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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 7
| Issue : 2 | Page : 178-185 |
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A study to formulate maximum surgical blood order schedule at a Tertiary Care Referral Teaching Institute in Andhra Pradesh
Gudditi Sandhya, Bandi Suresh Babu, KV Sreedhar Babu, Arun Rajendran, Abha Chandra, Hulikal Narendra, Y Mutheeswaraiah, V Venkatarami Reddy, VV Ramesh Chandra, Nallabothula Anil Kumar, C Keerthi, C Ravikanth, G Prashanth
Department of Transfusion Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| Date of Submission | 08-Jul-2022 |
| Date of Decision | 21-Aug-2022 |
| Date of Acceptance | 07-Oct-2022 |
| Date of Web Publication | 5-Nov-2022 |
Correspondence Address:
Bandi Suresh Babu
Department of Transfusion Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/gjtm.gjtm_55_22
Background and Objectives: Blood transfusion is the mainstay of treatment for several serious illnesses, surgical, and trauma patients. The aim of this study is to develop maximum surgical blood order schedule (MSBOS) for surgeries in our institute to formulate certain guidelines to prevent the over-ordering of blood and promote reasonable ordering of blood. Patients and Methods: All the patients undergoing surgeries in General Surgery, Surgical Gastroenterology, surgical oncology, Cardiovascular and Thoracic Surgery, Neurosurgery, Urology, and Orthopedics Departments requesting blood were included in this study. Cross-match-to-transfusion (CT) ratios, transfusion probability (TP), and transfusion index (TI) were calculated for individual specialties and surgeries. Based on these parameters, MSBOS was formulated. Results: During the study period, a total of 2724 patients posted for elective surgical procedures necessitating blood among various surgical departments were included in the study. A total of 5812 units of packed red blood cells were requested and cross-matched for the study population. Among these, 1831 units were transfused with a blood utilization percentage of 31.50% (6%–60%). The overall CT ratio of our study was 4.21. The overall TP was 31.69% and the overall TI was 0.56. Conclusion: Implementation of MSBOS is helpful in achieving the goal of rational usage of blood. Based on the results, we grouped the surgical procedures which need type and screen, type and hold, and type and cross-match.
Keywords: Blood typing and cross-matching, surgical blood loss, transfusion
How to cite this article:
Sandhya G, Babu BS, Sreedhar Babu K V, Rajendran A, Chandra A, Narendra H, Mutheeswaraiah Y, Reddy V V, Ramesh Chandra V V, Kumar NA, Keerthi C, Ravikanth C, Prashanth G. A study to formulate maximum surgical blood order schedule at a Tertiary Care Referral Teaching Institute in Andhra Pradesh. Glob J Transfus Med 2022;7:178-85 |
How to cite this URL:
Sandhya G, Babu BS, Sreedhar Babu K V, Rajendran A, Chandra A, Narendra H, Mutheeswaraiah Y, Reddy V V, Ramesh Chandra V V, Kumar NA, Keerthi C, Ravikanth C, Prashanth G. A study to formulate maximum surgical blood order schedule at a Tertiary Care Referral Teaching Institute in Andhra Pradesh. Glob J Transfus Med [serial online] 2022 [cited 2023 Mar 28];7:178-85. Available from: https://www.gjtmonline.com/text.asp?2022/7/2/178/360489 |
| Introduction | |  |
Blood transfusion is the mainstay of treatment for several serious illnesses, surgical and trauma patients.[1] Providing safe blood is demanding in developing countries due to the scarcity of blood donors and because of unsuitable blood ordering and usage from clinicians.[2] With the progress made in the field of medicine and the advent of new technology, transfusion is safer than ever before; even then, like all therapeutic interventions it involves many significant and often unwanted side effects and underestimated risks.[3] The request for blood units for all patients in general and preoperative surgical patients, in particular, is often based on assumptions on an individual patient basis, following logical decisions as a habit than as per need, with potential for exhaustion of the blood center resources.[4]
It has been noticed that the preoperative ordering of blood often exceeds the original need leading to unnecessary cross-matching. The turnaround time and work required for cross-matching of each patient receiving a treatment both medically and surgically is considerable, out of which only a small amount is originally utilized for transfusion. Obvious excessive blood ordering is clearly seen, with results showing high blood cross-matched to the transfused ratio in most blood centers not following standard operating procedures for proper inventory management. Once cross-matched, the blood bag is held on hold resulting in inventory difficulties for blood centers, decreased availability for other patients, and possible wastage of blood units.[5] In this way, the blood bag received from the inventory for cross-matching remains elusive for other patients for the specified time period. Therefore, it is imperative to utilize this scanty and costly product reasonably.
Scarcity of blood is already a major problem, and in addition to that, the over-ordering of blood is imposing excessive demand on national and local blood transfusion services, thereby causing overburden on the blood center staff and extra financial burden to the blood center and to the patients.[3],[6]
Previously, some blood centers and hospitals had their own preoperative guidelines on the basis of which blood is used to be issued for surgeries according to the need of that specific surgeon, which resulted in over-ordering of the blood. At present also, there are no standard guidelines for the optimal utilization of blood.[7] Number of studies have started due to an increase in demand for blood and its blood components with rising transfusion-associated cost and morbidity to review appropriate utilization and usage of blood ordering practice.[8],[9]
Aims and objectives
With this background, this study plans to develop maximum surgical blood order schedule (MSBOS) for planned elective surgeries in the institute, to specify and formulate certain guidelines to prevent over-ordering of blood and to promote reasonable blood utilization as per the need of the surgery in our institute.
| Materials and Methods | | |
This prospective observational study was conducted at the Department of Transfusion Medicine, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, for a duration of 1 year from March 2020 to February 2021.
Ethical clearance
Institutional Ethics Committee Approval was obtained before starting the study (Roc. No.AS/11/IEC/SVIMS/2017) dated March 23, 2020.
Inclusion criteria
All the patients undergoing surgeries in general surgery (GS), surgical gastroenterology (SGE), surgical oncology (SO), cardiothoracic and vascular surgery (CTVS), neurosurgery (NS), urology and orthopedics departments for whom blood was requested were included in this study after obtaining written informed consent.
Exclusion criteria
The patients who requested blood components other than whole blood and packed red blood cells (PRBC), who were admitted to medical wards and the patients who had not given written informed consent were excluded from the study.
Methodology
All blood transfusion requests registered during the study period were analyzed, and the requests for PRBC were taken into the study. The related patient and transfusion details are documented in a Microsoft Excel sheet (Redmond, USA), and indices calculated are shown in [Table 1].[3]
The final table of MSBOS was formulated as follows if transfusion probability (TP) <30%, Type and Hold (T and H) was suggested. If TP >30% and patient required r3 units of blood, Type and Screen (T and S) was suggested. If TP >30% and if patient required r3 units of blood, Type and Cross-match (T and C) was suggested.
Statistical analysis
The data were analyzed with the Statistical Package for the Social Sciences (SPSS) version 26.0 (Redmond, Washington, USA).
| Results | | |
During the study period, a total of 2724 patients posted for elective surgical procedures necessitating blood among various surgical departments were included in the study [Figure 1]. Among the study population, males were 1505 (55.25%) and females were 1219 (44.75%). The age ranged from 2 to 95 years, majority of the patients were in the age group of >60 years (29.07%). [Table 2] shows the age distribution of patients among various surgical specialties. | Figure 1: Department wise distribution of patients. CTVS: Cardiothoracic and vascular surgery, GS: General surgery, NS: Neuro surgery, Ortho: Orthopedics, SGE: Surgical gastro enterology, SO: Surgical oncology
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 | Table 2: Age distribution of patients among different surgical specialities
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A total of 5812 units of PRBC were requested and cross-matched for the 2724 requested patients. Among these, 1831 units were transfused with blood utilization percentage of 31.50% (6%–60%). The overall cross-match/transfuse (C/T) ratio of our study was 4.21. The overall TP was 31.69%, and the overall transfusion index (TI) was 0.56.
Cardiothoracic and vascular surgery
Blood utilization from the department of CTVS was about 52%. All the procedures at CTVS had efficient usage of blood, with the overall C/T ratio, TP, TI, and MSBOS being 1.93, 70.08%, 2.01, and 3.01, respectively. Hence, we recommend T and S policy for all the procedures performed in the CTVS department as per formulation for MSBOS in our institute.
General surgery
Utilization rate of 18.18% was observed in the GS department in our study, denoting over-ordering of blood. All the procedures required only a single unit of PRBC as per MSBOS calculated in our study, and hence the implementation of T and H policy is the preferred policy for all procedures except for amputation, where T and C was preferred.
Neurosurgery
The blood utilization was 22.38%, and efficient blood usage was seen with clipping of aneurysm, kyphoplasty, and burr-hole evacuation procedures. The observed TP (40.08%) and TI (0.7) values reflect the appropriateness for transfusion and appropriateness for the number of units cross-matched; hence, the existing T and C policy can be continued in the NS department.
Orthopedics
The observed blood utilization rate was 60.37%. It is the highest blood-utilizing surgical specialty in our institute, and efficient blood usage was seen with all the procedures except ankle arthrodesis, with a C/T ratio of >2.5. TP (66.33%) and TI (0.94) values reflect appropriateness for transfusion and for the number of units cross-matched; hence, existing T and C policy can be continued in the orthopedics department.
Surgical gastroenterology, surgical oncology
Blood utilization rates were similar in both SGE and SO specialties, with 25.35% and 24.55%, respectively. In both specialties, efficient blood usage was not found, but TP and TI values reflect appropriateness for transfusion and appropriateness for the number of units cross-matched, and hence, no changes are made from the existing cross-matching policy in these specialties. However, for common bile duct (CBD) exploration, longitudinal pancreatic jejunostomy, triple bypass, and hemicolectomy in SGE and for feeding jejunostomy, penectomy, thyroidectomy, and laryngectomy in SO, T, and H policy is recommended.
Urology
Poor blood utilization rate of 6.15% was observed in the urology department with a C/T ratio of higher values (16.26), TP (6.23%), and TI values (0.1), showing inappropriateness, and hence, the preferred policy was T and H policy.
The C/T ratio, TP, TI, MSBOS, and suggested policies of various elective procedures are shown in [Table 3],[Table 4],[Table 5],[Table 6],[Table 7],[Table 8]. | Table 3: Cross-match-to-transfusion ratio, transfusion probability, transfusion index, maximum surgical blood order schedule, and suggested policies of various elective procedures of cardiothoracic and vascular surgery and general surgery
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 | Table 4: Cross-match-to-transfusion ratio, transfusion probability, transfusion index, maximum surgical blood order schedule, and suggested policies of various elective procedures of neurosurgery
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 | Table 5: Cross-match-to-transfusion ratio, transfusion probability, transfusion index, maximum surgical blood order schedule, and suggested policies of various elective procedures of orthopedics
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 | Table 6: Cross-match-to-transfusion ratio, transfusion probability, transfusion index, maximum surgical blood order schedule, and suggested policies of various elective procedures of surgical gastroenterology
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 | Table 7: Cross-match-to-transfusion ratio, transfusion probability, transfusion index, maximum surgical blood order schedule, and suggested policies of various elective procedures of surgical oncology
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 | Table 8: Cross-match-to-transfusion ratio, transfusion probability, transfusion index, maximum surgical blood order schedule, and suggested policies of various elective procedures of urology
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| Discussion | | |
The study aimed to assess the blood component usage in various surgical departments and to study the blood utilization pattern for the common surgeries performed in various surgical departments of our institute.
Cardio thoracic and vascular surgery
In our study, effective blood usage denoted by an overall C/T ratio of 1.93, appropriateness for transfusion (70.08%) as well as for units cross-matched (2.01) were found for all the procedures of the CVTS department. The findings are similar to the studies done by Kuchhal et al.,[10] Thabah et al.,[11] and Hashemi et al.[12]
General surgery
The findings of our study are similar to the findings of a study done by Hashemi et al., as effective blood usage (C/T ratio) and appropriateness for transfusion (TP) and appropriateness for units cross-matched (TI) were found only for one procedure, i.e., amputation.[12]
Neurosurgery
In our study, the overall C/T ratio for neurosurgical procedures is 4.46, denoting inappropriate blood order, which is similar to a study by Saringcarinkul and Chuasuwan[13] showed high C/T ratios. The TP and TI values were within defined limits for all the neurosurgical procedures indicative of the appropriateness of transfusion and appropriateness of units cross-matched, which is similar to the studies done at Guilan University of Medical Sciences, Rasht, Iran (TP = 76.42%, TI = 1.07).[14]
Orthopedics
In our study, the overall C/T ratio was 1.66, which is similar to a study by Kumari et al.[1] in which the overall C/T ratio was 2.1. Appropriateness of blood transfusion and appropriateness of blood units cross-matched with TP and TI values for open reduction and internal fixation (ORIF) femur fracture – 72.33% and 1.08, total knee replacement (TKR) – 51.06% and 0.61, ORIF for tibia and fibula fracture – 81.82% and 1.04, total hip replacement – 80% and 1.01, respectively, were observed in our study which is similar to the study by Thabah et al.[11]
Surgical gastroenterology
Efficient usage with a C/T ratio of 2.25 was found only for cystogastrostomy in our study. Appropriateness of blood transfusion and appropriateness of blood units cross-matched was found for all procedures of SGE except for CBD exploration and colostomy closure with TP values of 19.23% and 10%, respectively, and TI values of 0.38 and 0.2, respectively, in our study which is similar to the study by Thabah et al. whose findings for CBD exploration and colostomy closure with TP values of 25% and 0%, respectively, and TI values of 0.28 and 0, respectively.[11]
Surgical oncology
Effective blood ordering was found for only one procedure, abdominoperineal resection (APR), out of the 15 procedures included in our study; this is in contrast to a study done by Hashemi et al. where effective blood usage was seen for almost all procedures of SO.[12] The TP findings of our study are similar to a study done by Karki, as the appropriateness of blood transfusion was found for almost all the procedures in both studies.[15] The TI findings are also similar to a study done by Karki with low TIs for gastrectomy, modified radical mastectomy, and thyroidectomy being 0.07, 0.21, and 0.2, respectively, and high TIs for Whipple's procedure, APR and resection being 3, 1.8, and 0.71 respectively as the appropriateness of units cross-matched was found for half of the procedures in both the studies.[15]
Urology
Effective blood ordering and appropriateness of blood transfusion and units cross-matched were not found for any of the procedures in the urology department, similar to a study by Hashemi et al.[12] The C/T ratio, TP, and TI of 16.26, 6.23%, and 0.10, respectively, found in our study are in contrast to a study by Karki, in which the C/T ratio, TP and TI were 3, 53% and 0.66, respectively.[15]
Comparative analysis of MSBOS in various surgeries among present study and previous studies is shown in the [Table 9],[Table 10],[Table 11][16],[17],[18],[19]. | Table 9: Comparative analysis of maximum surgical blood order schedule in various surgeries of cardiothoracic and vascular surgery, neurosurgery, and surgical gastroenterology with the present study and previous studies
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 | Table 10: Comparative analysis of maximum surgical blood order schedule in various surgeries of urology and surgical oncology with the present study and previous studies
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 | Table 11: Comparative analysis of maximum surgical blood order schedule in various surgeries of general surgery and orthopedics with the present study and previous studies
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| Conclusion | | |
Based on the indices obtained in our study, we tried to group surgeries into those which need T and S, those which need T and H, and those which need T and C. This might be helpful in achieving the goal of rational usage of blood by developing MSBOS. In coordination with the surgeons and anesthesiologists, MSBOS will be implemented, and time to time review of its implementation will be done for the proper usage of blood and blood components.
Limitations
Various factors, such as patient's age, the severity of diseases, and other clinical comorbid conditions, were not taken into consideration in our study. Hence, we were not able to make patient-specific blood order schedules for all the surgeries.
Although obstetrics and gynecology is one of the major blood-utilizing departments yet, as it is recently established at our institute and performing only minimal surgeries, we did not consider this department for formulating MSBOS.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]
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