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Audit of Blood Transfusion Services (BTS) in Total Knee Replacement (Tkr) And Total Hip Replacement (Thr) Surgery: A Prospective Study
Original Article
AUDIT OF BLOOD TRANSFUSION SERVICES (BTS) IN TOTAL KNEE REPLACEMENT (TKR) AND TOTAL HIP REPLACEMENT (THR) SURGERY: A PROSPECTIVE STUDY RN Makroo*, V Raina**, M Chowdhry†, UK Thakur‡ and NL Rosamma§ *Director, **Senior Consultant, †Registrar, ‡Senior Technician, §Senior Technologist, Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India. Correspondence to: Dr RN Makroo, Director, Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India. Total knee and total hip arthroplasty surgery make up a significant proportion of elective orthopaedic surgery in our hospital. The blood transfusion services (BTS) are very important for the successful outcome of these surgeries. The present study was undertaken to monitor the Maximum Blood Order Schedule (MSBOS) and cross match transfusion ratio (C:T ratio) in 349 patients of TKR & THR in our hospital. Majority of the patients with pre-operative haemoglobin of more than 13 g/dL in both the categories (TKR and THR) did not receive any transfusion. C:T ratio of THR (1.3:1) was better compared to TKR (1.44:1). The MSBOS of 2 units of red cells for TKR is appropriate while for THR it should be 3 units of red cells for unilateral THR and 4 units of red cells for bilateral THR especially for patients with pre-operative haemoglobin less than 11 g/dL. Key Words: THR, TKR, C: T ratio, MSBOS
INTRODUCTION TOTAL hip replacement (THR) surgery began in 1960 and Total knee replacement (TKR) was first described in 1971 [1]. Patients undergoing TKR and THR surgery frequently require blood transfusions with evidence showing significant variation in the use of transfusions, related more to the attitude of the clinician than patient parameters [2]. The present study was undertaken to monitor the Maximum Blood Order Schedule (MSBOS) and cross match transfusion ratio (C: T ratio) in TKR & THR. The MSBOS is a list which shows the number of blood units routinely crossmatched pre-operatively for elective surgical procedures which is based on a retrospective analysis of actual blood usage for various surgical procedures. The aim is to exactly match the amount of blood crossmatched to the amount of blood transfused in various surgical procedures and in this way, reduce blood wastage. According to the Maximum Surgical Blood Ordering Schedule (MSBOS) of our Institute 2 units are to be requested for TKR and 4 units of PRC are to be requested for THR. MATERIALS AND METHODS The study was done in Department of Transfusion Medicine, Indraprastha Apollo Hospitals, New Delhi, between October 2007 and January 2009. We prospectively audited 349 patients undergoing primary knee or hip arthroplasty. All patients had a full blood count measured before surgery in the preoperative assessment Apollo Medicine, Vol. 6, No. 1, March 2009
28
clinic. Data recorded for this initial audit included: (i) clinical details; (ii) preoperative haematological indices; (iii) number of units transfused (iv) average number of units transfused per patient (v) percentage of patient transfused (vi) Crossmatch: Transfusion (C:T) ratio. A C:T ratio was calculated as number of units requested/ number of units transfused. (vii) Reassess the Maximum Surgical Blood Order Schedule (MSBOS) for these surgeries. RESULTS Out of the 349 patients, 208 (59.6%) patients underwent TKR and 134 (40.4%) patients underwent THR (Fig.1). In patients of TKR 65 (31.2%) were males and 143 (68.75%) were females. Out of the 65 males, 46 (70.76%) patients underwent unilateral arthroplasty and 19 (29.23%) underwent bilateral arthroplasty (Fig.1). 59 units (average 1.28 per patient) of allogenic red cells were transfused in male patients who underwent unilateral arthroplasty with mean pre-operative haemoglobin of 10.5 g/dL. 16 (34.78%) patients did not receive any transfusion in this group with a mean pre-operative haemoglobin 13.6 g/dL. 46 units (average 2.42 per patient) of allogenic red cells were transfused in bilateral arthroplasty with a mean pre-operative haemoglobin of 10.4 g/dL. 2 (10.52%) patients did not receive any transfusion in this group with mean pre-operative haemoglobin of 13.7 g/dL. Out of 143 females, 85
Original Article
(59.4%) patients underwent unilateral arthroplasty and 58 (40.6%) underwent bilateral arthroplasty (Fig. 1). 140 units (average 1.65 units per patient) of allogenic red cells were transfused in female patients who underwent unilateral arthroplasty with mean preoperative haemoglobin of 10.4 g/dL. 25 (29.41%) patients did not receive any transfusion in this group with a mean pre-operative haemoglobin of 12.7 g/dL. 139 units of allogenic red cells (average 2.39 units per patient) were transfused in bilateral arthroplasty with a mean pre-operative haemoglobin of 10.6 g/dL. 3 (5.17%) patients did not receive any transfusion in this group with a mean preoperative haemoglobin of 13.6 g/dL. Crossmatch: Transfusion (C:T) ratio for TKR was 1.44:1 (Fig.2).
not receive any transfusion in this group with mean preoperative haemoglobin of 12.6 g/dL. 55 units (average 3.92 units per patient) of allogenic red cells were transfused in bilateral arthroplasty with mean preoperative haemoglobin of 10.2 g/dL. One (7.14%) patient did not receive any transfusion in this group with preoperative haemoglobin of 14 g/dL. C:T ratio for THR was 1.3:1(Fig. 2). DISCUSSION TKR and THR surgery make up a significant proportion of elective orthopaedic surgery in our Hospital. Patients having orthopaedic surgery often require a blood transfusion at some point in their treatment [3]. In THR, the blood loss occurs during and after the surgery. According to Sturdee, et al [3], 22–97% patient required a transfusion of blood units in THR surgery.
In patients of THR, 84(62.69%) were males and 50 (37.31%) were females. Out of the 84 males, 75 (89.28%) patients underwent unilateral arthroplasty and 9 (10.72%) underwent bilateral arthroplasty (Fig.1). 153 units (average 2.04 units per patient) of allogenic red cells were transfused in male patients who underwent unilateral arthroplasty with mean pre-operative haemoglobin of 10.3 g/dL. 17 (22.66%) patients did not receive any transfusion in this group with a mean pre-operative haemoglobin of 13.58 g/dL. 36 units (average 4 units per patient) of allogenic red cells were transfused in bilateral arthroplasty with a mean pre-operative haemoglobin of 10.4 g/dL. One (11.11%) patient did not receive any transfusion in this group with a pre-operative haemoglobin of this patient who did not receive any units was 15 g/dL. Out of 50 females, 36 (72%) patients underwent unilateral arthroplasty and 14 (28%) underwent bilateral arthroplasty (Fig.1). 88 units (average 2.44 units per patient) of allogenic red cells transfused in female patients who underwent unilateral arthroplasty with mean preoperative haemoglobin of 10.2 g/dL. 9 (25%) patients did
Hemoglobin trigger for blood transfusion: Pre and Post operative The present study indicates that the pre-operative hemoglobin has an important role in deciding wether a person would require transfusion during the course of his surgery. Most of the patients with preoperative hemoglobin t13 gm/dL did not receive any transfusion during their stay in the hospital. This was true for both THR and TKR irrespective of unilateral or bilateral surgery. However, most of the patients who did receive transfusion had a hemoglobin well below 11 gm/dL. These facts signify that preoperative hemoglobin should be done beforehand as it indicates wether the patient would require or not require transfusion. According to Adams and Lundy [4], patients should be transfused if the postoperative haemoglobin falls below 10 g/dL or the haematocrit to below 30%. This practice has been abandoned now and according to the British Transfusion Task Force elderly patients can be allowed a
Fig.1. Sex distribution in Unilateral/Bilateral TKR and THR
Fig. 2.
29
Crossmatch: Transfusion (C: T) ratio for TKR was 1.44: 1.
Apollo Medicine, Vol. 6, No. 1, March 2009
Original Article
haemoglobin as low as 8.0 g/dL, and younger patients as low as 7.0 g/dL before transfusion is required [5]. As a result of studies of the haematological indices in Jehovah’s witnesses who have undergone major surgery, we have considerable information regarding the low levels of haemoglobin which can be tolerated [5]. The transfusion trigger in our hospital is 8.0 g/dL which is in accordance with British transfusion task force [5] and the study done by Sturdee et al. [3].
Table1. TKR Vs THR TKR
THR
Total no. of patients
208
134
Male
65
84
Female
143
50
Male unilateral
46 (70.76%) 75(89.28%)
Transfusion received
30 (65.22%) 58 (77.33%)
According to the study done by Roger, et al. [2] the transfusion trigger of 8.0 g/dL still remains controversial. They believe that the real decision for the transfusion can only be made in the light of clinical experience.
Pre-op Hb
10.5 g/dL
Transfusion not received
16 (34.78%) 17 (22.66%)
Blood utilisation in TKR and THR All said and done, there were still a lot of differences in the blood utilization between the TKR and THR surgery. On an average more units of red cells are required in THR surgery than TKR. In general, bilateral elective surgeries require more blood than unilateral surgeries. Bilateral THR surgery, irrespective of the sex distribultion requires more i.e. around 4 units of red cells. The C:T ratio was better with THR. This means although the number of units transfused per patient were more in THR, most of the units that were arranged were eventually issued and transfused. This resulted in better utilization and less wastage in unnecessary crossmatching extra units in THR as compared to TKR. The C:T ratio was 1.44:1 for TKR and 1.3:1 for THR. These are well in accordance with the studies done elsewhere [2,3]. The C:T ratio provides information on the efficiency of the blood ordering practices. Although a C:T ratio of 1 would be ideal and most efficient, A C: T ratio upto 2 is permissible and is usually not asscoiated with increased outdating [6]. This signifies that most of the blood that is arranged is issued and it prevents any loss in terms of unnecessary cross-matches to provide compatible blood unit. Maximum surgical blood ordering schedule (MSBOS)
Pre-op Hb
13.6 g/dL
13.58 g/dL
No. of units transfused
59
153
Transfusion rate
1.28 units
2.04 units
Male bilateral
19 (29.23%) 9 (10.72%)
Transfusion received
17 (89.47%) 8 (88.9%
Pre-op Hb
10.4 g/dL
10.4 g/dL
Transfusion not received
2 (10.52%)
1 (11.1%)
Pre-op Hb
13.7 g/dL
15 gm/dL
No. of units transfused
46
36
Transfusion rate
2.42 Units
4 units
Female unilateral
85 (59.4%)
36
Transfusion received
60 (70.58%) 27 (75%)
Pre-op Hb
10.4 g/dL
10.2 g/dL
Transfusion not received
25 (29.4%)
9 (25%)
Pre-op Hb
12.7 g/dL
12.6 g/dL
No. of units transfused
140
88
Transfusion rate
1.65 units
2.44
Female bilateral
58 (40.6%)
14 (28%)
Transfusion received
55 (94.8%)
13 (92.86%)
Pre-op Hb
10.6 g/dL
10.2 g/dL
Transfusion not received
3 (5.17%)
1 (7.14%)
Pre-op Hb
13.6 g/dL
14 g/dL
No. of units transfused
139
55
Transfusion rate
2.39 units
3.92 units
C:T ratio
1.44:1
1.3:1
units irrespective of sex distribution. However, the bilateral THR surgery required around 4 units. Therefore, MSBOS for THR can be divided into 3 units for unilateral surgery and 4 units for bilateral surgery.
The aim of MSBOS is to exactly match the amount of blood crossmatched to the amount of blood transfused in various surgical procedures and in this way, reduce blood wastage [7]. According to the Maximum Surgical Blood Ordering Schedule (MSBOS) of our Institute 2 units are to be requested for TKR and 4 units of PRC are to be requested for THR. This is in accordance with the study done by Saluja et al. [8]. However, in the present study it was found that MSBOS for TKR is appropriate but for THR most of the unilateral surgeries required less than 3 Apollo Medicine, Vol. 6, No. 1, March 2009
10.3 g/dL
CONCLUSION Most of the patients with preoperative hemoglobin t13 gm/dL do not receive any transfusion. THR has a better C:T ratio than TKR surgery. MSBOS for TKR is appropriate (unilateral and bilateral). MSBOS for THR 30
Original Article
should be 3 units for unilateral surgery and 4 units for bilateral surgery.
4. Adams RC, Lundy JS. Anaesthesia in cases of poor surgical risk: some suggestions for decreasing the risk. Surg Gynae Obstet 1942; 74:1011-1019.
REFERENCES
5. Helm, et al. A strategy for reducing blood-transfusion requirements in elective orthopaedic surgery: audit of an algorithm for arthroplasty of the lower limb. J Bone Joint Surg [Br] 2003;85-B:484-489.
1. Reilly RFO, Burgess IA, Zicat B. The prevalence of venous thromboembolism after hip and knee replacement surgery. Medical Journal of Australia 2005; 182: 154-159.
6. Rahman M, Akhtar GN. An audit of blood ordering practices in hospital queen Elizabeth, Kota Kinabalu, Subah, Malaysia. Pak J Med Sci. 2001; 17 (3): 147-150.
2. Rogers BA, Johnstone DJ. Audit on the efficient use of cross-matched blood in elective total hip and total knee replacement. Ann R Coll Surg Engl 2006; 88: 199-201.
7. Wong L, Cheng G. Type and screen of blood units at a teaching hospital. HKMJ 1995:1: 27-30.
3. Sturdee SW, Beard DJ, Nandhara G, Sonanis SV. Decreasing the blood transfusion rate in elective hip replacement surgery using an autologous drainage system. Ann R Coll Surg Engl 2007; 89: 136-139.
8. Saluja et al. Feasibility of pre-operative autologous blood donation in Indian patients with elective orthopaedic surgery. Indian J Med Res 2006; 124: 505-512.
31
Apollo Medicine, Vol. 6, No. 1, March 2009
AUDIT OF BLOOD TRANSFUSION SERVICES (BTS) IN TOTAL KNEE REPLACEMENT (TKR) AND TOTAL HIP REPLACEMENT (THR) SURGERY: A PROSPECTIVE STUDY RN Makroo*, V Raina**, M Chowdhry†, UK Thakur‡ and NL Rosamma§ *Director, **Senior Consultant, †Registrar, ‡Senior Technician, §Senior Technologist, Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India. Correspondence to: Dr RN Makroo, Director, Department of Transfusion Medicine, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India. Total knee and total hip arthroplasty surgery make up a significant proportion of elective orthopaedic surgery in our hospital. The blood transfusion services (BTS) are very important for the successful outcome of these surgeries. The present study was undertaken to monitor the Maximum Blood Order Schedule (MSBOS) and cross match transfusion ratio (C:T ratio) in 349 patients of TKR & THR in our hospital. Majority of the patients with pre-operative haemoglobin of more than 13 g/dL in both the categories (TKR and THR) did not receive any transfusion. C:T ratio of THR (1.3:1) was better compared to TKR (1.44:1). The MSBOS of 2 units of red cells for TKR is appropriate while for THR it should be 3 units of red cells for unilateral THR and 4 units of red cells for bilateral THR especially for patients with pre-operative haemoglobin less than 11 g/dL. Key Words: THR, TKR, C: T ratio, MSBOS
INTRODUCTION TOTAL hip replacement (THR) surgery began in 1960 and Total knee replacement (TKR) was first described in 1971 [1]. Patients undergoing TKR and THR surgery frequently require blood transfusions with evidence showing significant variation in the use of transfusions, related more to the attitude of the clinician than patient parameters [2]. The present study was undertaken to monitor the Maximum Blood Order Schedule (MSBOS) and cross match transfusion ratio (C: T ratio) in TKR & THR. The MSBOS is a list which shows the number of blood units routinely crossmatched pre-operatively for elective surgical procedures which is based on a retrospective analysis of actual blood usage for various surgical procedures. The aim is to exactly match the amount of blood crossmatched to the amount of blood transfused in various surgical procedures and in this way, reduce blood wastage. According to the Maximum Surgical Blood Ordering Schedule (MSBOS) of our Institute 2 units are to be requested for TKR and 4 units of PRC are to be requested for THR. MATERIALS AND METHODS The study was done in Department of Transfusion Medicine, Indraprastha Apollo Hospitals, New Delhi, between October 2007 and January 2009. We prospectively audited 349 patients undergoing primary knee or hip arthroplasty. All patients had a full blood count measured before surgery in the preoperative assessment Apollo Medicine, Vol. 6, No. 1, March 2009
28
clinic. Data recorded for this initial audit included: (i) clinical details; (ii) preoperative haematological indices; (iii) number of units transfused (iv) average number of units transfused per patient (v) percentage of patient transfused (vi) Crossmatch: Transfusion (C:T) ratio. A C:T ratio was calculated as number of units requested/ number of units transfused. (vii) Reassess the Maximum Surgical Blood Order Schedule (MSBOS) for these surgeries. RESULTS Out of the 349 patients, 208 (59.6%) patients underwent TKR and 134 (40.4%) patients underwent THR (Fig.1). In patients of TKR 65 (31.2%) were males and 143 (68.75%) were females. Out of the 65 males, 46 (70.76%) patients underwent unilateral arthroplasty and 19 (29.23%) underwent bilateral arthroplasty (Fig.1). 59 units (average 1.28 per patient) of allogenic red cells were transfused in male patients who underwent unilateral arthroplasty with mean pre-operative haemoglobin of 10.5 g/dL. 16 (34.78%) patients did not receive any transfusion in this group with a mean pre-operative haemoglobin 13.6 g/dL. 46 units (average 2.42 per patient) of allogenic red cells were transfused in bilateral arthroplasty with a mean pre-operative haemoglobin of 10.4 g/dL. 2 (10.52%) patients did not receive any transfusion in this group with mean pre-operative haemoglobin of 13.7 g/dL. Out of 143 females, 85
Original Article
(59.4%) patients underwent unilateral arthroplasty and 58 (40.6%) underwent bilateral arthroplasty (Fig. 1). 140 units (average 1.65 units per patient) of allogenic red cells were transfused in female patients who underwent unilateral arthroplasty with mean preoperative haemoglobin of 10.4 g/dL. 25 (29.41%) patients did not receive any transfusion in this group with a mean pre-operative haemoglobin of 12.7 g/dL. 139 units of allogenic red cells (average 2.39 units per patient) were transfused in bilateral arthroplasty with a mean pre-operative haemoglobin of 10.6 g/dL. 3 (5.17%) patients did not receive any transfusion in this group with a mean preoperative haemoglobin of 13.6 g/dL. Crossmatch: Transfusion (C:T) ratio for TKR was 1.44:1 (Fig.2).
not receive any transfusion in this group with mean preoperative haemoglobin of 12.6 g/dL. 55 units (average 3.92 units per patient) of allogenic red cells were transfused in bilateral arthroplasty with mean preoperative haemoglobin of 10.2 g/dL. One (7.14%) patient did not receive any transfusion in this group with preoperative haemoglobin of 14 g/dL. C:T ratio for THR was 1.3:1(Fig. 2). DISCUSSION TKR and THR surgery make up a significant proportion of elective orthopaedic surgery in our Hospital. Patients having orthopaedic surgery often require a blood transfusion at some point in their treatment [3]. In THR, the blood loss occurs during and after the surgery. According to Sturdee, et al [3], 22–97% patient required a transfusion of blood units in THR surgery.
In patients of THR, 84(62.69%) were males and 50 (37.31%) were females. Out of the 84 males, 75 (89.28%) patients underwent unilateral arthroplasty and 9 (10.72%) underwent bilateral arthroplasty (Fig.1). 153 units (average 2.04 units per patient) of allogenic red cells were transfused in male patients who underwent unilateral arthroplasty with mean pre-operative haemoglobin of 10.3 g/dL. 17 (22.66%) patients did not receive any transfusion in this group with a mean pre-operative haemoglobin of 13.58 g/dL. 36 units (average 4 units per patient) of allogenic red cells were transfused in bilateral arthroplasty with a mean pre-operative haemoglobin of 10.4 g/dL. One (11.11%) patient did not receive any transfusion in this group with a pre-operative haemoglobin of this patient who did not receive any units was 15 g/dL. Out of 50 females, 36 (72%) patients underwent unilateral arthroplasty and 14 (28%) underwent bilateral arthroplasty (Fig.1). 88 units (average 2.44 units per patient) of allogenic red cells transfused in female patients who underwent unilateral arthroplasty with mean preoperative haemoglobin of 10.2 g/dL. 9 (25%) patients did
Hemoglobin trigger for blood transfusion: Pre and Post operative The present study indicates that the pre-operative hemoglobin has an important role in deciding wether a person would require transfusion during the course of his surgery. Most of the patients with preoperative hemoglobin t13 gm/dL did not receive any transfusion during their stay in the hospital. This was true for both THR and TKR irrespective of unilateral or bilateral surgery. However, most of the patients who did receive transfusion had a hemoglobin well below 11 gm/dL. These facts signify that preoperative hemoglobin should be done beforehand as it indicates wether the patient would require or not require transfusion. According to Adams and Lundy [4], patients should be transfused if the postoperative haemoglobin falls below 10 g/dL or the haematocrit to below 30%. This practice has been abandoned now and according to the British Transfusion Task Force elderly patients can be allowed a
Fig.1. Sex distribution in Unilateral/Bilateral TKR and THR
Fig. 2.
29
Crossmatch: Transfusion (C: T) ratio for TKR was 1.44: 1.
Apollo Medicine, Vol. 6, No. 1, March 2009
Original Article
haemoglobin as low as 8.0 g/dL, and younger patients as low as 7.0 g/dL before transfusion is required [5]. As a result of studies of the haematological indices in Jehovah’s witnesses who have undergone major surgery, we have considerable information regarding the low levels of haemoglobin which can be tolerated [5]. The transfusion trigger in our hospital is 8.0 g/dL which is in accordance with British transfusion task force [5] and the study done by Sturdee et al. [3].
Table1. TKR Vs THR TKR
THR
Total no. of patients
208
134
Male
65
84
Female
143
50
Male unilateral
46 (70.76%) 75(89.28%)
Transfusion received
30 (65.22%) 58 (77.33%)
According to the study done by Roger, et al. [2] the transfusion trigger of 8.0 g/dL still remains controversial. They believe that the real decision for the transfusion can only be made in the light of clinical experience.
Pre-op Hb
10.5 g/dL
Transfusion not received
16 (34.78%) 17 (22.66%)
Blood utilisation in TKR and THR All said and done, there were still a lot of differences in the blood utilization between the TKR and THR surgery. On an average more units of red cells are required in THR surgery than TKR. In general, bilateral elective surgeries require more blood than unilateral surgeries. Bilateral THR surgery, irrespective of the sex distribultion requires more i.e. around 4 units of red cells. The C:T ratio was better with THR. This means although the number of units transfused per patient were more in THR, most of the units that were arranged were eventually issued and transfused. This resulted in better utilization and less wastage in unnecessary crossmatching extra units in THR as compared to TKR. The C:T ratio was 1.44:1 for TKR and 1.3:1 for THR. These are well in accordance with the studies done elsewhere [2,3]. The C:T ratio provides information on the efficiency of the blood ordering practices. Although a C:T ratio of 1 would be ideal and most efficient, A C: T ratio upto 2 is permissible and is usually not asscoiated with increased outdating [6]. This signifies that most of the blood that is arranged is issued and it prevents any loss in terms of unnecessary cross-matches to provide compatible blood unit. Maximum surgical blood ordering schedule (MSBOS)
Pre-op Hb
13.6 g/dL
13.58 g/dL
No. of units transfused
59
153
Transfusion rate
1.28 units
2.04 units
Male bilateral
19 (29.23%) 9 (10.72%)
Transfusion received
17 (89.47%) 8 (88.9%
Pre-op Hb
10.4 g/dL
10.4 g/dL
Transfusion not received
2 (10.52%)
1 (11.1%)
Pre-op Hb
13.7 g/dL
15 gm/dL
No. of units transfused
46
36
Transfusion rate
2.42 Units
4 units
Female unilateral
85 (59.4%)
36
Transfusion received
60 (70.58%) 27 (75%)
Pre-op Hb
10.4 g/dL
10.2 g/dL
Transfusion not received
25 (29.4%)
9 (25%)
Pre-op Hb
12.7 g/dL
12.6 g/dL
No. of units transfused
140
88
Transfusion rate
1.65 units
2.44
Female bilateral
58 (40.6%)
14 (28%)
Transfusion received
55 (94.8%)
13 (92.86%)
Pre-op Hb
10.6 g/dL
10.2 g/dL
Transfusion not received
3 (5.17%)
1 (7.14%)
Pre-op Hb
13.6 g/dL
14 g/dL
No. of units transfused
139
55
Transfusion rate
2.39 units
3.92 units
C:T ratio
1.44:1
1.3:1
units irrespective of sex distribution. However, the bilateral THR surgery required around 4 units. Therefore, MSBOS for THR can be divided into 3 units for unilateral surgery and 4 units for bilateral surgery.
The aim of MSBOS is to exactly match the amount of blood crossmatched to the amount of blood transfused in various surgical procedures and in this way, reduce blood wastage [7]. According to the Maximum Surgical Blood Ordering Schedule (MSBOS) of our Institute 2 units are to be requested for TKR and 4 units of PRC are to be requested for THR. This is in accordance with the study done by Saluja et al. [8]. However, in the present study it was found that MSBOS for TKR is appropriate but for THR most of the unilateral surgeries required less than 3 Apollo Medicine, Vol. 6, No. 1, March 2009
10.3 g/dL
CONCLUSION Most of the patients with preoperative hemoglobin t13 gm/dL do not receive any transfusion. THR has a better C:T ratio than TKR surgery. MSBOS for TKR is appropriate (unilateral and bilateral). MSBOS for THR 30
Original Article
should be 3 units for unilateral surgery and 4 units for bilateral surgery.
4. Adams RC, Lundy JS. Anaesthesia in cases of poor surgical risk: some suggestions for decreasing the risk. Surg Gynae Obstet 1942; 74:1011-1019.
REFERENCES
5. Helm, et al. A strategy for reducing blood-transfusion requirements in elective orthopaedic surgery: audit of an algorithm for arthroplasty of the lower limb. J Bone Joint Surg [Br] 2003;85-B:484-489.
1. Reilly RFO, Burgess IA, Zicat B. The prevalence of venous thromboembolism after hip and knee replacement surgery. Medical Journal of Australia 2005; 182: 154-159.
6. Rahman M, Akhtar GN. An audit of blood ordering practices in hospital queen Elizabeth, Kota Kinabalu, Subah, Malaysia. Pak J Med Sci. 2001; 17 (3): 147-150.
2. Rogers BA, Johnstone DJ. Audit on the efficient use of cross-matched blood in elective total hip and total knee replacement. Ann R Coll Surg Engl 2006; 88: 199-201.
7. Wong L, Cheng G. Type and screen of blood units at a teaching hospital. HKMJ 1995:1: 27-30.
3. Sturdee SW, Beard DJ, Nandhara G, Sonanis SV. Decreasing the blood transfusion rate in elective hip replacement surgery using an autologous drainage system. Ann R Coll Surg Engl 2007; 89: 136-139.
8. Saluja et al. Feasibility of pre-operative autologous blood donation in Indian patients with elective orthopaedic surgery. Indian J Med Res 2006; 124: 505-512.
31
Apollo Medicine, Vol. 6, No. 1, March 2009