Use of Blood in Elective

Deba P. Sarma, MD

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
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.

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 If this blood is not used, it may become outdated during the reserved period.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 (Dr 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.
to Dec


12-month period from Jan 1, 1976, 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

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

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Table 1.—Blood Data for Elective

Surgical Procedures, 1976*
Units Cross Matched (C) vs Units Trans¬ fused (T)
Av No. Cross

General surgery

Patients Cross Matched vs Patients Given Transfusions

Table 2.—Elective Surgical Procedures for Type and Screen
General surgery

(C-T Ratio)
144/25(5.78) 131/37(3.54) 73/6(12.17) 29/9(3.22) 17/1(17.0) 127/58(2.19) 31/11(2.82) 27/3(9.0) 22/12(1.83) 17/4(4.25) 12/0(0) 319/28(11.39) 16/6(2.67) 25/11(2.27) 22/4(5.50) 30/2(15.0) 130/29(4.48) 60/11(5.45) 87/30(2.90) 136/62(2.19) 25/0(0) 20/0(0) 43/16(2.69) 64/3(21.33) 47/12(3.92) 25/14(1.79) 10/0(0) 1,689/394(4.29)

Matched per Patient vs Av No. Used per Patient Cross Matched

Gastrectomy Laparotomy Cholecystectomy Colectomy Vagotomy Orthopedics Hip procedures Amputations Spinal fusions Open reduction
Total knee

31/14 30/5


Cholecystectomy Vagotomy Orthopedics Spinal fusions Iliac crest bone graft Urology Prostatectemy, transurethral Lithotomies, ureterollthotomy pelvlllthotomy Neurosurgery Laminectomy
Vascular surgery



Arteriovenous fistula


2.08/0.23 Thoracic surgery

Plastic surgery Skin flap
2.00/0 2.22/0.19 3.20/1.20


Iliac crest bone graft

Urology Prostatectomy, transurethral Prostatectomy (suprapubic, perineal) Nephrectomy Urethroplasty Lithotomies (uretero-, pyelo-) Neurosurgery Laminectomy Cranlotomy Otolaryngology Laryngectomy with or without
radical neck dissection Vascular surgery Aortofemoral bypass Arterlovenous fistula

12/2 54/15



4.14/1.43 5.04/2.30 2.08/0

Endarterectomy Aneurysm resection
Thoracic surgery





Medlastinoscopy Thoracotomy Lobectomy
Plastic surgery Skin flap



'Total number of




for which blood



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.

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 12month 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 aboveknee amputations. The high C-T ratios for such proce¬ dures as cholecystectomy, vagotomy, spinal fusions, total knee, transure¬ thral prostatectomy, lithotomies, laminectomy, craniotomy, mediasti-

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 CountyUniversity of Southern California Medical Center.2 This is unacceptably high. Such a C-T ratio means that the number of units cross matched is more than four times the number of units 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 ordered in 1976. In other words, 40% of elective surgery cases with blood ordered 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, of which 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

noscopy, and

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medical director of the blood bank bears the full responsibility of dis¬ seminating the information and con¬ vincing the physicians of the impor¬ tance and the purpose of typing and screening. Most of the physicians still believe in the traditional "routine 2 unit type and cross match." Once the procedure is explained, ie, that typed and screened blood is 99.99% safe in regard to avoiding the transfusion of incompatible blood,45 and that blood will be available on demand if needed for patients who have previously only had typing and screening, then the physicians are enthusiastically sup¬ portive of this substitution. As of this date, our guideline for typing and screening has been fully imple¬ mented. An adequate number of units of blood is being kept in the inventory to cover the typing and screening cases. If the screening uncovers any irregular antibody, it is identified, and few units of blood that have been

screened for the corresponding anti¬ gen for which the patient has the

antibody Anytime


been typed and screened needs blood in an emergency, it is immediately dispatched, and cross matching is started at the same time. Physicians have also been instructed that the guideline is only for routine cases. For any unusual or high-risk patient, cross matching rather than a typing and screening procedure should be
After the physicians accept the concept of typing and screening, the

kept in the blood bank. patient whose blood has


individual chiefs of different subspecialties of surgery are consulted. By mutual discussion and understanding, additional guidelines for ordering blood for typing and cross matching for elective surgical procedures are then prepared. The data from Table 1 are used to formulate these guide¬ lines. Many surgeons believe that it is

the responsibility of the primary phy¬ sicians to decide how many units of blood should be ordered for the patients. Pathologists, who are not directly taking care of the patients, traditionally do not set guidelines for primary care physicians. To settle this issue, the blood bank director must openly communicate and jointly develop the guidelines for the clinical services. Otherwise, chances of suc¬ cessful implementation of such guide¬ lines are slim. The guidelines for typing and cross matching for most of the subspecialties have been prepared and implemented; but, because they


included in this report. Implementa¬ tion of guidelines for typing and screening and for typing and cross matching, if done in two phases, seems to be more easily understood and accepted by the physicians.

totally complete, they



State J Med 76:532-537,1976. 2. Rouault C, Gruenhagen J: Reorganization of blood ordering practices. Transfusion 18:448\x=req-\ 453, 1978.

1. Mintz PD, Nordine RB, Henry JB, et al: Expected hemotherapy in elective surgery. NY

3. Boral LI, Dannemiller FJ, Stanford W, et al: A guideline for anticipated blood usage during elective surgical procedures. Am J Clin Pathol 71:680-684, 1979. 4. Boral LI, Henry JB: The type and screen: A safe alternative and supplement in selected

surgical procedures. Transfusion 17:165-170,

1977. 5. Boral LI, Hill SS, Apollon CJ, et al: The type and screen, revisited. Am J Clin Pathol


April 15,

public institutions from the control politicians. This goes further than our suggestion, since it involves the 2,500 or more positions in the penal and charitable


institutions, most of which are not filled by physicians. It is plain, however, that the filling of these places also with experts
would be in the line of medical progress. How are we to obtain these experts? That is the question which another bill now before the Illinois legislature undertakes to solve. This bill provides an appropria¬ tion of $15,000 yearly for the training of state employees in and by the State Uni¬

Special Training

for Employees in State Institutions




the need of expert pointed out knowledge and of special training for the administrative work of public institutions and of public boards. So palpable has been the deterioration of many public charita¬ ble institutions under the recurring politi¬ cal changes of the last dozen years that public opinion has compelled the introduc¬ tion into the present legislature of a bill for a state merit law. As the agitation has been great enough to pledge both political parties and the governor of the state


versity. Any training of experts for public ser¬ vice is still more or less experimental in
this country; but this measure which actu¬ ally provides that the university shall take a hand in the training of a prison guard or of an asylum attendant is bold, indeed. It will seem to the Philistine foolishness and to the politician a stumbling block, but to the student of criminal psychology and to the alienist it will seem a welcome public recognition of a condition that should be remedied. Every one at all acquainted with hospitals for the insane knows that the physician can only give the briefest per¬ sonal attention to each patient and that


to such a measure, we may

a law will be secured which will protect all the appointments to the


the whole system of treatment depends for its efficacy on the attendant. In the same way it is the prison guard—the shop foreman—in whose hands, if anywhere, the reformation of the prisoner must lie. Yet these positions are filled by peo¬ ple chosen haphazard or, worse, "pulled" in.. The training ought certainly to be prac¬ tical, the student should be given a happy balance of clinical work and of theoretical teaching. There should be enough theory to make him understand the clinic and respect his task. We judge that much of the instruction would necessarily be given in the form of lectures by experts in the institutions themselves. Whatever the methods which experience might develop for the suggested teaching, the very pro¬ posal puts a new face on the otherwise cold and barren aspect of a civil-service law, whose more obvious virtues are merely negative. To keep plundering and igno¬ rance out of public institutions should not be sufficient to satisfy us. We must fill these institutions with medical spirit and with scientific ardor. We must demand for the baffling task of restoring the mentally and morally sick the finest ability and the best training.
. .

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