R. G. Craig, Alder Hey Children's NHS Foundation Trust, UK

Background and context

Local, accurate and up to date information regarding the likelihood of transfusion for major spinal surgery is necessary for informed consent.1 A retrospective review was conducted to identify what proportion of patients having major spinal surgery at Alder Hey Hospital received allogeneic blood products in the perioperative period from January 2023 to September 2023. Adherence to the agreed maximum surgical blood ordering schedule (MSBOS) was assessed for each case that was transfused. Problems and inefficiencies relating to the two-sample rule and cross-matching were identified.2


The spinal surgery service database of all operations performed between the 1st January 2023 and the 31st August 2023 was searched to identify patients having:

  • posterior instrumented fusion – 88 patients
  • removal of growing rods and definitive posterior spinal fusion – 7 patients
  • removal of MAGEC growing rods – 1 patient
  • exchange of MAGEC growing rods to traditional growing rods – 1 patient
  • insertion of traditional growing rods – 3 patients

This identified a total of 100 patients.

14 patients received a transfusion of blood products.

9 patients were transfused in theatre and 3 of these had further transfusions on the ward post-op.

4 patients were transfused on the ward post-op without having any intra-op transfusion.

1 patient was transfused on the ward pre-op.

12 patients received packed red cells transfusions, 2 patients received FFP, one patient received cryoprecipitate and one patient received platelets.

4 of the 14 patients who received a transfusion had adolescent idiopathic scoliosis (AIS). 6% of patients with AIS were transfused (4 out of 63). 2 of the 4 patients with AIS who were transfused were only transfused post-op on the ward.

A lack of understanding regarding the two-sample rule and a deviation from the MSBOS were identified. The transfusion threshold for post-op patients who are not actively bleeding should be a haemoglobin concentration of < 70 g/l. In this review patients transfused on the ward post op had a haemoglobin concentration above this.

Strategy for change

The information from this review is currently used when consenting patients. Spinal specialist nurses will implement an education package for junior doctors working on the orthopaedic ward.

Measures of improvement

Local, accurate and up to date information on the likelihood of transfusion is available for the consent process. Adherence to the MSBOS and avoidance of unnecessary blood sampling and acceptance of a transfusion threshold of Hb < 70 g/l for patients who are not bleeding will be the subject of future audit.

Lessons learnt

Information for consent should use local data. Unnecessary blood samples are taken because of a lack of understanding of the two-sample rule. Knowledge of the MSBOS is poor.

Message for others

Review transfusion data to inform consent.


  1. General medical Council. Decision making and consent. 30 September 2020. www.gmc.uk.org/guidance
  2. Goodnough LT, Viele M, Fontaine MJ et al. Implementation of a two-specimen requirement for verification of ABO/Rh for blood transfusion. Transfusion 2009; 49: 1321-1328
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