Cross-match to transfusion ratio(C/T), (ii) Transfusion probability(T%), (iii) Transfusion index(TI), (iv) MSBOS.
Results: Atotal of 2370patients underwent 214 different elective procedures are included in this study. Totally, 1184 red blood cells units were cross-matched, and only 625 units(52.7%) were transfused to 331patients. The overall C/T ratio calculated was 1.8, TI was 0.5 and T% was 61.7%. All these figures were found to be within the desirable range. Based on these indices, MSBOS was formulated for each procedure.
Conclusion: The study indicated an adequate overall ratio of C/T, T%, and TI except a few surgeries that showed transfusion indices beyond accepted levels. Developing a blood ordering policy(MSBOS), to guide the clinicians regarding blood usage can decrease over ordering of blood thereby reducing unnecessary compatibility testing, returning of unused blood, and wastage due to outdating.

Keywords: Blood transfusion, crossmatch to transfusion ratio, cross-matched blood, maximum surgical blood ordering schedule, packed red blood cells, transfusion index, transfusion probability


How to cite this article:
Kuchhal A, Negi G, Gaur DS, Harsh M. Blood utilization practices in elective surgical patients in a Tertiary Care Hospital of Uttarakhand. Glob J Transfus Med 2016;1:51-6

How to cite this URL:
Kuchhal A, Negi G, Gaur DS, Harsh M. Blood utilization practices in elective surgical patients in a Tertiary Care Hospital of Uttarakhand. Glob J Transfus Med [serial online] 2016 [cited 2019 Mar 25];1:51-6. Available from: http://www.gjtmonline.com/text.asp?2016/1/2/51/189843




  Introduction Top


The ordering of blood is a common practice in elective surgical procedures. It is essential that the usage of blood and blood products be kept to a bare minimum and used only when absolutely necessary.[1] It is estimated that only about 30% of cross-matched blood is used in elective surgery.

The preoperative request for blood units is often based on worst case assumptions. Consequently, if unnecessary blood orders can be reasonably waived, it will reduce both workload and financial expenditure. We need to optimize the quantity of blood being cross-matched, by assigning each elective surgical procedure, a tariff of transfusion.[2]

At present, the transfusion requirements for patients undergoing surgical procedures are being overestimated. Blood units arranged for elective surgery remain unutilized and get discarded. Currently, there are no specific evidence-based guidelines for the appropriate amount of blood products to be ordered for specific procedures. Rather, excessive blood products are ordered due to outdated preoperative institutional or surgeon-specific guidelines.[3]

The consequence of such a practice include increased cost to the patient, outdating of blood, overburdening of blood bank personnel, depletion of blood bank resources, and wastage of time.[4] Furthermore, the cost of production, storage and separation of products, hospital transfer, tests for blood safety, and the typing and cross-matching add to the importance of appropriate application and use of blood product.[5] To this effect, the maximum surgical blood ordering schedule(MSBOS) is one such approach, but there are certain drawbacks which include the individual differences in transfusion requirements.[4]

The study was performed with the aim of evaluating whether preoperative blood cross-matching in our hospital is well adjusted to the actual intraoperative blood usage and whether the standards need revalidation. The main purpose of the study is to address the problem of blood-over-ordering and in developing a policy for rational use of blood using MSBOS for planned surgeries.


  Materials and Methods Top


A hospital-based retrospective cross-sectional study was conducted during July 2014–August 2014 in those patients who underwent elective surgeries over a period of 1-year from January 2013 to December 2013. Ethical clearance was taken from Ethics Committee of the University.

Blood requisitions and transfusions performed in these departments were compiled and reviewed. For every patient, the number of units requested, cross-matched, and transfused along with number of patients cross-matched and transfused were collected from discharged patient medical records and O. T. and blood bank registries.

Inclusion criteria: all the planned surgeries in the following specialties-general surgery, gynecology, orthopedic, cardiothoracic and neurosurgery, requesting for packed red blood cells(PRBC) were included in this study.

Emergency cases which needed PRBC for surgery were excluded from the study.

The data were compiled using the information available in blood bank requisition forms, databases, old surgical records, and discharge sheets. An analysis of the ordering and transfusion of PRBC was performed. The blood/component form being used in the hospital was reviewed.

The data were coded so as to respect the privacy of the patient and maintain the patient–doctor confidentiality.

Blood utilization indices were calculated as follows:



  1. Cross-match to transfusion ratio(C/T ratio) = number of units cross-matched/number of units transfused A ratio of 2.5 and below was considered indicative of significant blood usage
  2. Transfusion probability(T%) = number of patients transfused/number of patients cross-matched×100

    A value of 30% and above was considered indicative of significant blood usage
  3. Transfusion index(TI) = number of units transfused/number of units cross-matched

    A value of 0.5 or more was considered indicative of significant blood utilization
  4. Maximal surgical blood order schedule(MSBOS) =1.5×TI.


Based on the above parameters, MSBOS was developed for different planned surgeries.


  Results Top


A total of 2370patients were included in this study. Only surgical patients were included. These patients underwent 214 different elective procedures in various departments included in this study. Atotal of 1184 RBC units were cross-matched for these procedures and out of these only 625 units(52.7%) were transfused to 331patients. Approximately, 47% of the total cross-matched units were not transfused, i.e.,a total of 559 units cross-matched for these 214 surgeries (559/1184 units) were not transfused to any patient [Table 1].
Table 1: Blood cross-match and transfusion patterns for surgeries performed in various departments

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In Department of General Surgery, the overall C/T ratio was 0.45 and the overall T% and TI were 66.9% and 0.56, respectively [Figure 1],[Figure 2],[Figure 3].
Figure 1: CT ratio for all departments

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Figure 2: TI ratio for all departments

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Figure 3: T% for all departments

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In Department of Gynecology and Obstetrics, the overall C/T ratio was 2.2 with the highest C/T ratio of 3.6 for vaginal hysterectomy. Moreover, the overall T% and TI were 42.4% and 0.4, respectively.

In Department of Orthopedics, the overall C/T ratio was 0.4 with the highest C/T ratio of 2.5 for biopsy procedure. The overall T% and TI were 62.5% and 0.6, respectively.

In Department of Neurosurgery, the overall C/T ratio was 2.4 with high C/T ratio of>2.5 for cervical spine fixation procedures and discectomy procedures. The overall T% and TI were 56% and 0.4, respectively.

In Department of CTVS, the overall C/T ratio was 1.9 with the highest C/T ratio of>2.5 for atrial septal defect(ASD) Closure, Exploration for clot evaluation, pericardiectomy, peripheral embolectomy, and wound debridement procedures. The overall T% and TI were 100% and 0.5, respectively[Table 2], [Table 3], [Table 4], [Table 5], [Table 6].
Table 2: Maximum surgical blood ordering schedule for Department of Orthopedics

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Table 3: Maximum surgical blood ordering schedule for Department of Neurosurgery

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Table 4: Maximum surgical blood ordering schedule for Department of Gynaecology

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Table 5: Maximum surgical blood ordering schedule for Department of Cardiothoracic and vascular surgery

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Table 6: Maximum surgical blood ordering schedule for Department of General Surgery

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  Discussion Top


Blood transfusion is an essential component of patient treatment services. The main aim of blood transfusion is to ensure patient recovery as well as safety and at the same time ensuring appropriate use, thereby avoiding unnecessary use of blood in clinical practice. Blood is precious and scarce and should, therefore, be used rationally to avoid misuse and wastage. An ideal approach is to calculate the C/T ratio, TI, and T% for each procedure or surgery separately. This helps in formulating the blood ordering schedule accurately for each department.

This study was mainly an audit of blood component usage in various surgical departments, and it provided us with extremely useful data regarding the component usage and actual requirements in each department per procedure. This information can form the basis for recommendations for blood conservation. It also helps to study the appropriateness of use of PRBC in each department thus assisting in formulating blood ordering schedules, as well as ensuring rational use of blood and avoiding wastage of blood.

Numerous studies have shown that requests for blood exceed its real use, leading to financial waste and unnecessary work by personnel. It is, therefore, essential to do local studies to assess these habits and produce local guidelines.

Blood and blood components also carry numerous risks and significant cost. Acareful assessment of the risks and benefits of allogenic transfusion is essential for a good patient outcome. The risk of transfusion-transmitted infections is a grave threat to patients receiving blood transfusion. The estimated risks of transfusion have dramatically decreased over the recent years as tests of increased sensitivity such as the nucleic acid test have reduced infectious window periods. Despite this fact, it is recommended to transfuse blood only if absolutely necessary.

The present study was done to analyze the usage of PRBC in various departments. The overall C/T ratio calculated was 1.8 and did not exceed 2.5 for any of the departments in our center. The overall TI was found to be 0.5, and T% was 61.7%. All these figures were found to be in the desirable range overall.

The C/T ratio in the Departments of CTVS, Neurosurgery, Gynecology, Orthopedics, and General surgery were 1.9, 2.4, 2.2, 0.4, 0.5, and 0.5, respectively. Ahigh C/T (>2.5) ratio was observed in few individual surgical procedures, for example, vaginal hysterectomy, orthopedic biopsy procedures, cervical spine fixation, discectomy, ASD closure, pericardiectomy, peripheral embolectomy, etc.

A number of authors, used C/T ratio for evaluating blood transfusion practices. Ideally, this ratio should be 1.0, but a ratio of 2.5 and below was suggested to be indicative of efficient blood usage. Arulselvi et al. also found that the overall C/T ratio calculated did not exceed 2.5 for any of the departments in their study.[1] However, other studies have reported much higher C/T ratios >2.5.[3],[4],[6],[7]

The disparities in C/T ratios among various studies arise due to different blood transfusion practices at various centers. High C/T ratios are seen due to a tendency to request more units of blood than what is actually required in each procedure. This over ordering of blood might due to overestimation of blood loss by surgeons and trying to ensure safety measures in the event of excessive unexpected blood loss during surgery.

Many studies have suggested the importance of probability of transfusion for a given procedure(T%), which indicates efficient use of blood and a value of 30% and above has been suggested to be appropriate based on these recommendations, the results of the present study revealed an adequate overall T% of 61.7%, which was indicative of appropriate utilization of PRBC units. The T% also varies among various centers and departments and studies have reported values ranging from 8.9% to 79.3%.[6],[7]

Regarding TI, a value of 0.5 or more is indicative of efficient blood usage and signifies the appropriateness of number of units transfused. The TI reported in the current study was also found to be 0.5 overall. This was higher than that which has been found in another study which reports TI from 0.05 to 0.4.[6]

Preoperative over-ordering of blood has been documented in a number of studies. The current study revealed that 559/1184 cross-matched blood units were unutilized. The calculated RBC units were <0.5 units in a large number of procedures and hence we recommend a group and save policy for them. According to the American Association of Blood Banks recommendations, if the antibody screening is negative and there are no previous records of detecting such antibodies, a serological testing to detect ABO incompatibility is adequate, and antiglobulin testing in performing cross-match may be skipped. Benefits of such a type and screen(T and S) include reduced cost of reagents(used for cross-match), improved turnaround time, and decreased workload of the laboratory personnel. Most importantly, it helps reduce unnecessary loss of blood supply due to outdating of blood.

In our institute, units are kept reserved for up to 3days for a patient and because of this practice, the rate of discard of PRBC due to nonusage has decreased. To further reduce unnecessary cross-matching, MSBOS is the need of the hour for every hospital. All hospital-based blood banks should formulate a blood ordering schedule for appropriate blood ordering and usage. Frequent audits and feedback are also essential to improve the blood utilization practices.

Appropriate ordering of blood components according to a planned schedule helps to avoid indiscriminate ordering of blood and saves blood bank resources, time, as well as money. MSBOS has been in use since 1975 and has been undergoing periodic modifications since the time of implementation. The initial formulation of MSBOS was done using Mead's criterion. According to this criterion, the number of RBCs calculated was one and half times the TI for each surgical procedure. It also helps to ensure availability of adequate blood in emergency situations.

The present study has some limitations in terms of a small sample size and we therefore recommend larger, prospective multicenter studies.

The hospital blood banks and the hospital transfusion committees have the responsibility of formulation of blood ordering schedules. After implementation, frequent reviews and modifications are essential to assess the impact.


  Conclusion Top


The study indicated an adequate overall ratio of C/T, T%, and TI except a few surgeries that showed transfusion indices beyond accepted levels. In many surgical procedures, routine cross-match and preparation were not found to be necessary. Developing a blood ordering policy, to guide the clinicians regarding blood usage for surgical procedures, can decrease over ordering of blood thereby reducing unnecessary compatibility testing, returning of unused blood, and wastage due to outdating. In addition, antibody screening of patient as part of pretransfusion testing(T and S), defined protocols and policies for emergency transfusions and laying down guidelines/triggers for transfusion would lead to better utilization of blood and blood components. Maximum surgical blood order schedules should be formulated for selected surgical procedures with regular auditing, feedback, and modifications to improve blood ordering and utilization.

Acknowledgments

Special thanks to M. S. Talekar for her contribution and constant support. The authors would also like to thank the Research Committee, Hospital Management, blood bank staff and study participants at the SRHU university. The project had been conducted as part of Short Term Studentship(STS) program conducted by the Indian Council of Medical Research(ICMR).

Financial support and sponsorship

The study was funded by ICMR.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
ArulselviS, RangarajanK, SunitaS, MisraMC. Blood transfusion practices at a level one trauma centre: A one-year retrospective review. Singapore Med J 2010;51:736-40.  Back to cited text no. 1
    
2.
SubramanianA, SagarS, KumarS, AgrawalD, AlbertV, MisraMC. Maximum surgical blood ordering schedule in a tertiary trauma center in northern India: Aproposal. JEmerg Trauma Shock 2012;5:321-7.  Back to cited text no. 2
    
3.
AlamMM, SobaniZA, ShamimMS, AhmadK, MinaiF. Primary elective spine arthrodesis: Audit of institutional cross matched to transfused(C/T) ratio to develop blood product ordering guidelines. Surg Neurol Int 2013;4Suppl5:S368-72.  Back to cited text no. 3
    
4.
SubramanianA, RangarajanK, KumarS, SharmaV, FarooqueK, MisraMC. Reviewing the blood ordering schedule for elective orthopedic surgeries at a level one trauma care center. JEmerg Trauma Shock 2010;3:225-30.  Back to cited text no. 4
    
5.
KhoshrangH, MadaniAH, RoshanZA, RamezanzadehMS. Survey on blood ordering and utilisation patterns in elective urological surgery. Blood Transfus 2013;11:123-7.  Back to cited text no. 5
    
6.
KozarzewskaM, MackowiakM, StelerJ, KreftaM, HasakL, Kardel-ReszkiewiczE. The analysis of surgical blood order protocol. Anestezjol Intens Ter 2011;43:71-3.  Back to cited text no. 6
    
7.
BelaynehT, MesseleG, AbdissaZ, TegeneB. Blood requisition and utilization practice in surgical patients at university of Gondar hospital, Northwest Ethiopia. JBlood Transfus 2013;2013:758910.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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