Problem-based Learning Topic: Preoperative Blood Typing
Instructions:
Pls. answer the following specified problem-based learning issues and questions in the management of a patient with regards to preoperative blood typing.
Dr. Reynaldo O. Joson
A 56-year-old Filipino woman with preoperative diagnosis of breast cancer, right, and fibroadenoma, left. She has no associated co-morbidities. She is scheduled for total mastectomy and axillary dissection right and prophylactic total mastectomy, left.
Issues and Questions:
- Will you order for a preoperative blood typing in this particular patient? Whatever be your answer, yes, no, or it depends, expound on your answer.
- Is it routine to have a preoperative blood typing before any type of major surgery? Yes or No?
- If it should not be a routinary practice, what are the indications for ordering for a preoperative blood typing in patients for surgery? Pls. answer as detailed as possible.
- Currently, how much does it cost to have a blood typing done on a private basis in the Philippine General Hospital and in a private hospital outside PGH (please indicate the name of hospital canvassed).
Inputs from residents
Resident: SMT
Issues and Questions:
1. Will you order for a preoperative blood typing in this particular patient? Whatever be your answer, yes, no, or it depends, expound on your answer.
For this particular patient, I would not order preoperative blood typing. Patient is a 56/F, with no comorbidities, for a procedure with minimal risk of blood loss. Furthermore, patient’s history does not indicate any cause for a low baseline Hgb (i.e. did not undergo neoadjuvant chemotherapy, breast mass not actively bleeding, not fungating).
2. Is it routine to have a preoperative blood typing before any type of major surgery? Yes or No?
No, it is not routine to have preoperative blood typing done before any type of major surgery. This depends on patient factors and the kind of surgery to be done. For elective breast surgery patients, only a minimal number of patients require transfusion preop/intraop/postop, most of these patients requiring transfusion have patient factors that indicated likely transfusion. Hence, routine blood typing for elective breast surgery patients may not be done, as it is a waste of clinical resources.
3. If it should not be a routinary practice, what are the indications for ordering for a preoperative blood typing in patients for surgery? Pls. answer as detailed as possible.
Indications for ordering preoperative blood typing in patients for surgery:
• Known hematological comorbidities
• Underwent neoadjuvant chemotherapy (likely with known blood type)
• Actively bleeding, fungating breast mass
• Major surgery expecting major blood loss
4. Currently, how much does it cost to have a blood typing done on a private basis in the Philippine General Hospital and in a private hospital outside PGH (please indicate the name of hospital canvassed).
BLOOD TYPING RATES
Philippine General Hospital – 725
Manila Doctors Hospital – 1000
Manila Med – 456
St. Luke’s – 1000
Makati Medical Center – 950
The Medical City -810
UST Hospital – 415
Asian Hospital and Medical Center – 650
Cardinal Santos Medical Center – 398
REFERENCES:
Malik, H., Bishop H., & Winstanley, J. (2008). Audit of blood transfusion in elective breast cancer surgery – do we need to group and save pre-operatively? Annals Royal College Surgeons of England 90(6):472-473. Retrieved April 25, 2023 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647238/
Prichard, R.S., Keefe, M.O., McLaughlin, R., Malone, C., Sweeney, K. J., & Kerin, M. J. (2011). A study of pre-operative type and screen in breast surgery: improved efficiency and cost saving. Irish Journal of Medical Science 180, 513-516. Retrieved April 25, 2023 from https://link.springer.com/article/10.1007/s11845-010-0668-y
Zaidi, A., Mannan, H., Choudhry, Z., Khan, S.M., Khan, H.M., Naheed, R., Khan, A.I., & Parvaiz, M.A. (2021). Time to cross off routine preoperative blood crossmatch in mastectomy. Journal of Clinical Research. Vol 5:3. Retrieved April 25, 2023 from https://www.hilarispublisher.com/open%5B1%5Daccess/time-to-cross-off-routine-preoperative-blood-crossmatch-in-mastectomy.pdf
Resident: AM
Issues and Questions:
1. Will you order for a preoperative blood typing in this particular patient? Whatever be your answer, yes, no, or it depends, expound on your answer.
Given the profile of the patient, I will not order for a preoperative blood typing. This particular patient does not present with any associated comorbidities that warrants preoperative blood typing for a subsequent blood transfusion. Such includes a history of a known coagulopathy, grossly and actively bleeding breast mass, and if the contemplated surgical procedure will result in a significant amount of blood loss causing hemodynamic instability intraoperatively.
2. Is it routine to have a preoperative blood typing before any type of major surgery? Yes or No?
Routine preoperative blood typing is not a prerequisite to any type of major surgery. No two major surgeries are alike, and each is tailored to the needs of the patient. Numerous components are put into consideration prior to requesting preoperative blood typing. This includes the medical history of the patient, the clinical background of the disease, the outcome and prognosis of the surgical procedure, including the calculated or expected amount of blood loss intraoperatively. As mentioned earlier, preoperative blood typing is likely warranted in cases wherein the contemplated surgical procedure for the patient is anticipated to result a significant amount of blood loss leading to hemodynamic instability and intraoperative complications.
3. If it should not be a routinary practice, what are the indications for ordering for a preoperative blood typing in patients for surgery? Pls. answer as detailed as possible.
– Patient with known coagulopathies
– Patient presenting with preoperative anemia in the background of low hemoglobin levels
– Gross and active bleeding seen in contemplated operative site
– Significant blood loss is expected from a major surgery
4. Currently, how much does it cost to have a blood typing done on a private basis in the Philippine General Hospital and in a private hospital outside PGH (please indicate the name of hospital canvassed).
Currently, it costs Php 725.00 to have blood typing done on a private basis in Philippine General
Hospital. List of blood typing rates in private hospitals outside PGH are as follows:
Asian Hospital and Medical Center – Php 650.00
Cardinal Santos Medical Center – Php 398.00
Makati Medical Center – Php 950.00
Manila Doctors Hospital – Php 1000.00
Manila Med – Php 456.00
The Medical City – Php 810.00
St Luke’s Medical Center – Php 1000.00
UST Hospital – Php 415.00
REFERENCES:
Agarwal, V., & Das, S. (2020). Rationalizing blood transfusion in elective breast cancer surgery: Analyzing justification and economy. Asian Journal of Transfusion Science. 2020 Jan-Jun; 14(1): 39–3. doi: 10.4103/ajts.AJTS_107_17
Conclusion: We conclude that routine compatibility test is not justified for all patients undergoing breast surgery. A more targeted approach is needed to reduce blood demand and associated cost to patient and blood transfusion services.
We conclude that the likelihood of perioperative blood transfusion is more in certain types of breast surgery; however, overall transfusion in breast surgeries is rare. For all patients, the routine compatibility test is not justified, and such practice leads to significant loss of time, manpower, and clinical resources. Since no patient or disease parameter singly or collectively dictates the necessity of blood transfusion, therefore, a more targeted approach is needed to reduce blood demand and associated cost to patient and blood transfusion services.
Resident: JV
Issues and Questions:
- Will you order for a preoperative blood typing in this particular patient? Whatever be your
answer, yes, no, or it depends, expound on your answer.
Total mastectomy with axillary dissection is a surgical procedure that typically involves minimal
blood loss and therefore does not require blood transfusion. The incidence of significant blood
loss during total mastectomy and axillary dissection is low, and the need for blood transfusion is
rare. Hence, preoperative blood typing may not be necessary for patients undergoing this
procedure, especially in this case that the patient is known to have no other co-morbidities,
including blood dyscrasias or anemia.
- Is it routine to have a preoperative blood typing before any type of major surgery? Yes or No?
Preoperative blood typing is not routinely required before all types of major surgery. The need
for preoperative blood typing depends on several factors, including the specific surgical
procedure being performed, the patient’s individual medical history, and the likelihood of
significant blood loss during the procedure. In general, preoperative blood typing is more likely
to be required for surgeries that are expected to result in significant blood loss or that carry a
higher risk of bleeding or other complications. In low-resource settings or emergency situations,
preoperative blood typing may be skipped in order to expedite the surgical procedure.
- If it should not be a routinary practice, what are the indications for ordering for a preoperative
blood typing in patients for surgery? Pls. answer as detailed as possible.
The indications for ordering a preoperative blood typing in patients for surgery may vary
depending on the patient’s individual medical history and the specific surgical procedure being
performed. However, some general indications for preoperative blood typing may include:
- Anticipated significant blood loss during surgery: Patients undergoing surgeries that
are expected to result in significant blood loss, such as major abdominal surgeries or surgeries
involving blood vessels, may require a blood transfusion.
- Patient history of anemia or bleeding disorders: Patients with a history of anemia or
bleeding disorders may require blood transfusions during surgery. Preoperative blood typing can
help to ensure that compatible blood products are available if needed.
- Emergency surgeries: In emergency situations, there may not be time to perform full
panel crossmatching of blood products. In such cases, it may be necessary to have pre-typed
blood products available in case of bleeding or other complications during the procedure.
- Certain types of surgeries: Some surgical procedures, such as cardiac surgeries or
organ transplants, may require blood transfusions. Preoperative blood typing may be necessary
to ensure that compatible blood products are available if needed.
- Currently, how much does it cost to have a blood typing done on a private basis in the Philippine
General Hospital and in a private hospital outside PGH (please indicate the name of hospital
canvassed).
Hospital Price of Blood Typing (Php)
- Philippine General Hospital 810
Asian Hospital and Medical Center 725
Cardinal Santos Medical Center 1000
Makati Medical Center 456
Manila Doctors Hospital 1000
Manila Medical Center 950
St. Luke’s Medical Center 415
The Medical City 650
UST Hospital 398
Resident: MREAB
Issues and Questions:
- Will you order for a preoperative blood typing in this particular patient? Whatever be your answer, yes, no, or it depends, expound on your answer.
I would not order a preoperative blood typing for this patient because first, patient though 56-year-old, has no other comorbidities that would warrant a possible blood transfusion like hematologic diseases. Second, the operation is pre-scheduled as elective basis, necessary preparations should have been done prior to the surgery, and the contemplated procedure also has a low risk of blood loss and should be done by capable surgeons to avoid such unnecessary intraoperative incidents such as massive blood loss. Third, ordering a preoperative blood typing is a waste use of resource. It will not benefit the patient, nor the team managing the case. We need to see patient holistically, and financial capability of the patient should also be put into account when managing them.
- Is it routine to have a preoperative blood typing before any type of major surgery? Yes or No?
No, having a preoperative blood typing is not a routine to any type of major surgery. Surgeries that involve cardiac or vascular in nature, may have preoperative blood typing in preparation for big and complex surgeries. But procedure like in the case presented is a perfect example of a major surgery which does not need a preoperative blood typing.
- If it should not be a routinary practice, what are the indications for ordering for a preoperative blood typing in patients for surgery? Pls. answer as detailed as possible.
Some of the indications of preoperative blood typing, are those patients with clotting disorders, that can be a high risk for intraoperative bleeding. Surgeries that involve highly vascularized organs such as the liver and kidney, may also benefit from pre-operative blood typing especially if the need arises for a massive transfusion.
Emergency surgeries, like in cases of trauma, blunt or penetrating injuries, may also benefit if blood type and Rh factor of the patient is known.
Though in general, blood typing is not a prerequisite to perform a surgery, assessment prior to operation and good clinical eye will tremendously affect the turnout of the operation performed.
- Currently, how much does it cost to have a blood typing done on a private basis in the Philippine General Hospital and in a private hospital outside PGH (please indicate the name of hospital canvassed).
Philippine General Hospital – 725
Asian Hospital and Medical Center – 650
Cardinal Santos Medical Center – 398
Makati Medical Center – 950
Manila Doctors Hospital – 1000
Manila Medical Center– 456
St. Luke’s Medical Center – 1000
The Medical City – 810
UST Hospital – 415
Resident: NKTS
Issues and Questions:
1. Will you order for a preoperative blood typing in this particular patient? Whatever be your answer, yes, no, or it depends, expound on your answer.
For this particular patient, I will not order for blood typing. Given her history and the nature of the operation, she is less likely to have intraoperative or postoperative bleeding. She does not have the risk factors that may predispose her to bleeding thus it will just add unnecessary cost to her operation.
2. Is it routine to have a preoperative blood typing before any type of major surgery? Yes or No?
No, it is not routine to do blood typing prior to major surgeries. We do blood typing when we anticipate the need to transfuse blood and if not getting blood typing will cause significant delays. Not all major surgeries would lead to blood loss requiring transfusion, thus risk stratification would play a role instead of customary practice.
3. If it should not be a routinary practice, what are the indications for ordering for a preoperative blood typing in patients for surgery? Pls. answer as detailed as possible.
Indications for ordering prep blood typing would include history of blood coagulopathy, comorbidities, anemia and hematologic malignancies, surgery with associated blood loss – factors which would increase the risk for blood transfusion.
4. Currently, how much does it cost to have a blood typing done on a private basis in the Philippine General Hospital and in a private hospital outside PGH (please indicate the name of hospital canvassed).
BLOOD TYPING RATES
Philippine General Hospital – 725
Manila Doctors Hospital – 1000
Manila Med – 456
St. Luke’s – 1000
Makati Medical Center – 950
The Medical City – 810
UST Hospital – 415
Asian Hospital and Medical Center – 650
Cardinal Santos Medical Center – 398
References:
Fadel, M. G., Patel, I., O’Leary, L., Behar, N., & Brewer, J. (2022). Requirement of preoperative blood typing for cholecystectomy and appendectomy: a systematic review. Langenbeck’s archives of surgery, 407(6), 2205–2216. https://doi.org/10.1007/s00423-022-02600-x
Konishi, T., Fujiogi, M., Shigemi, D., Matsui, H., Fushimi, K., Tanabe, M., Seto, Y., & Yasunaga, H. (2022). Risk Factors for Postoperative Bleeding Following Breast Cancer Surgery: A Nationwide Database Study of 477,108 Cases in Japan. World journal of surgery, 46(12), 3062–3071. https://doi.org/10.1007/s00268-022-06746-z
UC Davis Health. (2018, September 19). The Pre-operative type and screen: Why timing is everything. https://health.ucdavis.edu/blog/lab-best-practice/the-pre-operative-type-and-screen-why-timing-is-everything/2018/09
Practice Guidelines for Perioperative Blood Transfusion and Adjuvant Therapies: An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology 2006; 105:198–208 doi: https://doi.org/10.1097/00000542-200607000-00030
Resident: MLA
Issues and questions:
1. Will you order for a preoperative blood typing in this particular patient?
If given this patient, I will not order blood typing. Given the profile of this patient, she is a 56-year old female with no comorbidities and her breast mass is not actively bleeding and/or not fungating thus not warranting preoperative blood typing.
2. Is it routine to have a preoperative blood typing before any type of major surgery?
Routine preoperative blood typing is not warranted for major surgeries. However, ordering blood typing depends on several factors and is patient centered. (1) It will matter on what type of surgery will be performed on the patient, (2) we also need to consider co-morbidities of the patient if there’s anemia or any blood dyscrasia, (3) emergency situations where in significant blood loss is anticipated.
3. If it should not be a routinary practice, what are the indications for ordering for a preoperative blood typing in patients for surgery?
Blood typing is done for the following patients:
– Anticipated significant blood loss
– Presence of blood dyscrasia/anemia
– Presence of hereditary disorders like hemophilia and thalassemia
– Severe burn patients with significant blood loss
– Patients with increased risk of bleeding especially those on anticoagulants or antiplatelet drugs
– Major surgeries like those undergoing by-pass operations
4. Currently, how much does it cost to have a blood typing done on a private basis int he Philippine General Hospital and in a private hospital outside PGH.
Asian Hospital and Medical Center Php 725
Cardinal Santos Medical Center Php 1000
Makati Medical Center Php 456
Manila Doctors Hospital Php 1000
Manila Medical Center Php 950
Philippine General Hospital Php 810
St. Luke’s Medical Center Php 415
The Medical City Php 650
UST Hospital Php 398
Resident: JVM
Issues and Questions:
1. Will you order for a preoperative blood typing in this particular patient? Whatever be your answer, yes, no, or it depends, expound on your answer.
No. In my opinion, preoperative blood typing is not necessary in this case given that the patient’s surgery (mastectomy) carries a low risk of serious blood loss and that the patient has no co-morbidities that predispose her to serious blood loss that would warrant preoperative or intraoperative blood
transfusion.
2. Is it routine to have a preoperative blood typing before any type of major surgery?
No. Preoperative blood typing is not routine in all major surgery. Specific factors have to be taken into consideration so as not to waste patient resources in terms of preoperative diagnostics, such as the type of surgery, anticipated blood loss, co-morbidities, and blood parameters among others.
3. If it should not be a routinary practice, what are the indications for ordering for a preoperative blood typing in patients for surgery?
Indications for preoperative blood typing incude he following:
- Cardiovascular co-morbidity
- Preoperative treatment
- Anticoagulation treatment
- Hematologic malignancy
- Prolonged surgery
- Elderly patient
- History of perioperative bleeding
- Deranged baseline blood parameters
4. Currently, how much does it cost to have a blood typing done on a private basis int he Philippine General Hospital and in a private hospital outside PGH.
Philippine General Hospital Php 725
Makati Medical Center Php 465
St. Luke’s Medical Center Php 1000
Manila Doctors Hospital Php 1000
The Medical City Php 810
UST Hospital Php 415
Cardinal Santos Medical Center Php 950
Asian Hospital and Medical Center Php 650
References:
Zaidi, A., Mannan, H., Choudhry, Z., Khan, S.M., Khan, H.M., Naheed, R., Khan, A.I., & Parvaiz, M.A. (2021). Time to cross off routine preoperative blood crossmatch in mastectomy. Journal of Clinical Research. Vol 5:3. Retrieved April 25, 2023 from https://www.hilarispublisher.com/open%5B1%5Daccess/time-to-cross-off-routine-preoperative-blood-crossmatch-in-mastectomy.pdf
Time to Cross off Routine Preoperative Blood Crossmatch in Mastectomy!
Abstract
Ambreen Zaidi*, Huma Mannan, Zulqarnain Choudhry, Sameen Mohtasham Khan, Huma Majeed Khan, Ruqayya Naheed Khan, Amina Iqbal Khan and Muhammad Asad Parvaiz
Purpose: Blood transfusion in breast cancer surgery patients is now quite rare as surgical haemostatic techniques have become very meticulous. In our hospital, all patients planned for mastectomy have a routine blood cross match done preoperatively. The cost of this blood cross match comes down as about 10 United States dollars (USD) per patient. In this study, we looked at our mastectomy patients who required blood transfusion.
Methods: All mastectomy patients from January 2016 to June 2016 were included in our study. The data was derived from a prospectively maintained computerized database. Patient demographics, preoperative and postoperative haemoglobin levels, reasons and timings of blood transfusion were recorded.
Results: 182 patients had mastectomy during 6 months. 170 (93.4%) patients had preoperative blood crossmatch done. 15 patients (8.2%) required blood transfusion preoperatively. This was primarily for building up their haemoglobin levels (range 7.4-9.9 g/dL, mean 9.1 g/dL). 9 out of 15 of these patients underwent neoadjuvant chemotherapy.
Cost of blood crossmatch in these 15 patients needing transfusion was 150 USD compared to 1700 USD cost of cross matching all 170 patients. None of our patients required transfusion intra or post-operatively. Cost of blood crossmatch in 155 patients that never required blood transfusion was 1550 USD.
Conclusion: None of our mastectomy patients required blood transfusion in an emergency situation. 8.2% patients needed transfusion preoperatively, where there was ample time to crossmatch and arrange blood. We recommend that routine preoperative crossmatch in mastectomy patients can be safely avoided (with an additional benefit of saving cost 1550 USD over 6 months).
Ir J Med Sci
2011 Jun;180(2):513-6.
doi: 10.1007/s11845-010-0668-y. Epub 2011 Jan 1.
A study of pre-operative type and screen in breast surgery: improved efficiency and cost saving
R S Prichard 1, M O’Keefe, R McLaughlin, C Malone, K J Sweeney, M J Kerin
Affiliations expand
Abstract
Introduction: Patients undergoing major breast surgery have an almost negligible need for blood transfusions. However, type and screen requests are still routinely performed. This represents an inefficient utilization of resources and unnecessary workload for laboratory staff. The aim of this study was to ascertain whether pre-operative blood typing is justified in patients undergoing surgical procedures with an intermediate transfusion probability.
Methods: A retrospective analysis of all patients undergoing a mastectomy and axillary clearance, with or without breast reconstruction in the last 2 years was undertaken. The number of group and hold and cross-match samples that were performed were identified and compared to the number of patients requiring a blood transfusion. The overall cost of routine pre-operative blood typing was analysed.
Results: A total of 229 patients were identified. Of these, a group and hold was performed on 192 (83.8%) patients. Cross-matching was undertaken in thirty-one patients (13.5%). In total, five patients (2.1%) required transfusion. No patient was transfused intra-operatively. The overall cost of routine group and hold blood requests was 1,920 euros and of pre-operative cross-matching was 465 euros. Forty-seven units of blood was returned unused to the blood transfusion service at an estimated cost of 23,500 euros.
Conclusion: The need for routine group and hold blood requests is not justified for patients undergoing elective breast surgery and represents a waste of clinical resources. A more targeted approach will not only reduce the demand on blood products but also reduce the associated costs to blood transfusion services.
Blood Ordering Requests in Mastectomies:
The Need for a Routine Group and Hold
K. Chan, S. Keogh, N. Aucharaz, J. Buckley, A. Merrigan, S. Tormey
Department of Breast Surgery, University Hospital Limerick, Dooradoyle, Limerick, V94 F858.
Click to access Blood-Ordering-Requests-in-Mastectomies-The-Need-for-a-Routine-Group-and-Hold.pdf
Abstract
Aim
A group and hold (GH) forms part of the pre-transfusion compatibility testing and is requested in
anticipation of a possible blood transfusion. GH in the context of a low transfusion probability, such
as a mastectomy, are associated with significant costs. This study analyses the cost-benefit
associated with the routine request for a preoperative GH in patients undergoing mastectomies.
Methods
100 patients undergoing mastectomies from the period of September 2019 to October 2020 were
included. Data regarding blood order requests, units of blood transfused, perioperative
haemoglobin and laterality of mastectomy were collected.
Results
All patients had a routine preoperative GH. The average age in this cohort was 60.3 years. Rightsided mastectomy was the commonest procedure (n=52). The mean(s.d.) preoperative
haemoglobin was 13.0(1.4) g/dL. Only 15% of the cohort had a post-operative haemoglobin level
checked. The mean (s.d) drop in haemoglobin was 2.3(1.5) g/dL. Two patients received postoperative blood transfusions. The transfusion probability in this cohort was 2%.
Conclusions
This review demonstrates the low prevalence of blood transfusions in patients undergoing
mastectomies. The projected cost-savings associated with selective requests for GH are significant.
Moving forward, large prospective studies are required to develop validated scoring systems for the
implementation of a safe and targeted blood ordering approach.
UC Davis Health. (2018, September 19). The Pre-operative type and screen: Why timing is everything. https://health.ucdavis.edu/blog/lab-best-practice/the-pre-operative-type-and-screen-why-timing-is-everything/2018/09
The patient should be evaluated for their risk of needing blood transfusions. The maximum surgical blood order schedule (MSBOS) is used to determine general risk based on the procedure7. Patients with a >5% probability of transfusion based on procedure type are considered of sufficient risk to prepare for a possible transfusion8. Pre-op clinical evaluation is prudent to assess for co-morbidities that impact this risk stratification as well.
Best practices for reducing unnecessary preoperative blood orders and associated costs
Feb. 22, 2017
Courtney G. Masear
https://www.mlo-online.com/home/article/13009035/best-practices-for-reducing-unnecessary-preoperative-blood-orders-and-associated-costs
Every day, anesthesiologists and surgeons consider the appropriate preoperative blood product order for each patient entering the operating room. Blood product ordering includes obtaining either ABO group blood typing and red cell antibody screening (T/S) or a type and crossmatch for a specific number of units (T/C). A surgery with a low probability of transfusion does not require a blood product order, while other procedures may require just a T/S or additionally a T/C. Appropriate ordering is imperative to ensure that resources are directed to process samples and prepare products for cases with a likelihood of hemorrhage and transfusion and also to minimize costs associated with unnecessary testing.
MSBOS
A Maximum Surgical Blood Order Schedule (MSBOS) includes guidelines for preoperative blood product ordering and was first described in 1976 by Friedman.1 A MSBOS should ideally be institution- and procedure-specific, based on blood utilization data. In 2013, our team used data from our electronic Anesthesia Information Management System (AIMS) to analyze blood utilization data from more than 53,000 patients undergoing 135 categories of surgical procedures at our institution and ultimately developed an algorithm for deriving an institution-specific MSBOS.2 Our MSBOS includes a list of cases for which a preoperative blood order is unnecessary based on our institutional rate of transfusion. The backup plan for unexpected transfusions in such patients without blood orders is the use of type O red cells for emergency release, which is much safer than most providers acknowledge. With the implementation of our MSBOS, we hypothesized that our institution would see a reduction in unnecessary blood orders and thus associated cost savings.
What is the Msbos protocol?
The Maximum Surgical Blood Order Schedule (MSBOS) is a table of elective surgical procedures which lists the number of units of red cells routinely pre-operatively crossmatched and then transfused for each procedure.
https://www.hse.ie/eng/services/list/3/acutehospitals/hospitals/waterford/laboratoryservices/msbos.html#:~:text=A%20Maximum%20Surgical%20Blood%20Ordering,blood%20and%20optimise%20stock%20management.
ROJoson Comments:
The abovementioned patient was my patient. I did not order for a preop blood typing as I think it was not needed (even though a bilateral mastectomy would be done) as I was not expecting a blood loss volume that would require blood transfusion and I would utilize ways to control the blood loss (basically, the use of electrocautery machine and meticulous with immediate, full and secured control of any bleeding vessels that would be encountered during the dissection in the flap formation, mastectomy and axillary dissection). Also, there was no history of the patient having an abnormal bleeding tendency.
A preop blood typing was ordered by a surgical resident without clearing with me. I don’t know the reason/s behind the ordering – may be a ritualistic mindset brought about by being used to observing the routine practice of hospitals and other surgeons ordering blood typing for all patients for mastectomy. My patient did not need blood transfusion during and after the operation. But she ended paying the cost of the preop blood typing.
As a surgical educator, instead of reprimanding the resident who ordered for the blood typing, I decided to formulate a miniscule focused problem-based learning module and ask several residents to answer the four essential issues and questions. By responding, I expected the residents to have a more comprehensive, structured and longer-lasting learning (I hope).
Note: I also learned in the process. Specifically, when the residents included references (which I did not require), I got the information that it was or is still a global problem and issue afterall, that is, routinely ordering blood typing preop for mastectomy which is being discouraged if not frowned upon because of poor utility and added costs to patients and institutions (especially government-funded hospitals).
With the residents unanimously answering that preop blood typing in mastectomy is not routine and should not be ritualistic, but must have indications and justification, they were also made aware of the cost of the blood typing in private hospitals in the Philippines. Realizing the cost (highest – P1000,00), I hope they will be compassionate not to have their future patients spend unnecessarily.
Problem-based Learning in Surgery 