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

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

Transfusion Guidelines Beforehand, RBC transfusion according to “Handbook of Blood Transfusion for doctors & nurses PYNEH nd Ed.” New RBC transfusion guideline was implemented from Jan 2001

Old Guidelines 1998New Guidelines 2001 Hct < 40% or Hb < 13 g/dl Oxygen or ventilator dependent Hct  40% Severe Respiratory Illness Ventilator/CPAP, MAP >8 cmH 2 O FiO 2 > 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 cmH 2 O FiO % Hct < 27% or Hb < 8 g/dl Asymptomatic Hct  30% Respiratory disease requiring FiO % / nasal cannula O2 1/8-1/4 L/min CPAP/IPPV, MAP <6 cmH 2 O Sustained tachycardia (>180/min) or tachypnoea (>80/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  20% Asymptomatic Blood loss of > 10% of blood volumeAcute blood loss with shock

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

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 < 1000 g BW 1001 – 1500 g Data collection as listed

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 O 2 Days 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

Data Collection Compliance Indication for transfusion Compliance Old guideline New guideline

Data Analysis Using SPSS 9.0 Chi-square tests for discrete variables Student’s t tests for group means Linear regression for prediction estimation of transfusion Differences considered significant at a p value of < 0.05

Results No. of premature infants included TotalTransfused% Before Sep 1998 – Dec After Jan 2001 – Aug

Baseline Characteristics BW (g)  – – 1500Total Number Gestation (wk)24 – 2927 – 3028 – 3024 – 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)

Baseline Characteristics BeforeAfterp Number288- Mean birth weight (g) Mean gestation age (wks) Mean Hct at birth (%) Ventilation days (d) O 2 days (d) IVH (  G 3) (%) BPD (%) ROP (  G 3) (%) Phlebotomy blood loss (ml) Length of hospital stay (d) Age attaining weight 2200 g (d)

Comparison of Transfusion Pattern Before & After New Guideline 2001 Mean no. of transfusion episodes/patient Mean vol. of transfusion (ml/kg)/patient Mean Donor no. /patient TotalNo. Trans- fused % Trans- fused Day 14DischargeDay 14Discharge Before After Reduct ion p

Compliance with New Transfusion Guidelines Before (1998 – 2000)After (2001) No. of Transfusion Episodes 8516 % Compliance with Guideline % Compliance with Guideline N/A Ordering of Transfusion % Pre MRCP % Post MRCP % FHKAM3.575 % 2 nd Round

Non-compliance Old guideline -4 episodes Pre-MRCP1 Post-MRCP1 FHKAM2 2 nd Round3 New guideline -1 episode FHKAM1 2 nd Round1

Transfusion & Phlebotomy Loss BW (g)  – – 1500 NICHD 2001* ( ) Total N No. of Transfusion/patient Mean (range) 4 (2 – 7)3 (1-7)2 (1-7) 1.1  (1-7) Transfused % with % with % with % with  Volume (ml/kg/patient) Mean (range) 80 (39 –177) 41 (15 – 95) 23 (14–53) 15  9 51 (14 –177) No. of Donor/patient3 (1- 4)2 (1 –3)2 (1 –4)- Phlebotomy loss  Day 14 (ml/kg/patient)  Phlebotomy loss > Day 14 (ml/kg/patient)

Transfusion Indications BW (g)  – – 1500 NICHD 2001 ( ) Number of Transfusion Episodes  Moderate ventilatory support % Ventilatory respiratory support % No ventilatory supp O 2 or CPAP % Increased O 2 support % Apnoea / Bradycardia % Asymptomatic % Old guideline – Hct < 0.40 % Old guideline – Hct < 0.35 % Old guideline – Hct < 0.27 % Non – compliance %

Blood Investigations Performed Before ( )After (2001) BW (g)  – 1500  – 1500 N Age (day)  14 > 14  14 > 14  14 > 14  14 > 14 CBP (n) Hct (n) RFT (n) LFT (n) ABG (n) Blood Culture (n) Phlebotomy loss (ml/kg)

Risk Factors for Total Volume of Transfusion R 2 = Risk FactorSignificance (p) Total Phlebotomy blood loss< Hct% at birth0.023 Ventilation Days0.025 Birth weight0.370 IVH0.712 BPD0.62 O 2 Days0.944

Discussion Compliance Generally is good Before Old Guideline95.3% New Guideline50.6% After Old GuidelineNA New Guideline93.8%

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

Discussion Reduction of Phlebotomy blood loss (ml/kg) Before  Day 14Day 15 - Discharge  After  Comparable to NICHD 2001

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

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

Comparison of Transfusion Guidelines Hct %PYNEH 1998 PYNEH 2001 NICHD 2001  Moderate ventilatory support  40  35 Ventilatory respiratory support  40  35  30 No ventilatory supp O 2 or CPAP  35  30  25 Increased O 2 support  35  30  25 Apnoea / Bradycardia  35  30  25 Asymptomatic  27  20

Thank you

Old guidelines 1998 Hct < 40% or Hb < 13 g/dl if oxygen or ventilator dependent Hct < 35% or Hb < 10 g/dl if symptomatic Hct < 27% or Hb < 8 g/dl if asymtomatic Blood loss of > 10% of blood volume New guidelines 2001 Hct  40%, severe respiratory illness Ventilator/CPAP, MAP >8 cmH 2 O FiO 2 > 50% Severe congenital heart disease with cyanosis/heart failure Hct  35% Ventilator/CPAP, MAP 6-8 cmH 2 O FiO % Hct  30% Respiratory disease requiring FiO % / nasal cannula O2 1/8-1/4 L/min CPAP/  IPPV, MAP <6 cmH 2 O Sustained tachycardia (>180/min) or tachypnoea (>80/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

Risk Factors for Volume of Transfusion  14 days

Risk Factors for Total Volume of Transfusion R 2 = Risk FactorBetaSignificance Total Phlebotomy blood loss0.633< Hct% at birth Ventilation Days Birth weight IVH BPD O 2 Days

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