Retrospective Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. May 18, 2021; 12(5): 292-300
Published online May 18, 2021. doi: 10.5312/wjo.v12.i5.292
Reducing unnecessary crossmatching for hip fracture patients by accounting for preoperative hemoglobin concentration
Raj M Amin, Varun Puvanesarajah, Yash P Chaudhry, Matthew J Best, Sandesh S Rao, Steven M Frank, Erik A Hasenboehler
Raj M Amin, Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA 94305, United States
Varun Puvanesarajah, Sandesh S Rao, Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21205, United States
Yash P Chaudhry, Department of Orthopaedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA 19122, United States
Matthew J Best, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MD 02114, United States
Steven M Frank, Department of Anesthesiology, Critical Care Medicine, Baltimore, MD 21205, United States
Erik A Hasenboehler, Department of Orthopaedics, Johns Hopkins School of Medicine, Baltimore, MD 21205, United States
Author contributions: Amin RM, Puvanesarajah V, Best MJ, and Hasenboehler EA designed the research study; Amin RM, Chaudhry YP, and Rao SS analyzed the data; Amin RM, Chaudhry YP, Puvanesarajah V, Frank SM, and Hasenboehler EA wrote and edited the manuscript; All authors have read and approve the final manuscript.
Institutional review board statement: Institutional review board approval was obtained for this study (IRB CR00016216).
Conflict-of-interest statement: Hasenboehler EA is a paid consultant for DePuy Synthes Trauma. He receives grant support as well as a grant for a research fellow from DePuy Synthes Trauma. He is also a paid lecturer and faculty for AO North America Trauma and has stock ownership in Summit Med Ventures. Other authors have no conflict-of-interest to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Erik A Hasenboehler, MD, Assistant Professor, Department of Orthopaedics, Johns Hopkins School of Medicine, 4940 Eastern Avenue, Baltimore, MD 21205, United States. ehasenb1@jhmi.edu
Received: January 16, 2021
Peer-review started: January 16, 2021
First decision: January 24, 2021
Revised: February 18, 2021
Accepted: April 9, 2021
Article in press: April 9, 2021
Published online: May 18, 2021
Processing time: 115 Days and 19 Hours
Abstract
BACKGROUND

Maximum surgical blood order schedules were designed to eliminate unnecessary preoperative crossmatching prior to surgery in order to conserve blood bank resources. Most protocols recommend type and cross of 2 red blood cell (RBC) units for patients undergoing surgery for treatment of hip fracture. Preoperative hemoglobin has been identified as the strongest predictor of inpatient transfusion, but current maximum surgical blood order schedules do not consider preoperative hemoglobin values to determine the number of RBC units to prepare prior to surgery.

AIM

To determine the preoperative hemoglobin level resulting in the optimal 2:1 crossmatch-to-transfusion (C:T) ratio in hip fracture surgery patients.

METHODS

In 2015 a patient blood management (PBM) program was implemented at our institution mandating a single unit-per-occurrence transfusion policy and a restrictive transfusion threshold of < 7 g/dL hemoglobin in asymptomatic patients and < 8 g/dL in those with refractory symptomatic anemia or history of coronary artery disease. We identified all hip fracture patients between 2013 and 2017 and compared the preoperative hemoglobin which would predict a 2:1 C:T ratio in the pre PBM and post PBM cohorts. Prediction profiling and sensitivity analysis were performed with statistical significance set at P < 0.05.

RESULTS

Four hundred and ninety-eight patients who underwent hip fracture surgery between 2013 and 2017 were identified, 291 in the post PBM cohort. Transfusion requirements in the post PBM cohort were lower (51% vs 33%, P < 0.0001) than in the pre PBM cohort. The mean RBC units transfused per patient was 1.15 in the pre PBM cohort, compared to 0.66 in the post PBM cohort (P < 0.001). The 2:1 C:T ratio (inpatient transfusion probability of 50%) was predicted by a preoperative hemoglobin of 12.3 g/dL [area under the curve (AUC) 0.78 (95% confidence interval (CI), 0.72-0.83), Sensitivity 0.66] in the pre PBM cohort and 10.7 g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.88] in the post PBM cohort. A 50% probability of requiring > 1 RBC unit was predicted by 11.2g/dL [AUC 0.80 (95%CI, 0.74-0.85), Sensitivity 0.87] in the pre PBM cohort and 8.7g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.84] in the post-PBM cohort.

CONCLUSION

The hip fracture maximum surgical blood order schedule should consider preoperative hemoglobin in determining the number of units to type and cross prior to surgery.

Keywords: Hip fracture; Transfusion; Blood conservation; Hemoglobin; Type and cross; Maximum surgical blood order schedule

Core Tip: Implementation of patient blood management programs has led to a decrease in transfusion needs in hip fracture surgery patients. Preoperative hemoglobin plays a significant role in determining transfusion needs in these patients. Maximum surgical blood order schedules should be adjusted based on preoperative hemoglobin values to reduce unnecessary blood product waste and conserve resources.