Soaring healthcare costs have prompted an assessment of the liberal use of laboratory testing in medical practice. Specifically, several studies have commented on the overuse of laboratory work in the perioperative care of a surgical patient.3,4
Mandated preoperative type and screen testing prior to elective surgeries is a prime example. While a single type and screen may not be expensive, when noting the large numbers of routine surgeries completed annually, the cumulative expense of the individually low-costing type and screens becomes significant.
The incidence of major vascular injury during laparoscopic cholecystectomy described in the literature is low, ranging from 0.11% to 0.34%, according to different authors.2
The incidence of major vascular injury during pelvic laparoscopic surgery goes from 0.06% to 0.75%.5
Usal et al2
described the cost effectiveness of routine type and screen testing before laparoscopic cholecystectomy. With a risk of transfusion of 0.46% for laparoscopic cholecystectomy and 5.47% for open cholecystectomy, his institution modified their preoperative protocol to omit routine type and screen testing without reducing quality of care. The real incidence of emergency transfusion due to vascular injury was 0.07% (2/2589).
Ransom et al5–8
studied the cost effectiveness of preoperative routine type and screen testing for different procedures in a department of obstetrics and gynecology. They concluded that for elective laparoscopic surgery,5
and expected vaginal delivery,8
the incidence of transfusion was 0%, 3.3%, 0.66%, and 0.46%, respectively. His conclusions directly led his institution to cancel the routine type and screen testing prior to these procedures.
Similarly, Lin et al9
retrospectively audited preoperative blood orders for several procedures. They concluded that certain procedures including cholecystectomy and appendectomy have a low-transfusion probability and therefore preoperative blood sampling could be safely eliminated.
If we analyze the transfusion outcomes by age groups, we see that the risk of transfusion is still low, being <1% with a slight increase in the risk among older patients compared with younger patients. Looking only at age is not an indication for type and screening of patients who need appendectomy, cholecystectomy, or hernia repair. The risk of transfusion seems to be related to a preexisting medical condition (anticoagulation treatment, preoperative anemia) other than the procedure per se; that is why the indication for type and screen must be done based on the clinical characteristics of each patient.
In the unlikely case of a major complication that requires an emergency blood transfusion, an uncrossmatched O-negative universal donor can be initiated while a formal crossmatching is undertaken. At our patient institution, the type and screen process takes 20 minutes to 30 minutes with blood available for delivery to the OR immediately thereafter. Advancements in transfusion technologies have led to steady decreases in crossmatching times while retaining satisfactory detection of clinically significant antigen-antibody interactions. The use of O-negative blood has the advantage that this group has already been screened for the presence of the most significant non-ABO antibodies. With the prevalence of irregular erythrocyte antibody in the general population ranging between 1.9% and 2.5%, the risk of transfusion-related adverse reactions is equally low. Rapid administration of O-ve blood acceptably addresses any hemodynamic instability in an emergency situation with evidence that no patient has died from a transfusion complication and the rate of seroconversion in Rh-ve patients is low.10
Additional transfusion options including a rapid-spin restricted crossmatch (which effectively confirms ABO compatibility) and group-specific blood (which is more readily available than screened O-negative blood) provide viable alternatives for blood compatibility in an emergent situation. In our parent institution, a routine type and screen takes 20 minutes to 30 minutes with subsequent blood available immediately thereafter.
The approximate cost of the type and screen test is $30 US dollars. Eliminating this test for routine appendectomies, cholecystectomies, and hernia repairs will bring an annual savings of $55,000 per year at our parent institution.
We recommend the elimination of routine preoperative type and screen testing due to the low incidence of transfusions for cholecystectomies, appendectomies, and hernia repairs and the rapid availability of blood in the exceptional case of major bleeding.