4 evaluation of requirement · blood requirement prior to surgery. results: there were 50 patients...

Abstract : Aims & objectives: To study the pattern of blood ordering and transfusion practices

in patients undergoing elective maxillofacial surgery in a Mahatma Gandhi Dental college and

hospital and Mahatma Gandhi General hospital. Materials and methods: Clinical trial was

carried out in 50 patients requiring Blood Transfusion in elective maxillofacial surgical

procedures. The study was carried from January 2014 to October 2015. All Cases of

maxillofacial surgical procedures done under GA. Under each procedure the number of patients,

estimated blood volume (EBV) and estimated blood loss (EBL). Indices such as the cross

matched/transfused ratio (C/T ratio), transfusion index(TI) and transfusion probability(%T)

were calculated. Maximum surgical blood ordering schedule (MSBOS) calculated to determine

blood requirement prior to surgery. Results: There were 50 patients (age range: 8-62years) in the

study. 54 units of blood were crossmatched, 25 were transfused (CT ratio 2.16). 54.0% patients

did not require transfusion during entire hospital stay. %T was 46 %, TI was 0.50 and MSBOS

was 0.5 all these variables were significant. Difference between male and female Hb,Hct, EBV,

Post Op Hb, Post Op Hct, Post Transfusion Hb and Post Transfusion Hct were statistically

significant(p<0.05). Conclusion: We had utilized only 46% of blood, 54 % of was not utilized.

We were cross matched according to procedure and preop Hb. The use of vasoconstrictor agent,

hypotensive anaesthesia, ligation and diathermy of vessels, to reduce bleeding is a recommended

approach to the conservation of blood. In order to relegate unnecessary crossmatching, blood

ordering schedule catering to surgeon and patient requirements is essential.

2 3 4 51Ashish Soni, Sunil Sharma, Bindu Bhardwaj, Punit Chitlangia, Vikas Singh1 2 36 Prateek Agarwal : Postgraduate Student, Professor and Head, Professor,

-5 64 Reader, Senior lecturer, Department of Oral and Maxillofacial Surgery, Mahatma Gandhi Dental College and Hospital, Jaipur

INTRODUCTION :

Blood transfusion is the transfer of blood or blood

components from one person (the donor) into the bloodstream

of another person (the recipient). The history of blood

transfusions begins in the 17th century. In 1628, a British

physiologist William Harvey published the first information

about the human circulatory system.[1]

Early transfusions used whole blood, but modern medical

practice commonly uses only components of the blood, such

as red blood cells, white blood cells, plasma, clotting factors,

and platelets. Historically, transfusion was used to maintain

blood haemoglobin concentration above 10 g/dL and a

haematocrit above 30%. (The "10/30 rule").[2]

In recent years, influenced by an increasing demand for cost-

effectiveness, there has been an increased awareness of the

need for optimum distribution and utilization of safe blood

and blood products.3 Surgical precision is important;

clinicians should pay attention to other parameters such as the

patients' haemoglobin level, intra-operative blood loss and

operation time.[4]

Many units of blood routinely ordered by surgeons are not

utilised but are held in reserve and thus are unavailable for

EVALUATION OF REQUIREMENT AND PROTOCOLS OF BLOOD TRANSFUSION IN PATIENTS UNDERGOING ELECTIVE ORAL AND MAXILLOFACIAL SURGERY: A CLINICAL STUDY

Keywords :

C/T, %T, TI, MSBOS,

Blood loss.

Source of support : Nil

Conflict of interest : None

Journal of University

University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 11

University J Dent Scie 2016; No. 2, Vol. 2

Original Research

Papers

Dental Sciences

other needy patients. This can impose inventory problems for

blood bank, loss of shelf life and wastage of blood. [5]

It is important to improve the efficacy of ordering system for

maximum blood utilisation and formulation of Maximum

Surgical Blood Order Schedule (MSBOS) for common

procedures where a complete cross-match appears

mandatory. A maximum surgical blood order schedule

(MSBOS) provides guidelines for frequently performed

elective surgical procedures by recommending the maximum

number of units of blood to be cross matched

preoperatively.[6]

AIMS & OBJECTIVES : Aims of this study was to study the

pattern of blood ordering and transfusion practices in patients

undergoing elective maxillofacial surgery in a Mahatma

Gandhi Dental college and hospital and Mahatma Gandhi

General hospital, Jaipur and to suggest improvement in the

efficacy of blood ordering system for maximum utilization

and to improve blood transfusion protocol for elective

maxillofacial surgical procedures.

MATERIALS AND METHODS : This study was

undertaken in patients reporting to the Indoor Patient

Department (IPD) of oral and maxillofacial surgery,

Mahatma Gandhi Dental College & Hospital and general

hospital, Jaipur. The study was carried from January 2014 to

October 2015. All Cases of maxillofacial surgical procedures

done under GA. Clinical trial was carried out in 50 patients

requiring Blood Transfusion in elective maxillofacial surgical

procedures.

Inclusion criteria were all patients were planned for elective

maxillofacial surgical procedures for which blood transfusion

was anticipated. Exclusion criteria were bleeding disorder

patients. After evaluation and obtaining the written informed

consent, all the patients included in the study were

investigated with preoperative blood grouping and cross

matching. Data included the extent, diagnosis of lesion, and

medical comorbidities.[7]

Preoperatively Name, Age, Gender, type of surgery, Reasons

for seeking surgery, haemoglobin concentration, blood group

and units of blood cross-matched, duration of surgery

assessed. Traditionally, the decision to transfuse red blood

was based upon the '10/30 rule'; to maintain blood

haemoglobin (Hb) concentration above 10 g/dl and a

haematocrit above 30%.[]

1

In the intraoperative assessment data regarding haematocrit

value before transfusion, and blood units and or colloids

replaced were recorded. All cases were done under general

anaesthesia. The surgical site was infiltrated with adrenaline

(1:200,000) before making the incision. For all the patients, 1

unit of homologous blood was cross-matched for the

surgery.[8]

Estimated blood volume (EBV) was calculated for each

patient using the body weight formula (75 mL/ kg for men, 66

ml/kg for women). Estimated blood loss (EBL) was

calculated by weighing sponges, measuring suctioned blood,

and adjusting for the volume of irrigation solution used during

the operation.9 Under each procedure the number of patients,

units of blood cross-matched and numbers of units transfused

were recorded and the following indices were calculated for

each procedure.

• Cross match transfusion ratio (C/T ratio) = No of

units cross-matched / No of units transfused. A ratio

of 2.5 and below was considered indicative of

significant blood usage.[5]

• Transfusion probability (%T) = No of patients

transfused / No of patients cross matched × 100. A

value of 30 or more was considered indicative of

significant blood usage.[5]

• Transfusion Index (TI) = No of units transfused / No

of patients cross matched. A value of 0.5 or more

was considered indicative of significant blood

utilisation.[5]

• Maximum surgical blood ordering schedule

(MSBOS): This was calculate using Mead's

criterion.[5]

MSBOS = 1.5 X TI

Where TI = Transfusion Index

RESULTS : The study was designed to evaluate the

requirements and protocol of blood transfusion in the patients

undergoing elective maxillofacial surgery. A total of 50

patients who underwent elective procedures in our hospital,

were included in the study. There were 37 males (74%) and 13

females (26%). Out of the 54 units of blood cross matched,

only 25 (46 %) were transfused. 29(54 %) of the total cross



matched units were not transfused. 27 (54%) of the 50 patients

did not require transfusion during entire hospital stay.

Various procedures such as Open Reduction and Internal

Fixation, Cystic Enucleation+ Cystic Enucleation &

Decortication, Maxillectomy, Exicision of Fibrous Band &

Reconstruction, Bilateral Sagittal Split Osteotomy , Gap

Arthroplasty with Interpositional Graft, Capsulorrhaphy,

wide excision of left buccal mucosa followed by marginal

mandibulectomy and Plate Retrieval were performed during

the study, table 1 shows the blood cross matched, transfused

and unused blood in these procedures.

Table-1. No. of Units of Blood Cross Matched, Transfused

and unused according to Surgical Procedures

Seven of the all elective surgery procedures, i.e. Open

Reduction and Internal Fixation, Cystic Enucleation+ Cystic

Enucleation & Decortication, Maxillectomy, Exicision of

Fibrous Band & Reconstruction, Bilateral Sagittal Split

Osteotomy and Plate Retrieval had C/T ratio below than 2.5.

In Gap Arthroplasty with Interpositional Graft C/T ratio was

higher than 2.5. In procedures capsulorrhaphy and wide

excision of left buccal mucosa followed by marginal

mandibulectomy, C/T was nil. A ratio of 2.5 and below was

considered indicative of significant blood usage. The

probability the patient would undergo transfusion (%T) was

>30 in all procedures except capsulorrhaphy and wide

excision of left buccal mucosa followed by marginal

mandibulectomy. A value of 30 or more was considered

indicative of significant blood usage. Six out of ten elective

procedures had TI > 0.5 and four procedures had TI < 0.5. A

value of 0.5 or more was considered indicative of significant

blood utilisation. Eight of the ten elective surgery procedures

had MSBOS more than 0.5 units and two procedures MSBOS

less than 0.5. When the number of units calculated is less than

0.5 units, a group and save policy is advocated. When it is

more than 0.5 units, the number of units is rounded off to the

nearest integer. (table.2)

Table 2. Analysis of Blood Transfusion Data for Different

Elective Surgical Procedures

The mean age was 31.30±14.23 years (mean±SD) with range

of 8-62 years. The mean cross match unit in the study was 1.08

± 0.34 units (mean±SD) with range of 1-2 units. The mean pre

op transfusion in the study was 0.18±0.44 units (mean±SD)

with range of 0-2 units mean post op transfusion was

0.34±0.48 units with range of 0-1 unit and mean unused blood

was 0.56±0.50 units with range of 0-1unit. The mean

estimated blood volume in the study was 4460.20± 1096.28

ml (mean±SD) with range of 1350-6000 ml and estimated

blood loss was 382.34 ± 161.61 ml (mean±SD) with range of

100-750 ml. The mean preoperative hemoglobin in the study



was 11.26±1.29g/dl (mean±SD) with range of 8.3-15.5g/dl,

mean postoperative hemoglobin was 10.6 ±1.17g/dl

(mean±SD) with range of 9-14.4 g/dl and mean post

transfusion Hb was 11.9 ± 0.91 g/dl (mean±SD) with range of

9.9-13.2 g/dl. The mean preoperative hematocrit in the study

was 34.45±3.71 % (mean±SD) with range of 27.3-48.1, mean

postoperative hematocrit was 32.90±3.36% (mean±SD) with

range of 28-46.1 % and mean post transfusion hematocrit was

34.03 ± 2.98% (mean±SD) with range of 30-42.9 %. (Table.

3)

Tables-3. Variables Assessed in the Study Sample (n = 50)

DISCUSSION

Blood transfusion plays a major role in the management of

maxillofacial patients. The outcome of this study showed that

not all surgeries require blood transfusion. Any surgical

procedure resulting in patients losing about 20% or more of

their blood, usually entails providing a transfusion to make

sure that the patients stay healthy and suitable during surgery

and recovery. Avoiding blood loss and using blood products

judiciously enhances surgical outcome and better patient

care.[4]

National blood policy (2007) of National AIDS Control

Organisation Ministry of Health and Family Welfare

Government of India, states to encourage appropriate clinical

use of blood and blood products. Strategy of this policy is that

the blood shall be used only when necessary. Blood and blood

products shall be transfused only to treat conditions leading to

significant morbidity and mortality that cannot be prevented

or treated effectively by other means.[10]

Boral Henry was the first, and a number of authors then after,

used cross-match to transfusion ratio for evaluating blood

transfusion practices.[11] The cross-match: transfusion ratio

is the number of units cross-matched for a procedure divided

by the total number of units transfused, and is an index of the

efficiency of ordering and use of blood, and should be less

than [2.5.12]

The transfusion index is a measure of the amount of blood

used for a given procedure. A value of less than 0.5 suggests

that cross-matched blood is unlikely to be required. A

transfusion probability of less than 30% is also a strong

indication for grouping and saving only. This is a ratio of the

number of appropriate transfusions for the total number of

operations.[12]

The term MSBOS has been used to describe a list of common

elective surgeries with the maximum number of units of blood

to be cross-matched preoperatively. In the absence of a

Maximum Blood Ordering Schedule, there is a high surge in

additional costs to the patient, rise in the amount of blood that

is outdated and an increase in blood transfusion centers'

workload. MSBOS formulation has been developed using

Mead's criterion. According to this criterion, the number of

RBCs calculated is one and a half times the transfusion index

for each surgical procedure. According to the report of Boral

and Henry which was based on Mead's criterion, if a

procedure uses <0.5 units of blood per procedure, a pre-

operative cross-match is not appropriate.[8]

In this study we had cross matched 54 blood units in 50

patients. Out of 54 units of blood only 25 (46%) units were

cross matched. Remaining 29 (54%) units were unused.

Arulselvi Subramanian (2012) et al 13 conducted a similar

study to compile and review the blood utilization for two key

departments (Neurosurgery and Surgery) Shows similar

results with 60% of the total crossmatched units which were

not transfused. Study by Nagarekha kulkarni et al (2012)6

showed that 74% of the total crossmatched units were not

transfused. M Vibhute et al (2000)5 showed that 76.86% of

the total crossmatched units were not transfused. Davoudi-

kiakalayeh et al (2013)14 showed that 69% of the total

crossmatched units were not transfused.

The C/T ratio in this study was less than 2.5 which was

significant for all procedures except for gap arthroplasty with

interpositional graft, Capsulorrhaphy and wide excision of

Left buccal mucosa followed by marginal mandibulectomy.

The transfusion probability in this study was more than 30



which was significant for all procedures except,

Capsulorrhaphy, and wide excision of Left buccal mucosa

followed by marginal mandibulectomy. The transfusion

index in this was more than 0.50 which was significant for all

procedures except for Open Reduction and Internal Fixation,

gap arthroplasty with interpositional graft, Capsulorrhaphy

and wide excision of Left buccal mucosa followed by

marginal mandibulectomy. The MSBOS was less than 0.5

which was significant for all procedures except for

Capsulorrhaphy and wide excision of Left buccal mucosa

followed by marginal mandibulectomy. In our study overall

C/T ratio was 2.16, transfusion index was 0.5, transfusion

probability was 46% and MSBOS was more than 0.75.All

these variables shows that blood cross matching was

significant. Arulselvi Subramanian (2012)13 analysed

prospectively compiled blood bank records of the patients

undergoing elective surgical and neurosurgical procedures,

shows that over all C/T ratio was more than 2.5, transfusion

index was less than 0.5, transfusion probability was less than

30 and MSBOS was less than 0.5, all these variables shows

that blood cross matching was not significant. O.O. Omisakin

(2013)4 conducted a study in maxillofacial surgery patients

and showed that the overall C/T ratio was 1.10; transfusion

index was 0.62, transfusion probability was 85%. These

results were similar with our study results.

CONCLUSION : In order to relegate unnecessary cross-

matching, blood ordering schedule catering to surgeon and

patient requirements is essential. It is crucial for every

institutional blood bank to formulate a blood ordering

schedule, and the clinicians to take the initiative to order

blood for the scheduled procedures in accordance with the

devised MSBOS for appropriate usage of blood resources.

Regular auditing and periodic feedbacks are also vital to

improve the blood utilization practices. Blood ordering

pattern needs to be revised and over-ordering of blood should

be minimized. It is an ideal method in saving hospital

resources and manpower. In order to reduce unnecessary

cross matching, “type, screen and hold” procedure must be

implemented. However, one must confirm the availability of

blood for emergency situation before the start of the surgery.

In this study we had utilized only 46% of blood; remaining

54% of blood was not utilized. The reason for blood not

utilized was the less amount of blood loss intra-operatively

due to the use of vasoconstrictor agent, hypotensive

anaesthesia, use of tranexamic acid, and ligation and

diathermy of vessels. The use of vasoconstrictor agent (used

infiltration of adrenaline 1: 200,000) to reduce bleeding is a

recommended approach for the conservation of blood. Due to

the use of electrocautery, blood loss was reduced to some

extent.

To conclude this study preoperatively blood cross matching is

required in major Maxillofacial Surgeries such as large

pathologies in which excision and reconstruction is required

and in aesthetic correction surgeries. Whereas in Open

Reduction & Internal Fixation and TMJ surgeries we can

avoid the blood cross matching prior to surgery.

References:

1. Rafa³ Nowak, Ewa Zawiœlak, Maciej Kielan, Marta

Greczner. The Necessity of Autologous Blood

Transfusion in Patients Undergoing Orthognathic

Surgery Procedures – Review of Literature. Dent.

Med. Probl. 2013; 50, 2, 223–227.

2. Iyer SS, Shah J. Red blood cell transfusion strategies

and Maximum surgical blood ordering schedule.

Indian Journal of Anaesthesia. 2014; 58(5):581-

589.

3. Lt Col PK Gupta, Lt Col Harsh Kumar, Air Cmde

RN Diwan. Blood Ordering Strategies in the Armed

Forces— A Proposal. MJAFI 2003; 59: 302-305.

4. O. O. Omisakin, S. O. Ajike, S. M. Aminu, S. E.

Eguma. Blood ordering and transfusion practices in

maxillofacial surgery in a Nigeria tertiary hospital.

I n t e r n a t i o n a l R e s e a r c h o n M e d i c a l

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5. Vibhute M, Kamath SK, Shetty A. Blood utilisation

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2000 Jan-Mar; 46(1):13-7.

6. Nagarekha kulkarni. An analysis of blood usage in

an elective surgeries and its Wastage at medical

college hospital. Journal of evolution of medical and

dental sciences. 2012 Nov: 1(5): 661.

7. Osterman JL, Arora S. Blood product transfusions

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Aug; 32(3):727-38.

8. Adeyemo WL, Ogunlewe MO, Desalu I, Ladeinde

AL, Adeyemo TA, Mofikoya BO, Hassan OO,

Akanmu AS. Frequency of homologous blood

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palate surgery. Indian J Plast Surg. 2010 Jan;

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9. Samman N, Cheung LK, Tong AC, Tideman H.

Blood loss and transfusion requirements in

orthognatic surgery. J Oral Maxillofac Surg. 1996

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10. National Blood Policy. National AIDS Control

organisation , Ministry of Health and Family

Welfare, Government of India, New Dehli, 2007; 5,

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11. Zbigniew M. Szczepiorkowski and Nancy M.

Dunbar Transfusion guidelines: when to transfuse

Hematology 2013 2013:638-644;

12. Dhariwal DK, Gibbons AJ, Kittur MA, Sugar AW.

Blood transfusion requirements in bimaxillary

osteotomies. Br J Oral Maxillofac Surg. 2004 Jun;

42(3):231-5.

13. Subramanian A, Sagar S, Kumar S, Agrawal D,

Albert V, Misra MC. Maximum surgical blood

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CORRESPONDENCE AUTHOR :

Dr. Ashish Soni

86/139, Pratap Nagar, Sanganer

Jaipur, Rajasthan.

E-mail : [email protected]



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