Blood transfusions play a major role in the resuscitation and management of surgical patients [
The preoperative request of blood units, especially in elective surgery, is often based on the worst case assumptions, demanding large quantities of blood or overestimating the anticipated blood loss, of which little is ultimately used [
Since the introduction of blood transfusion into clinical practice, its appropriate use has been the subject for debate. It has been reported that only 30% of crossmatched blood is used in elective surgery [
In addition, a number of studies in many countries of the world have shown overordering of blood by surgeons with utilization ranging from 5 to 40% [
Common variations in rates of transfusion may be due to many factors, including differing opinions on the threshold level of hemoglobin below which a patient needs blood transfusion, differences in surgical and anesthetic techniques, cancellation of cases, differences in case mix, preoperative anemia, and lack of availability of transfusion protocols. This may reflect uncertainty about the relative benefits and risks of transfusion and the different perceptions of the value of minimizing blood loss and subsequent transfusion [
A number of indices are used to determine the efficiency of blood ordering and utilization system. Boral Henry was the first that suggested the use of crossmatch to transfusion ratio (C/T ratio) in 1975 [
Unnecessary ordering of blood for surgical patients can be reduced without having any detrimental effect on the quality of patient. Use of blood conservation policies such as the MSBOS has succeeded in limiting unnecessary transfusion practices [
Evaluating blood ordering and transfusion practices and subsequent developing of a blood ordering schedule, which serves as a guide to anticipated normal blood usage for elective and emergency surgical procedures, can decrease overordering of blood. University of Gondar Hospital has no blood bank for its own, and it gets the necessary blood for its patients from Regional blood bank Branch of Ethiopian Red Cross Society. The Blood Bank has regular voluntary blood collection campaign schedule. But it does not fulfill the requirement of the need of patients in the hospital. Due to these, the patients are forced to collect their blood either from their relatives (family, friends) or paid donors. In this regard, studies assessing blood requisition and transfusion practices are scarce in Ethiopia particularly in Gondar Hospital. Therefore, the aim of this study was to assess the efficiency of blood requisition and transfusion practices for patients undergoing both elective and emergency surgical procedures.
A hospital based cross-sectional study was conducted in those patients who underwent elective and emergency surgeries in University of Gondar Hospital over a period of five-months from November 2012 to March 2013. It is a 5000-bed tertiary teaching hospital performing 11,238 surgical procedures per year.
Blood requisition and transfusion of surgical, obstetrics, and gynecological cases were compiled and reviewed. Patient’s age and sex, number of units prepared, crossmatched, and transfused, number of patients crossmatched and transfused, source of blood donation or collection, and type of anesthesia were collected from discharged patient medical records and blood bank registries.
Data were coded, entered, and analyzed using SPSS Version 16. Blood utilization indices were computed with the following equation. Crossmatch to transfusion ratio (C/T ratio) = number of units crossmatched/number of units transfused. A ratio of 2.5 and below is considered indicative of significant blood usage. Transfusion probability (%T) = number of patients transfused/number of patients crossmatched × 100. A value of 30% and above was considered indicative of significant blood usage. Transfusion index (TI) = number of units transfused/number of patients crossmatched. A value of 0.5 or more was considered indicative of significant blood utilization. Maximal Surgical Blood Order Schedule (MSBOS) = 1.5 × TI. In current study blood was wasted when a patient failed to use his/her already prepared blood in any case.
Ethical clearance was taken from Ethical Board of University of Gondar. Participants were communicated individually about the purpose of the study and verbal informed consent was taken before the interview. Confidentiality of the information was assured by using code numbers than personal identification names and keeping questionnaires locked.
During the study period a total of 1,412 patients underwent major elective and emergency surgical procedures. Among these, 982 patients were requested to prepare 1,072 units of blood.
Majority of the patients were female (51.9%), underwent surgery in elective schedule, surgical cases in surgical department, underwent surgery under general anesthesia and prepared their blood from replacement donation, as shown in Table
Sociodemographic and other characteristics surgical patients at University of Gondar Hospital, Ethiopia, 2013
S.N | Characteristics | Total (no.) | Percent (%) |
---|---|---|---|
1 | Sex | ||
Male | 472 | 48.1% | |
Female | 510 | 51.9% | |
2 | Source of donation | ||
Voluntary | 176 | 17.9% | |
Replacement | 896 | 82.1% | |
3 | Type of operation | ||
Elective | 628 | 63.9% | |
Emergency | 354 | 36.1% | |
4 | Type of anesthesia | ||
General | 668 | 68.0% | |
Spinal | 314 | 32.0% | |
5 | Department/cases | ||
Surgery | 599 | 60.9% | |
Gynecology and obstetrics | 383 | 39.1% | |
6 | Total units of blood prepared | 1,072 | 100% |
7 | Total units of blood crossmatched | 1,072 | 100% |
8 | Total units of blood transfused | 468 | 43.6% |
9 | Preoperative blood units replaced | 34 | 7.2% |
10 | Intraoperative blood units replaced | 143 | 30.6% |
11 | Postoperative blood units replaced | 291 | 62.2% |
12 | Total units of blood wasted | 604 | 56.4% |
During the five months of study period, blood requisition was made to 644 patients undergoing surgery in surgical department and 428 from gynecologic and obstetrics department (Gyn/obs). From a total of 1,072 units of blood crossmatched, only 468 units were transfused. These showed that 43.6% of total blood crossmatched was utilized, leaving 56.4% of the units crossmatched not transfused to the patient who prepared, that is, wasted.
Gynecology and obstetrics department was the department with the highest number of both patients crossmatched (63.2%) and transfused (64.4%). On the other hand, surgery was the department with the highest number of both blood units crossmatched (60.1%) and transfused (59.8%). Of the 354 patients who underwent emergency operation, 418 units of blood were crossmatched and 209 patients received 230 units of blood transfusion. In case of patients who underwent elective operation, 654 units of blood were crossmatched, out of which only 77 patients received 238 units of blood for their procedures. Generally the highest crossmatched units but the least transfusion units were made for elective patients as compared to emergency cases, as shown in Table
Comparison between number of units crossmatched and transfused in operated patients in University of Gondar Hospital, Ethiopia, 2013.
Department | Number of units | Number of patients | ||
---|---|---|---|---|
Crossmatched |
Transfused |
Crossmatched |
Transfused |
|
Surgery |
||||
Elective |
412 (63.9) | 154 (55.0) | 54 (24.3) | 43 (42.1) |
Emergency |
232 (36.1) | 126 (45.0) | 168 (75.7) | 59 (57.9) |
Subtotal | 644 (60.1) | 280 (59.8) | 222 (36.8) | 102 (35.6) |
Gynecology and obstetrics |
||||
Elective |
242 (56.5) | 84 (44.6) | 146 (38.4) | 34 (18.4) |
Emergency |
186 (43.5) | 104 (55.4) | 234 (61.6) | 150 (81.6) |
Subtotal | 428 (39.9) | 188 (40.2) | 380 (63.2) | 184 (64.4) |
As shown in Table
Blood utilization indices of surgical patients at University of Gondar Hospital, Ethiopia, 2013
Department | Blood utilization indices | ||||||||
---|---|---|---|---|---|---|---|---|---|
C/T ratio | %T | TI | |||||||
N | D | I | N | D | I | N | D | I | |
Surgery | |||||||||
Elective |
412 | 154 | 2.6 | 43 | 54 | 0.79 | 154 | 54 | 2.85 |
Emergency |
232 | 136 | 1.7 | 59 | 168 | 0.35 | 136 | 168 | 0.81 |
Subtotal | 644 | 280 | 2.3 | 102 | 222 | 0.46 | 280 | 222 | 1.26 |
Gynecology and obstetrics | |||||||||
Elective |
242 | 84 | 2.9 | 34 | 146 | 0.23 | 84 | 146 | 0.57 |
Emergency |
186 | 104 | 1.8 | 150 | 234 | 0.64 | 104 | 234 | 0.44 |
Subtotal | 428 | 188 | 2.3 | 184 | 380 | 0.48 | 188 | 380 | 0.49 |
Total |
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Abbreviations: N stands for numerator; D stands for dominator; I stand for index. C/T: crossmatch transfusion ratio, %T: the probability of transfusion, and TI: transfusion index.
In department of surgery, for instance, overall C/T ratio was 2.3 with high ratio in elective than emergency (2.6 versus 1.7). In addition, the overall %T was 46.2% with 35.0% in emergency and 79.3% in elective patients.
On the other hand, in department of gynecology and obstetrics, the overall C/T ratio was 2.3 with elective surgical patients having the highest C/T ratio (2.9) than emergency patients (1.8). Moreover, the overall %T and TI were 48.2% and 0.49, respectively.
Blood and its component play a major role in the resuscitation and management of both elective and emergency surgical patients. Despite this advantage, currently there is a limited supply with increasing demand and underutilization of the requested blood worldwide [
Preoperative overordering of blood has been documented since 1976, when Friedman et al. published their findings. Subsequently, a number of studies have also showed over ordering of blood in different parts of the countries [
Since the introduction of blood transfusion into clinical practice, its appropriate use has been the subject of debate. It has been reported that only 30% of crossmatched blood is used in elective surgery [
The current study revealed that 56.4% of the cross- matched blood was unutilized. This finding was almost comparable to that reported in northern India study where 59.0% of blood crossmatched was unutilized [
Boral Henry was the first, and a number of authors then after, used crossmatch to transfusion ratio [
The present study also demonstrated that C/T ratio was similar across the emergency patients of surgical (1.7) and gynecology and obstetrics (1.8) departments. This was somewhat similar to that reported in Egyptian [
Mead et al. [
Regarding transfusion index (TI), a value of 0.5 or more is indicative of efficient blood usage and signifies the appropriateness of number of units transfused [
In conclusion the overall ratio of C/T, %T, and TI index were considered to be optimal as compared with the standard figures, even though majority of the crossmatched blood was not utilized by the patient. In vast majority of elective surgical procedures routine crossmatch and preparation are not necessary. Moreover C/T ratios of elective patients in each department showed inefficient utilization of ordered blood. Developing a blood ordering policy, which is a guide to expect normal blood usage for surgical procedures, can decrease over ordering of blood thereby reducing unnecessary compatibility testing, returning of unused blood, and wastage due to outdating. It also allows for a more efficient management of blood inventory. In this respect, the hospital blood transfusion committee should formulate maximum surgical blood order schedules for selected cold surgical procedures, conduct regular auditing about effectiveness of the blood requesting policy using the crossmatch to transfusion ratio, and offer periodic feedbacks to improve blood ordering, handling, distribution, and utilization practices of this scarce resource.
The authors declare that they have no conflict of interests.
Tadesse Belayneh participated in the conception, design, acquisition of the data and statistical analysis interpretation of the data, drafting of the paper, and critical revision of the manuscript. Gashaw Messele, Zewditu Abddisa, and Birhanmeskel Tegene participated in the design and critical revision of the manuscript. All authors read and approved the final manuscript.
The authors would like to thank University of Gondar (financial support), data collectors, and study participants.