BLOOD-ORDERING FOR OTOLARYNGOLOGY

DEBA P. SARMA, MD; PAUL A. GUILLORY, MD

A retrospective study of blood-ordering practices and blood use for elective otolaryngologic surgery was done. In several procedures where blood is rarely used, routine crossmatching of blood 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 usage. A guideline for preoperative bloodorder is proposed, that if implemented, may substantially reduce excessive crossmatching of blood resulting in better utilization of blood without jeopardizing patient care.

for Tmatching of blood is a standard typing and crosspractice for elecHE PREOPERATIVE REQUEST

tive otolaryngologic surgery as in other surgical specialties. The major reason for preoperative blood order is to provide readily available blood to the patients suffering from any serious hemorrhage during the surgical procedure. On receiving the blood order from the physician the personnel in the blood bank crossmatch the requested number of units of blood and hold them in a reserved status for the specific patient. During the reserved period (usually 24 to 48 hours), this blood is not available to other patients. If the blood is not transfused to the specific patient, the blood may become outdated during the holding period. In several studies a~4 of blood usage in elective surgical procedure in our institution, the number of units of blood ordered for crossmatching for a large number of surgical procedures far exceeds the number of units of blood actually transfused. Other investigators have described similar experiences.5"7 After analyzing the pattern of blood use in the local hospitals, a guideline for blood-ordering for elective surgery can be suggested. This guideline is based on the information of how much blood had been used in the

TABLE 1

BLOOD DATA FOR OTOLARYNGOLOGIC SURGERY, 1976-1977 Numbers of Units Crossmatched Number of Patients 1
3 1 1 2 2

Procedures Thyroglossal cyst excision Caldwell-Luc procedure Caldwell-Luc procedure with ethmoidectomy Ethmoidectomy Glossectomy, hemiglossectomy Glossectomy with mandibulectomy Glossectomy, mandibulectomy and radical neck dissection Laryngectomy Laryngectomy with radical neck dissection Mandibulectomy Mandibulectomy with radical neck dissection Mandibular or maxillary osteotomy Maxillectomy Maxillectomy with radical neck dissection Radical neck dissection Tumor of palate excision

VS Number of Units Transfused (C-T Ratio)

2/0 (0) 9/1 (9)

Average Number of Units Crossmatched per Patient VS Average Number of Units Transfused per Patient 2/0 0.33
2/1 2/1 2/0 3/0

2/1 (2) 2/1 (2) 4/0 (0)

6/0 (0)

2 7 17 1 2 2 5 1 19 2

9/4 (2.25) 24/12 (2) 66/29 (2.28) 2/0 (0) 7/2 (3.5) 6/0 (0) 22/9 (2.44) 4/4 (1) 79/28 (2.82) 6/0 (0)

4.50/2 3.43/1 .71 3.88/1.71

2/0

3.5/1
3/0

4.4/1 .8
4/4

4.16/1.47
3/0

Averages have been rounded to the nearest 0.01 for each procedure.

past for a specific surgical procedure to suggest how much blood should be crossmatched preoperatively for the same procedure. For the cases in which blood usage during surgery is negligible, a "type and screen" (T&S) of blood can be a safe alternative to type and crossmatch.8'10 In T&S, the patient's red cells are typed for ABO-Rh and his serum is screened for unexpected antibodies but actual crossmatching between the donor's red cells and the recipient's serum is not done. Blood bank keeps an inventory of ABO-RH compatible units (also free of any unexpected antibodies) for immediate availability 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.8'10

MATERIALS AND METHODS

For a 24-month period (January 1, 1976 to December 31,1977), all patients who underwent various elective otolaryngologic procedures were identified from the operating room record. The blood bank records of those patient were reviewed to determine the number of units of blood (whole blood and packed red cells) that were crossmatched preoperatively and the number of units transfused for each patient. The blood may have been used intraoperatively or within 24 hours postoperatively. This information was summed and averaged for each procedure. The patients for whom no crossmatching was requested were excluded from the study.

TABLE 2 GUIDELINE FOR PREOPERATIVE BLOOD ORDER FOR OTOLARYNGOLOGY

Number of units to be crossmatched or 'type and screen' (T&S) Procedures Branchial cleft cyst excision Caldwell-Luc procedure Carotid body tumor resection Ethmoidectomy Glossectomy, hemiglossectomy Jaw, neck, tongue dissection Laryngeal biopsy Larygectomy Laryngectomy with radical neck dissection Mandibulectomy Mastoidectomy Maxillary osteotomy Maxillectomy Nasal fracture, reduction Nasal septum, submucosal excision Orbital exploration Radical neck dissection Septoplasty Tumor of palate, excision Tympanoplasty i
Bora!
7

Summary Recommendation T&S T&S 4 T&S

2 4 T&S 2 5 2 2 T&S 2 T&S T&S 1 2 T&S T&S T&S

Boyd

deJongh"

Lockwood' T&S 2 2 T&S 2 6 2 2 2 2 T&S

RouaulF 2 2 T&S

Stehling
T&S T&S 4 T&S 2 4 2 4 2 2 1 2 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

RESULTS
The results are shown in Table 1.

COMMENT
Otolaryngologists routinely request type and crossmatch of certain number of units of blood for elective surgical procedures. On receiving the blood order along with a tube of the patient's blood, the technologist in the blood bank first determines the patient's blood type (ABO-Rh). Next, the patient's serum is screened for the presence of any irregular antibodies by incubating the serum with a panel of red cells containing most of the common red cell antigens. The next step is the crossmatch procedure, which is an in vitro simulation of what may happen when the typespecific donor blood is transfused into a recipient. The donor's red cells are incubated with the recipient's (patient's) serum to detect their compatibility by an absence of red cell agglutination or hemolysis. Once donor units of blood are crossmatched for a specific patient, those units are set aside in a reserved status

for that particular patient. These units are taken out of the blood bank inventory pool and are not available for any other patient until they are released by the requesting physician or the holding period exceeds the allowable reserved period (24 to 48 hours) as determined by the blood bank. In the T&S procedure, the patient's blood is typed (ABO and Rh), the serum is screened for irregular antibodies, but the actual crossmatch between the patient's blood and donor's blood is not done. Blood bank keeps an inventory of appropriate type-specific antibody-free units of blood to cover any anticipated needs. If blood is urgently needed in the operating room, type specific units are immediately available from the blood bank inventory. Crossmatching is immediately started after the blood is dispatched from the blood bank and in many cases results of the crossmatches are available before the transfusions start. Even without a crossmatch, typed and screened blood is 99.99% safe in regard to avoiding incompatible transfusion.8'10 Thus, for low-risk surgical procedures with minimal chance of excessive blood-loss T&S is

"*"

definitely more appropriate than a routine crossmatch. The real advantage of T&S is that is does not tie up a number of units of blood for specific patients, as would occur if standard crossmatches were done. Table 1 shows the blood ordering pattern for otolaryngologic procedures. Whereas blood is regularly used in procedures such as laryngectomies and radical neck dissections, transfusion is rare in procedures such as osteotomies and Caldwell-Luc procedures. A reasonable number of units of blood should be crossmatched for the procedures regularly using intraoperative transfusions. For other cases with no significant blood use, there is no need for crossmatch rather a T&S is adequate.

Table 2 summarizes the recommendations by var ious authors regarding the number of units of blood to be crossmatched or only typed and screened for various otolaryngologic procedures. We have been using such a guideline in our hospital since 1979 with complete cooperation from the surgeons. A close communication between the surgical staff and the blood bank personnel is essential for a successful im plementation of such a guideline. Reduced crossmatches result in a reduction of outdating of blood, better control of blood bank inventory, and a better utilization of the frequently limited supply of blood. The proper use of the guideline may provide more cost-effective medical care without jeopardizing pa tient safety.

REFERENCES
1. Sarma DP: Use of blood in elective surgery. JAMA 1980;243:1536-1538. 2. Sarma DP: A rational blood -ordering policy for urology. Urology 1985;20:343-346. 3. Sarma DP: Do we need to crossmatch blood for elective laminectomy? Neurosurgery 1983;13:569-571. 4. Sarma DP: Preoperative blood ordering for vascular surgery. / La State Med Soc 1985;137:45-47. 5. Mintz PD, Nordine RB, Henry JB, et al: Expected hemotherapy in elective surgery. NY State J Med 1976;76:532-537. 6. Rouault C, Gruenhagen J: Reorganization of blood ordering practices. Transfusion 1978;18:448-453. 7. Boral LI, Dannemiller FJ, Stanford W, et al: A guideline for anticipated blood usage during elective surgical procedures. Am J Clin Pathol 1979;71:680-684. 8. Boral LI, Henry JB: The type and screen: a safe alternative and supple ment in selected surgical procedures. Transfusion 1977 ;17-.163-168. 9. Boral LI, Hill SS, Apollon CJ, et al: The type and screen, revisited. Am J Clin Pathol 1979;71:578-581. 10. Boyd PR, Sheedy KC, Henry JB: Type and screen: Use and effectiveness in elective surgery. Am J Clin Pathol 1980;73:694-699. 11. dejongh DS, Feng CS, Frank S, et al: Improved utilization of blood for elective surgery. Surg Gynecol Obstet 1983;156:326-328. 12. Lockwood WB: To crossmatch or not to crossmatch: A question of ef fective blood utilization. / Ky Med Assoc 1983;81:289-302. 13. Stehling LC: Preoperative blood ordering. Int Anesthesiol Clin 1982;20:4557.

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

Reprinted from pages 49-52 of the August, 1987, Journal of the Louisiana State Medical Society
Copyright, 1987, by the Journal of the Louisiana State Medical Society, Inc.

Sarma DP, Guillory PA(1987): Blood-ordering for otolaryngology. J La State Med Soc. 139:49-52. PMID: 3655765 [PubMed - indexed for MEDLINE]