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Use of blood in elective surgery

Use of blood in elective surgery

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Published by Deba P Sarma
Sarma DP (1980): Use of blood in elective surgery. JAMA 243:1536-1538. PMID: 7359736 [PubMed - indexed for MEDLINE]

Deba P Sarma, MD.,
Use of Blood in Elective Surgery


• A retrospective study of blood-ordering practices and blood use for elective surgical procedures at the Veterans Administration Medical Center of New Orleans shows a cross match-to-transfusion ratio of 4.29. To reduce this ratio, a guideline for ABO-Rh type and antibody screen (type and screen) is implemented. This avoids routine cross matching for those surgical procedures where blood is seldom transfused.
(JAMA 243:1536-1538, 1980)


A PROFESSIONAL letter in 1976 from the Department of Medicine and Surgery of the Veterans Administra¬tion raises concerns about ineffective use of blood. Once blood is cross matched for a specific recipient, it is held in a reserved status for that person and is not available to other patients. If this blood is not used, it may become outdated during the reserved period. In our hospital, this reserved period is usually 24 hours.
A second aspect relates to the growing realization that, for certain elective surgical procedures, the num¬ber of cross-matched units that are ordered frequently exceeds considera¬bly the number actually transfused. If the cross match-to-transfusion (C-T) ratio is high, the blood bank is bur-dened with keeping a large blood inventory, excessive personnel time,
From the Department of Pathology. Veterans Administration Medical Center and Louisiana State University Medical Center. New Orleans.
Reprint requests to Department of Pathology. VA Medical Center. 1601 Perdido St. New Orleans. LA 70146 (Or Sarma).

and high outdating of units.
The VA recommends that the blood bank director of each local facility study and analyze the pattern of blood use and develop guidelines for ordering blood for elective surgery. For the procedures in which the aver-age number of units transfused per case is 0.5 or less, determination of ABO-Rh type and a screen of the patient's serum for unexpected anti-bodies (typing and screening) is sug-gested in lieu of type and cross matching, provided ABO-Rh compati¬ble units are readily available.
This report will provide our experi-ence of blood use for elective surgical procedures in the VA Medical Center at New Orleans.
METHOD
-
For a 12-month period from Jan 1,1976, to Dec 31, 1976, the elective surgical proce-dures with blood ordered were tabulated to show the number of units of blood (whole blood and packed RBCs) cross matched vs the number of units trans-fused for each case. The units used may

have been transfused in the operating room or within 24 hours postoperatively. This information was summed and aver-aged for each procedure. Only those proce-dures performed five or more times are reported.
From these data a guideline for ordering typing and screening was prepared for those procedures using an average of 0.5 or less units per patient.
RESULTS
The results are shown in Table 1. The averages have been rounded off to the nearest 0.01 for each procedure, and the operations have been divided into subspecialties. Next to the name of operations, Table 1 shows the num¬ber of patients who were cross matched for that procedure vs the number of patients who were actually given transfusions. The next column shows the total number of units of blood cross matched vs the total num¬ber of units transfused. The number of cross-matched units divided by the number of transfused units gives the C-T ratio in the parentheses. The last column shows the average number of units cross matched per patient vs the average number of units used per patient cross matched.
Table 2 shows the list of surgical procedures under different subspe-cialties, where typing and screening is recommended. In all these cases, with exception of laminectomy, the aver¬age number of units transfused per



1536 JAMA. April 18. 1980—Vol 243. No. 15



Sarma DP (1980): Use of blood in elective surgery. JAMA 243:1536-1538. PMID: 7359736 [PubMed - indexed for MEDLINE]

Deba P Sarma, MD.,
Use of Blood in Elective Surgery


• A retrospective study of blood-ordering practices and blood use for elective surgical procedures at the Veterans Administration Medical Center of New Orleans shows a cross match-to-transfusion ratio of 4.29. To reduce this ratio, a guideline for ABO-Rh type and antibody screen (type and screen) is implemented. This avoids routine cross matching for those surgical procedures where blood is seldom transfused.
(JAMA 243:1536-1538, 1980)


A PROFESSIONAL letter in 1976 from the Department of Medicine and Surgery of the Veterans Administra¬tion raises concerns about ineffective use of blood. Once blood is cross matched for a specific recipient, it is held in a reserved status for that person and is not available to other patients. If this blood is not used, it may become outdated during the reserved period. In our hospital, this reserved period is usually 24 hours.
A second aspect relates to the growing realization that, for certain elective surgical procedures, the num¬ber of cross-matched units that are ordered frequently exceeds considera¬bly the number actually transfused. If the cross match-to-transfusion (C-T) ratio is high, the blood bank is bur-dened with keeping a large blood inventory, excessive personnel time,
From the Department of Pathology. Veterans Administration Medical Center and Louisiana State University Medical Center. New Orleans.
Reprint requests to Department of Pathology. VA Medical Center. 1601 Perdido St. New Orleans. LA 70146 (Or Sarma).

and high outdating of units.
The VA recommends that the blood bank director of each local facility study and analyze the pattern of blood use and develop guidelines for ordering blood for elective surgery. For the procedures in which the aver-age number of units transfused per case is 0.5 or less, determination of ABO-Rh type and a screen of the patient's serum for unexpected anti-bodies (typing and screening) is sug-gested in lieu of type and cross matching, provided ABO-Rh compati¬ble units are readily available.
This report will provide our experi-ence of blood use for elective surgical procedures in the VA Medical Center at New Orleans.
METHOD
-
For a 12-month period from Jan 1,1976, to Dec 31, 1976, the elective surgical proce-dures with blood ordered were tabulated to show the number of units of blood (whole blood and packed RBCs) cross matched vs the number of units trans-fused for each case. The units used may

have been transfused in the operating room or within 24 hours postoperatively. This information was summed and aver-aged for each procedure. Only those proce-dures performed five or more times are reported.
From these data a guideline for ordering typing and screening was prepared for those procedures using an average of 0.5 or less units per patient.
RESULTS
The results are shown in Table 1. The averages have been rounded off to the nearest 0.01 for each procedure, and the operations have been divided into subspecialties. Next to the name of operations, Table 1 shows the num¬ber of patients who were cross matched for that procedure vs the number of patients who were actually given transfusions. The next column shows the total number of units of blood cross matched vs the total num¬ber of units transfused. The number of cross-matched units divided by the number of transfused units gives the C-T ratio in the parentheses. The last column shows the average number of units cross matched per patient vs the average number of units used per patient cross matched.
Table 2 shows the list of surgical procedures under different subspe-cialties, where typing and screening is recommended. In all these cases, with exception of laminectomy, the aver¬age number of units transfused per



1536 JAMA. April 18. 1980—Vol 243. No. 15



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Published by: Deba P Sarma on Nov 23, 2009
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12/16/2014

 
Use
 of
 Blood
 in
 Elective
 Surgery
Deba
 P.
 Sarma,
 MD
A
 retrospective
 study
 of
 blood-ordering
 practices
 and
 blood
 use
 for
elective
 surgical
 procedures
 at
 the
 Veterans
 Administration
 Medical
 Center
of
 New
 Orleans
 shows
 a
 cross
 match-to-transfusion
 ratio
 of
 4.29.
 To
 reducethis
 ratio,
 a
 guideline
 for
 ABO-Rh
 type
 and
 antibody
 screen
 (type
 and
 screen)
is
 implemented.
 This
 avoids routine
 cross
 matching
 for
 those
 surgical
procedures
 where
 blood
 is
 seldom
 transfused.
(JAMA
 243:1536-1538,
 1980)
A
 PROFESSIONAL
 letter
 in
 1976
from
 the
 Department
 of
 Medicine
 and
Surgery
 of
 the
 Veterans
 Administra¬
tion
 raises
 concerns
 about
 ineffective
use
 of
 blood.
 Once
 blood
 is
 cross
matched
 for
 a
 specific
 recipient,
 it
 is
held
 in
 a
 reserved
 status
 for that
person
 and is
 not
 available
 to
 other
patients.
 If
 this
 blood
 is
 not
 used,
 it
may
 become
 outdated
 during
 the
reserved
 period.
 In
 our
 hospital,
 this
reserved
 period
 is
 usually
 24
 hours.
A
 second
 aspect
 relates
 to
 the
growing
 realization
 that,
 for
 certain
elective
 surgical
 procedures,
 the
 num¬
ber
 of
 cross-matched
 units
 that
 are
ordered
 frequently
 exceeds
 considera¬
bly
 the number
 actually
 transfused.
 If
the
 cross
 match-to-transfusion
 (C-T)
ratio
 is
 high,
 the
 blood
 bank
 is
 bur¬
dened
 with
 keeping
 a
large
 blood
inventory,
 excessive
 personnel
 time,
and
 high
 outdating
 of
 units.
The
 VA
 recommends
 that
 the
 bloodbank
 director
 of
 each
 local
 facility
study
 and
 analyze
 the
 pattern
 of
blood
 use
 and
 develop
 guidelines
 for
ordering
 blood
 for
 elective
 surgery.
For
 the
 procedures
 in
 which
 the
 aver¬
age
 number of
 units
 transfused
 per
case
 is
 0.5
 or
 less,
 determination of
ABO-Rh
 type
 and
 a
 screen
 of
 the
patient's
 serum
 for
 unexpected
 anti¬
bodies
 (typing
 and
 screening)
 is
sug¬
gested
 in
 lieu
 of
 type
 and
 cross
matching,
 provided
 ABO-Rh
 compati¬
ble
 units
 are
readily
 available.
This
 report
 will
 provide
 our
experi¬
ence
 of
 blood
 use
 for
 elective
 surgical
procedures
 in
 the
 VA
 Medical Center
at
 New
 Orleans.
METHOD
For
 a
 12-month
 period
 from
 Jan
 1,
 1976,
to
 Dec
 31,1976,
 the elective
 surgical
 proce¬
dures
 with
 blood
 ordered
 were
 tabulated
to
 show
 the
 number of
 units
 of
 blood
(whole
 blood and
 packed
 RBCs)
 cross
matched
 vs
 the number
 of
 units
 trans¬
fused
 for
 each
 case.
 The
 units
 used
 may
.
have
 been
 transfused
 in
 the
 operating
room
 or
 within
 24
 hours
 postoperatively.
This
 information
 was
 summed
 and
 aver¬
aged
 for
 each
 procedure.
 Only
 those
 proce¬
dures
 performed
 five
 or
 more
 times
 are
reported.
From
 these
 data
 a
 guideline
 for
 ordering
typing
 and
 screening
 was
 prepared
 for
those
 procedures
 using
 an
 average
 of
 0.5
 or
less
 units
 per
 patient.
RESULTS
The
 results
 are
 shown
 in
 Table
 1.
The
averages
 have
 been
 rounded off
to
 the
 nearest
 0.01
 for
 each
 procedure,
and
 the
 operations
 have
 been
 divided
into
 subspecialties,
 Next
 to
 the
 name
of
 operations,
 Table
 1
 shows
 the
 num¬
ber
 of
 patients
 who
 were
 cross
matched
 for that
 procedure
 vs
 thenumber of
 patients
 who
 were
actually
given
 transfusions.
 The
 next
 column
shows
 the
 total
 number
 of
 units
 of
blood
 cross
 matched
 vs
 the
 total
 num¬
ber
 of
 units
 transfused.
 The
 numberof
 cross-matched
 units divided
 by
 thenumber of transfused
 units
 gives
 the
C-T
 ratio
 in
 the
 parentheses.
 The
 last
column
 shows
 the
 average
 number
 ofunits
 cross
 matched
per
 patient
 vs
 the
average
 number of
 units
 used
 per
patient
 cross
 matched.
Table
 2
 shows
 the
 list
 of
 surgical
procedures
 under
 different
 subspe¬
cialties,
 where
 typing
 and
 screening
 is
recommended.
 In
 all
 these
 cases,
 with
exception
 of
 laminectomy,
 the
 aver¬
age
 number
 of
 units transfused
 per
From
 the
 Department
 of
 Pathology,
 Veterans
Administration Medical Center
 and
 Louisiana
State
 University
 Medical
 Center,
 New
 Orleans.
Reprint
 requests
 to
Department
 of
 Pathology,
VA
 Medical
 Center,
 1601
 Perdido
 St,
 New
Orleans,
 LA
 70146
 (Dr
 Sarma).
 
 at Creighton University Med Ctr on November 22, 2009 www.jama.comDownloaded from 
 
Table 1.—Blood
 Data
 for
 Elective
 Surgical
 Procedures,
 1976*
Patients
Cross
Matched
 vs
Patients
Given
Operations
Units
 Cross
Matched
 (C)
 vs
Units
 Trans¬
fused
 (T)
Transfusions
(C-T
 Ratio)
Av
 No.
 Cross
Matched
 perPatient
 vs
 Av
 No.
Used per
 PatientCross
 Matched
General
 surgery
Gastrectomy
 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
Orthopedics
Hip
 procedures
 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
Urology
Prostatectomy,
 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)
Neurosurgery
Laminectomy
 54/15
 130/29(4.48)
Cranlotomy
 60/11(5.45)
 4.29/0.79
Otolaryngology
Laryngectomy
 with
 or
 without
radical
 neck
 dissection
 87/30(2.90)
 4.14/1.43
Vascular
 surgery
Aortofemoral
 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
 or
 repair
 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
 surgery
Skin
 flap
 5/0
 10/0(0)
Total
 546/168
 1,689/394(4.29)
 3.09/0.72
'Total
 number
 of
procedures
 for which blood
 was
 ordered,
 775.
patient
 cross
 matched
 is
 less
 than
 0.5.
Of
 54
 patients
 cross
 matched
 for
laminectomy,
 one
 patient
 used
 4
 units
of
 blood,
 whereas
 others
 used
 1
 or
 2
units.
 After
 this
 particular
 patient
was
excluded,
 the
 average
 number
 of
units
 used
 per
 patient
 cross
 matched
was
 0.47.
COMMENT
Table
 1
 shows
 that
 the
 types
 of
elective
 surgical
 procedures
 are
fairly
limited
 in
 our
 institution,
 a
 580-bed,
general
 medical
 and
 surgical
 care
facility.
 The
 primary
 reason
 for
 this
limitation
 is
 that
 included
 in
 this
study
 were
only
 the
 surgical
 proce¬
dures
 with
 a
 blood
 order
 performed
five
 or
 more
 times
 during
 the
 12-
month
 period.
 Many surgical
 proce¬
dures,
 such
 as
 hernia
 repair
 and
 liver
biopsy,
 were
 done
 five
 times
 or more
during
 the
 period
 without
 an
 order
for
 blood,
 and
 they
 are
 excluded
 from
the
 study.
 The
 secondary
 reason
 is
that
 obstetric-gynecologic
 and
 pédiat¬
rie
 surgical
 procedures
 are
 not
 per¬
formed
 in
 our
hospital.
 Because
 of
 our
elderly
 patient
 population,
 there
 is
 an
unusually
 large
 number
 of
 certain
procedures
 such
 as
 transurethral
prostatectomy,
 mediastinoscopy,
 lam¬
inectomy,
 and
 aortofemoral
 bypass.
For
 below-knee
 amputations
 blood
 is
rarely
 required.
 Amputations
 in
 Ta¬
ble
 1
 consisted of
 primarily
 above-knee
 amputations.
The
 high
 C-T
 ratios
 for
 such
 proce¬
dures
 as
cholecystectomy,
 vagotomy,
spinal
 fusions,
 total
 knee,
 transure¬
thral
 prostatectomy,
 lithotomies,
laminectomy,
 craniotomy,
 mediasti-
Table
 2.—Elective
 Surgical
Procedures
 for
 Type
 and
 Screen
General
 surgery
Cholecystectomy
Vagotomy
Orthopedics
Spinal
 fusions
Iliac
 crest
 bone
 graft
Urology
Prostatectemy,
 transurethral
Lithotomies,
 ureterollthotomy
 and
pelvlllthotomy
NeurosurgeryLaminectomy
Vascular
 surgery
Arteriovenous
 fistula
Endarterectomy
Thoracic
 surgery
Mediastinoscopy
Plastic
 surgery
Skin
flap
noscopy,
 and
 thoracotomy
 observed
 in
this
 study
 have
 been
 also
 noted
 by
other
 observers.13
 An
 overall
 C-T
ratio
 of
 4.29
 for
 our
 institution
 in
 1976
is
 comparable
 to
 the
 C-T
 ratio
 of
 4.1
observed
 in the
 Los
 Angeles
 County-
University
 of
 Southern
 California
Medical
 Center.2
 This
 is
 unacceptably
high.
 Such
 a
 C-T
 ratio
 means
 that
 thenumber
 of units
 cross
 matched
 is
more
 than
 four
 times the number
 ofunits
 actually
 transfused. A
 C-T
 ratio
of
 2.5
 or
 less
 is
 more
acceptable
 in
 an
institution
 like
 ours
 where
 most
 of
the
 blood
 requests
 come
 from
 interns
and
 residents.
 To
 reduce
 the
 C-T
ratio,
 one
 should
 implement
 typing
and
 screening
 and
 not
 cross
matching
on
 specimens
 from all
 the
 procedures
where the
 average
 number
 of units
transfused
 per
 patient
 cross
 matched
is
 less
 than
 0.5.
 Table
 2
 shows
 this
 list
of
 procedures,
 which
 make
 up
 313
 of
775
 cases
 for
 which
 blood
 was
 orderedin
 1976.
 In
 other
 words,
 40%
 of
elective
 surgery
 cases
 with
 bloodordered
 in
 1976
 could
 have
 had
 typing
and
 screening
 rather
 than
 cross
matching.
 In
 terms
 of
 blood,
 this
means
 that
 727
 units of
 blood
 were
cross
 matched
 for
 these
 313
 cases,
 ofwhich
 only
 72
 units
 were
 transfused.
If
 typing
 and
 screening
 had
 been
 used
for
 these
 patients,
 the
 blood
 bank
would
 have
 been
 relieved
 of
 inventory
problems
 and
 screening
 would
 also
have
 helped
 to
 reduce
 outdating,
allowed
 for
 more
 efficient
 allocation
of
 technologists'
 time,
 and
 reduced
the
 overall
 cost
 of
 the
 blood
 bank's
operation.
The
 safety
 of
 typing
 and
 screening
has
 been
 adequately
 studied.45
 The
 
 at Creighton University Med Ctr on November 22, 2009 www.jama.comDownloaded from 

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