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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 6-9

Patterns of blood products utilization at a tertiary care center in the Southern Region of Saudi Arabia


1 Department of Internal Medicine, College of Medicine, King Khalid University, Abha, Saudi Arabia
2 Department of Internal Medicine, Aseer Central Hospital, Abha, Saudi Arabia
3 Department of Laboratory and Blood Bank, Aseer central Hospital, Abha, Saudi Arabia
4 Department of Pathology, College of Medicine, King Khalid University, Abha, Saudi Arabia

Date of Submission06-Jul-2020
Date of Decision16-Aug-2020
Date of Acceptance18-Sep-2020
Date of Web Publication15-Mar-2021

Correspondence Address:
Dr. Husain Y Alkhaldy
Department of Internal Medicine, College of Medicine, King Khalid University, P.O. Box 641, Abha
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joah.joah_112_20

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  Abstract 

MATERIALS AND METHODS: A total of 457 blood transfusion requests for 244 patients were received over a 3-month period. Registered demographic characteristics (age, sex, and nationality), ward, type of blood, and hemoglobin concentration before transfusion for all the patients were collected.
RESULTS: A total of 1328 blood products were requested, while 780 (59%) units were transfused. The cross-matched packed red cells/transfusion ratio was 1.8, while request/transfusion was 1.7 for the fresh frozen plasma and 1.23 for platelets. Packed red blood cells were the main blood product used in blood transfusion (BT). General surgery/orthopedics and intensive care unit were reported with a greater number of requests. The main indications noted for blood requisition were surgery and anemia.
CONCLUSIONS: Current guidelines appear to be respected within services regarding BT decision criteria. However, about half of the requested blood is not transfused which suggest further improvement. Adherence to established guidelines seems variables among different departments. Elective transfusion medicine rotations for all trainees and specialized dedicated sessions for doctors may help in further betterment of utilization of blood bank services.

Keywords: Blood transfusion, crossmatched, surgery, transfusion ratio, wastage


How to cite this article:
Alkhaldy HY, AlShahrani BS, M. Alkhaldi A, A. Alqahtani AS, Muhayya I, Alqahtani M, Eissa M. Patterns of blood products utilization at a tertiary care center in the Southern Region of Saudi Arabia. J Appl Hematol 2021;12:6-9

How to cite this URL:
Alkhaldy HY, AlShahrani BS, M. Alkhaldi A, A. Alqahtani AS, Muhayya I, Alqahtani M, Eissa M. Patterns of blood products utilization at a tertiary care center in the Southern Region of Saudi Arabia. J Appl Hematol [serial online] 2021 [cited 2021 Jun 23];12:6-9. Available from: https://www.jahjournal.org/text.asp?2021/12/1/6/311326


  Introduction Top


Blood transfusion (BT) is indicated to restore hemodynamic balance, assure appropriate tissue oxygenation, and avoid further complications such as any adverse cardiac events and postoperative anemia.[1]

In Saudi Arabia, blood products are invaluable resources that come from healthy unpaid volunteers, so the health-care professionals must consider cost/benefit balance when they come to decide whether to perform this procedure. BT is one of the most common medical procedures during hospitalization with high cost associated that burden the health-care system.[2]

Nonetheless, there are potential complications related to BT such as allergic, infectious, and immunomodulating adverse events that can even lead to death. Moreover, BT is often an overused therapeutic resource. Hence, the process of BT should ensure patient care both in treating the potential life-threatening blood loss and reducing the hazards directly associated to BT.[3]

The medical societies are directing their efforts to reduce risks and associated costs related to BT. Different medical societies have also promoted actions to avoid unnecessary BT. For the indication of anemia, most recent transfusion guidelines by the American Association of Blood Banks recommends that packed red blood cell (PRBC) transfusions in most hospitalized patients should be performed when hemoglobin (Hb) concentration is below 7 g/dl if the patient is stable and below 8 g/dl if cardiac disease is present or the patient is undergoing cardiac or orthopedic surgery.[4]

Furthermore, after red blood cell single-unit transfusion, the society recommends to reevaluate the patient if not actively bleeding and stable. These guidelines have been based on evidence from clinical trials performed to develop BT programs and improve quality care, and the research studies have proven the same or even better outcomes as compared to other strategies that indicate BT when the patient's Hb is below 9–10 g/dl.[5]

Despite the availability of societies endorsed guidelines that govern indications of blood requisition and transfusion, adherence to these guidelines is variable. Clinicians do not always agree on what criteria should be established, and BT policies are not always standardized. This heterogeneity within medical services can lead to overuse and over-request of blood units that hinder blood bank working, overloading the staff, and wasting a valuable limited blood unit. It has been also reported that 20% of all transfused blood in a hospital is requested by surgical cases.[6] However, previous studies explained that blood transfusion requests (BTRs), particularly in elective surgery, are often based in pessimist expectations of potential risks with, sometimes, very low probability of taking place, which leads to over-request of blood units.[7]

Current practice regarding blood unit requests supports a maximum of 2:1 blood ordering, meaning that if a service orders 2 blood units and administers only one; a good significant use of blood is being held.[8]

This study was designed to assess the BTRs during a 3-month period in a tertiary care center from Southern Saudi Arabia to determine if significant blood waste is taking place and if so, to understand which hospital services tend to request unnecessary blood units.


  Materials and Methods Top


This cross-sectional study, approved by Research Ethical Committee of Aseer Central Hospital (REC#2018-05-20) in October 20 2018, was conducted during January and March 2019 by analyzing the record of blood bank for all in house received BTRs. We registered demographic data (sex, age, and nationality) from the patients who received transfusion requests during the period and the transfusion request data (type of transfusion, indication, crossmatch, and blood type). Patients were followed until discharge from inpatient hospitalization to assure no other transfusions were missed. Cross-matched to transfusion ratio (C/T ratio) or request to transfusion ratio in the case of PRBCs was used to measure the efficiency of blood ordering practice. BTRs from outside the hospital were excluded.

Statistical analysis

Qualitative data were expressed as percentage, and quantitative data were reported as mean ± standard deviation. Statistical analysis was performed using GraphPad Prism version 7.0 Software.


  Results Top


A total of 1328 (458 requests) blood products were ordered for crossmatching for 244 patients during the 3-month study period. The patient's demographics are depicted in [Table 1]. The major blood component used for transfusion was PRBCs (74.1%) and the major causes for BT indication were surgery (43.0%) and anemia (17.2%). General surgery service requested more blood products, 27.3% (total of 125 BTR), followed by orthopedic surgery, 26.2%( total of 120 BTR), and medical services,18.7% ( total of 86 BTR). Most of the received requests came from intensive care unit (ICU) wards (32%), followed by the general wards (30%).
Table 1: Biodemographic data for patients with the blood transfusion requests in Aseer Central Hospital

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Overall, 780 units (59%) were transfused, giving an overall request to transfusion ratio of 1.7. The overall crossmatch transfusion ratio of packed red blood was 1.8 [Table 2]. However, analysis per request shows a variable C: T ratio reaching of up to 6 [Table 3].
Table 2: Number of units requested and use of blood components for transfusion

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Table 3: Request to transfusion ratio, per request, among different specialties

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  Discussion Top


This study was carried out to assess the BTRs in Aseer Central Hospital, Southern region of Saudi Arabia. Findings of this study show that PRBC was the major blood component requested for transfusion. As shown in [Table 1], surgery and anemia were the most frequent indications of BT in this study. This finding correlates well with other studies conducted locally and in developing countries.[9] Moreover, surgical departments including general surgery, orthopedics, trauma, and plastic surgery (burns) requested more blood units than medical departments. Analysis of the distribution of BTRs showed that requested blood for patients in ICU was mainly due to trauma and anemia (60%). While in the coronary care unit, the main cause of blood request was only related to anemia (100%).

Current transfusion practices suggest that the ratio of 2:1 is appropriate, i.e., for every two units arranged one has been used. While the ratio of 1.0 is considered ideal, indicating the usage of every single unit that has been crossmatched.[10] Finding of the current results indicates a good utilization of blood in Aseer Central Hospital. Overall, the C/T ratio of 1.84 was observed which indicates that more than half of the cross-matched blood components' utilization. In the general surgery and orthopedics departments, the C/T ratio was lower (1.4) than medical services (1.7). Lower ratio of C/T in general surgery and orthopedics cases below 2 signifies no significant wastage of blood components in these two departments. It has been reported in a local study that the C/T ratio in the cardiac surgery department was 1:1.[9] which is better than the current study. The possible explanation could be the utilization of all blood components arranged during cardiac bypass surgeries, while in the current study, it was not limited to cardiac surgeries. In a study by Abdel Gader et al., 2015, the ratio of C/T of 10:1 was observed in obstetrics and gynecology department, indicating only 10% utilization of cross-matched blood.[9] This explains the standby arrangement of blood products with a fear of bleeding in gynecological issues. Hence, it is clear that the C/T ratio could be partly correlated with the department of the hospital and clinical situation.

In literature, a wide range of C/T ratios have been reported ranging from 1.0 to sometimes 3.0–6.0. Using C/T ratio as a parameter, studies across the world show inappropriate blood usage (C/T ratio >2.5) in many countries such as Tanzania, Ethiopia, Malaysia, Egypt, and Zambia with C/T ratios 3.7, 2.3, 5.0, 3.9, and 2.8, respectively.[11],[12],[13],[14],[15]

In addition to the crossmatch and utilization of blood products, the correlation of Hb and indication of BT were also explored in this study. It was observed that, when the level of Hb was <7 g/dL, approximately 95% of the patients received BT, which correlates well with the current transfusion guidelines.[16] It has been reported that low Hb is the major trigger for BTRs and intraoperative measurement of Hb increases the appropriate use of blood.[17]

The Maximum blood ordering schedule (MBOS) maximizes the usage of blood, minimizes wastage, and promotes appropriate blood usage in elective surgery by reducing the workload of unnecessary crossmatching and issuing of blood and optimize stock management.[18] Another approach that could be developed is the ”type and screen only.” Type indicates the ABO and Rh blood typing while screen means testing the of patient's plasma/serum for clinically significant irregular antibodies. This approach has shown promising results.[19]


  Conclusions Top


Appropriate management of BTRs can help reduce overall blood wastage and blood bank overload, allowing a more efficient system. Furthermore, patient outcome benefits from efficiency in BT, which means, only giving blood when needed and not ”just in case.” The blood bank started to contact ordering physicians and surgeons to minimize crossmatching for standby unless the need for blood is highly anticipated. Medical staff preparation and awareness of current guidelines along with their collaboration for well functioning of blood bank department is critical. Blood banking education is underrepresented in both undergraduate and postgraduate education. Saudi commission for health specialties might consider implementing a mandatory rotation for both medical and surgical trainees in the blood bank, to foster the understanding of basic blood bank principles.

Acknowledgment

The authors would like to thank Dr. Yahya M. Alkhaldi for help with statistical analysis, Mr. Ibrahim S. Al Ghamdi, and all individuals who are working in the department of laboratory and blood bank in Aseer Central Hospital for providing help during this research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abdelsattar ZM, Hendren S, Wong SL, Campbell DA Jr., Henke P. Variation in transfusion practices and the effect on outcomes after noncardiac surgery. Ann Surg 2015;262:1-6.  Back to cited text no. 1
    
2.
Healthcare Cost and Utilization Project. Most Frequent Procedures Performed in US Hospitals; 2010. Available from: https://www.hcup-us.ahrq.gov/reports/stat briefs/sb149.pdf. [Last accessed on 2020 Apr 20].   Back to cited text no. 2
    
3.
Peters J, Pendry K. Patient blood management: An update of current guidance in clinical practice. Br J Hosp Med (Lond) 2017;78:88-95.  Back to cited text no. 3
    
4.
Carson JL, Guyatt G, Heddle NM, Grossman BJ, Cohn CS, Fung MK, et al. Clinical practice guidelines from the AABB: Red blood cell transfusion thresholds and storage. JAMA 2016;316:2025-35.  Back to cited text no. 4
    
5.
Sadana D, Pratzer A, Scher LJ, Saag HS, Adler N, Volpicelli FM, et al. Promoting high-value practice by reducing unnecessary transfusions with a patient blood management program. JAMA Intern Med 2018;178:116-22.  Back to cited text no. 5
    
6.
Alamri AA, Alnefaie MN, Saeedi AT, Hariri AF, Altaf A, Aljiffry MM. Transfusion practices among general surgeons at a tertiary care center: A survey based study. Med Arch 2018;72:418-24.  Back to cited text no. 6
    
7.
National Institute for Health and Clinical Excellence (2015) Chronic Kidney Disease: Managing Anaemia. Available from: www.nice.org.uk/guidance/ng8/resources/chronic-kidney-disease-managing-anaemia-51046844101. [Last accessed on 2019 Oct 20].  Back to cited text no. 7
    
8.
Hasan O, Khan EK, Ali M, Sheikh S, Fatima A, Rashid HU. ”It's a precious gift, not to waste”: Is routine cross matching necessary in orthopedics surgery? Retrospective study of 699 patients in 9 different procedures. BMC Health Serv Res 2018;18:804.  Back to cited text no. 8
    
9.
Abdel Gader AG, AlGhumlas AK, Al Momen AK, Badri M. A 23 years audit of packed red blood cell consumption in a university hospital in a developing country. Transfus Apher Sci 2015;53:300-7.  Back to cited text no. 9
    
10.
Hall TC, Pattenden C, Hollobone C, Pollard C, Dennison AR. Blood transfusion policies in elective general surgery: How to optimise cross-match-to-transfusion ratios. Transfus Med Hemother 2013;40:27-31.  Back to cited text no. 10
    
11.
Akoko LO, Joseph AB. Blood utilization in elective surgery in a tertiary hospital in Dar Es Salaam, Tanzania. Tanzan J Health Res 2015;17:1-8.  Back to cited text no. 11
    
12.
Belayneh T, Messele G, Abdissa Z, Tegene B. Blood requisition and utilization practice in surgical patients at university of Gondar Hospital, northwest Ethiopia. J Blood Transfus 2013;2013:doi: 10.1155/2013/758910.  Back to cited text no. 12
    
13.
Jayaranee S, Prathiba R, Vasanthi N, Lopez CG. An analysis of blood utilization for elective surgery in a tertiary medical centre in Malaysia. Malays J Pathol 2002;24:59-66.  Back to cited text no. 13
    
14.
Ibrahim SZ, Mamdouh HM, Ramadan AM. Blood utilization for elective surgeries at main University Hospital in Alexandria, Egypt. J Am Sci 2011;7:683-9.  Back to cited text no. 14
    
15.
Mwambungu A, Siulapwa N, Mugala D, Chishimba M. Analysis of blood cross-match ordering practice in surgical patients at Ndola Central Hospital. Int J Healthc Sci 2015;3:278-84.  Back to cited text no. 15
    
16.
Watson S, Kendrick K. Management of anaemia and blood transfusion in critical care - Implementing national guidelines in ICU. BMJ Qual Improv Rep 2014;doi: 10.1136/bmjquality.u202106.w1109.  Back to cited text no. 16
    
17.
Niraj G, Puri GD, Arun D, Chakravarty V, Aveek J, Chari P. Assessment of intraoperative blood transfusion practice during elective non-cardiac surgery in an Indian tertiary care hospital. Br J Anaesth 2003;91:586-9.  Back to cited text no. 17
    
18.
Friedman BA, Oberman HA, Chadwick AR, Kingdon KI. The maximum surgical blood order schedule and surgical blood use in the United States. Transfusion 1976;16:380-7.  Back to cited text no. 18
    
19.
Alavi-Moghaddam M, Bardeh M, Alimohammadi H, Emami H, Hosseini-Zijoud SM. Blood transfusion practice before and after implementation of type and screen protocol in emergency department of a University Affiliated Hospital in Iran. Emerg Med Int 2014;2014:316463.  Back to cited text no. 19
    



 
 
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  [Table 1], [Table 2], [Table 3]



 

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