Reducing Unnecessary Preoperative Blood Orders in Anterior Skull Base Surgical Procedures: Evidence-Based Strategies to Optimize Preoperative Blood Orders and Utilization

Background: The clinical trend in skull base neurosurgery is Type and Crossmatch (T&C) with the reservation of packed red blood cells (PRBCs) in anticipation of potential blood loss. However, these reserved PRBCs are often not transfused, leading to unnecessary financial costs, impact on blood banking protocols and misallocation of workforce hours, with minimal clinical impact. This study presents the current best practices for blood transfusion, focusing on the timing of requests, transfusions, and the identification of high-risk procedures that may require intraoperative blood transfusions.

Methods: A retrospective chart review of patients undergoing anterior skull base surgery at our institution from 2014 to 2022 was performed. Data collection included basic demographics, comorbidities, hemodynamic status, number of requested units, laboratory orders (Type and Screen [T&S] Type and Crossmatch [T&C]), intraoperative blood loss and indication, tumor type and size, and number of PRBC units transfused. Statistical analysis was performed to investigate variables that could help predict the use of requested blood units.

Results: From 2014 to 2022, a total of 539 patients (mean age: 51.6 years and mean BMI: 28) underwent anterior skull base surgery, 485 (90%) patients had crossmatch and hold orders prior to surgery with 950 units of packed red blood cells requested and crossmatched (T&C). Of these, only 19 (3.9%) required subsequent transfusion. 54 patients who did not undergo crossmatching did not require transfusion. Univariate and multivariate logistic regression among different preoperative comorbidities did not reveal any comorbidity as a statistically significant predictor of intraoperative transfusion. Tumor type and size were both determined to be statistically significant indicators (p ≤ 0.001 for both groups) for a subsequent transfusion. Particularly, out of 19 patients needing transfusion, 12 patients (63%) harbored a meningioma. In addition, mean tumor size for those needing transfusion was 361.2 versus 73.9 cm³ for those who did not. Mean estimated blood loss was 909.0 mL for the transfused group and 195.0 mL for the non-transfused group (p < 0.001). The “real-time” processing for crossmatching and transfusion in a type and screen patient at the time of transfusion decision (1 unit PRBCs: 12 minutes for crossmatching + 6 minutes for transportation, totaling 18 minutes) is compared to the “real-time” transfusion for a patient with a prior type and crossmatch (2 units PRBCs: 6 minutes for processing + 6 minutes for transportation, totaling 12 minutes). This comparison highlights the impact of both methods on patient care.

Conclusion: This study demonstrates the low rates of intraoperative PRBC transfusion (3.9%) in anterior skull base surgery. Preoperative crossmatching (T&C) and holding are often unnecessary for the majority of patients replacing this with a Type and Screen (T&S) protocol. The tumor size (361.2 cm³) and tumor type (meningioma) should be considered to guide the Type and Cross protocol. Identifying patients at risk for transfusion to guide preoperative type and crossmatch practices at each institution should be considered a best practice to reduce overall costs and improve workforce efficiency.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
07 February 2025