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NEUROSURGERY

Copyright 1983 by the Congress of Neurological Surgeons

Vol. 13. No. 5. 1983 Printed in U.S.A.

Brief communications

Do We Need to Cross Match Blood for Elective Laminectomy?

Deba P. Sarma, M.D.
Department of Pathology, Veterans Administration Medical Center and Louisiana State University Medical Center, New Orleans, Louisiana

Elective laminectomy cases do not need a routine order for typing and cross matching of blood. Data from the literature and from personal experience in the blood bank of a 580-bed general hospital are presented to support this conclusion. An ABO-Rh type and an antibody screen can safely substitute for routine cross matches for such cases. The use of type and screen rather than cross match allows the blood bank to distribute limited blood resources more efficiently without jeopardizing the patients. (Neurosurgery 13:569-571, 1983) Key words: Blood cross match, Blood type and screen, Elective laminectomy Surgeons usually order typing and cross matching of a couple of units of blood for each case of elective laminectomy. The personnel in the blood bank cross match the requested number of units of blood and keep them in a reserved status for the specific recipient. This blood is unavailable to other patients until the physician releases the blood or the holding period exceeds the maximal allowable reserved period established by the blood bank (usually 24 to 48 hours). If this blood is not transfused, it may become outdated during the reserved period. In a previous study of blood usage for elective surgical procedures in our 580-bed general medical and surgical care hospital, I showed that for a large number of surgical procedures the number of units of blood ordered for cross matching far exceeds the number actually transfused (8). For 54 cases of laminectomy, 130 units of blood were cross matched; however, only 29 units of blood were transfused to 15 of those patients. In 1979 we implemented type and screen (T&S) for elective laminectomy cases. In T&S, the patient's red cells are typed for ABO-Rh and his serum is tested for unexpected antibodies. An inventory of ABO-Rh-compatible units (also free of unexpected antibodies) is kept in the blood bank for immediate availability to the operating room for emergency need. Even without a cross match, the type-compatible and screened blood is 99.99% safe in regard to avoiding the transfusion of incompatible blood (2, 3). I am describing our experience with laminectomy cases since the type and screen program was instituted which indicates that cross matching can be safely replaced by type and screen for such cases. MATERIALS, METHODS, AND RESULTS For a 24-month period, January 1, 1980, to December 31, 1981, elective laminectomy cases were reviewed in regard to the response of the surgical staff to our substituting T&S for cross matching. A total of 80 patients underwent elective 569 laminectomy. Blood was not ordered for 6 patients, and they did not receive any blood intraoperatively. A request for type and cross match was received for 25 cases. A total of 50 units were cross matched, of which 19 units were transfused to 12 patients. Each patient received 1 to 2 units. Surgeons requested T&S for 49 patients (61 %), 34 of whom did not receive any transfusion. The surgeons, while in the operating room, asked the blood bank to convert T&S to a cross match for 17 patients, of whom 12 received a total of 18 units of blood. The number of units transfused per patient varied from 1 to 2. There were 3 cases with a request for T&S in which 4 units of blood that was not cross matched were transfused because the blood was needed urgently. There was no untoward reaction in any of these cases. A cross match was started on each of these cases immediately after blood was released from the blood bank. While the patients were receiving the transfusion, the results of the cross match procedures were available, and they all were compatible. In the other 12 cases in which the blood was only typed and screened and the surgeon wanted to transfuse intraoperatively, there was adequate time for the blood bank personnel to cross match the units before the transfusion was started. DISCUSSION A blood bank receives a request for typing and cross matching for a certain number of units of blood for a patient along with a tube of the patient's blood. The technologist in the blood bank first determines the patient's blood typeABO group as well as Rh system (RhD positive or RhD negative). Next, the patient's serum is screened for the presence of any irregular antibodies by incubating the serum with a panel of red blood cells designed to represent most of the common red cell antigens. The next step is the cross match procedure, which is an in vitro simulation of what may happen when the type-specific donor blood is transfused into a recipient. The technologist incubates the donor red blood cells with the recipient's (patient's) serum and determines their compatibil-

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SARMA
TABLE

Neurosurgery, Vol. 13, No. 5

1 Average No. Units Cross Matched per Patient 2.86 2.18 4 3.04 2.50 2.41 2.72 Average No. Units Transfused/No. Patients Cross Matched 0.32 0.05 0.43 0.70 0.16 0.54 0.43

Blood Ordered and Used for Elective Laminectomies

Reference No. Patients Cross Matched/No. Patients Transfused 44/NA" 105/4 7/NA 248/NA 98/8 54/15 No. Units Cross Matched/No. Units Transfused 126/14 229/5 28/3 754/173 245/16 130/29 1512/240

Mintz et al., 1976(6) Hough etal.. 1978(4) Rouault and Gruenhagen, 1978(7) Lang and Drozda. 1979(5) Boral et al., 1 979 ( 1 ) Sarma, 1980(8) Total " NA. not available.

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ity by the absence of any red cell agglutination or hemolysis. Once a certain number of donor units are cross matched for a specific patient, these units are set aside and reserved for that particular patient. These units are not available for any other patient until they are released by the requesting physician or the holding period exceeds the maximal allowable holding period (24 to 48 hours) as determined by the individual blood bank. In the T&S procedure, the patient's blood is typed (ABO and Rh), the serum is screened for antibodies, and the blood bank keeps an inventory of appropriate type-specific units (also screened for antibodies) to cover the anticipated needs. For low risk elective surgical procedures, T&S is a more appropriate procedure than cross match. If blood is required, a type-specific unit is immediately available from the blood bank inventory. An advantage of the T&S procedure is that it avoids tying up a number of units for specific patients, as would occur if routine cross matches were done. How often does a patient need a blood transfusion during elective laminectomy? Review of literature shows the pattern of blood usage for laminectomy (Table 1). On the average, surgeons request a cross match of 2 to 3 units of blood for each case of laminectomy, but a very small number of patients receive a transfusion ( 1 , 5 , 8). Once the advantage and safety of substituting T&S for cross match is understood, physicians enthusiastically support the concept. In 1976, surgeons requested cross matched blood for all 54 cases of elective laminectomy in our hospital (8). There has been about a 70% reduction in cross match requests during 1980 and 1981. Close communication and cooperation between the surgical staff and the blood bank personnel was the single most important reason for the success of our T&S program. Reduced cross match requests and appropriate clinical decisions resulting in converting T&S to cross matches for some cases have helped the blood bank to allocate our blood resources more appropriately without jeopardizing safe patient care. ACKNOWLEDGMENT The author thanks Karen Dunn for excellent secretarial assistance.
Received for publication, February 18,1983: accepted, July 2, 1983. Reprint requests: Deba P. Sarma, M.D., 1601 Perdido Street, New Orleans. Louisiana 70146.

procedures. Am J Clin Pathol 71:680-684, 1979. 2. Boral LI, Henry JB: The type and screen: A safe alternative and supplement in selected surgical procedures. Transfusion 17:163-168, 1977. 3. Boyd PR. Sheedy ICC, Henry JB: Type and screen: Use and effectiveness in elective surgery. Am J Clin Pathol 73:694-699. 1980. 4. Hough AJ, Russel W, Driver G, Gardner WA: Blood transfusion practices in surgery: An approach to intrahospital analysis. South Med J 71:1100-1104, 1978. 5. Lang GE, Drozda EA Jr: Survey of blood ordering practices for 12 elective surgical procedures. Wis Med J 78:27-31, 1979. 6. Mintz PD, Nordine RB, Henry JB. Webb WR: Expected hemotherapy in elective surgery. NY State J Med 76:532-537. 1976. 7. Rouault C, Gruenhagen J: Reorganization of blood ordering practices. Transfusion 18:448-453, 1978. 8. Sarma DP: Use of blood in elective surgery. JAMA 243:1536-1538, 1980.

COMMENTS This type and screen program has been in effect for 5 years with resultant savings of countless units of whole blood, expense, and single unit transfusions. Our experience documents an infrequent requirement for cross match of whole blood, less than 5% of the cases of uncomplicated laminectomy, and no serious consequences have occurred because of delay occasioned by the need for the preparation of cross matched blood. John M. Tew, Jr., M.D. Cincinnati, Ohio

REFERENCES
1. Boral LI, Dannemiller FJ, Stanford W, Hill SS. Cornell TA: A guideline for anticipated blood usage during elective surgical

In this report Sarma musters evidence from the literature as well as his personal experience to support the contention that the use of routine preoperative typing and cross matching of blood is not necessary in cases of elective laminectomy. Instead, the use of an ABO-Rh type and antibody screen is a recommended substitute. This approach has already been suggested for neurosurgical cases with a low probability of operative blood transfusion (1). In fact, the safety of transfusion based only on the results of a type and screen is so high that some have suggested elimination of the cross match altogether. In the present paper as well as in the reports summarized in Table 1, it is likely that the cases included under the operative procedure of "laminectomy" range from simple disc operation to more extensive surgery (i.e., metastatic

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tumors and spinal stenosis). The likelihood of blood transfusion during neurosurgical laminectomy for disc disease is so low that type and screen are certainly sufficient. However, some cases of laminectomy for metastatic disease and extensive spinal stenosis, particularly in a patient who may already have mild to moderate anemia, might be better prepared for by full type and cross match. Certainly, intelligent use of the above approach will provide more cost-effective medical care as well as better use of the

frequently limited supply of blood by the blood bank and its components. Morris W. Pulliam Bethesda, Maryland
Pulliam MW: Use of blood and its components, in Carmel PW (ed): Clinical Neurositrgerv. Baltimore, Williams & Wilkins, 1981, vol 28, pp 14-70.

Sarma DP (1983): Do we need to crossmatch for elective laminectomy? Neurosurgery 13:569571. PMID: 6646383 [PubMed - indexed for MEDLINE]