Audit of RBC Transfusion in Premature Infants 2001

1
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

2
Objectives

• To assess the compliance of RBC transfusion with
  new guidelines 2001
• To assess the effectiveness of new guidelines in
  reducing the number of RBC transfusions in
  premature infants

3
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

4
Old Guidelines 1998 Old Guidelines 1998 New Guidelines 2001 New Guidelines 2001
Hct lt 40 or Hb lt 13 g/dl Oxygen or ventilator dependent Hct ? 40 Severe Respiratory Illness Ventilator/CPAP, MAP gt8 cmH2O FiO2 gt 50 Severe congenital heart disease with cyanosis/heart failure
Hct lt 35 or Hb lt 10 g/dl Symptomatic Hct ? 35 Moderate Respiratory Illness Ventilator/CPAP, MAP 6-8 cmH2O FiO2 35-50
Hct lt 27 or Hb lt 8 g/dl Asymptomatic Hct ? 30 Respiratory disease requiring FiO2 25-35 / nasal cannula O2 1/8-1/4 L/min CPAP/IPPV, MAP lt6 cmH2O Sustained tachycardia (gt180/min) or tachypnoea (gt80/min) for 24 hours Apnoea/bradycardia ?10/24 hours or ?2 requiring bag mask ventilation Cessation of weight gain x 4 days Undergoing major surgery
Hct lt 27 or Hb lt 8 g/dl Asymptomatic Hct ? 20 Asymptomatic
Blood loss of gt 10 of blood volume Blood loss of gt 10 of blood volume Acute blood loss with shock Acute blood loss with shock
5
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

6
Method

• Data collection Retrospective
• All neonatal RBC transfusion episodes were
  retrieved from blood bank
• Selection of cases according to inclusion
  exclusion criteria
• Trace all old records
• Subgroup
• BW lt 1000 g
• BW 1001 1500 g
• Data collection as listed

7
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
• O2 Days
• BPD (36 wks PCA)
• IVH (? G 3)
• ROP (? G 3)
• Total no./vol. Transfusion at ? 2 weeks gt 2
  weeks to discharge
• No. of donor exposure

8
Data Collection

• Compliance
• Indication for transfusion
• Compliance
• Old guideline
• New guideline

9
Data Analysis

• Using SPSS 9.0
• Chi-square tests for discrete variables
• Students t tests for group means
• Linear regression for prediction estimation of
  transfusion
• Differences considered significant at a p value
  of lt 0.05

10
Results

• No. of premature infants included
• Total Transfused
• Before
• Sep 1998 Dec 2000 45 28 62.2
• After
• Jan 2001 Aug 2001 25 8 32.0

11
Baseline Characteristics
BW (g) ? 1000 1001 1250 1251 1500 Total
Number 12 14 10 36
Gestation (wk) 24 29 27 30 28 30 24 30
First Hct mean(range) 49 (40.7 60) 52.8 (45 59) 53.8 (40.7 60.7) 51.8 (40.7 60.7)
Length of Hospital Stay (d) mean(range) 127 (74 273) 87 (64 159) 72 (46 180) 100 (46 273)
Age attaining weight 2.2 kg (d) mean(range) 77 (36 99) 63 (47 80) 44 (35 61) 64 (35 99)
12
Baseline Characteristics
Before After p
Number 28 8 -
Mean birth weight (g) 1090 1135 0.645
Mean gestation age (wks) 27.8 28.5 0.288
Mean Hct at birth () 52.3 48.7 0.151
Ventilation days (d) 14.0 3.9 0.007
O2 days (d) 32.7 32.0 0.949
IVH (? G 3) () 3.6 0 0.778
BPD () 39.3 37.5 0.631
ROP (? G 3) () 10.7 0 0.459
Phlebotomy blood loss (ml) 55.9 32.8 0.002
Length of hospital stay (d) 99.6 84.4 0.463
Age attaining weight 2200 g (d) 63.1 59.6 0.629
13
Comparison of Transfusion Pattern Before After
New Guideline 2001
Mean no. of transfusion episodes/patient Mean no. of transfusion episodes/patient Mean vol. of transfusion (ml/kg)/patient Mean vol. of transfusion (ml/kg)/patient Mean Donor no. /patient
Total No. Trans-fused Trans-fused Day 14 Discharge Day 14 Discharge Mean Donor no. /patient
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
Reduction - - 30.2 0.9 1.6 14.9 23.1 0.5
p 0.086 0.001 0.17 0.002 0.132
14
Compliance with New Transfusion Guidelines
Before (1998 2000) 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 Ordering of Transfusion Ordering of Transfusion
Pre MRCP 15.3 12.5
Post MRCP 81.2 12.5
FHKAM 3.5 75
2nd Round 83.5 81.3
15
Non-compliance

• Old guideline - 4 episodes
• Pre-MRCP 1
• Post-MRCP 1
• FHKAM 2
• 2nd Round 3
• New guideline - 1 episode
• FHKAM 1
• 2nd Round 1

16
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 (2 7) 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 (39 177) 41 (15 95) 23 (1453) 15 ? 9 51 (14 177)
No. of Donor/patient 3 (1- 4) 2 (1 3) 2 (1 4) - 2 (1 4)
Phlebotomy loss ? Day 14 (ml/kg/patient) 39 23 19 26 ? 15 28
Phlebotomy loss gt Day 14 (ml/kg/patient) 38 20 11 26 ? 15 25
17
Transfusion Indications
BW (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 O2 or CPAP 14 8.1 0 1.6
Increased O2 support 2 8.1 0 14.5
Apnoea / Bradycardia 16 13.5 21.4 6.5
Asymptomatic 0 0 7.1 0
Old guideline Hct lt 0.40 20 5.4 21.4 -
Old guideline Hct lt 0.35 12 32.4 7.1 -
Old guideline Hct lt 0.27 0 5.4 21.4 -
Non compliance 4 2.7 7.1 29.0
18
Blood Investigations Performed
Before (1998-2000) Before (1998-2000) Before (1998-2000) Before (1998-2000) After (2001) After (2001) After (2001) 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 gt 14 ? 14 gt 14 ? 14 gt 14 ? 14 gt 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
19
Risk Factors for Total Volume of
Transfusion R2 0.870
Risk Factor Significance (p)
Total Phlebotomy blood loss lt 0.001
Hct at birth 0.023
Ventilation Days 0.025
Birth weight 0.370
IVH 0.712
BPD 0.62
O2 Days 0.944
20
Discussion

• Compliance
• Generally is good
• Before
• Old Guideline 95.3
• New Guideline 50.6
• After
• Old Guideline NA
• New Guideline 93.8

21
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
  with National Institute of Child Health and Human
  Development (NICHD) 2001

22
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

23
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

24
Discussion

• Speculation with modification of guideline,
  limiting blood loss use of micro-methods
  (POCT), non-invasive laboratory monitoring,
  further more conservative transfusion approach
  may be adopted
• ? Use of Erythropoietin for preterm infants in
  PYNEH

25
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 O2 or CPAP ? 35 ? 30 ? 25
Increased O2 support ? 35 ? 30 ? 25
Apnoea / Bradycardia ? 35 ? 30 ? 25
Asymptomatic ? 27 ? 20 ? 20
26
Thank you
27

• Old guidelines 1998
• Hct lt 40 or Hb lt 13 g/dl
• if oxygen or ventilator dependent
• Hct lt 35 or Hb lt 10 g/dl
• if symptomatic
• Hct lt 27 or Hb lt 8 g/dl
• if asymtomatic
• Blood loss of gt 10 of blood volume

• New guidelines 2001
• Hct ? 40, severe respiratory illness
• Ventilator/CPAP, MAP gt8 cmH2O
• FiO2 gt 50
• Severe congenital heart disease with
  cyanosis/heart failure
• Hct ? 35
• Ventilator/CPAP, MAP 6-8 cmH2O
• FiO2 35-50
• Hct ? 30
• Respiratory disease requiring FiO2 25-35 / nasal
  cannula O2 1/8-1/4 L/min
• CPAP/ ? IPPV, MAP lt6 cmH2O
• Sustained tachycardia (gt180/min) or tachypnoea
  (gt80/min) for 24 hours
• Apnoea/bradycardia ?10/24 hours or ?2 requiring
  bag mask ventilation
• Cessation of wt gain x 4 days
• Undergoing major surgery
• Hct ? 20 asymptomic
• Acute blood loss with shock

28
Risk Factors for Volume of Transfusion ? 14 days
29
Risk Factors for Total Volume of
Transfusion R2 0.870
Risk Factor Beta Significance
Total Phlebotomy blood loss 0.633 lt 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
O2 Days 0.608 0.944
30
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 (CLD, ROP), length of stay age to
  attain weight 2200 g (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
• The inverse relationship between Hct at birth
  and total volume of transfusion need further
  analysis