Page 30 - World Journal of Laparoscopic Surgery

Cost Analysis of Blood Group and Antibody Screening for Emergency Appendicectomy: Should We Stop?
screening had been requested. The transfusion laboratory then Table 1: Total number of appendicectomies identified in our unit over
identified which of these patients had been issued blood in the a 3 year period and the surgical approach
perioperative or postoperative period and whether this was type Total emergency appendicectomies 645
specific or O-negative blood. Laparoscopic 603 (93%)
Open 42 (7%)
results
A total of 645 emergency appendicectomies were identified of
which 603 were laparoscopic cases and 42 open. There were 334 Table 2: Cost breakdown of screening and blood usage
male and 311 female patients with a median age of 29 (range 16–83). Cost per patient Total cost of Total cost of
Of all 645 cases, 1 (0.2%) patient received a blood transfusion (1 of group and group and Cost per unit of transfusions (2
unit in recovery and 1 unit in the postoperative period). Both these screen screen blood units)
units were type-specific blood following full crossmatch. £35.00 £22,470.00 £132.72 £265.44

dIscussIon
In our study, in a cohort of 645 patients, we established that the the need for preoperative screening is removed and therefore a
incidence of perioperative transfusion was 0.2%, comparable to reason for potential delay can be avoided.
2
the previously published rate of 0.36%. In our study, there were
no massive transfusion events requiring O-negative blood. The conclusIon
one patient who required blood was able to wait for type-specific To conclude, our study has confirmed that the rate of transfusion
blood to be available. in appendicectomy is extremely low, suggesting that the routine
At present, the National Transfusion Service charge the same use of blood group and antibody screening is unnecessary. Our
6
for a unit of blood regardless of blood type (£132.72). It has been recommendation would be to crossmatch on an as-required basis
proposed that O-negative blood should attract an additional and use O-negative where urgent blood is required. The potential
6
charge (£180), the reason being that O-negative blood is the cost saving of this practice to our trust would be £22345, and if this
universal donor group and thus stocks of this should be protected. were extrapolated across the NHS, this could be in the region of
The differential charge would be to encourage use of type-specific £1.1M with very little impact on the demand for O-negative blood.
blood where possible.
If blood products are required in the vast majority of cases, references
the use of blood products is an urgent clinical need but not an
emergency requiring activation of a major hemorrhage protocol; 1. Thomson PM, Ross J, Mukherjee S, et al. Are routine blood group
in our study, no patients required an emergency transfusion. A wait and save samples needed for laparoscopic day case surgery? World
J Surg 2016;40(6):1295–1298. DOI: 10.1007/s00268-016-3463-8.
of up to 60 minutes for blood to be available would not constitute a 2. Barrett-Lee J, Vatish J, Vazirian-Zadeh M, et al. Routine blood group
significant clinical risk. Not having a prior group and screen would and antibody screening prior to emergency laparoscopy. Ann R Coll
add approximately 15 minutes to this process due to the need to Surg Engl 2018;100(4):322–325. DOI: 10.1308/rcsann.2018.0033.
sample blood and deliver it to the hematology laboratory. The risk 3. Yazer MH. The blood bank “black box” debunked: Pretransfusion
of unexpected antibodies at group and screen is approximately testing explained. CMAJ 2006;174(1):29–32. DOI: 10.1503/cmaj.050919.
7
1.5%. Therefore, if 0.2% of cases require transfusion, the chance of 4. UK Transfusion guidelines. Joint United Kingdom (UK) Blood
a patient undergoing emergency appendicectomy needing blood Transfusion and Tissue Transplantation Services Professional
and it not being available is negligible (0.003%) (Tables 1 and 2). Advisory Committee, https://www.transfusionguidelines.org/
If routine crossmatch was removed from our trust, this would transfusion-handbook/7-effective-transfusion-in-surgery-and-
critical-care/7-3-transfusion-management-of-major-haemorrhage
have saved £22,435. It is estimated that there are approximately - accessed 24th September 2019.
50,000 emergency appendicectomies carried out in the United 5. Strobel E. Hemolytic transfusion reactions. Transfus Med Hemother
8
Kingdom every year. If our data were extrapolated to these 50,000 2008;35(5):346–353. DOI: 10.1159/000154811.
cases, then crossmatching when required rather than routinely 6. NHSBT pricing proposals 2018-2019. Available from https://nhsbtdbe.
group and antibody screening every patient would save £1.1M. blob.core.windows.net/umbraco-assets-corp/15273/ncg-pricing-
Further advantages of this strategy are reducing burden on the proposals-july-board-paper-26-july-2018-v-3-0.pdf [Accessed 8th
blood transfusion service and to remove a potential delay in patient April 2019].
transfer to the theater whilst waiting for group and screen tests to 7. Ko KH, Yoo BH, Kim KM, et al. Frequency of unexpected antibody
and consideration during transfusion. Korean J Anesthesiol
be carried out, with the associated potential to increase morbidity 2012;62(5):412–417. DOI: 10.4097/kjae.2012.62.5.412.
from the condition. By transfusing O-negative blood in massive 8. Baird Daniel LH, Constantinos S, Christos K, et al. Acute appendicitis.
hemorrhage and carrying out crossmatch on an as-required basis, BMJ 2017;357:j1703.

World Journal of Laparoscopic Surgery, Volume 13 Issue 3 (September–December 2020) 129