In this study, all patients were cross-matched before the operation, but only 36.7% of these patients received blood transfusions. There are a limited number of studies in the literature investigating blood management in patients undergoing lung resection [1, 6]. Previous studies have reported blood transfusion rates of 13–27% in patients undergoing lobectomy and up to 25–30% in patients undergoing pneumonectomy. Rates vary widely due to the characteristics of patient populations [1, 6, 7, 9].

Recently, Abdelsattar et al. have reported that they performed transfusion in 7.1% of 6280 patients who underwent non-cardiac thoracic surgery. This study represents the most comprehensive analysis of transfusion needs among patients undergoing non-cardiac thoracic surgery to date. This study has also been the largest evaluating the need for type & screen (TS) in patients undergoing elective non-cardiac thoracic surgery. Only 50% of the patients had TS performed before the operation [1]. In another comprehensive study, Azizgolshani et al. argued that routine TS is not necessary before esophagectomy and lung resection [7].

The blood transfusion rates in this study have partially been consistent with the literature, and we found that we were wasting blood in our blood management process. We did not apply institutional supervision-based procedures to estimate blood loss during our elective operations. This led to the surgeon making subjective estimates for blood preparation at his discretion. This caused us to routinely cross-match and reserve blood in high-risk lobectomy and pneumonectomy operations. Considering that, especially in developed countries, TS is often preferred instead of cross-match and that this is not performed on all patients [1, 6, 10], it is concluded that our clinical practices must be altered.

When the indices in this study were evaluated, it was seen that we reserved too much blood and caused blood waste (CT: 3.88, %T: 36.7, TI: 0.78). Many indices have been introduced since the 1970s to assess correct blood use. In 1975, we first used the CT ratio. An ideal ratio of 1.0 signifies the transfusion of all cross-matched blood. A ratio of ≤ 2.5 indicates appropriate blood use. Proposals emerged in the 1980s to evaluate the effectiveness of blood transfusion using T%. A value of ≥ 30% indicates significant blood use. In 1975, they introduced another index, TI. A value of ≥ 0.5 indicates significant blood use [5, 8]. Griffiths et al. found the CT rate to be 4.02 in patients to whom they performed thoracotomy. Meads et al. reported the T% rate as 5% in patients who underwent thoracotomy Another study found this rate to be 47.7% for lobectomy and pneumonectomy [8, 11]. We think that the literature is diverse because the need for blood transfusion lung resection varies widely and there are different procedures even in the same specialty. Although the rates in our study seem to be better than those in the literature, it is thought that cross-matching all patients, the number of transfused units, and the low number of transfused patients have caused these results. Therefore, we are planning to develop a new blood preparation strategy to enhance the results.

In this study, there was a positive correlation between the amount of blood allocated and used and the length of hospital and intensive care unit stays for the patients. We think that this actually indicates that patients with bleeding have a prolonged length of stay in the intensive care unit and in the hospital. In addition to the burden of bleeding on the healthcare system, it has been reported in many studies that blood transfusion preparation and blood transfusion itself are a burden on the healthcare system [1, 4, 12]. Turkey estimates the annual cost of blood transfusion at 100 million dollars. With the studies started in 2019 to improve blood management, the transfusion rate was reduced by 23.24% and the total cost by 15% [12, 13]. We came to the same conclusion again: we need to use audit-based methods to predict blood loss or do patient-specific blood management. This is because long hospital and intensive care stays put a lot of stress on the healthcare system, and blood preparation is not always necessary.

The limitations of our study are that it is retrospective and single-center and that our number of patients is small. Our choice of thoracotomy might be considered a limitation for the study, as minimally invasive surgical techniques are more common, but this also makes our study valuable. Our hospital is a tertiary hospital with a blood bank, so access to blood products is easy and fast. Our study gives the idea that surgeons should not overdo blood preparation when performing lobectomy and pneumonectomy with thoracotomy in similar hospitals.