|Year : 2007 | Volume
| Issue : 3 | Page : 200-204
An audit of blood transfusion in elective neuro-surgery
Sandeep Bhatnagar1, IB Udaya2, GS Umamaheswara Rao3
1 Specialist Grade I, World Health Organisation Fellow, Department of Neuroanaesthesia, National Institute of Mental Health and Neurosciences, Bangalore 560 029, India
2 P.G.Student, Department of Neuroanaesthesia, National Institute of Mental Health and Neurosciences, Bangalore 560 029, India
3 Professor, Department of Neuroanaesthesia, National Institute of Mental Health and Neurosciences, Bangalore 560 029, India
|Date of Acceptance||18-Apr-2007|
|Date of Web Publication||20-Mar-2010|
G S Umamaheswara Rao
Professor, Department of Neuroanaesthesia, National Institute of Mental Health and Neurosciences (NIMHANS)
Source of Support: None, Conflict of Interest: None
Neurosurgery is generally believed to be associated with major blood loss and large volumes transfusion of blood and blood product. Recent advances in neurosurgical techniques and concepts relating to blood transfusions have helped to decrease the need for intraoperative transfusions. In the present audit conducted in an advanced tertiary neurological centre performing the entire range of neurosurgery, 31% of patients undergoing surgery required blood product transfusion. Surgery on inracranial tumors was associated with a significantly higher blood loss (P<0.006) and transfusion than surgery on other lesions. Spinal surgery required the lowest rates of transfusion. Among the intracranial tumors, meningiomas required the highest volumes of transfusion (P<0.001). Rates of blood transfusion in paediatric patients were the same as those for the entire group. In children less than 15 years, surgery for intracranial tumors and craniosynostosis were the main procedures requiring blood transfusion, while no blood transfusion was required for surgical procedures for hydrocephalus and spinal myelomeningoceles. Single unit transfusions, which accounted for 34% of all blood products transfused, were more frequent in paediatric patients (22 out of 45 in children ≤15 years) and intracranial tumors(24 out of 45).
Keywords: Audit; Blood transfussion; Elective Neurosurgery.
|How to cite this article:|
Bhatnagar S, Udaya I B, Umamaheswara Rao G S. An audit of blood transfusion in elective neuro-surgery. Indian J Anaesth 2007;51:200-4
|How to cite this URL:|
Bhatnagar S, Udaya I B, Umamaheswara Rao G S. An audit of blood transfusion in elective neuro-surgery. Indian J Anaesth [serial online] 2007 [cited 2019 Dec 10];51:200-4. Available from: http://www.ijaweb.org/text.asp?2007/51/3/200/61142
| Introduction|| |
Complications associated with blood transfusion such as haemolytic reactions, transmission of infections (malaria, human immunodeficiency virus, serum hepatitis, cytomegalo virus), metabolic disturbances, coagulation disorders, and immune suppression have been appreciated in recent years. The need to limit homologous blood and blood component transfusion has been emphasized in many studies and audits relating to transfusion practices ,,,, . Many conventional haemostatic techniques used in general surgery are not applicable in neurosurgical procedures. Therefore, neurosurgery has always been believed to be associated with high volume of blood loss and blood product replacement. Recent advances in neurosurgical instrumentation and routine use of microsurgical techniques have significantly helped to decrease the operative blood loss. Use of techniques of autologous blood transfusion and intraoperative haemodilution and acceptance of low postoperative haemoglobin levels have also decreased the need for intraoperative homologous blood transfusion ,,,, . The aim of the present study is to audit the intraoperative transfusion of patients undergoing neurosurgical operations in the light of recent changes in neurosurgical techniques and awareness of clinicians about the need to decrease homologous blood transfusion.
| Methods|| |
The study was performed at the National Institute of Mental Health and Neurosciences, Bangalore, carrying out about 1500-1800 elective neurosurgical operations per year. The data was collected prospectively over a two-month period from all the patients undergoing elective neurosurgery. Since the present study was only an audit of the use of blood and blood products during the normal course of surgery and the information was collected from the anaesthesia charts at the end of each surgery, ethics committee approval was not sought. Patients undergoing surgery for head trauma and other emergency neurosurgery were not included in the study. Demographic data and preoperative haematological and haemodynamic parameters were noted. Intraoperatively, heart rate, blood pressure, oxygen saturation, and end tidal carbon dioxide pressure were continuously monitored. The anaesthetic, haemodynamic and fluid management was carried out as per the discretion of the anaesthesiologist in charge of the patient. Visual estimation of blood loss based on the blood volume collected in the suction bottle and in the operative site drapes was carried out. The decision to transfuse blood or blood products was made by the attending anaesthesiologist. The number and nature of blood products used, the time taken for transfusion of each product, haemodynamic changes during transfusion and any complications associated with transfusion were noted. The volume and nature of intraoperative fluid transfusion, and urine output were also recorded. Postoperatively, haemodynamic parameters and any need for mechanical ventilation were also noted.
All data are expressed as mean±S.D. All continuous variables namely age, weight, haemoglobin concentration, HR, SBP, DBP, estimated blood loss, volume of fluid transfused and urine output were analysed by Student's t-test. Posthoc Bonferroni's test was used where indicated to find out significant differences in transfusion requirements among different types of surgery. Analysis of nonparametric data such as the incidence of preoperative hypertension and comparison of the number of units of transfusion in various types of surgery were carried out by using a Chi-square test. A P value < 0.05 was considered statistically significant. Statistical analysis was carried out using SPSS version10.0 software.
| Results|| |
A total of 253 patients were operated upon during the study period. Of these, 78 patients (31% of all operated patients) received blood transfusions. A total of 131 units of blood or blood products were transfused, which included 85 units of whole blood, 43 units of packed cells and 3 units of fresh frozen plasma.
The age, weight, preoperative haemoglobin concentration, heart rate and blood pressure were comparable between patients who received transfusion and those who did not receive transfusion. The incidence of preoperative hypertension was also similar between the two groups [Table 1].
The volume of blood loss and the distribution of blood transfusion among the various surgical procedures are shown in [Table 2]. Patients with intracranial tumors constituted the majority who received transfusion; among the intracranial tumors, meningiomas had the highest requirement of transfusion.
In transfused patients, haemodynamics were stable throughout the study. Blood pressure and heart rate before and after transfusion of each unit were not significantly different. Patients who received blood products also received significantly higher volumes of crystalloids intraoperatively. They also had a significantly higher urine output in the intraoperative period [Table 3].
Forty-five patients received single unit transfusions, while 20, 7, and 5 patients received by 2, 3 and 4 unit transfusions respectively. Single unit transfusions were received by all groups of patients, but the majority of it was received by patients with intracranial tumors (P<0.04). Three or more units of transfusion was limited mainly to patients with intracranial tumors.
| Paediatric patients|| |
There were 60 patients aged 15 years or less, of whom 22 required transfusion making the frequency of transfusion in this group similar to that of the rest of the patients. Surgery on intracranial tumors and procedures for correction of craniosysnostosis required the majority of transfusion (16 and 3 units respectively). Single unit transfusion accounted for 19 out of 22 total transfusions in children. Surgical procedures for hydrocephalus and spinal myelomeningoceles did not require any transfusion.
| Discussion|| |
In the present audit, only 31% of neurosurgical operations required blood or blood product transfusion. The transfusion rates were higher among patients undergoing surgery for intracranial tumours compared to those undergoing surgery for vascular lesions or for other pathologies. Eighty one out of the 131 units transfused (62%) were received by patients with intracranial tumours. Among the intracranial tumors, meningiomas received more frequent and larger volumes of transfusion. Requirement of transfusion was very low among patients operated upon for spinal lesions.
Awareness of complications such as haemolytic reactions, transmission of infections, metabolic disturbances, coagulation disorders, and immunosuppression associated with blood transfusions and better definition of the indications for blood and blood product transfusion have changed the attitudes of the physicians towards more rational transfusion practices. The present study was aimed to understand the current practices of blood and blood product transfusion in a neurosurgical centre. This understanding is expected to minimise transfusion rates in future.
The overall rates of transfusion were fairly low (only 31% of all surgeries) in this series. Most of the blood transfusion was carried out in patients with brain tumors, especially those with meningiomas. This is not surprising considering the fact that meningiomas are very vascular. Welldelineated superficially located meningiomas may not be associated with major blood loss. But haemostasis may be difficult and blood loss is higher in deep-seated meningiomas. The majority of meningiomas in our series who received transfusion (11 out of 15) belonged to the latter category. The mean blood loss of 834 ± 578 mL in meningiomas in our study is similar to that in other reports (1014 mL without any preoperative intervention  and 621-917 mL with three different techniques of preoperative embolisation  ).
Transfusion rates among patients with spinal lesions in this series were low because the majority of operations involved either discectomy, spinal instrumentation for spondylosis or fixation of unstable atlanto-axial joints. Blood loss during spinal procedures has been shown to depend on the procedures carried out; simple discectomy may not require blood transfusion, and fusion without instrumentation may also be associated with only moderate blood loss. It is only fusions with instrumentation that have been shown to require large volumes of blood replacement  . In our series too, 6 out of nine transfusions in spinal surgery were required by patients with tuberculous spinal lesions and those requiring spinal instrumentation.
The low rates of blood transfusion in vascular neurosurgery in this series are also supported by other reports. In a series of 71 ruptured cerebral aneurysms, only four patients (5.6%)required intraoperative blood transfusion  .
Transfusion in paediatric patients in our series was largely limited to brain tumors and craniosynostosis. High rates of transfusion in craniosynostosis is noted in neurosurgical literature and the impact of recent instrumentation and acceptance of lower postoperative haemoglobin levels, on intraoperative blood transfusion have been documented recently  .
There is a relatively large proportion of single unit transfusions in our series. Though it appears to be against the modern practices, a closer look at the data reveals that the group that received single unit transfusions had more children; 19 out of 45 patients receiving single unit transfusions were less than 15 years old as against 3 out of 33 in patients who received multiple units of transfusion. Mean age of patients receiving single unit transfusion was 25±20 years while it was 35±14 years in patients who received multiple units of transfusion (P<0.01). Since the mean body weight was also lower in patients who received single unit transfusion (37±21 vs 51±12 kg), a single unit transfusion would have accounted for replacement of a relatively larger proportion of the patient's blood volume. Recent literature suggests an increasing trend for single unit transfusions in an intensive care setting as the physicians are adopting lower transfusion triggers  . It remains to be seen if a similar trend would evolve with regard to intraoperative transfusion. A systematic review of transfusion literature, in fact, suggests that the effects of conservative transfusion triggers on functional status, morbidity, and mortality, particularly in patients with cardiac disease, need to be tested in large clinical trials  .
With regard to the types of blood products transfused, whole blood constituted 65% of all the transfused units, packed cells 33% and fresh frozen plasma 2%. This represents a change towards use of components rather than whole blood, though a desirable level of component use is much higher. Very low consumption of fresh frozen plasma in our series is reflective of the relatively large proportion of whole blood transfusion and also low incidence of massive transfusions that would have necessitated the use of fresh frozen plasma
Stable haemodynamics before and after transfusion and larger volume of crystalloid infusion in patients who required blood products, in the present series, indicate a balanced approach to the usage of IV fluids and blood products that does not allow major cardiovascular changes due to hypovolemia in a patient with intraoperative blood loss.
The volume of crystalloid transfusion was higher in patients receiving blood transfusion. This represents our usual practice of trying to replenish the initial blood loss with crystalloids and also replacement of uncovered blood loss with crystalloids by an approximate ratio of 1 to 3.
The implication of our study is that a significant proportion of neurosurgical operations may be performed without the need for blood transfusion. Discretion may be used in requesting for cross match depending on the expected blood loss. Blood reservation and prior cross matching may be justified for meningiomas.
Though the rates of blood product transfusion are low in the present study, we see a scope for further reduction of homologous blood transfusion. This probably may be achieved with more frequent use of haemodilution and autologous blood collection where it is feasible. Autologous blood transfusions were demonstrated to be safe in patients undergoing intracranial surgery and to be more cost-effective than allogenic blood transfusions. Intraoperative autologous blood transfusions may be used alone in more than half of the patients requiring transfusions during intracranial surgery and decrease the amount of allogenic blood used  . The role of procoagulant agents such as aprotonin in neurosurgery has been investigated in some studies. The available results suggest that the drug is safe and effective in neurosurgical patients  . With the use of fibrin glues to secure haemostasis and routine preoperative embolisation of the vascular tumors, the need for blood transfusion may probably be reduced further. Future studies must explore the possibility of further reduction of homologous blood transfusion in Indian context through the above measures.
The limitation of the present audit is that it is limited only to elective neurosurgery and does not take into account the transfusion requirements of emergency surgery. Surgical procedures for head injuries may be associated with substantial blood loss due to coagulopathy caused by brain injury.
In conclusion, less than one third of neurosurgical operations require intraoperative blood product transfusion. Transfusion requirement is higher for brain tumors compared with other lesions; meningiomas require larger volumes of transfusion than other tumors. In the present study, single unit transfusions accounted for 34% of all blood product transfusion; these were required more frequently in children and patients with brain tumors.
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[Table 1], [Table 2], [Table 3]