Injury(1986)17,26!5-266 Printedin GreatBritain 265

Blood use in urgent of the femoral neck

John Robbins Department of Community Health,

Raymond F. Steingold

operations for patients with fractures

University of Leicester

Department of Orthopaedic Surgery, Leicester Royal Infirmary

Unnecessary preoperative cross-matching of blood wastes time and money and may increase morbidity and mortality by delaying a necessary operation. One hundred and ninety- three consecutive patients who underwent semi-urgent opera- tive treatment for fractures of the neck of the femur at a large district general hospital were evaluated. Of the patients with haemoglobin values of 11 g/d1 or more, only 12 per cent required transfusion for the operation. None of the patients with fractures treated by ‘pinning’ required a transfusion. It is our opinion that patients with normal preoperative haemo- globin levels can undergo operative treatment for fractures of the neck of femur after typing but without the necessity of cross-matching blood.

INTRODUCTION A GROWING concern over the expense of cross- matching blood for elective operations has been ex- pressed by a number of authors, including Huang et al. (1980), Sarmad (1980), Argov and Shecker (1981) and Smallwood (1983). The necessity of having blood avail- able before urgent or semi-urgent operations has important implications for blood bank reserves but also raises other matters. When blood is required to be available before operations, it may be necessary to delay the operation because blood banks are unwilling or unable to cross-match blood other than for emer- gency purposes outside regular working hours. In some instances the delay may increase morbidity and mortal- ity. To our knowledge, the question of the necessity for having cross-matched blood available before urgent operations has not been previously considered.

There is no unanimity about the requirements for blood in the treatment of fractured neck of the femur. Campbell (1976) reports that all patients at one centre routinely receive 3 units of blood during the operation. In a study of elective surgical procedures in Australia, Seshadri et al. (1979) noted that approximately 3.5 per cent of patients with fractures of the neck of the femur received blood about the time of operation. In many cases, ‘folklore’ or ‘force of habit’ seems to dictate that patients be cross-matched before the operation. However, in a search of the orthopaedic literature, we find no specific recommendations based on clinical evidence as to how much blood should be available for urgent orthopaedic operations. A large national survey undertaken by Friedman et al. (1976) studied the blood used in major surgical procedures and recommended

4-5 units of blood be available for arthroplasty and 2 units for closed reduction and internal fixation. These authors did not, however, take into account the pa- tients’ haemoglobin levels before they were operated on.

METHODS AND RESULTS Over a 20-week period, 216 patients were admitted to Leicester Royal Infirmary with fractures of the neck of the femur. The patients were all seen before being operated on, their orthopaedic radiographs were re- viewed, and their haemoglobin levels were noted. The operative notes were later reviewed to ascertain what operations they had undergone. Records of the blood bank were reviewed to find out whether the patients received transfusions from 24 hours before until 24 hours after operation. The standard practice was to cross-match 2 units of blood before operating.

Of the 216 consecutive patients admitted with frac- tured neck of the femur, 196 patients were treated surgically. Twenty patients were treated conservatively or died without operation. Three other patients were removed from the analysis because of the type of operation (two had total hip replacements to treat underlying degenerative disease and a special extended prosthesis was used once because of metastatic cancer). Table I shows the distribution of haemoglobin values preoperatively and units transfused in the remaining 193 patients. There is, as would be expected, a very high correlation between the two (Pearson r, P<O@Ol). Furthermore, 17 per cent of patients who were transfused received only 1 unit of blood.

Eighty per cent of the patients had a preoperative haemoglobin of more than 11 g/dl. In this group only 12 per cent required transfusion and none of the 28 pa- tients with subcapital fractures treated by multiple pins (Howse screws, A0 screws, Knowles pins) required a transfusion. Tables-II and ZZZ show those patients with a normal haemoglobin, the sites of their fractures and types of operation. The patients with a normal preop- erative haemoglobin who were treated by hemiarthro- plasty were only slightly more likely to require transfu- sion at the time of operation (12/70) than those treated by blade and plate (6/56). This does not approach statistical significance (chi squared, P>O-05).

266 Injury: the British Journal of Accident Surgery (1986) Vol. 17IN0.4

Table I. Units of blood transfused in patients with different preoperative haemoglobins

No. of Preoperative haemoglobin (g/d/) units transfused 6-6-g 7-7.9 8-8.9 9-9.9 10-10.9 11-11.9 12-12.9 13-13.9 14-14.9 15-159 16-16.9 Unknown Total

0 0 0 1 1 12 34 32 28 24 12 3 3 151 1 0 0 0 2 1 1 1 1 1 0 0 0 7 2 or more 1 3 3 6 9 4 5 3 1 0 0 0 35

Total 1 3 4 9 22 39 38 32 26 12 3 4 193

Table il. Operative blood transfusions in patients with preoperative haemoglobins of at least 11 g/d\, by fracture type

Type of fracture

Blood transfusion

Subcapital Subcapital grade I-11 grade Ill-IV lntertrochanteric Subtrochanteric Unknown Total

No Yes

Total

19 65 45 4 3 136 0 12 5 1 0 18

19 77 50 5 3 154

Tab/e /I/. Operative blood transfusions in patients with pre- operative haemoglobins of at least 11 g/dl, by type of operation

Type of operation Blood transfusion Pins Hemiarthroplasty Blade and plate Total

No 28 58 50 136 Yes 0 12 6 18

Total 28 70 56 154

DISCUSSION Acknowledgement This work was carried out by Dr Robbins while on sabbatical leave with the Department of Community Health, University of Leicester. He thanks his associ- ates in the Department for their support in this project.

Patients who are anaemic before operation should be typed and cross-matched in time for it. In this study, most patients had HbSll g/dl, and preoperative anaemia cannot be seen as a reason for having blood available. If blood can be typed and screened for unusual antibodies, it appears to us unnecessary to cross-match these patients before operation. Massive uncontrollable bleeding is not likely in this type of operation. The likelihood of using blood for patients with Hb>ll g/d1 was only one in nine. The blood that was used was in patients undergoing hemiarthroplasties or internal fixation of intertrochanteric fractures. None of the cases of subcapital fractures treated by pinning required transfusions.

REFERENCES Argov S. and Shecker Y. (1981) Is routine cross-matching for

two units of blood necessary in elective surgery? Am. Med. J. Surg. 142, 370.

Guidelines for making blood available before elec- tive operations have been suggested by De Jongh et al. (1983) but a policy for urgent or semi-urgent operations is also necessary. In many areas of the world, because of geographic or economic restraints, routine or semi- urgent cross-matching of blood will be carried out only at certain times. By not cross-matching blood before op- eration for every patient with a femoral fracture and a haemoglobin of more than 11 g/dl, noteworthy savings could be made. Less time would be spent by the staff of the blood bank in this task and, importantly, patients could be operated on without the delay of waiting for time-consuming and at times unavailable procedures from the blood bank. In addition, less blood would be wasted by holding it in readiness and possibly exceed- ing the expiry date.

Campbell A. J. (1976) Femoral neck fractures in elderly women: a prospective study. Age Aging 5, 102.

De Jongh D. S., Feng C. S., Frank S. et al. (1983) Improved utilization of blood for elective surgery. Surg. Gynecal. Obstet. 156, 326.

Friedman B. A., Oberman H. A., Chadwick A. R. et al. (1976) The maximum surgical blood order schedule and surgical blood use in the United States. Transfusion 16, 380.

Huang S. T., Lair J., Floyd D. M. et al. (1980) Type and hold system for better blood utilization. Transfusion 20, 725.

Sarmad P. (1980) Use of blood in elective surgery. JAMA 243, 1536.

Seshadri R. S., O’Dell W. R., Roxby D. et al. (1979) Effective use of blood in elective surgery. Med. J. Aust. 2, 575.

Smallwood J. A. (1983) Use of blood in elective general surgery: an area of wasted resources. Br. Med. J. 286, 868.

Paper accepted 20 September 1985.

Requests for reprints should be addressed fo: Mr R. F. Steingold, Consultant Orthopaedic Surgeon, Manor Hospital, Manor Court Road, Nuneaton.