Preoperative Type and Screen is Unnecessary in Elective Anatomic Lung Resection and Esophagectomy

The evaluation of patient blood management in lung resection under thoracotomy

OBJECTIVE

Unnecessary blood preparation by surgeons adversely affects blood bank stocks and the healthcare system in many ways. In this study, it is aimed to evaluate the patient blood management strategy in patients in whom we performed lobectomy and pneumonectomy with thoracotomy.

METHODS

A total of 87 patients have been included in this study. Patient specific data, such as demographic information, laboratory information, preoperative blood ordering, and blood transfusion information have been recorded.

RESULTS

All patients were cross-matched, but only 32 (36.7%) of the patients received blood transfusions. Although a total of 264 units of blood had been reserved, the amount of blood used for transfusion was 68 (25.7%) units. The cross-match / transfusion rate was 3.88, the transfusion index was 0.78, and the transfusion probability was 36.7%. There is a positive and statistically significant correlation between the amount of blood allocated (r = 0.591, p = 0.00) and the duration of intensive care and hospital stay (r = 0.266, p = 0.013). There was also a positive and statistically significant correlation between the amount of blood used and the duration of intensive care and hospital stay (r = 0.422, p = 0.00) (r = 0.474, p = 0.00).

CONCLUSION

In elective lung resection performed by thoracotomy, the amount of blood wasted during the patient's blood preparation process is high. During the patient blood preparation process, institution-controlled programs should be implemented instead of subjective evaluation at the discretion of the surgeon Planning a patient-specific blood preparation process to alleviate the burden on the healthcare system may prove to be more efficient.

Reducing Unnecessary Type and Screens Prior to Thoracic Surgery: A Quality Improvement Initiative

INTRODUCTION

Previous work identified that routine preoperative type and screen (T&S) testing before elective thoracic surgery is overutilized. We hypothesized that instituting a quality improvement (QI) initiative to change practice would significantly reduce this unnecessary testing, reduce costs, and improve healthcare efficiency.

MATERIALS AND METHODS

A QI initiative was developed at a single, academic center to reduce empiric T&S ordering before elective anatomic lung resections. Two interventions were implemented: 1) education based on current institutional data and 2) an electronic medical record order set modification. Utilization of T&S testing, blood transfusion data, and perioperative outcomes were tracked and compared between a preintervention group (2015-2018) and a postintervention group (2020-2021). Cost data were derived from institutional charges and Centers for Medicare & Medicaid Services fee schedules.

RESULTS

Of the 553 patients included: 420 were in the preintervention group and 133 were in the postintervention group. The rate of routine T&Ss significantly dropped after implementing the QI initiative (97 versus 20%, P ≤ 0.001). Additionally, no difference in blood transfusion rate was observed (4.3 versus 2.3%, P = 0.29), and there were no differences noted in postoperative complications (P = 0.82), 30-day readmission (P = 0.29), or mortality (P = 0.96). Based on current volumes of ∼200 anatomic lung resections/year, estimated cost savings from reducing T&S testing from 97 to 20% would be at least $40,000 a year.

CONCLUSIONS

Our QI initiative significantly reduced the use of routine T&S testing. This practice change was achieved while maintaining excellent outcomes demonstrating routine preoperative T&S testing can be safely reduced in most elective thoracic surgery.

Preoperative Type and Screen Before General Thoracic Surgery: A Nomogram to Reduce Unnecessary Tests

BACKGROUND

A preoperative type and screen (T&S) is traditionally routinely obtained before noncardiac thoracic surgery; however an intraoperative blood transfusion is rare. This practice is overly cautious and expensive.

METHODS

We included adult patients undergoing major thoracic surgery at the Mayo Clinic from 2007 to 2016. Patients receiving a T&S blood test ≤72 hours of surgery was the main exposure. We randomly split the cohort into derivation and validation datasets. We used multiple logistic regression to create a parsimonious nomogram predicting the need for a T&S in relation to the likelihood of intraoperative blood transfusion. We validated the nomogram in terms of discrimination, calibration, and negative predictive value.

RESULTS

Of 6280 patients 46.1% had a preoperative T&S, but only 7.1% received intraoperative transfusions. The derivation dataset had 4196 patients. Patients who had a T&S were more likely to have baseline hemoglobin level <10 g/dL (7.9% vs 3.6%, P < .001) and less likely to have minimally invasive operations (36.1% vs 43.5%, P < .001) but were otherwise similar in baseline age and comorbidities. A transfusion threshold of 5% was selected a priori. The nomogram included age, planned operation, approach, body mass index, and preoperative hemoglobin. The nomogram was validated with a c-statistic of 86% and a negative predictive value of 97.9%. Patients who needed a blood transfusion but who did not have a preoperative T&S did not have a higher rate of mortality (P = .121).

CONCLUSIONS

An intraoperative blood transfusion during major thoracic surgery is a rare event. Patient who required transfusion but did not have a T&S did not have worse outcomes. A simple nomogram can aid in the selective use of T&S orders preoperatively.