Time to Cross off Routine Preoperative Blood Crossmatch in Mastectomy!

Ambreen Zaidi^*, Huma Mannan, Zulqarnain Choudhry, Sameen Mohtasham Khan, Huma Majeed Khan, Ruqayya Naheed Khan, Amina Iqbal Khan and Muhammad Asad Parvaiz
^*Correspondence: Ambreen Zaidi, Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, Pakistan, Tel: +4407951215228, Email:

Keywords

Blood grouping • Crossmatching • Blood transfusion • Breast cancer • Mastectomy • Surgical blood loss

Introduction

In our hospital, patients undergoing elective mastectomy for confirmed breast cancer are usually admitted to the ward one day prior to the surgery. Duty doctors take detailed history and make note of their physical examination. A battery of tests is requested, depending on the patient’s past medical history. Such patients are required to routinely have a blood sample sent for preoperative grouping and crossmatching one day before surgery. The blood bank provides 1 unit of packed red blood cells (RBCs), taken as approximately 300 ml, for each mastectomy patient. The next day patients undergo surgery, where some require blood transfusion while others do not. Routine blood crossmatching is one of the commonest tests done by our blood bank laboratory. The cost incurred for this crossmatch is 10 United States dollars (USD) per patient. Like many other institutes, blood over-ordering is a common practice in our hospital. Many surgeons order blood crossmatching only on the basis of habit. This leads to problems in blood bank inventory management. This may lead to extra laboratory work and also incur extra costs [1,2].

In addition to this cost and waste of human resources, blood transfusion carries the additional risks of ABO incompatible transfusions, acute and delayed reactions, post-transfusion complications and infections related to blood transfusions (Hepatitis B, Hepatitis C and HIV) [3-5]. Blood transfusion in breast cancer surgery patients is becoming rare due to meticulous haemostatic surgical techniques. Blood loss during mastectomy depends on multiple factors. The surgical technique and expertise and the available equipment for controlling haemorrhage will all influence the amount of blood loss [6]. The amount of blood loss during mastectomy also depends on certain patient factors, such as inherited disorders of haemostasis, past history of coagulopathies and history of anticoagulant drugs usage [7].

In our hospital, in order to minimize perioperative blood loss in such patients, their blood-thinning medicines are stopped 1-2 week prior to surgery, if it is safe to do so. In addition, surgeons use various techniques to minimize blood loss including monopolar diathermy, ligaclipsTM, vicryl sutures/ties and ligasureTM. A suction drain is secured in mastectomy cavity to monitor volume of blood loss. Postoperatively patients have external compression of mastectomy flaps by a pressure dressing which at times may be covered by an additional crepe bandage. The aim of the study was to see whether we could safely avoid the routine preoperative blood cross-match in some of our elective mastectomy patients.

Patients and Methods

Inclusion criteria

• After receiving approval from the institution review board, data of all patients undergoing mastectomy between January and June 2016, over the age of 18 years was reviewed from a prospectively maintained computerized database.

• Patient demographics, preoperative and postoperative haemoglobin levels, reasons and timings of blood transfusion were recorded.

• Perioperative blood transfusion was defined as transfusion done within a time period of 1 week before and 1 week after the date of surgery.

• The cost of a cross-match was estimated to be approximately 10 USD.

Exclusion criteria

• Patients having bilateral breast surgeries and patients with known inherited disorders of hemostasis

Results

182 patients underwent mastectomy during the study period of 6 months. Out of these, 170 (93.4%) patients had preoperative blood crossmatch done (Figure 1).

15 patients (8.2%) required blood transfusion preoperatively (Table 1) for building up their haemoglobin levels (range 7.4-9.9 g/dL, mean 9.1 g/dL) (Table 2). Out of these 15 patients that were transfused preoperatively, 9 had received neoadjuvant chemotherapy.

Table 1: Timing of preoperative blood transfusion in mastectomy patients.

Table 2: Preoperative blood transfusions in mastectomy patients and their preoperative hemoglobin levels.

Thus out of 182 mastectomies, only 15 patients (8.24%) patients needed transfusion preoperatively (Table 3), where there was ample time to crossmatch and arrange blood.

Table 3: Blood crossmatch and transfusions in mastectomy patients.

Crossmatch Transfusion Ratio was found to be 11.33: 1, that is for every 11.33 crossmatch request, only one transfusion was carried out (Table 3).

Cost of blood crossmatch in these 15 patients needing transfusion was 150 USD compared to 1700 USD cost of crossmatching 170 patients.

None of our patients required transfusion intra or postoperatively (Figure 2). Cost of blood crossmatch in 155 patients that never required blood transfusion was 1550 USD. This resulted in extra costs and resources wasted in arranging preoperative blood units.

Discussion

The ordering of blood units needs to be planned and monitored preoperatively by the surgeon and his team. All members of the surgery and anesthesia team need to be aware that such practices can lead to cost savings [1,8].

In our hospital, most mastectomy patients never need postoperative blood transfusion, as excessive blood loss during surgery is very rare. Ideally the surgeon should be able to predict an approximate surgical blood loss along with an approximate need for blood units to be transfused. This can improve efficacy of the blood ordering system and can significantly lower the burden on the blood bank [6,9]. Excessive crossmatch is costly and unnecessarily puts a burden on the limited hospital resources. Malik et al. [10] have suggested revising the hospital’s blood grouping and crossmatching policies that add an unnecessary burden on the patients and hospital blood labs.

Lin et al. [2] calculated indices for different types of surgical procedures. Furthermore the number of procedures (P), number of requests for pretransfusion test (R), and the number of patients transfused (T) were also recorded and certain indices were calculated from these values.

Transfusion probability is a percentage (%) defined by Mead et al. [11] as the number of patients transfused (T) ÷ Number of patients crossmatched (P) × 100 surgical procedures with transfusion probability less than 5% have been considered as rarely requiring transfusion. These procedures are expected to have minimal blood loss and it has been considered safe to disregard a preoperative blood order. If the procedures have transfusion probability greater than or equal to 20%, they are considered as commonly requiring transfusion. A value of greater than 30% has been considered to an indication of significant blood usage [2,11].Palmer et al. [12] have stated that in postoperative surgical and medical patients, red blood cells should only be crossmatched and transfused in response to a demonstrated anemia. If a surgery is expected to involve minimal blood loss, a type and screen order has been recommended for surgical procedures that require blood in less than 10% of cases [2,13].

Mostly, preoperative blood crossmatching is performed in anticipation of a potential need based on the surgeon’s own transfusing experience. The actual need for a transfusion may never materialize, and subsequently, many blood units that are crossmatched before surgery are never transfused [12]. Each hospital has its own policies regarding transfusion. Since there is a lack of randomized clinical trials regarding blood transfusion guidelines, worldwide different evidence-based transfusion guidelines and strategies have been introduced. These lead to better utilization of blood products and are cost effective and safe. Some strategies include preoperative risk assessment, optimized preoperative haemoglobin levels and different surgical techniques to minimize blood loss [14-17].

Friedman et al. [18-20] have proposed the use of a Maximum Surgical Blood Order Schedule (MSBOS). This is a measure to limit the number of units held out of circulation and thus limiting the risk of the products getting expired. The MSBOS guidelines are widely accepted and have been shown to reduce unnecessary crossmatching, thus decreasing blood bank costs [12,21-24]. The blood grouping, crossmatch and screening policy means that the patient’s blood is grouped and the serum is screened for red cell allow-antibodies. The units are only crossmatched if an actual need for transfusion occurs [2,20]. Auditing of the surgical blood ordering practice can lead to improvement in the use of blood products for transfusion [2,9,14,19-24]. Many blood banks have switched to computer-based crossmatching. This not only reduces the time of grouping and crossmatching to minutes but also has the potential to reduce unnecessary crossmatching [12,25,26].

Lin et al. [2] have recommended that blood crossmatch should be reserved for only those patients whose preoperative haemoglobin levels are less than 10 g/dL and the availability of blood for an emergency situation should be confirmed preoperatively. In selective cases, excessive blood loss can be predicted. For example with large breast sizes [6], and in pre-existing conditions such as hypertension, chemotherapy induced low platelet counts or any known coagulopathies [27]. When crossmatched blood is not transfused, it burdens the blood bank resources. An increased blood inventory has to be maintained. There are also an increased number of blood units that will expire before usage [12,18]. The blood transfusion audit has become an essential aspect in formulating guidelines for surgical blood ordering. Data concerning surgical blood orders should be reviewed periodically. Blood ordering strategies and policies should be revised based on an audit of each individual hospital. Such policies require coordination between surgery, anesthesia and transfusion medicine teams and should also obtain approval of the hospital’s transfusion committee [2].

Conclusion

In our study, none of the mastectomy patients required blood transfusion in emergency situation warranting preoperative cross-match in the whole cohort. The 8.2% patients that did need transfusion preoperatively, mostly due to low haemoglobin levels after administration of neoadjuvant chemotherapy, had ample time to get their blood crossmatched and arranged preoperatively. The majority of our mastectomies fall in the category of those procedures that rarely require blood transfusion. Based on our data, we recommend that the routine preoperative crossmatch of all mastectomy patients, irrespective of their hemoglobin levels, is an unnecessary process that adds burden to the limited hospital resources, blood bank, patients and their families. In addition it adds to the workload of the already over-burdened hospital staff. Preoperative blood cross-match should be reserved for only those patients whose preoperative haemoglobin levels are less than 10 g/dL or in selective cases, where excessive blood loss during surgery can be predicted well beforehand due to large breast size, pre-existing bleeding or coagulation disorders and low platelet counts. We can annually save up to approximately 3100 USD by reviewing our blood ordering strategy. The hospital’s grouping and crossmatching policy and guidelines need to be reviewed periodically and blood transfusion audits should be made mandatory. This will minimize unnecessary crossmatch requests.

Conflict of Interest

The authors have no conflict of interest to declare.

Declaration

No direct funding was allocated for this study.

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