Sarma DP(1987): A guideline for preoperative blood ordering for orthopedic surgery: J La State Med Soc 139:49-50.

PMID: 3585301 [PubMed - indexed for MEDLINE]

A GUIDELINE FOR PREOPERATIVE BLOOD ORDERING FOR ORTHOPEDIC SURGERY

DEBA P. SARMA, MD

Intraoperative transfusion is common only in a few orthopedic procedures, such as, open reduction, spinal fusion, and hip replacement. Transfusion of blood is rare among the vast majority of the other surgical procedures. In the cases where blood is seldom used, routine crossmatching can be substituted by "type and screen." A guideline for preoperative blood ordering based on the experience of a large number of authors is proposed. If properly implemented it may lead to better utilization of blood without jeopardizing patient safety.

SEVERAL PREVIOUS articles, have suggested guideiNlines for blood ordering for Idifferent surgical spe-

cialities, such as urology1 and vascular surgery.2 In the present communication I am proposing a guideline for orthopedic surgery. The guideline (Table 1) is based on the recommendations of various authors.-"10 The last column shows the summary of all the recommendations.

COMMENT
It is a standard practice in orthopedic surgery, as in other surgical specialities, to order typing and crossmatching of blood for elective surgical procedures. The purpose of crossmatch is to have the blood readily available for any remote possibility of serious intraoperative bleeding. On receiving a request for crossmatch of blood for certain number of units, the technologist in the blood bank first determines the patient's blood type (ABO and Rh). Next, the patient's serum is incubated with a panel of red cells containing most of the common red cell antigens thereby screening the patient's serum for the presence of any irregular antibodies. The last step is the actual crossmatch procedure where the patient's serum is incubated with the donor red

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TABLE 1 GUIDELINE FOR PREOPERATIVE BLOOD ORDER FOR ORTHOPEDIC SURGERY

Number of Units to be Crossmatched or "Type and Screen" (T & S) Procedures Amputation arm leg Arthroplasty Arthroscopy Arthrotomy Bone Lesion, excisionai biopsy Closed reduction of fracture without internal fixation Dupuytren's contracture reiease Hip nailing Hip pin removal Laminectomy Medial menisectomy Open reduction BoraP Boyd* Friedman'
Lockwood6 Mead7

Mintz*

Rouaulf3 ___ -------------T&S T&S ---------------4

Stehling'-

Summary Recommenda tion T&S T&S T&S T&S T&S T&S T&S T&S 2 T&S T&S T&S 2-4

-------- T&S -------- T&S

T&S

----------------------------0 0-1 0 ------------

_____
T&S

____ T&S
------

___
T&S

--------------T&S

----------------------

T&S T&S T&S T&S

--------T&S T&S

-----T&S

-----------------------------------

--------T&S 2 T&S T&S T&S 2-4

-------------------------T&S

-------T&S

---------------------2 T&S T&S

-------- T&S -------- T&S -------- ------------- T&S

T&S

---------

-----------------------------------T&S --------------------------

-------2 -------3-4

--------T&S --------4(hipfemur) T&S (others) ---------------T&S 4 ---------

T&S

-----T&S

-------- T&S 2 ------

------

-------1

Osteotomy, biopsy Shoulder reconstruction Spinal fusion Tendon and ligament transfers Total hip replacement Total knee replacement

-------- T&S T&S -----3-4 ------------- T&S 2-3 -----T&S

------------

T&S

4-5 ------5-6 --------

--------------------------------4

---------------------

3 2

-------------------------T&S

T&S

-------4

------

--------------T&S

T&S T&S 4 T&S 4 T&S

cells to test their compatibility by the absence of red cell agglutination or hemolysis. Once the specific units are crossmatched for a specific patient, those units are set in a reserved status and are not available for any other patient until the requesting physician releases the blood or the period for reserved status exceeds the maximum allowable time established by the blood bank (usually 24 to 48 hours). If blood is not used, it may become outdated during this holding period. In "type and screen" (T&S) procedure, the patient's blood is typed (ABO and Rh), the serum is screened for antibodies but the last step of crossmatch (incubating patient's serum with donor's red cells) is not done. The blood bank keeps an inventory of typespecific units (also screened for antibodies) to cover any anticipated needs. If blood is required, a typespecific unit is immediately available from the blood bank. In T&S procedure no specific unit is held in

reserved status for any specific patient thus making the units of blood available to any patient who needs it. The T&S procedure can be substituted for routine crossmatching for a large number of elective surgical procedures where blood is seldom used. In several studies of blood use in elective surgical procedures in our hospital, I have shown that for a large number of surgical procedures we have been doing excessive crossmatches."'13 Other authors also have similar experience.3 8 9 After analyzing the pattern of blood use in our hospital, I, in close consultation with the various subspecialty chiefs, have formulated a "guideline for blood ordering for elective surgery" that has been in effect in our hospital since 1979. The guideline is based on the data showing how much blood had been used in the past for a specific procedure to suggest how much blood should be crossmatched preoperatively for the same procedure. The procedures for which blood is seldom used, only a "type and screen" is done. The type-compatible and JOURNAL VOL 139 NO 4 APRIL

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screened blood is 99.99% safe in regard to avoiding incompatible transfusion.4 14-15 A close examination of the Table shows that most of the authors recommend "type and screen" for the vast majority of the orthopedic procedures. Only in open reduction of fractures, spinal fusions, and total hip replacements a crossmatch may be routinely ordered. Implementation of a preoperative blood order guideline may reduce too much crossmatching and outdatmg of blood. This approach may provide a more cost-effective patient care as well as better use of the frequently limited supply of blood.

15. Boral LI, Hill SS, Apollon C], et al: The type and screen, revisited. Am } Clin Pathoi 1979:71:578-581.

Dr. Sarma is from the Department of Pathology at the Veteran' Administration Medical Center and Louisiana State University Medicai School in Neu' Orleans, LA. Requests for reprints should be sent to Deba P. Sarma, MD, 1601 Perdido Street. New Orleans, LA 70146.

ACKNOWLEDGEMENTS
I thank Mrs. Roey Holliday for excellent secretarial assistance.

REFERENCES
1. Sarma DP: A rational blood ordering policy for urology. Urology 1985:26:343-346. 2. Sarma DP: Preoperative blood ordering for vascular surgery. / La State Med Soc 1985;137:45-47. 3. Boral LI, Dannemiller FJ, Stanford W. et al: A guideline for anticipated blood usage during elective surgical procedures. Am I Clin Pathoi 1979:71:680-684. 4. Boyd PR, Shudy KC, Henry JB: Type and screen: Use and effectiveness in elective surgery. Am ] Clin Pathoi 1980:73:694699. 5. Friedman BA, Oberman HA, Chadwick AR, et al: The maxi mum surgical blood order schedule and surgical blood use in the United States. Transfusion 1976:16:380-387. 6. Lockwood \V: To crossmatch or not to crossmatch: A question of effective blood utilization. / Ky Med Assoc 1983;81:298-302. 7. Mead JH, Anthony CD, Sattler M: Hemotherapy in elective surgery. An incident report, review of the literature, and al ternatives for guideline appraisal. Am / Clin Pathoi 1980:74:2232?7 8. Mintz PD, Nordine RB, Henry JB, et al: Expected hemotherapy in elective surgery. NY Stare"/ Med 1976;76:532-537. 9. Rouault C, Gruenhagen J: Reorganization of blood ordering practices. Transfusion 1978:18:448-453. 10. Stehling LC: Preoperative blood ordering. Int Anesthefiol Clin 1982: 20:45-57. 11. Sarma DP: Use of blood in elective surgery. JAMA 1980:243:15361538. 12. Sarma DP: Do we need to crossmatch blood for transurethral prostatectomv7 Urology 1982;20:151-153. 13. Sarma DP: Do we need to crossmatch blood for elective iaminectomy? \eurosurgery 1983:13:569-571. 14. Boral LI. Henry JB: The type and screen: A safe alternative and supplement in selected surgical procedures. Transfusion 1977; 17:163-168.

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