New horizons for reduction of blood use: Patient blood management.

A countrywide study over the eras indicates overuse of blood transfusion can have considerable risks to patients accompanied by significant costs of blood transfusion for patients, hospitals, and health-care systems. Besides, more than 30% of the world's population is anemic. Typically, blood transfusion helps continue suitable oxygen transfer in anemia, i.e., more and more documented as a threatening factor with several adverse outcomes including long hospitalization, morbidity, and mortality. Transplantation of allogeneic blood is thus like a two-edged sword. There is no doubt that the blood transfusion is a life-saving treatment, but it should be underpinned by much of up-to-date health-care services. The new theory considered for patient blood management (PBM) also discusses the timely application of evidence-based surgical and clinical theories and focuses on patient outcomes. Furthermore, PBM involves a multidisciplinary methodology to reduce unnecessary transfusions, minimize costs, and cut risks.

Perioperative transfusion analysis and blood ordering schedule update for total knee arthroplasty / 中国输血杂志

【Objective】 To investigate the perioperative rate of allogeneic red blood cell (RBC) transfusion in patients who underwent total knee arthroplasty (TKA) and its risk factors, and to identify its cross-match to transfusion ratio (C∶T ratio). 【Methods】 Anesthetic data of patients who underwent TKA from January 2014 to October 2019 in Peking Union Medical College Hospital were collected and analyzed retrospectively. Perioperative allogeneic RBC transfusion rate was calculated, and binary Logistic regression analysis was performed to identify its risk factors in these patients. The overall C∶T ratio was calculated and divided into subgroups based on surgery type and age group. 【Results】 The study enrolled 2 903 patients. The perioperative rate of allogeneic RBC transfusion in TKA patients was 10.9% (95% CI 9.8%~12.0%) and overall C∶T ratio was 5.6∶1. The independent risk factors leading to perioperative allogeneic RBC transfusion included advanced age(OR=1.025, 95% CI 1.009~1.042, P<0.01), preoperative hemoglobin level(OR=0.966, 95% CI 0.954~0.978, P<0.001), preoperative anemia(OR=3.543, 95% CI 2.052~6.119, P<0.001), hematological diseases(OR=6.462, 95% CI 2.479~16.841, P<0.001), bilateral surgery(OR=7.681, 95% CI 5.759~10.245, P<0.01) and revision surgery(OR=9.584, 95% CI 4.360~21.065, P<0.001). 【Conclusion】 The risk factors for perioperative allogeneic RBC transfusion in TKA patients included advanced age, preoperative low hemoglobin level, preoperative anemia, hematological diseases, bilateral surgery and revision surgery. Only type and screen tests are recommended if patients receiving unilateral primary TKA surgery are less than 75 years old without anemia and hematological diseases, while at least one to four units of blood should be cross-matched if patients are with preoperative anemia and hematological diseases or will receive bilateral and revision arthroplasty.

Establishment of the maximum surgical blood order schedule for cesarean sections / 中国输血杂志

【Objective】 To establish the catalog of maximum surgical blood order schedule(MSBOS) for cesarean sections with different obstetric complications, so as to guide the doctors of clinical and Blood Transfusion Department to prepare blood reasonably. 【Methods】 The blood transfusion data during cesarean sections from January to October 2021 in our hospital were collected via medical record information system and blood bank system.The blood recipients were classified according to the main obstetric complications. The incidence of blood transfusion, per capita RBC transfusion units, blood transfusion index (TI) and other indicators were calculated, the literature and the risk of massive hemorrhage were referred, and the actual situation of Obstetrics Department was considered to formulate the obstetric MSBOS of our own. 【Results】 1) The blood recipients during cesarean sections were mainly diagnosed as placental abruption, placental implantation, central placenta previa and severe preeclampsia; the incidence of blood transfusion of them was 17.9%(20/112), 17.7%(15/85), 16.8% (27/161)and 5.2%(9/173), respectively, and TI indexes was 0.9, 1.3, 1.0 and 0.3, respectively. 2) The MSBOS of Obstetrics Department in our hospital had been established, and the blood preparation for obstetric surgery was divided into three categories: T(blood typing)/S(antibody screening), T(blood typing)/S(antibody screening)/C(crossmatch) 2 U, and T/S/C 4 U. 【Conclusion】 The establishment of MSBOS in Obstetrics Department of our hospital provides references for preparing blood reasonably.

A Prospective Single Centre Study of Preoperative Blood Ordering Versus Actual Usage Among Patients Undergoing Elective Curative Oncological Resections in a Tertiary Care Hospital in India.

This study was a prospective, observational study aimed to look at the preoperative ordering schedule, pattern of usage of blood products for elective oncological surgeries in order to develop an institutional maximal surgical blood ordering schedule (MSBOS) in a tertiary university setting teaching Hospital. All biopsy proven, consenting, cancer patients of age 18 to 80 years who underwent elective curative cancer surgery over a period of 1 year were included. Various details such as nature of procedure, preoperative haemoglobin, intraoperative blood loss, duration of surgery, and number of units cross-matched and used were recorded and analysed. For each procedure, cross-match to transfusion (CT) ratio, transfusion index (TI), and transfusion probability (T%) were calculated using standard formulas. In all, 740 patients underwent elective curative cancer surgery in 1 year, majority being women and head and neck cancer being most common site. Overall, 312 patients received blood or component transfusion in the intraoperative and/or postoperative (within 48 h) period constituting 42% of all patients, although 70% of patients had preserved packed cells and 55% had preserved fresh frozen plasma (FFP). Cross-matching of blood was adequate only in cases of liver surgeries, maxillectomy, staging laparotomy for ovarian carcinoma, and urological malignancies with a desirable CT ratio falling within 2.5. An institution specific-MSBOS was developed. The study found a significant over-ordering of blood products. By implementing MSBOS, one can plan the collection and stocking of blood products thereby saving money, labour, and time.

Transfusion Requirements and Blood Bank Support in Heart and Lung Transplantation.

OBJECTIVE: Transplantations may require massive transfusion of blood products. Therefore, blood banks need to predict, prepare, and supply the required amount of blood products. METHODS: We measured the volume of transfused blood components as red blood cells, fresh frozen plasma, platelets, and cryoprecipitate in 54 and 89 patients who received heart and lung transplantation, respectively, in our hospital between January 2012 and December 2019. RESULTS: Platelets were the most frequently transfused blood component. Transfusion volumes during heart and lung transplantation surgeries differed: red blood cells, 7.83 units vs 14.84 units; fresh frozen plasma, 2.67 units vs 12.29 units; platelets, 13.13 units vs 23.63 units; and cryoprecipitate, 1.74 units vs 2.57 units; respectively. The average transfusion volume of transplants was different each year. CONCLUSION: Periodic evaluation of transfusion requirements will facilitate the efficient management of blood products at the time of transplantation and help blood banks predict changes in blood requirements.

Current situation of surgical blood ordering and value of optimizing preoperative blood ordering / 中国输血杂志

【Objective】 To retrospectively analyze the situation of surgical blood ordering in our hospital and explore the value of optimizing preoperative blood ordering. 【Methods】 Surgical blood ordering and utilization data of West China Hospital of Sichuan University from 2012 to 2018 were gathered to evaluate the rationality of preoperative blood ordering by calculating the indicators including transfusion rate, transfusion probability, transfusion index etc. and recommend preoperative blood ordering guided by transfusion index ≥ 0.3, the transfusion rate ≥ 5%, and the transfusion index ≥ 0.5 respectively to calculate the cost saved. 【Results】 1) The preoperative blood ordering of Department of Cardiac Surgery and Burn Plastic Surgery were relatively rational, while other Surgery Departments was excessive, especially the Thoracic Surgery; 2) Among the top fifteen surgeries ranked by blood ordering rate, the blood ordering was rational for mitral valve replacement, ventricular septum (repair/occlusion), and aortic valve replacement, while excessive for other 12 surgeries, especially for lung resection surgery; 3) The surgical blood ordering guided by the three indicators can reduce 19% ~80% theoretically, saving 0.39~1.28 million yuan per year. 【Conclusion】 Preoperative blood ordering of the Department of Cardiac Surgery and Burn Plastic Surgery in our hospital is relatively rational. While excessive blood ordering exists in other surgical departments, especially for thoracic surgery. The establishment of Maximum Surgical Blood Order Schedule can reduce unnecessary blood ordering and improve blood utilization, and save manpower and material resources, and reduce the costs of patients.

Wastage of Blood Units at Tertiary Care Hospitals of Lahore.

INTRODUCTION:  Blood and its products are the most valuable resource in every healthcare institution. Judicial use of these limited resources is necessary and important to maintain sufficient supply. Blood products and its transfusion system are being evaluated by the use of several markers. The use of crossmatch to transfusion ratio (C/T) was first proposed by Boral Henry in 1975. Nowadays, the C/T ratio is being used by researchers to assess transfusion practices. Ideally, (C/T) ratio has to be 1.0 but it has been suggested that a ratio of 2.5 or less would indicate effective blood use. OBJECTIVE: To assess crossmatch to transfusion ratio (C/T ratio), transfusion probability (%T), and transfusion index (TI) in patients of medical and surgical wards. To assess the wastage of blood components/whole blood units. METHODS:  A cross-sectional study was conducted at Mayo Hospital/King Edward Medical University, Lahore, Services Hospital Lahore, and Alkhidmat Blood Bank Surrayya Azeem Hospital between January 2019 and June 2019. Nonprobability convenient sampling was performed and all collected data were entered and analyzed by using statistical package for social sciences (SPSS version 20). RESULTS:  The total patients who were ordered to arrange blood were 1322 for which overall 2715 crossmatches had been done. Among these crossmatches, a total of 1536 of the donors were bled for from which only 815 units had been transfused to the patients. Overall C/T ratio was found to be 3.33 and the overall wastage was 38.9%. CONCLUSIONS:  Blood transfusion is considered useful in the management of surgical as well as medical patients. Too many units are ordered out of which the majority are wasted due to nonutilization. There is a need for standard operating procedures for transfusion of blood. There shall be regular audits to improve the blood collection, treatment, delivery, and usage practices of this scarce resource.

Review of the Abstracts on Advances in Transfusion Medicine at Hematocon 2018.

Research issues are gradually being focussed upon in the fast evolving discipline of blood transfusion services (BTS), that was initially focussed on development of a safe and adequate blood and blood component supply. The poster presentations of ongoing research in the BTS at the Haematocon 2018 dwelt upon the knowledge, attitude and practice studies with reference to voluntary blood donation, analysis of the reasons for blood donor deferral, role of donor infectious disease screening towards early clinical intervention in the asymptomatic blood donor, the clinical trigger for red blood cells transfusion and its effect on length of stay in hospital and morbidity, maximum surgical blood ordering schedule, massive transfusion and alloimmunization apart from granulocyte transfusion and internal audit of platelet usage in BTS. Research across all dimensions of the BTS covering the entire spectrum from donors' vein to the recipients' completing the "vein to vein" transfusion chain in the Indian context will help generate evidence to lay a sound foundation for the blood services.

Excessive quantities of red blood cells are issued to the operating room.

OBJECTIVES: To determine what percentage of red blood cell (RBC) units that were issued to the operating room (OR) were returned unused, and to determine how often all of the RBCs that were issued for a patient were returned unused using the institution's maximum surgical blood ordering schedule (MSBOS) as a guide. BACKGROUND: The MSBOS provides guidelines for blood ordering, but is merely a suggestion for the ordering clinicians. This study examined how closely ordering practices followed the MSBOS, and how often ordered RBCs were actually transfused. METHODS: For a 4-week period, RBC issue and utilization data were collected on elective surgery patients who were eligible for electronic cross-match at a tertiary care hospital. These data were compared to the MSBOS. RESULTS: There were 1350 surgical procedures performed. Of these cases, 439 patients had a type and screen (T&S) performed, and 215/439 (49%) patients had at least 1 RBC issued during their case. To these 215 patients, 742 RBC units were issued and 537/742 (72%) of these units were returned to the blood bank unused. In 152/215 (71%) cases with issued RBCs, all of the RBCs were returned to the blood bank unused. Amongst the surgical categories in this study, the percentage of cases where none of the issued RBCs were transfused ranged from 38 to 93%. CONCLUSIONS: Significant numbers of RBC units are issued but not transfused during surgery. Involving the surgical team in the blood issuing process and using a data-driven MSBOS may reduce the number of unused units.

[Preoperative blood ordering in elective colon surgery: requirement or routine?]. / Solicitud de sangre preoperatoria en cirugía programada de colon: ¿necesidad o rutina?

BACKGROUND: Preoperative blood ordering is frequently in elective colon surgery, even for procedures that rarely require blood transfusion. Most often this procedure is performed without proper analysis of the real needs. The aim of this study was to evaluate the patients who receive transfusion and determining their associated factors. METHODS: Retrospective study of all consecutive patients scheduled for elective colon surgery was carried out at 2007-2012. Several clinico-pathological and surgical variables were analyzed and predictive blood transfusion indices such as the cross-matched/transfusion ratio (C/T ratio), transfusion index and transfusion probability were calculated. Patients were divided in 2 groups according have received perioperative surgical transfusion or not. RESULTS: There were 457 surgery patients. A total of 171 blood units, in a 74 patients were perioperative transfused. Overall cross-matched transfused ratio was 5.34, the transfusion probability 162%, and the transfusion index 0.18. Variables that were significantly associated with receiving blood transfusion in a multivariable analysis were a preoperative haemoglobin level less than 10 g/dl (OR: 309.8; 95% CI: 52.7-985.2), chronic pulmonary obstructive disease (OR: 3.7; 95% CI: 1.3-10.7), oral anticoagulant therapy (OR: 5.7; 95% CI: 1.7-19.4) and surgical time over 120 min (OR: 10.7; 95% CI: 4.7-24.1). CONCLUSIONS: Likelihood of receiving perioperative transfusion in elective colon surgery is very low. Among their associated factors, the haemoglobin level less than 10 g/dl is the one with strongest association. Those patients with such low preoperative haemoglobin level should not be scheduled for elective colon surgery until they received specific treatment.

Blood Transfusion Policies in Elective General Surgery: How to Optimise Cross-Match-to-Transfusion Ratios.

OBJECTIVE: Preoperative over-ordering of blood is common and leads to the wastage of blood bank resources. The preoperative blood ordering and transfusion practices for common elective general surgical procedures were evaluated in our university hospital to formulate a maximum surgical blood order schedule (MSBOS) for those procedures where a cross-match appears necessary. METHODS: We evaluated blood ordering practices retrospectively in all elective general surgical procedures in our institution over a 6-month period. Cross-match-to-transfusion ratios (C:T) were calculated and compared to current trust and the British Society of Haematology (BSH) guidelines. The adjusted C:T ratio was also calculated and was defined as the C:T ratio when only cross-matched blood used intraoperatively was included in the calculation. RESULTS: 541 patients were identified during the 6-month period. There were 314 minor and 227 major surgeries carried out. 99.6% (n = 226) of the patients who underwent major surgery and 95.5% (n = 300) of the patients having minor surgery had at least a group and save (G and S) test preoperatively. A total of 507 units of blood were cross-matched and 238 units were used. The overall C:T ratio was therefore 2.1:1, which corresponds to a 46.9% red cell usage. There was considerable variation in the C:T ratio, depending on the type of surgery performed. The adjusted C:T ratio varied between 3.75 and 37. CONCLUSIONS: Compliance with transfusion policies is poor and over-ordering of blood products commonplace. Implementation of the updated recommended MSBOS and introduction of G and S for eligible surgical procedures is a safe, effective and cost-effective method to prevent preoperative over-ordering of blood in elective general surgery. Savings of GBP 8,596.00 per annum are achievable with the incorporation of updated evidence-based guidelines in our university hospital.

Maximum surgical blood ordering schedule in a tertiary trauma center in northern India: A proposal.

CONTEXT: Over ordering of blood is a common practice in elective surgical practice. Considerable time and effort is spent on cross-matching for each patient undergoing a surgical procedure. AIMS: The aim of this study was to compile and review the blood utilization for two key departments (Neurosurgery and Surgery) in a level 1 trauma center. A secondary objective was to formulate a rational blood ordering practice for elective procedures for these departments. MATERIALS AND METHODS: Analysis of prospectively compiled blood bank records of the patients undergoing elective surgical, neurosurgical procedures was carried out between April 2007 and March 2009. Indices such as the cross-matched/transfused ratio (C/T ratio), transfusion index and transfusion probability were calculated. The number of red cell units required for each procedure was calculated using the equation proposed by Nuttall et al, using preoperative hemoglobin and postoperative hemoglobin for each elective surgical procedure. RESULTS: There were 252 surgery patients (age range: 2-80 years) in the study. One thousand and eighty-eight units of blood were cross-matched, 432 were transfused (CT ratio 2.5). 44.0% patients did not require transfusion during entire hospital stay. Three (50%) elective procedures had CT ratio >2.5and 4 (66.6%) elective procedures had TI <0.5. There were 200 neurosurgery patients (age range: 2-62 years) in the study. Total 717 units of blood were cross-matched and 161 transfused (CT ratio 4.5). Nine elective procedures had CT ratio >2.5, with five of them exceeding 4. In procedures like spinal instrumentation the CT ratio was <2.5 and 10 (90.9%) of elective procedures had TI <0.5. CONCLUSIONS: In this study 40% and 22% of cross-matched blood was being utilized for elective general surgery and neurosurgical procedures, respectively. The calculated required blood units for all elective Trauma surgery procedures were more than 2 units. The calculated required blood units were less than 0.5 units in four of the 11 neurosurgical procedures, and hence only one unit should be arranged for them. It is crucial for every institutional blood bank to formulate a blood ordering schedule. Regular auditing and periodic feedbacks are also vital to improve the blood utilization practices.

Reviewing the blood ordering schedule for elective orthopedic surgeries at a level one trauma care center.

BACKGROUND: Patients undergoing elective orthopedic surgeries often incur excess blood loss necessitating transfusion. The preoperative placement of blood requests frequently overshoots the actual need resulting in unnecessary crossmatching. AIMS: Our primary goal was to audit the blood utilization in elective orthopedic surgeries in our hospital over a 1-year period and recommend a blood ordering schedule. MATERIALS AND METHODS: A retrospective analysis of patients who underwent elective orthopedic surgeries over a period of 1 year was done. The data collected include patients' age, sex, type of surgical procedure, pre- and postoperative hemoglobin (Hb) levels, number of units crossmatched, returned, transfused, crossmatch to transfusion ratio (C:T), transfusion indices, estimated blood loss for each surgical procedure, and the actual and predicted fall in Hb. We propose a blood ordering schedule based on surgical blood ordering equation. RESULTS AND CONCLUSIONS: A total of 487 patients with a median age of 37±17 years (mean ± standard deviation) were evaluated. One thousand three hundred and seventy-seven units of blood were crossmatched and only 564 units were transfused to 260 patients. Fifty-nine percent of the units crossmatched were not transfused. Six of the 12 elective procedures had a C:T ratio higher than 2.5. Ten of the 12 procedures (83.3%) had a low transfusion index (TI < 0.5). The calculated red blood cell units were less than 0.5 in 5 of the 12 elective procedures, and hence we recommend a group and save policy for these procedures. Blood ordering schedule based on patient and surgical variables would provide an efficient way of blood utilization and management of resources.

Blood Ordering Strategies in the Armed Forces - A Proposal.

Over ordering blood is a common practice in medicine. This can be corrected by a simple means of changing the blood ordering pattern. A retrospective study was carried out in a tertiary care hospital of Armed Forces for a three year period to study the blood ordering strategies in the hospital. The total units demanded and the corresponding units issued were estimated. Thereafter, transfusion probability and ratio of units cross-matched to actual units transfused (C/T ratio) was calculated. In this study, using Mead's criterion, transfusion probability and C/T ratio, transfusion guidelines for all cases requiring transfusion is proposed. The study also identifies the common cases where 'Type and Screen' (T&S) procedure could be introduced in cases where the transfusion probability is low. The other group where transfusion probability is high, a maximum surgical blood ordering schedule (MSBOS) has been determined to identify the number of units to be cross-matched and kept ready before the procedure. The implementation of this proposal will avoid over-ordering of blood and will promote maximum utilization.

Clinical Evaluation of Effective Hemotherapy in Elective Surgery / 대한마취과학회지

For the purpose of effective utilization of donated blood with limited shelf life, the author investigated the transfusion data which were used for 778 patients who received 2,556 units of blood during the period from Jan. to Dec., 1988 in Pusan National University Hospital. The data were statistically studied and optimal guide line in elective surgery was established. The results were as follows. 1) In the period under study, transfusion ratio of each surgical department were from 37.6% to 83.6%. 2) Average CT ratio of elective surgical procedure was 1. 4 3) Number of crossmatched and transfused blood were about 4.7 units and 3.3 units by operating procedure in elective surgery, respectively. 4) The ratio of usage of blood component was 14.0%, and 120 of 778 transfused patients (15.4%) received a single unit transfusion. On the basis of these results and overviewed literature, it is summarized that established MSBOS & T & S order would be of value for decreasing in rate of outdating blood, overusage of blood, excessive crossmatching and laboratory costs.