Variation in the use of type and crossmatch blood ordering among patients undergoing hepatic and pancreatic resections

Survey of Maximum Blood Ordering for Surgery (MSBOS) in elective general surgery, neurosurgery and orthopedic surgery at the Poursina Hospital in Rasht, Iran, 2017

INTRODUCTION

Blood is a valuable life resource that depends on the donation of blood by the community. As a result, it is crucial that the manner in which this expensive resource is used be correct and reasonable.

OBJECTIVE

The purpose of this study was to investigate the Maximum Blood Ordering for Surgery (MSBOS) in general, orthopedic and neurosurgical elective surgeries at the Poursina Hospital in Rasht in 2017.

METHODS

According to the patient file number information, such as gender, age, type of surgery, number of blood units requested, number of cross-matched blood units, number of blood units transfusion, number of patients undergoing transfusion, number of patients who were cross-matched, initial hemoglobin and the underlying disease, was extracted from the HIS (Hospital Information System). Based on the collected data, a descriptive report of the cross-match to transfusion ratio (C/T), transfusion index (TI) and transfusion probability (%T) was performed, using average and standard deviation, by using the SPSS 16.

RESULTS

In the present study, 914 patients from the neurosurgery, orthopedic and general surgery wards of the Poursina Hospital were studied. Of these, 544 were male (59.5%) and 370 were female (40.5%), aged 1-99 years, with a mean age of 43 years. The frequency distribution of C/T in this study was 1.29 in neurosurgery, 1.95 in orthopedic surgery and 1.96 in general surgery. This study indicated that the C/T index was above the normal standard level in four different kinds of surgery, including leg fracture (2.71), cholecystectomy(2.71), forearm fracture (2.70), and skin graft (2.62).The C/T index was at the maximum normal level in thyroidectomy surgery (2.5). The other surgeries had the normal C/T index.

CONCLUSION

Overall, all of the MSBOS indices were at the standard level in this study, although C/T indices were higher than the standard level in the surgeries for cholecystectomy, leg fracture, forearm fracture, hand fracture and skin graft.

Perioperative blood transfusions following hepatic lobectomy: A national analysis of academic medical centers in the modern era

BACKGROUND

The purpose of the study was to characterize the prevalence and impact of perioperative blood use for patients undergoing hepatic lobectomy at academic medical centers.

METHODS

The University HealthSystem Consortium (UHC) database was queried for hepatic lobectomies performed between 2011 and 2014 (n = 6476). Patients were grouped according to transfusion requirements into high (>5 units, 7%), medium (2-5 units, 6%), low (1 unit, 8%), and none (0 units, 79%) during hospital stay for comparison of outcomes.

RESULTS

Over 20% of patients undergoing hepatic lobectomy received blood perioperatively, of which 35% required more than 5 units. Patients with high transfusion requirements had increased severity of illness (p < 0.01). High transfusion requirements correlated with increased readmission rates (23.4% vs. 19.2% vs. 16.6% vs. 13.5%), total direct costs ($31,982 vs. $20,859 vs. $19,457 vs. $16,934), length of stay (9 days vs. 8 vs. 7 vs. 6), and in-hospital mortality (10.8% vs. 2.0% vs. 0.9% vs. 2.0%) compared to medium, low, and no transfusion amounts (all p < 0.01). Neither center nor surgeon volume were associated with transfusion use.

CONCLUSION

High transfusion requirements after hepatic lobectomy in the United States are associated with worse perioperative quality measures, but may not be influenced by center or surgeon volume.

Validation of a Nomogram to Predict the Risk of Perioperative Blood Transfusion for Liver Resection

BACKGROUND

Nomograms may be important clinical tools to estimate the preoperative risk of transfusion and allow for preemptive arrangements for alternatives to allogeneic blood transfusions.

METHODS

A multicentric international cohort of 1345 patients who underwent hepatectomy for benign or malign liver diseases was used to validate a nomogram developed by the Memorial Sloan-Kettering Cancer Center.

RESULTS

A total of 449 (33.3 %) patients received a blood transfusion after hepatectomy. Several variables were associated with the need of transfusion on univariate analysis: age, BMI, hemoglobin, PT-INR, bilirubin, AST, ALT, GGT, albumin, primary liver cancer, and number of segments resected. The MSKCC nomogram, including the number of segments resected, diagnosis (primary vs. non-primary), extrahepatic organ resection, as well as platelet and hemoglobin levels, had a good predictive ability (AUC = 0.69). The frequency of patients transfused ranged from 19 % for patients who were at "low risk" (<20 % risk to be transfused) up to 68 % for patients at "high risk" (>70 % risk to be transfused). The nomogram was tested in a multivariable model including other factors associated with risk of transfusion. The final model included age (OR 1.02, 95 % CI 1.01-1.03, p < 0.001), PT-INR (OR 1.54, 95 % CI 1.01-2.36, p = 0.048), and bilirubin (OR 1.86, 95 % CI 1.09-3.18, p = 0.021). The prediction ability for the integrated prediction model was AUC = 0.73.

CONCLUSION

The MSKCC nomogram was an effective clinical tool able to predict the perioperative risk of transfusion in our independent external validation. The inclusion of patient age, as well as factors associated with liver functional status (bilirubin and PT-INR), improved the predictive ability of the MSKCC nomogram.

Improvement of the Surgical Apgar Score by Addition of Intraoperative Blood Transfusion Among Patients Undergoing Major Gastrointestinal Surgery

BACKGROUND

The surgical Apgar score (SAS) has been shown to correlate with postoperative outcomes. A key component of the SAS is estimated blood loss (EBL), which has been shown to be inaccurate and discordant with intraoperative blood transfusion. Given this, the objective of the current study was to assess the added predictive value of the including receipt of intraoperative transfusion to the SAS.

METHODS

We identified 1833 patients undergoing major gastrointestinal surgery (pancreatic, hepato-biliary, and colorectal) between January 1, 2010 and August 31, 2013 at Johns Hopkins Hospital. The primary outcome was postoperative complications or death. A modified SAS was created by assigning a "0" EBL score for every patient who received an intraoperative blood transfusion, regardless of the actual EBL. Model performance was tested using logistic regression and c-statistic.

RESULTS

Mean EBL of the entire cohort was 250 mL. Two hundred ninety-two patients (15.9 %) received at least 1 unit of blood intraoperatively. Approximately, one half of patients (55.1 %) who had an EBL <1000 mL received an intraoperative transfusion. Patients who received an intraoperative transfusion (transfusion n = 94, 32.2 % vs. no transfusion n = 221, 14.3 %; P < 0.001) and those with increasing EBL had a higher incidence of postoperative morbidity and/or death (≤100 mL: 11.6 %, 101-600 mL: 16.9 %, 601-1000 mL: 24.5 %, >1000 mL: 29.2 %; P < 0.001). The variance inflation factor between EBL and intraoperative transfusion was 1.23 for postoperative morbidity/mortality, suggesting that the multicollinearity between the two variables was low. With the inclusion of intraoperative transfusion in the modified SAS, the modified model (c-statistic 0.6552) had an improved discrimination of predicting postoperative morbidity and mortality as compared to the original SAS (c-statistic 0.6391) (P = 0.01). The modified SAS demonstrated improvement in predicting raw differences in the incidence of postoperative morbidity/mortality based on the overall score (P < 0.05).

CONCLUSIONS

The inclusion of intraoperative transfusion in a modified SAS significantly improves the risk-stratifying ability of the score with regard to postoperative morbidity and mortality. Given the variability of intraoperative transfusion, its discordance with EBL, and its strong negative impact on postoperative outcomes, we strongly support the inclusion of this factor in a modified SAS.