Audit of RBC Transfusion

8/11/2019 Audit of RBC Transfusion

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Audit of RBC Transfusion

in Premature Infants 2001

Dr Ho Hing Tung (Paediatrics)

Dr Sherman Lee (Clinical Audit)

Dr Raymond Chu (Haematology)

Pamela Youde Nethersole Eastern Hospital


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Objectives To assess the compliance of RBC transfusion with new

guidelines 2001

To assess the effectiveness of new guidelines in reducingthe number of RBC transfusions in premature infants


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Transfusion Guidelines Beforehand, RBC transfusion according to Handbook of

Blood Transfusion for doctors & nurses PYNEH 1998 2nd

Ed. New RBC transfusion guideline was implemented from

Jan 2001


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Old Guidelines 1998 New Guidelines 2001

Hct < 40% or

Hb < 13 g/dl

Oxygen or

ventilator

dependent

Hct 40% Severe Respiratory Illness

Ventilator/CPAP, MAP >8 cmH2O

FiO2> 50%

Severe congenital heart disease

with cyanosis/heart failure

Hct < 35% or

Hb < 10 g/dl

Symptomatic Hct 35% Moderate Respiratory Illness

Ventilator/CPAP, MAP 6-8 cmH2O

FiO235-50%

Hct < 27% or

Hb < 8 g/dl

Asymptomatic Hct 30% Respiratory disease requiring FiO2

25-35% / nasal cannula O2 1/8-1/4 L/min

CPAP/IPPV, MAP 180/min) or

tachypnoea (>80/min) for 24 hours

Apnoea/bradycardia

10/24 hours or

2requiring bag mask ventilation

Cessation of weight gain x 4 days

Undergoing major surgery

Hct 20% Asymptomatic

Blood loss of > 10% of blood volume Acute blood loss with shock


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Method

Inclusion criteria:

Inborn baby with birth weight 1500 g

Date of birth from 1 Sep 1998 to 31 Aug 2001

Date of discharge from 1 Sep 1998 to 30 Oct 2001

Exclusion criteria: Babies not born in PYNEH

All perinatal & neonatal deaths before discharge

Infants required transfer out of hospital


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Method Data collectionRetrospective

All neonatal RBC transfusion episodes were

retrieved from blood bank Selection of cases according to inclusion & exclusion

criteria

Trace all old records

Subgroup

BW < 1000 g

BW 10011500 g

Data collection as listed


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Data Collection Demographic

Name

ID Sex

Gestation

Birth weight

DOB

DODay 14

DODischarge

Length of stay

Age attain 2.2 kg

Clinical

First Hct % at birth

Ventilation Days O2Days

BPD (36 wks PCA)

IVH (G 3)

ROP (G 3)

Total no./vol.

Transfusion at 2 weeks

& > 2 weeks to discharge

No. of donor exposure


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Data Collection Compliance

Indication for transfusion

Compliance Old guideline

New guideline


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Data Analysis Using SPSS 9.0

Chi-square tests for discrete variables

Students ttests for group means Linear regression for prediction estimation of transfusion

Differences considered significant at a pvalue of < 0.05


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Results

No. of premature infants included

Total Transfused %

Before

Sep 1998Dec 2000 45 28 62.2

After

Jan 2001Aug 2001 25 8 32.0


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Baseline CharacteristicsBW (g) 1000 10011250 12511500 Total

Number 12 14 10 36

Gestation (wk) 2429 2730 2830 2430

First Hct %

[mean(range)]

49

(40.760)

52.8

(4559)

53.8

(40.760.7)

51.8

(40.760.7)

Length of Hospital Stay

(d)

[mean(range)]

127

(74273)

87

(64159)

72

(46180)

100

(46273)

Age attaining weight

2.2 kg (d)

[mean(range)]

77

(3699)

63

(4780)

44

(3561)

64

(3599)


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Comparison of Transfusion Pattern Before &

After New Guideline 2001Mean no. of

transfusion

episodes/patient

Mean vol. of

transfusion

(ml/kg)/patient

Mean

Donor

no.

/patient

Total No.

Trans-

fused

%

Trans-

fused

Day 14 Discharge Day 14 Discharge

Before 45 28 62.2 1.3 3 23.8 55.9 2.1

After 25 8 32.0 0.4 1.4 9.0 32.8 1.6

Reduct

ion

- - 30.2 0.9 1.6 14.9 23.1 0.5

p 0.086 0.001 0.17 0.002 0.132


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Compliance with New Transfusion Guidelines

Before (19982000) After (2001)

No. of Transfusion

Episodes

85 16

% Compliance with

Guideline 2001

50.6 93.8

% Compliance with

Guideline 1998

95.3 N/A

Ordering of Transfusion

% Pre MRCP 15.3 12.5

% Post MRCP 81.2 12.5

% FHKAM 3.5 75

% 2ndRound 83.5 81.3


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Transfusion & Phlebotomy Loss

BW (g) 1000 1001

1250

1251

1500

NICHD

2001*

(1251-1500)

Total

N 16 21 31 59 68

No. of Transfusion/patient

Mean (range)

4 (27) 3 (1-7) 2 (1-7) 1.1 1.7 3 (1-7)

Transfused % with 0 25 33.3 67.7 95 47.1% with 1 0 28.6 19.4 3 17.6

% with 2 31.3 9.5 6.5 2 13.2

% with 3 43.8 28.6 6.5 0 22.1

Volume (ml/kg/patient)

Mean (range)

80

(39177)

41

(1595)

23

(1453)

15 9 51

(14177)

No. of Donor/patient 3 (1- 4) 2 (13) 2 (1 4) - 2 (14)

Phlebotomy loss Day 14

(ml/kg/patient)

39 23 19 26 15 28

Phlebotomy loss > Day 14(ml/kg/patient)

38 20 11 25


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Transfusion IndicationsBW (g) 1000 1001

1250

1251

1500

NICHD

2001

(1251-1500)

Number of Transfusion Episodes 50 37 14 59

Moderate ventilatory support % 32 13.5 14.3 24.2

Ventilatory respiratory support % 0 10.8 0 22.6

No ventilatory supp O2or CPAP % 14 8.1 0 1.6

Increased O2support % 2 8.1 0 14.5

Apnoea / Bradycardia % 16 13.5 21.4 6.5

Asymptomatic % 0 0 7.1 0

Old guidelineHct < 0.40 % 20 5.4 21.4 -



Noncompliance % 4 2.7 7.1 29.0


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Blood Investigations Performed

Before (1998-2000) After (2001)

BW (g) 1000 1000 1001

1500

1001

1500

1000 1000 1001

1500

1001

1500

N 10 10 18 18 2 2 6 6

Age (day) 14 > 14 14 > 14 14 > 14 14 > 14

CBP (n) 3.8 9.5 4.4 9.6 3.3 7 2.7 3.3

Hct (n) 14.6 9.1 7.4 2.6 9.3 7.7 5.3 3.2

RFT (n) 16.1 18.9 14.7 10.9 9 12.3 8.3 5.7

LFT (n) 2.7 9.3 2.7 6.4 2.7 7.7 1.9 4.1

ABG (n) 45.1 24.5 33.8 12.4 18.3 6.3 19.4 4.1

Blood

Culture (n)

1.8 1.4 1.3 0.7 1.7 2.3 1.4 0.3

Phlebotomy

loss (ml/kg)

41.5 41.1 22.9 18.2 23.6 21.5 16.8 11.9


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Risk Factors for Total Volume of Transfusion

R2= 0.870

Risk Factor Significance (p)

Total Phlebotomy blood loss < 0.001

Hct% at birth 0.023

Ventilation Days 0.025

Birth weight 0.370

IVH 0.712

BPD 0.62

O2Days 0.944


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Discussion

Compliance

Generally is good

Before Old Guideline 95.3%

New Guideline 50.6%

After

Old Guideline NA New Guideline 93.8%


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Discussion

Reduction of RBC Transfusion

Before 62.2%

After 32%

Reduction of transfusion may due to More conservative new guideline

Decreased phlebotomy blood loss

Infants were less ill

RBC transfusion rate still higher if comparing withNational Institute of Child Health and Human

Development (NICHD) 2001


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Discussion

Reduction of Phlebotomy blood loss (ml/kg)

Before Day 14 Day 15 - Discharge

1000 41.5 41.1 1001-1500 22.9 18.2

After

1000 23.6 25.1

1001-1500 16.8 11.9 Comparable to NICHD 2001


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Discussion Implementation of new guidelines can largely reduce the

number of blood transfusions in premature infants

Reduction of phlebotomy loss contribute significantly to

reduction in transfusion requirements

Morbidities (BPD, ROP), length of stay & age to attain

weight 2.2 kg (growth) were not significantly different

with the implementation of new guideline

Although our phlebotomy blood loss is comparable to

NICHD, our transfusion rate is still higher

The total volume of transfusion was largely accounted by

phlebotomy blood loss & ventilation days


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Discussion

Speculationwith modification of guideline, limiting

blood loss & use of micro-methods (POCT), non-invasivelaboratory monitoring, further more conservative

transfusion approach may be adopted

? Use of Erythropoietin for preterm infants in PYNEH


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Comparison of Transfusion Guidelines

Hct % PYNEH

1998

PYNEH

2001

NICHD

2001

Moderate ventilatory support 40 40 35

Ventilatory respiratory support 40 35 30

No ventilatory supp O2or CPAP 35 30 25

Increased O2support 35 30 25

Apnoea / Bradycardia 35 30 25

Asymptomatic 27 20 20


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Thank you


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Old guidelines 1998

Hct < 40% or Hb < 13 g/dl

if oxygen or ventilator

dependent


if symptomatic


if asymtomatic

Blood loss of > 10% of blood

volume

New guidelines 2001

Hct 40%, severe respiratory illness

Ventilator/CPAP, MAP >8 cmH2O

FiO2> 50%

Severe congenital heart disease with

cyanosis/heart failure

Hct 35%

Ventilator/CPAP, MAP 6-8 cmH2O

FiO235-50%

Hct 30% Respiratory disease requiring FiO225-

35% / nasal cannula O2 1/8-1/4 L/min

CPAP/ IPPV, MAP 180/min) or

tachypnoea (>80/min) for 24 hours

Apnoea/bradycardia10/24 hours or 2requiring bag mask ventilation

Cessation of wt gain x 4 days

Undergoing major surgery

Hct 20% asymptomic

Acute blood loss with shock


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Risk Factors for Volume of Transfusion 14 days

Coefficientsa

29.815 57.393 .519 .608

.404 .750 .207 .538 .595

2.571E-03 .032 .025 .081 .936

-.424 .770 -.108 -.550 .587

8.118E-02 6.667 .003 .012 .990

8.099 13.470 .161 .601 .552

7.926E-03 .580 .005 .014 .989

-.130 .207 -.136 -.629 .534

(Constant)

GTOTAL/KG


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Risk Factors for Total Volume of Transfusion

R2= 0.870

Risk Factor Beta Significance

Total Phlebotomy blood loss 0.633 < 0.001

Hct% at birth - 0.219 0.023

Ventilation Days 0.263 0.025

Birth weight 0.891 0.370

IVH 0.292 0.712

BPD 0.079 0.62

O2Days 0.608 0.944


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Discussion Implementation of new guidelines can largely reduce the

number of blood transfusions in premature infants

Reduction of phlebotomy loss contribute significantly toreduction in transfusion requirements

Morbidities (CLD, ROP), length of stay & age to attainweight 2200 g (growth) were not significantly differentwith the implementation of new guideline

Although our phlebotomy blood loss is comparable toNICHD, our transfusion rate is still higher

The total volume of transfusion was largely accounted byphlebotomy blood loss & ventilation days

The inverse relationship between Hct% at birth and totalvolume of transfusion need further analysis

Audit of RBC Transfusion

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