Indications of blood transfusion in ent
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Indications for Blood Transfusion in ENT
Blood transfusion in ENT follows both general surgical principles and ENT-specific considerations. The key point from Scott-Brown's is that blood transfusion should be avoided whenever possible, and most routine ENT procedures (e.g., sinus surgery) rarely require transfusion. However, there are clear indications:
General Surgical Indications (applicable in ENT)
These three core indications come from Bailey & Love's (28th ed.) and apply across all surgical specialties:
- Acute blood loss - to replace circulating volume and maintain oxygen delivery
- Perioperative anaemia - to ensure adequate oxygen delivery during the perioperative phase
- Symptomatic chronic anaemia - without haemorrhage or impending surgery
(Bailey and Love's Short Practice of Surgery, 28th ed.)
ENT-Specific Indications
1. Post-tonsillectomy Haemorrhage
This is the most well-known ENT-specific scenario requiring transfusion. The National Prospective Tonsillectomy Audit (NPTA) defined significant haemorrhage as a bleed that:
- Prolonged the patient's stay in hospital
- Required blood transfusion
- Required return to the operating theatre
- Resulted in readmission for secondary haemorrhage
Haemorrhage rates vary by technique (primary rates 0.4-1.1%, secondary rates 1.0-5.5%). Parents/guardians must be counselled about the risk of major haemorrhage requiring transfusion at the time of consent.
(Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol. 2)
2. Double-jaw (Bimaxillary Orthognathic) Surgery
Patients requiring double-jaw procedures are the ENT patients most likely to require a blood transfusion. A US study concluded transfusion is no longer necessary during routine bimaxillary orthognathic surgery, but more complex cases remain at risk.
(Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol. 1 - Chapter 24)
3. Massive/Torrential ENT Haemorrhage
- Severe post-operative bleeds (e.g., after neck dissection, major head and neck resections)
- Uncontrolled epistaxis (e.g., in hereditary haemorrhagic telangiectasia/Osler-Weber-Rendu)
- Trauma to head and neck vessels
- Intraoperative haemorrhage during major ENT/head and neck surgery
4. Haematological Disorders Presenting to ENT
Scott-Brown's devotes a section specifically to haematological disorders presenting to ENT, including:
- Symptomatic anaemia from chronic disease (e.g., carcinoma of the larynx, hypopharynx, or nasopharynx causing chronic blood loss)
- After chemotherapy for head and neck malignancies
- Chronic haematological conditions (sickle cell disease, thalassaemia) where patients may present to ENT with complications
(Scott-Brown's Vol. 1, Chapter 24)
Transfusion Trigger (Haemoglobin Thresholds)
There is no universally agreed trigger. Local guidelines vary, but current evidence supports a restrictive transfusion strategy:
| Hb level (g/dL) | Recommendation |
|---|---|
| < 6 | Transfusion will probably benefit |
| 6-8 | Transfusion unlikely to benefit in absence of active bleeding or impending surgery |
| > 8 | No indication in absence of other risk factors |
| < 7 | Widely used restrictive trigger in surgical ICU patients |
- Historically, patients were transfused to achieve Hb >10 g/dL - this is now shown to be unnecessary and associated with increased morbidity/mortality.
- Patients with ischaemic heart disease or other cardiovascular comorbidities may require a higher trigger due to limited cardiac reserve.
(Bailey and Love's 28th ed.; Scott-Brown's Vol. 1)
Blood Components Used in ENT
| Component | Indication in ENT |
|---|---|
| Red Blood Cells (RBC) | Massive haemorrhage, symptomatic anaemia, post-chemotherapy, chronic haematological conditions |
| Fresh Frozen Plasma (FFP) | Coagulopathy, massive haemorrhage, DIC, liver disease (12-15 ml/kg dose) |
| Cryoprecipitate | Massive haemorrhage with fibrinogen < 1.5 g/L; rich in fibrinogen, Factor VIII, vWF |
| Platelets | Thrombocytopenia with active bleeding, or pre-operatively if platelets <50 x 10⁹/L |
(Scott-Brown's Otorhinolaryngology, Vol. 1 - Chapter 24)
Alternatives to Blood Transfusion in ENT
- Autologous pre-donation: Patient pre-donates their own blood up to 3 weeks before elective ENT surgery
- Intraoperative cell salvage (cell saver): Blood collected, washed, and returned intraoperatively
- Tranexamic acid (TXA): Shown to be effective in epistaxis, especially when conventional therapy fails and in hereditary haemorrhagic telangiectasia
- Erythropoietin: Used preoperatively to optimise Hb in anaemic patients before major surgery
- Iron supplementation: Treat iron deficiency anaemia before elective surgery
(Scott-Brown's Vol. 1; Roberts & Hedges' Clinical Procedures in Emergency Medicine)
Key Principle (BOX 24.1, Scott-Brown's)
"Ensure the right blood is transfused to the right patient at the right time in the right place and for the right indication."
Surgical specialties are responsible for up to 40% of blood transfusions in the UK. In ENT specifically, only 0.46% of sinus surgery patients actually required transfusion in a German retrospective review, reflecting excellent surgical technique and patient blood management.
(Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol. 1 - Chapter 24)
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