Blood Transfusion In Elective Orthopaedic Surgeries At The Kenyatta National Hospital

Abstract

Introduction

Blood transfusion can be a life saving intervention. However if given when it is not necessary, the patient receives no benefit and is exposed to unnecessary risk. Many of the patients undergoing major elective orthopaedic surgeries are cross matched and transfused despite having an adequate pre-operative hemoglobin level. Some degree of blood loss can be incurred provided the loss is replaced with intravenous fluid to maintain normovolemia before blood transfusion becomes necessary. The patient hemoglobin though important should not be the sole deciding factor of initiating transfusion. This study is to assess the number of patients that get transfused during elective orthopaedic surgeries, and if the transfusions are rational and not just based on clinical acumen. Objective: To evaluate the rationale for blood transfusion in patients undergoing elective orthopaedic surgeries at the Kenyatta National Hospital Design: cross sectional descriptive study

Study setting: The orthopaedic wards, orthopaedic theatres and the blood transfusion unit at the KNH. Study population: All patients over the age of 12 years undergoing elective orthopaedic surgery at the KNH Methodology: The patients' demographic data, medical history and physical examination findings was recorded in a patient proforma. Total blood loss of patients undergoing various orthopaedic surgeries was assessed and calculated by measuring the blood soaked swabs, measuring the weight of blood in the suction bottle and estimating the amount of blood that had spilt on the floor. The allowable blood loss was also assessed, this will be compared to the amount of intravenous fluid the patient has received. A pre transfusion hematocrit was done and the amount of blood that was transfused was noted. Patients that were transfused were assessed to determine if the transfusions were rational or irrational.

Data collection: The allowable blood loss was calculated using the hemodilution method

(Appendix I). Blood loss was calculated by weighing blood soaked gauze swabs

measuring the weight of blood in the suction bottle and estimating the amount of blood

on the floor. The amount of intravenous fluid was recorded and monitoring of the patients pulse rate, blood pressure and urine output was done

Results: A total number of 80 patients were assessed. Male comprised a higher

percentage (66.3%) compared to females 33.7%. patients that were transfused were put in four categories including trauma, spine arthoplasty and tumors. Patients that had comminuted fractures were associated with more blood loss with a mean of 1325.55ml compared to patients who had simple fractures (570.27ml). Patients operated after six weeks also lost more blood (1148ml) compared to patients operated earlier. Patients who were operated using general anesthesia lost more blood (1248 ml) compared to those that received spinal anesthesia. This is probably attributable to the hypotensive effect spinal anesthesia has. Surgeries that diathermy was used lost less blood (1071ml) compared to no diathermy (1818ml). Most of the patients that were transfused only received one pint of blood. This contributed about 76 % of the patients in the study. Of those transfused 35% were irrationally transfused according to the WHO criteria.

Conclusion and Recommendation;

Of all the patients who received blood transfusion during the study period only 65 % required blood by the WHO criteria. 35% were transfused irrationally. The risk of disease transmission especially during the window period is quite high and transfusion should be avoided unless necessary. The cost also of preparing a pint of blood is quite high and also technically demanding. Thus blood that is available should be used only when absolutely necessary.

The WHO criteria for blood transfusion during surgery should be adapted and implemented for patients undergoing elective orthopaedic surgeries at Kenyatta National Hospital