Should a type and screen (blood typing and screening) be ordered for all preoperative (preop) surgeries?

Type and Screen for Preoperative Surgeries: When to Order

Type and screen should NOT be ordered routinely for all preoperative surgeries but should be selectively ordered based on surgical procedure risk and patient factors that increase transfusion probability.

Evidence-Based Approach to Type and Screen Orders

The decision to order preoperative type and screen should be guided by:

1. Surgical Risk Assessment

• High Blood Loss Risk Procedures:

  • Cardiovascular surgery
  • Major orthopedic procedures
  • Neurosurgery
  • Major vascular procedures
  • Procedures where blood loss >500 ml is anticipated 1

• Low Blood Loss Risk Procedures:

  • Cataract surgery
  • Minor outpatient procedures
  • Minimally invasive procedures with expected minimal blood loss 1, 2

2. Patient-Specific Risk Factors

Type and screen is indicated for patients with:

• History of anemia
• Liver disease
• Hematologic disorders
• Recent blood loss
• Extremes of age with comorbidities 1, 3

Recommended Algorithm for Type and Screen Orders

1. Order type and screen for:

   • Patients undergoing cardiovascular surgery
   • Patients undergoing major surgery (grade 3 or 4)
   • ASA class 2 or 3 patients with cardiovascular disease undergoing intermediate or major surgery
   • Patients with history of anemia, bleeding disorders, or recent blood loss
   • Patients in whom significant perioperative blood loss is anticipated 1, 3

2. Type and screen is NOT indicated for:

   • ASA class 1 patients younger than 40 years undergoing low-risk surgery
   • Patients in their usual state of health undergoing cataract surgery
   • Minimally invasive procedures with historically low transfusion rates (<1%) 1, 2

Benefits of Selective Type and Screen Approach

Implementing a selective approach to type and screen offers significant benefits:

• Reduces unnecessary laboratory testing
• Decreases blood bank resource utilization
• Prevents holding up blood bank reserves
• Reduces aging and wastage of blood units
• Generates substantial cost savings 4, 2, 5

Implementation Considerations

• Studies show that 40% of cross-matches performed are unnecessary 4
• For minimally invasive hysterectomies, 42.7% had type and screen ordered but only 2.9% received transfusions 2
• A selective type and screen policy can reduce cross-matching requests by 12% while maintaining patient safety 5

Special Populations

Patients with Sickle Cell Disease

• Multidisciplinary collaboration between surgeon, anesthetist, hematologist, and blood bank specialist is mandatory
• Preoperative transfusion decisions should be made on a case-by-case basis 1

Common Pitfalls to Avoid

1. Over-ordering blood products: Leads to resource waste and increased costs
2. Under-ordering in high-risk cases: May delay transfusion in emergency situations
3. Failing to identify patients with anemia: Preoperative anemia is common and associated with adverse outcomes
4. Not considering procedure-specific risks: Different procedures have vastly different transfusion probabilities

Quality Improvement Opportunity

Hospitals should develop a Maximum Surgical Blood Order Schedule (MSBOS) that specifies:

• Procedures requiring full cross-match
• Procedures where type and screen is sufficient
• Procedures where no preoperative blood testing is needed 4, 6

This approach has been shown to be safe, effective, and economical for managing preoperative blood orders 4, 5.