Is ‘Group and Save’ Blood Request Routinely Required for Nasopharyngeal Biopsy?

Objectives To establish our current practice of ‘group and save’ blood for nasopharyngeal tumour biopsy (NB), and to determine the rate of blood transfusions among patients who underwent NB under general anaesthesia. Methods A retrospective chart review of all patients who underwent biopsy of NB in our tertiary institution between January 2006 and December 2015 was undertaken. Those with Juvenile nasopharyngeal angiofibroma were excluded. Data retrieved included patients’ characteristics such as age/sex, anaemia, primary tumour extension, and histology. Outcome measures included rate of ‘group and save blood’ requests, intra-operative blood loss, blood transfusion rates. Comparison was made between those that were requested to group and save blood prior to surgery (group ‘A’) and the group ‘B’ that were not so requested. Results We analysed eligible 103 cases (71 males and 32 females) out of 121 nasopharyngeal biopsies over the study period. ‘Group and save’ blood was undertaken in 47.6% (49/103) of our patients. Only 12.2% of the requested blood was transfused. Among evaluated patient characteristics, only oropharyngeal tumour extension differ between the study groups (P = 0.025). Overall, 14% had significant intra-operative blood loss (>500 ml), while 9.7% were transfused. The rates of blood loss and transfusion were not significantly different between the study groups (P = 0.22 and 0.09 respectively). Significant factors that influenced transfusion were pre-operative anaemia and oropharyngeal tumour extension. Conclusion There was high rate of arbitrary request for ‘group and save blood’ prior to NB in our institution over the last decade, which seems largely unnecessary. We recommend it be undertaken only in the presence anaemia and extensive oropharyngeal tumour extension.


Introduction
Although serious primary and reactionary haemorrhages are known to occur following biopsy of some nasopharyngeal tumours, such haemorrhage is rarely seen with most benign and malignant tumours of the nasopharynx. Several reports have described the bleeding propensity of juvenile nasopharyngeal angiofibroma (JNA) [1][2][3]. There is always a risk of massive bleeding during attempt at obtaining biopsy specimen or surgical excision of this apparently benign, but locally invasive highly vascular nasopharyngeal tumour [1,2]. It is estimated that blood loss during surgical excision of JNA ranges from 200 to 5000 ml [3]. Fortunately this tumour is very rare, in the range of 1:150,000, [2] occurring almost exclusively in adolescent and young males. Majority of nasopharyngeal tumours are malignant, with nasopharyngeal carcinoma (NPC) constituting 70-80% of the nasopharyngeal malignancies [4,5]. These malignant masses are usually not prone to massive haemorrhage at biopsies. However in view of the perceive fear of morbid bleeding of JNA, most anaesthetists in our practice insist on blanket procurement of blood preoperatively as a safe measure against unexpected bleeding during a number of biopsies for nasopharyngeal tumours. In our experience, this has often resulted in unnecessary contentions between the otolaryngology and the anaesthetic teams, with resultant cancellation of cases and delays, as well as additional cost to the patients. The outcomes of these contentions are often dependent on the ability of surgeon to argue his case, or sometimes, on the personal relationship with the particular anaesthetist. Majority of our patients who were asked to group and save blood prior to nasopharyngeal biopsies (NB) were never eventually transfused, and no audit has been carried out to evaluate the usefulness, or otherwise of this practice. This study was therefore carried out to establish our current practice of 'group and save' blood for NB, as well as to determine the blood transfusion rates among patients who underwent NB under general anaesthesia.

Subjects and Method
We conducted a retrospective analysis of 103 Patients (71 males and 32 females) that underwent NB in our department between January 2006 and December 2015.

Ethical Considerations
The study protocol was approved by our institutional ethical review committee.

Study Protocol
The patients' data were retrieved from the registers of ENT out-patient clinics, theatre registers and patients case notes. All the cases with available histology results were included. Those excluded from analysis were those that showed derangements of clotting profile on preoperative work up, and those with histological diagnosis of JNA. Data extracted included their demographic information, documented symptoms and clinical signs, plain x-ray and/or computed tomography (CT) imaging records, disease staging, histology results, request for group and save blood, reasons for such request, estimated blood loss records, intra-operative/postoperative blood transfusion records, and duration of hospital stay.

Data Analysis
It was conducted using the SPSS statistical software (version 16.5; IBM Corp) Chi square and Fisher Exact test were used to find the significance of study parameters on categorical scale between two or more variables. T test was used to compare means of numerical variables. Statistical significance was set at P value of \0.05.

Results
The records of 136 patients who were diagnosed with nasopharyngeal tumours at the out-patient clinics over the study period were identified. Nasopharyngeal biopsies were carried out in 121 patients under general anaesthesia. The rest did not turn up for subsequent management after their initial contact. Out of the 121 biopsied cases, the records of 9 patients were not available. The histology of 5 patients revealed nonspecific inflammation, whereas the available haematological workup of 3 patients showed clotting profile derangements. There was one case of JNA confirmed at histology. We therefore analysed 103 cases that met our inclusion criteria. There were 71 males (69%) and 32 females, with M:F ratio of 2.2:1. Their mean age was 40.2 ± 18.2 years, and ranged from 3 to 77 years. The patients were analysed in two groups: 'group A' 49 (47.6%) represented those that were requested to save blood prior to NB, whereas cases in 'group B' 54 (52.4%) were not so requested. Table 1 outlined the patient characteristics in both groups. Apart from primary tumour extension to oropharynx, both groups did not differ significantly in all the evaluated characteristics. They did not also differ regarding the presence of anaemia (P = 0.395). However patients in group A were more likely to have extensive primary tumour (P = 0.025).
The various reasons for blood request were outlined in Table 2. Advanced primary tumour dominated the reasons for blood request (43%). Regardless of whether patients were requested to save blood or not, Table 3 shows no significant difference in the amount of blood loss between the two groups (P = 0.217). The records of blood transfusion among the patients were also outlined in Table 3. Overall, 9.7% of our patients were transfused, 7 were intra-operatively, while the remaining 3 patients were transfused during the immediate postoperative period. The transfusion rates in the groups A and B subjects were 12.2 and 7.4% respectively. The difference in the transfusion rates between the study groups was not significant (P = 0.094). Majority of the transfused subjects (80%) had some levels of anaemia preoperatively. Seven of the patents that received blood transfusion were among those with oropharyngeal tumour extension (18.9%), compared to 4.4% transfusion rate among those whose primary tumours were limited to the nasopharynx (P = 0.001). The transfusion rate did not differ significantly between the 23 patient with significant nose bleeding and those without such bleeding (P = 0.141).

Discussion
The emergence of the acquired immunodeficiency syndrome (AIDS) as well as risk of transmission of hepatitis B and C viruses has fuelled concerns of both physicians and their patients about safety of blood transfusions. The administration of homologous blood transfusion is recently undergoing more critical rationalization in health care managements of diseases [6,7]. Most surgeons now employ stringent criteria before such transfusions are administered to their patients even for major surgeries [8,9]. These days, several peri-operative blood conservative techniques which are geared towards minimizing blood transfusion during surgical procedures, are widely being employed [9][10][11].
Despite the current global trends, it is of interest to observe that the practice of procurement of blood prior to nasal and pharyngeal surgeries, such as tonsillectomies, nasal clearance/biopsies and nasopharyngeal biopsy are still the subject of debate between the anaesthetic and the surgical teams in our institution. Often the outcomes of such debates are hinged on the arbitral decisions of the anaesthetist. In this present study, we attempted to critically examine the justification routine request for group and save blood for nasopharyngeal biopsy of suspected NPC over the last 10 years in our tertiary institution.
We observed that at least 2 units of blood were procured in each of the 49(48%) patients who underwent nasopharyngeal biopsies. Out of this number, only 12.2% were eventually transfused during the intra-operative and immediate post-operative periods. Our overall transfusion rate was even less than 10%.
The implication is that about[87% of all saved blood for NB in our institution over the last decade was rather needless. This therefore calls to question the rationale behind these requests. However one may argue, as is often championed by the anaesthetists, that the need for precaution should dominate other considerations. In as much as the above may be correct, there is however compelling need to consider the enormous cost burden on our patients who often find it difficult to pay for the cost of the biopsy with attendant delays, resulting in late presentations at advanced stages of the disease. In this study, 36% of our patients had primary tumours extending to the oropharynx at presentation. In view of non-existent/poorly implemented health insurance scheme in our society at the moment, large majority of our patients are always faced with the challenges of out-of-pocket funding of all cost of surgical procedures including ancillary costs, such as procurement of blood. Many of our patients were lost to follow up after initial probably on account of cost. Some found it difficult to meet the cost of procuring even 1 unit of blood, and ended up delaying for additional number of weeks before they could come up with the requested 2 units of blood.   Although oropharyngeal tumour extension constitute the major reason for the requests to save blood and seems to correlate with transfusion, we found that a huge number of the affected patient did not require blood transfusion. It is understandable why oropharyngeal tumour extension formed the major reason for the request blood prior to NB. The extension of huge nasopharyngeal mass to the oropharyngx often paints a grotesque picture with the tendency to creating a scare to the uninitiated. Contrary to the perceived fear of haemorrhage, the real danger is often the challenge of securing the airway during anaesthesia which should rightly be the concern of the anaesthetic team.
There seem to be no significant difference in the patients' characteristics between those requested to group and save blood and those that were not. This observation highlights arbitrariness in the requests to save blood for NB in our institution.
In conclusion there was high rate of request for 'group and save blood' prior to NB in our institution over the last decade. The requests were mainly arbitrary, regardless of the histology of the nasopharyngeal mass, but majorly influenced by oropharyngeal extension of mass. Only a small percentage of the requested saved blood (13.9%) was transfused in the end. In the absence of juvenile nasopharyngeal angiofibroma and bleeding diathesis, we recommend the request for 'group and save blood' to be reserved for patient with significant anaemia and those with extensive oropharyngeal primary tumours extension, so as to avoid needless largely unaffordable additional cost of saved blood before nasopharyngeal biopsies regardless of history of nose bleeding.

Compliance with Ethical Standards
Conflict of interest None declared.
Ethical Approval This article does not contain any studies with human participants performed by any of the authors.