Sarma DP(1986): A rational blood-ordering policy for neurosurgery. J La State Med Soc 138:47-48.

PMID: 3794683 [PubMed - indexed for MEDLINE]

A RATIONAL BLOOD-ORDERING POLICY FOR NEUROSURGERY

DEBA P. SARMA, MD

Blood-ordering practices and blood use for elective neurosurgical procedures are discussed. In the procedures where blood is rarely used, routine crossmatching can be safely substituted by "type and screen." For the procedures using intraoperative transfusions regularly, a reasonable number of units should be crossmatched based on the experience of previous blood use. A guideline for preoperative blood-order for neurosurgery procedures is proposed that, if implemented, may substantially reduce cross-matching of blood resulting in better utilization of blood without jeopardizing patient care.

usually order typing nmatching of several units of blood forand crosseach opEUROSURGEONS

erative procedure. Once blood is crossmatched for a specific patient, it is held in a reserved status for that patient and is not available for other patients. If the blood is not transfused to the specific patient, the blood may become outdated during the holding period (usually 24 to 48 hours). In several studies1"5 of blood use in our institution, I have shown that for a large number of surgical procedures frequently the number of units ordered for crossmatching exceeds considerably the number actually transfused. Other authors have reported similar experience.6'8 An analysis of the pattern of past blood use in various surgical procedures can be used to develop a guideline for pre-operative blood-ordering. For the cases with rare use of blood during surgery, a "type and screen" (T&S) of blood can be safely

TABLE 1

NEW ORLEANS V.A. GUIDELINE FOR BLOOD ORDER FOR NEUROSURGERY Number of units to be crossmatched or "Type and Screen" (T&S)

Procedures

Laminectomy Craniotomy for brain tumor 2 aneurysm 2 A-V malformation 2 subdural hematoma Skull fracture 5th nerve T& resection Ventriculoperitoneal shunt

T&S

transfusion ratio of 4.75). A crossmatch-to-transfusion ratio of more than 2.5 is an indication of too much crossmatching.11 met with the Chief of Neurosurgery (Dr. Dean Echols) and together we formulated a guideline (Table 1) for blood-ordering for the neurosurgery cases. This guideline has been in use in our hospital since 1979. In a follow-up study,31 have noted a 70% reduction in crossmatch requests during 1980 and 1981 for the cases of elective laminectomies. Other observers7-8 have noted even much higher crossmatch-to-transfusion ratio for elective neurosurgical procedures.

S T&S T&S T&S

GUIDELINE FOR BLOOD-ORDERING FOR NEUROSURGERY

Table 2 (see page 53) summarizes the recommendations by various authors regarding the number of units of blood to be crossmatched or "typed and screened" for various neurosurgical procedures. Each hospital blood bank director should closely communicate with his surgical staff and come to a mutual agreement to follow such a guideline, modified by the input of the surgeons if necessary. A close cooperation and understanding between the surgical staff and the blood bank personnel is essential for a successful implementation of such a guideline. Reduced crossmatches result in reduction of outdating of blood, better control of blood bank inventory, and better utilization of frequently limited supply of blood. A proper use of a guideline may provide more cost-effective medical care without jeopardizing patient safety.

substituted for routine type and crossmatch.9 n In the T&S procedure, the patient's blood is typed (ABO and Rh), the serum is screened for unexpected antibodies, and the blood bank keeps an inventory of appropriate type-specific donor units (also screened for antibodies) to cover the anticipated needs. Because the actual crossmatching between the donor's red cells and the recipient's serum is not done, the donor units in the blood bank inventory are not set aside for any specific patient. The screened blood is immediately available to the operating room for any urgent need. Even in absence of a crossmatch, the type-compatible and screened blood is 99.99% safe in preventing incompatible transfusion.9'11 The purpose of this paper is to review my personal experience of blood use in neurosurgical procedures and propose a guideline for blood-ordering based on the recommendation of various authors.

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

OBSERVATION OF BLOOD USE IN NEUROSURGERY

I did a retrospective study of blood-ordering practices and blood use for elective surgical procedures at the VA Medical Center, New Orleans. The time covered was a 12-month period in 1976. The results of that study was published in 1980. : Surgeons requested crossmatched blood for all 54 cases of laminectomy and 14 cases of craniotorny that year. A total of 190 units of blood were crossmatched of which only 40 units were transfused to 18 patients (a crossmatch-to-

REFERENCES
1. Sarma DP: Use of blood in elective surgery. JAMA 1980;243:15361538. 2. Sarma DP: Do we need to crossmatch blood for transurethral prostatectomy? Urology 1982;20:151-153. 3. Sarma DP: Do we need to crossmatch blood for elective lam inectomy? Neurosurgery 1983;13:569-571. 4. Sarma DP: Preoperative blood-ordering for vascular surgery. / La State Med Soc 1985; 137:45-47. 5. Sarma DP: A rational blood-ordering policy for urology. Urology 1985;26:343-346.

TABLE 2 GUIDELINE FOR PREOPERATIVE BLOOD

ORDER FOR NEUROSURGERY or "Type and Screen" (T&S) Summary

Number of Units to be Crossmatched

Procedures Carpal tunnel procedures Cordotomy Cranioplasty Craniotomy, not otherwise specified for aneurysm for subdural or epidural hematoma for tumor Hypophysectomy Laminectomy for disc for tumor Laminectomy and fusion Nerve repair or exploration Scalp or skull lesion (no intracranial communication) Spinal cord tumor Transphenoidal hypophysectomy Ulnar nerve transposition Ventriculoperitoneal shunt

Bora/ 2 2

Boyd" T&S T&S T&S T&S T&S T&S T&S T&S T&S T&S

de/ongh T&S 2 2 2

12

Lockwood"
4 2 4 T&S 2

Mead"
T&S 2-3 T&S __

Rouault

5teh/;ng

15

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

T&S 2 4

T&S T&S 1 12 6

2 T&S 2 __ 2 T&S T&S

4-8 T&S __ T&S T&S T&S T&S T&S

_
T&S 2 T&S T&S

2 T&S

6. Mintz PD, Nordine RB, Henry JB, et al: Expected hemotherapy in elective surgery. NY State J Med 1976;76:532-537. 7. Rouault C, Gruenhagen J: Reorganization of blood-ordering practices. Transfusion 1978;18:448-453. 8. Boral LI, Dannemiller FJ, Stanford W, et al: A guideline for anticipated blood usage during elective surgical procedures. Am } Clin Pathol 1979;71:680-684. 9. Boral LI, Henry JB: The type and screen: A safe alternative and supplement in selected surgical procedures. Transfusion 1977;17:163-168. 10. Boral LI, Hill SS, Apollon CJ, et al: The type and screen, revisited. Am J Clin Pathol 1979;71:578-581. 11. Boyd PR, Sheedy KC, Henry JB: Type and screen use and effectiveness in elective surgery. Am J Clin Pathol 1980;73:694699. 12. dejongh DS, Feng CS, Frank S, et al: Improved utilization of blood for elective surgery. Surg Gynecol Obstet 1983;156:326-328. 13. Lockwood WB: To crossmatch or not to crossmatch: A question of effective blood utilization. / Ky Med Assoc 1983;81:298-302. 14. 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 Pathol 1980;74:223227. 15. Stehling LC: Preoperative blood ordering. Int Anesthesiol Clin 1982;20:45-57.
From the Department of Pathology, Veterans Administration Met Center and Louisiana State University Medical Sch New Orleans, Requests for reprints should be sent to Deba P. Sarma, MD, 1 Perdido Street, New Orleans, LA 70:

Reprinted from pages 47-48 and 53 of the November, 1986, Journal of the Louisiana State Medical Society
Copyright, 1986, by the Journal of the Louisiana State Medical Society, Inc.