Audit of blood requirement in breast and gall bladder surgery, do we really need to prepare blood

1. Audit of blood requirement in breast and gall bladder surgery, do we really need to prepare blood? Khalid Abdul Wahid MD Anas Daoud MD A.J Samara MD,FRCS(Dublin),MRCS,FMH(Swiss Board)

2. Introduction Preoperative over-ordering of blood is very common which leads to: holding up of the blood bank reserves ageing of blood conserves wastage of blood bank resources loss of money

3. Introduction ordering for blood is frequently based on subjective anticipation of blood loss instead of evidence based estimates of average requirement in a particular procedure [5]. Many surgeons prescribing blood are unaware of recommended published guidelines for transfusion practice and still adhere to historical practice

4. Introduction Reduction in unnecessary blood cross-matching can be achieved by careful evaluation of the transfusion requirements for each surgical procedure which allows the introduction of guidelines - Maximum Surgical Blood Ordering Schedule (MSBOS) -which expects the normal blood usage for a given elective surgical procedures [4, 12]

5. Introduction As surgery for breast cancer and gall bladder stones are very frequently done in our hospital, (64, 616 respectively) from Jan to Oct 2011. An average of (1358) units of blood donated and cross matched, each unit costs around (65) JD  

6. Method This is the first retrospective audit held in the department of general surgery- Al Bashir teaching hospital for patients who underwent elective breast cancer and gall bladder surgery( laparoscopic or open) over a 10 months period(Jan to Oct 2011), for which grouping and cross matching requested .

7. Method Our hospital guidelines states that every patient undergoing elective breast and gall bladder surgery should routinely have a blood sample sent for grouping and cross matching prior to operation.

8. Method Data of patients underwent elective breast surgery (mastectomy, wide local excision or Quadrentectomy) and cholecystectomies (laparoscopic or open) were obtained from theater and medical records. For each surgical procedure, the number of patients, units of blood crossmatched, units of blood and number of patients transfused were recorded

9.   1. C/T ratio = Number of units cross matched/ Number of units transfused   2. %T = Number of patients transfused x100/ Number of patient’s cross matched     3. TI = Number of units transfused / Number of “patients” cross matched  

10. Method Crossmatch to transfusion ratio (C/T ratio) should be 1 to 2.5 to be indicative of efficient blood usage . The probability of a transfusion for a given procedure is denoted by T% a value of 30% and above has been suggested as appropriate. The average number of units used per patient cross matched is indicated by the transfusion index (TI) and signifies the appropriateness of numbers of units’ cross matched, a value of 0.5 or more is indicative of efficient blood usage

11. Results

12. Results

13. Percentage of total units of blood ordered and transfused (total number of blood units1377)

14. Discussion Unnecessary cross matching leads to increase in wastage percentage, staff exhaustion, and financial damage. Some units which finally ended up being discarded had been cross matched many times [11].

15. Discussion Data from developing countries have shown gross over ordering of blood in 40% to 70% of patients [14], even in trauma patients, utilization are less than 50% [6] . Other studies as those conducted in Ilorin Teaching Hospital, and University of Benin Teaching Hospital, in Nigeria reported similar values of unutilized blood (69.7% and 70.0%, respectively) this might indicate that this malpractice is common in developed countries [14].

16. Discussion Numerous studies indicate that the introduction of MSBOS and group and screen Schedules have resulted in: substantial money saving reduction in outdated blood decrease in blood bank workload

17. Discussion 3.1% of patients with breast cancer in our study needed blood transfusion over 10 months period (2 out of 64 patients), one patient treated with Quadrentectomy+ axillary dissection(Q & A) received 4 units of blood due to accidental injury to axillary vein during surgery and the other one treated by modified radical mastectomy (MRM) was already anemic and blood given postoperatively, with C/T ratio of (4.5 and 40), T%(11 and 2.6) % and TI (0.44 and 0.052) for Q&A and MRM respectively, signifies great inappropriateness of number of units cross matched relative to transfused

18. Discussion While in 616 patients who underwent lap or open cholecystectomy only 5 patient’s (0.18%) transfused with 13 units of blood which reflect that blood ordering was a habit rather than a real need.  The Maximum Surgical Blood Order Schedule (MSBOS) is a table of elective surgical procedures which lists the number of units of red cells routinely crossmatched for them pre-operatively. It allows the more efficient use of blood stocks and reduces wastage

19. CONCLUSION We propose a draft Maximum Surgical Blood Ordering Schedule (MSBOS). It provides guidelines for frequently performed elective surgical procedures by recommending the maximum number of units of blood to be cross-matched preoperatively. Implementation of MSBOS will result in reduction of cost to the patients and a minimum saving of around (87035) JD

20. Recommendations 1. over ordering of blood has to be minimized. 2. Blood ordering pattern needs a definite change. 3. In surgeries with minimal anticipated blood loss, only blood grouping should be done, but one must confirm the availability of blood for emergency situations before starting surgery.

21. Take home message In vast majority of elective surgical procedures routine cross match is not necessary !!!!!!

22. Thank you