Article

Reduction in Red Blood Cell Transfusions Using a Bedside Analyzer in Extremely Low Birth Weight Infants

Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
Journal of Perinatology (Impact Factor: 2.07). 02/2005; 25(1):21-5. DOI: 10.1038/sj.jp.7211201
Source: PubMed
ABSTRACT
Preterm infants typically experience heavy phlebotomy losses from frequent laboratory testing in the first few weeks of life. This results in anemia, requiring red blood cell (RBC) transfusions. We recently introduced a bedside point-of-care (POC) blood gas analyzer (iSTAT, Princeton, NJ) that requires a smaller volume of blood to replace conventional Radiometer blood gas and electrolyte analysis used by our neonatal intensive care unit (NICU). The smaller volume of blood required for sampling (100 vs 300-500 microl), provided an opportunity to assess if a decrease in phlebotomy loss occurred and, if so, to determine if this resulted in decreased transfusions administered to extremely low birth weight (ELBW) infants.
We hypothesized that the use of the POC iSTAT analyzer that measures pH, PCO(2), PO(2), hemoglobin, hematocrit, serum sodium, serum potassium and ionized calcium would result in a significant decrease in the number and volume of RBC transfusions in the first 2 weeks of life.
A retrospective chart review was conducted of all inborn premature infants with birth weights less than 1000 g admitted to the NICU that survived for 2 weeks of age during two separate 1-year periods. Blood gas analysis was performed by conventional laboratory methods during the first period (designated Pre-POC testing) and by the iSTAT POC device during the second period (designated post-POC testing). Data collected for individual infants included the number of RBC transfusions, volume of RBCs transfused, and the number and kind of blood testing done. There was no effort to change either the RBC transfusion criteria applied or blood testing practices.
The mean (+/-SD) number of RBC transfusions administered in the first 2 weeks after birth was 5.7+/-3.74 (n=46) in the pre-POC testing period to 3.1+/-2.07 (n=34) in the post-POC testing period (p<0.001), a 46% reduction. The mean volume of RBC transfusions decreased by 43% with use of the POC analyzer, that is, from 78.4+/-51.6 ml/kg in the pre-POC testing group to 44.4+/-32.9 ml/kg in the Post-POC testing group (p<0.002). There was no difference between the two periods in the total number of laboratory blood tests done.
Use of a bedside blood gas analyzer is associated with clinically important reductions in RBC transfusions in the ELBW infant during the first two weeks of life.

Full-text

Available from: John A Widness, Aug 19, 2014
Original Article
Reduction in Red Blood Cell Transfusions Using a Bedside
Analyzer in Extremely Low Birth Weight Infants
Ashima Madan, MD
Rahi Kumar
Marian M. Adams, MD
William E. Benitz, MD
Sharon M. Geaghan, MD
John A. Widness, MD
BACKGROUND:
Preterm infants typically experience heavy phlebotomy losses from frequent
laboratory testing in the first few weeks of life. This results in anemia,
requiring red blood cell (RBC) transfusions. We recently introduced a
bedside point-of-care (POC) blood gas analyzer (iSTAT, Princeton, NJ) that
requires a smaller volume of blood to replace conventional Radiometer
blood gas and electrolyte analysis used by our neonatal intensive care unit
(NICU). The smaller volume of blood required for sampling (100 vs 300
500 ml), provided an opportunity to assess if a decrease in phlebotomy loss
occurred and, if so, to determine if this resulted in decreased transfusions
administered to extremely low birth weight (ELBW) infants.
OBJECTIVE:
We hypothesized that the use of the POC iSTAT analyzer that measures
pH, PCO
2
,PO
2
, hemoglobin, hematocrit, serum sodium, serum potassium
and ionized calcium would result in a significant decrease in the number
and volume of RBC transfusions in the first 2 weeks of life.
DESIGN/METHODS:
A retrospective chart review was conducted of all inborn premature infants
with birth weights less than 1000 g admitted to the NICU that survived for 2
weeks of age during two separate 1-year periods. Blood gas analysis was
performed by conventional laboratory methods during the first period
(designated Pre-POC testing) and by the iSTAT POC device during the second
period (designated post-POC testing). Data collected for individual infants
included the number of RBC transfusions, volume of RBCs transfused, and
the number and kind of blood testing done. There was no effort to change
either the RBC transfusion criteria applied or blood testing practices.
RESULTS:
The mean (±SD) number of RBC transfusions administered in the first 2
weeks after birth was 5.7±3.74 (n ¼ 46) in the pre-POC testing period to
3.1±2.07 (n ¼ 34) in the post-POC testing period (p<0.001), a 46%
reduction. The mean volume of RBC transfusions decreased by 43% with
use of the POC analyzer, that is, from 78.4±51.6 ml/kg in the pre-POC
testing group to 44.4±32.9 ml/kg in the Post-POC testing group
(p<0.002). There was no difference between the two periods in the total
number of laboratory blood tests done.
CONCLUSIONS:
Use of a bedside blood gas analyzer is associated with clinically important
reductions in RBC transfusions in the ELBW infant during the first two
weeks of life.
Journal of Perinatology (2005) 25, 2125. doi:10.1038/sj.jp.7211201
Published online 7 October 2004
INTRODUCTION
During the early weeks after birth, preterm infants commonly
receive multiple red blood cell (RBC) transfusions to treat anemia.
It is estimated that over 80% of infants with a birth weight
r1500 g will receive one or more blood transfusions.
1
Half of the
transfusions that these infants receive during their hospitalization
occur during the first 2 weeks of life.
2
Intensive laboratory testing
leading to phlebotomy losses during this period is one of the main
causes for the anemia.
3–5
In addition, phlebotomy ‘‘overdraw’’ in
excess of that needed by the laboratory is a common occurrence in
preterm infants.
6
The typical weekly phlebotomy loss for a preterm
infant during this period averages 15 to 30% of their total blood
volume in extremely low birth weight (ELBW) infants with birth
weights <1000 g, and nearly the same volume transfused in
compensation.
2
RBC transfusions have the risk of incompatibility
and transfusion reactions as well as viral infections.
7,8
In addition,
RBC administration is costly and adds to parental anxiety.
Therapeutic strategies aimed at reducing transfusions have
evaluated the use of strict RBC transfusion guidelines and
erythropoietin therapy, but reduction of phlebotomy loss is
paramount.
For ELBW infants, laboratory blood testing using bedside devices
offers a unique opportunity to reduce RBC transfusions. This
practice has been referred to as ‘‘near-patient testing’’ or point-of-
care testing (POC).
9
Recent technologic innovations in the design
Address correspondence and reprint requests to: Ashima Madan, MD, Division of Neonatology,
Stanford University School of Medicine, 750 Welch Road, #315, Palo Alto, CA 94304, USA.
Department of Pediatrics (A.M., M.M.A., W.E.B.), Stanford University School of Medicine, Stanford,
CA, USA; Stanford University (R.K.), Stanford, CA, USA; Department of Pathology (S.M.G.),
Stanford University School of Medicine, Stanford, CA, USA; and Department of Pediatrics (J.A.W.)
College of Medicine, University of Iowa, Iowa City, IA, USA
Journal of Perinatology 2005; 25:2125
r
2005 Nature Publishing Group All rights reserved. 0743-8346/05 $30
www.nature.com/jp 21
Page 1
and fabrication of biosensors and microprocessors have led to the
development of small, highly accurate bedside devices with rapid
analytic turnaround time, minimal specimen volumes, and low
pre-analytic error.
2,1013
Use of these devices to measure the most
commonly ordered blood tests could significantly decrease
phlebotomy loss and lead to a reduction in the need for RBC
transfusions among critically ill premature neonates.
1416
In a
prior study, Alves-Dunkerson et al.
14
estimated that arterial blood
drawn for blood gases and electrolytes accounts for 50 to 74% of
laboratory phlebotomy loss in VLBW infants in the first weeks
of life.
The introduction of one such device, the bedside point-of-care
(POC) analyzer (iSTAT Corp, Princeton, NJ) for blood gas analysis
in our neonatal intensive care unit (NICU) during the latter half of
2001, provided us with an opportunity to determine if use of the
device resulted in a clinically significant reduction in RBC
transfusions in ELBW infants. The iSTAT has been shown to be a
reliable alternative to traditional blood gas analyzers in the
neonatal population.
12
The iSTAT measures pH, PCO
2
,PO
2
,
hemoglobin, hematocrit, serum sodium, serum potassium and
ionized calcium on 100 ml of blood. Prior to the change to the use
of the iSTAT, our laboratory required 300 to 500 ml of blood for a
blood gas and electrolytes, 500 ml for a complete blood count or
hematocrit, 400 ml for serum electrolytes, 1000 ml for a panel of
electrolytes and four additional chemistry analytes (Chemistry 8),
and 1500 ml for a panel of 23 chemistry analytes that included
electrolytes (Chemistry 23). Based on the decreased blood volume
required for laboratory testing with the iSTAT, we hypothesized that
there would be a significant reduction in the number and volume
of RBC transfusions to ELBW infants during the first 2 weeks after
birth.
METHODS
Study Population
A retrospective chart review was conducted of all inborn infants
<1000 g admitted to the NICU that survived past 2 weeks of age
during two separate years (1998 and 2002). Erythropoietin was not
used during the study period.
Clinical and Laboratory Practices
Conventional bench top laboratory analysis during the first year
(designated pre-POC testing) was done using the Radiometer Blood
Gas and Electrolyte Analyzer (Model ABL 505, Radiometer America,
Inc., Westlake, OH). Bedside blood gas analysis during the second
year (designated post-POC testing) was performed using a point-of-
care analyzer (iSTAT, Princeton, NJ). During and between both
study periods, no uniform effort was made to modify clinical or
laboratory phlebotomy practices relative to the indications for, the
frequency of, or the procedure for laboratory blood testing. In
addition, RBC transfusion criteria and blood banking procedures
remained unchanged during the same period. The former criteria
were based on clinically significant acute blood loss; a hematocrit
(Hct) <35 in infants with an oxygen requirement, apnea,
tachypnea (respiratory rate >70/minute), or tachycardia (heart
rate >170/minute); a Hct r40% in infants with pulmonary or
cardiac disease; and a Hct <50% in infants with severe respiratory
failure. The volume of RBCs transfused was 15 ml/kg with the
mean hematocrit of the transfused blood varying between 55
and 60%.
Data Collection
Data collected by a retrospective chart review included the number
of transfusions and the volume of RBCs transfused during the first
2 weeks after birth. The iSTAT analyzer measures pH, PCO
2
,PO
2
,
hemoglobin, hematocrit, serum sodium, serum potassium and
ionized calcium on 100 ml of blood. Since this was a retrospective
study, we were unable to determine the exact volume of
phlebotomy losses associated with laboratory blood draw.
Nonetheless, an estimate of phlebotomy loss in the two groups was
derived based on the number of specific blood tests on individual
infants performed during each study period.
Statistical Methods
Data were compared using the MannWhitney test. A p-value
<0.05 was considered statistically significant.
RESULTS
Data were available in 46 of 55 inborn infants admitted to the
NICU in the pre-POC testing group and in all of the 34 infants in
the post-POC testing group. There were no differences between
study infants born during the two periods with respect to birth
weight, gestational age, race or pretransfusion hematocrit (Table 1).
There was no difference in total laboratory blood tests performed
on each infant between the two study periods (Table 1). Similarly
there was no difference between the groups with respect to either
the number of blood gas or complete blood count analyses
performed. A greater number of electrolyte tests and Chemistry 8
analyses were performed by the Radiometer in the pre-POC group.
However, a greater number of Chemistry 23 analyses were
performed in the post-POC group (Table 1).
The approximate volume of blood removed per infant during
the two study periods was estimated by multiplying the number of
tests performed by the volume of blood required to perform the
individual blood tests. Assuming the pre- and post-iSTAT volumes
of blood required for blood gas analysis were 400 and 200 ml
respectively, there was an estimated 30% reduction in the total
volume of blood removed for the blood tests listed in Table 1.
The mean number of RBC transfusions from day 0 to 14 was
5.7±3.74 in the pre-POC testing group and 3.1±2.07 in the post-
POC testing group (p<0.001), a 46% reduction (Figure 1). A
Madan et al. Bedside Analyzer Reduces Transfusions in ELBW Infants
22 Journal of Perinatology 2005; 25:2125
Page 2
statistically significant reduction in transfusions was also noted for
days 0 to 6 (3.5±2.02 v 1.8±1.26, p<0.001) and for days 7 to 13
(2.2±2.08 vs 1±1, p<0.01). Mean volume of RBC transfusions
administered was 78.4±51.6 ml/kg in the pre-POC testing group
and 44.4±32.9 ml/kg in the post-POC testing group (p<0.001), a
43% reduction (Figure 2). Statistically significant reductions in the
mean volume of RBC transfusions were also noted for days 0 to 6
(46±32 vs 25±22 ml/kg, p<0.001) and for days 7 to 13 (32±29
vs 19±18 ml/kg, p<0.02).
DISCUSSION
Anemia in the extremely low birth weight infant continues to be a
problem necessitating frequent blood transfusions. A majority of
these transfusions occur in the first 2 weeks after birth.
2
Avoiding
unnecessary blood transfusions and their associated complications
remains an important clinical goal. Although there are several
causes for anemia in premature infants, the most important
continues to be excessive phlebotomy losses necessitated by the
need to maintain adequate oxygenation and cardiopulmonary
stability.
1722
Several prior studies have shown that transfusions in
the ELBW infant can be decreased by delayed cord clamping at
delivery,
23,24
autologous placental blood transfusion,
25,26
decreased
phlebotomy losses by reducing laboratory testing,
27
introduction of
more conservative transfusion guidelines
21,28,29
and the use of
erythropoietin.
30
Table 1 Characteristics of Infants by Study Group
Pre-POC testing
(n ¼ 46)
Post-POC testing
(n ¼ 34)
Characteristics
Race
White 21 14
Black 4 1
Hispanic 14 11
Asian 6 8
Unknown 1 0
Birth weight (%)
r750 g 20 (43) 12 (35)
7511000 g 26 (57) 22 (65)
Gestational age (week)
Mean±SD 26±2.2 27±2
Male (%) 24 (52) 12 (53)
Pretransfusion Hct (%) 36.3±4.3 34.5±4.9
n ¼ 257 n ¼ 74
Blood gases 58±37 50±31
n ¼ 46 n ¼ 31
Complete blood count 15±7 13±4
n ¼ 44 n ¼ 32
Serum electrolytes* 3.4±4 1.6±2.6
n ¼ 44 n ¼ 33
Chemistry 8* 15.5±5.6 12.4±3.6
n ¼ 44 n ¼ 33
Chemistry 23* 2.1±1.2 3.9±2.6
n ¼ 44 n ¼ 32
All blood tests 94±47 81±33
n ¼ 44 n ¼ 32
*Mean±SD.
p<0.05.
CBC: complete blood count, Hct: hematocrit, POC: point-of-care.
Figure 1. Number of RBC transfusions in the pre-POC testing and
post-POC testing groups. The mean (±SD) of RBC transfusions that
were given to infants in the pre-POC testing (pre-POC) and post-POC
testing groups from day 0 to 6, day 7 to 13 and day 0 to 14 is shown.
Figure 2. Volume of RBC transfusions in the pre-POC testing and
post-POC testing groups. The mean (±SD) ml/kg of RBC transfusions
that were given to infants in the pre-POC testing (pre-POC) and post-
POC testing groups from day 0 to 6, day 7 to 13 and day 0 to 14 is
shown.
Bedside Analyzer Reduces Transfusions in ELBW Infants Madan et al.
Journal of Perinatology 2005; 25:2125 23
Page 3
Since phlebotomy loss from laboratory testing is the major
cause of anemia in the first 2 weeks after birth, a reduction in
these losses should result in a decrease in blood transfusions. The
availability of newer bedside POC devices that require smaller
volumes for blood gas and electrolyte analysis with rapid turn
around times provides the opportunity to decrease blood loss from
phlebotomy and potentially decrease transfusions.
During the first 2 weeks of life, we found a statistically and
clinically significant reduction in both the number of transfusions
and the volume of blood transfused following the introduction of
the iSTAT in the NICU. Although limited by a lack of direct
measurement of phlebotomy blood loss and no comparison of
severity of illness between two groups, the results of this
retrospective study strongly support the role of laboratory
phlebotomy loss as the primary cause of anemia leading to RBC
transfusion in the early weeks of life. Introduction of the iSTAT in
the post-POC period led to a decrease in the number of tests that
were sent to the laboratory. An estimate of the total phlebotomy
volumes based on the total number of almost all tests in both
groups showed a decrease of approximately 30% in the post-POC
group F a value that is close to the 43% reduction in RBC
transfusions. As shown in a previous study, it is possible that in
order to avoid redrawing a sample because of an insufficient
volume for analysis, the amount of blood drawn by the bedside
nurse or phlebotomist for a test sent to the laboratory was slightly
in excess of that requested.
6
Other studies have estimated additional
blood losses on to gauze and bedding at the time of drawing to be
about 10%.
31
It is also possible that extra care was instituted by the
bedside nurse to avoid drawing more than the exact amount of
blood required when performing the test with the iSTAT at the
bedside.
Other reported causes for a decrease in transfusions include the
use of erythropoietin
30
and more restrictive transfusion
guidelines.
21,28,29
In the present study, erythropoietin was not used
in the first 2 weeks of life. Although transfusion guidelines were
consistent throughout both study periods, transfusion was left to
the discretion of the attending physician and it was possible that
our NICU’s transfusion guidelines were always strictly followed. The
mean pretransfusion hematocrit was similar during both periods.
Thus, the decrease in transfusions seen in the post-POC testing
group was unlikely to be secondary to a higher threshold for
transfusing these infants.
Another possible explanation for the difference between the two
groups would be if there were a larger number of smaller and
sicker infants in the pre-POC testing group.
17
As shown in Table 1,
although there was a slightly higher percentage of infants with a
birth weight %750 g and a higher percentage of male infants in
the pre-POC testing group, these results were not statistically
significant.
In summary, the results of this study suggest that use of newer,
bedside devices can help reduce blood transfusions. Since the use of
the iSTAT unlike other in-line POC devices
914,32
does not require
the presence of an arterial catheter, it can potentially contribute
towards reducing phlebotomy losses and blood transfusions
throughout the infant’s hospital stay.
Acknowledgements
We acknowledge the technical assistance and data collection contributions of
Karen J. Johnson, RN from the University of Iowa and Teresa Newton, Bethany
Ball and the staff in Medical Records and the Blood Bank at Stanford University.
This work was presented in part at the Society for Pediatric Research Meeting in
May 2004 in San Francisco. This study was supported in part by funding provided
by the NIH General Clinical Research Centers Program (Grant RR00059).
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Bedside Analyzer Reduces Transfusions in ELBW Infants Madan et al.
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Page 5
  • Source
    • "Mahieu et al [8] (n=1397) found significant decreases in the number of transfusions per infant (2.53 versus 1.57), in the proportion of infants who required a transfusion and in phlebotomy losses, after a pointof-care analyzer (electrolytes, gas, hemoglobin, bilirubin) had been introduced in the NICU, despite steady numbers for the tests being performed. Madan et al [11] (n=80) also found a decrease in the number of transfusions and phlebotomy losses per infant. Point-of-care testing should be considered in preterm infants. "
    [Show abstract] [Hide abstract] ABSTRACT: Reducing blood loss and the need for blood transfusions in extremely preterm infants is part of effective care. Delayed cord clamping is well supported by the evidence and is recommended for infants who do not immediately require resuscitation. Cord milking may be an alternative to delayed cord clamping; however, more research is needed to support its use. In view of concerns regarding the increased risk for cognitive delay, clinicians should avoid using hemoglobin transfusion thresholds lower than those tested in clinical trials. Higher transfusion volumes (15 mL/kg to 20 mL/kg) may decrease exposure to multiple donors. Erythropoietin is not recommended for routine use due to concerns about retinopathy of prematurity. Elemental iron supplementation (2 mg/kg/day to 3 mg/kg/day once full oral feeds are achieved) is recommended to prevent later iron deficiency anemia. Noninvasive monitoring (eg, for carbon dioxide, bilirubin) and point-of-care testing reduce the need for blood sampling. Clinicians should strive to order the minimal amount of blood sampling required for safe patient care, and cluster samplings to avoid unnecessary skin breaks.
    Full-text · Article · Jan 2016 · Paediatrics & Child Health
  • Source
    • "The iSTAT measures pH, pCO2, hemoglobin, hematocrit, Na+, K+ and Ca2+. The implementation of this device resulted in a 30% decrease in total number of phlebotomies and a 43% decrease in transfusions in a group of 2-week-old neonates [15]. The POC system has gained popularity in many fields and this has led to a wide range of analyzers developed to measure different values of markers , electrolytes and other substances in the blood, and even more are being developed as the trend in countries like the USA shows an increase in the use of bedside point of care testing (POCT) [16]. "
    [Show abstract] [Hide abstract] ABSTRACT: Iatrogenic anemia caused by diagnostic blood sampling is a common problem in the intensive care unit, where continuous monitoring of blood parameters is very often required. Cumulative blood loss associated with phlebotomy along with other factors render this group of patients particularly susceptible to anemia. As it has been proven that anemia in this group of patients leads to inferior outcomes, packed red blood cell transfusions are used to alleviate possible threats associated with low hemoglobin concentration. However, the use of blood components is a procedure conferring a set of risks to the patients despite improvements in safety. Iatrogenic blood loss has also gained particular attention in neonatal care, where cumulative blood loss due to samples taken during the first week of life could easily equal or exceed circulating blood volume. This review summarizes the current knowledge on the causes of iatrogenic anemia and discusses the most common preventive measures taken to reduce diagnostic blood loss and the requirement for blood component transfusions in the aforementioned clinical situations.
    Preview · Article · Jan 2016 · Advances in Clinical and Experimental Medicine
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    • "A reduction in phlebotomy blood loss is recognized as the most effective measure for diminishing the need for RBC transfusions. Madan et al. showed a 46 % reduction in the number of transfusions in extremely-low-birthweight preterm infants using a bedside blood gas analyzer, which reduced the volume of blood for laboratory exams [34]. Mahieu et al. found a reduction in the percentage of premature newborns that received transfusions after adopting of a multi-parameter monitor for laboratory analyses (50.0 % to 38.9 %, p < 0.05) and a 38 % reduction in the number of transfusions per newborn (2.53 to 1.57; p < 0.01) [35]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Preterm infants in neonatal intensive care units frequently receive red blood cells (RBC) transfusions due to the anemia of prematurity. A number of variables related to gestational age, severity of illness and transfusion practices adopted in the neonatal unit where the neonate was born may contribute to the prescription of RBC transfusions. This study aimed to analyse the frequency and factors associated with RBC transfusions in very-low-birth-weight preterm infants. Methods: A prospective cohort of 4283 preterm infants (gestational age: 29.9 ± 2.9 weeks; birth weight: 1084 ± 275 g) carried out at 16 university hospitals in Brazil between January 2009 and December 2011 was analysed. Factors associated with RBC transfusions were evaluated using univariate and multiple logistic regression analysis. Results: A total of 2208 (51.6 %) infants received RBC transfusions (variation per neonatal unit: 34.1 % to 66.4 %). RBC transfusions were significantly associated with gestational age (OR: -1.098; 95%CI: -1.12 to -1.04), SNAPPE II score (1.01; 1.00-1.02), apnea (1.69; 1.34-2.14), pulmonary hemorrhage (2.65; 1.74-4.031), need for oxygen at 28 days of life (1.56; 1.17-2.08), clinical sepsis (3.22; 2.55-4.05), necrotising enterocolitis (3.80; 2.26-6.41), grades III/IV intraventricular hemorrhage (1.64; 1.05-2.58), mechanical ventilation (2.27; 1.74-2.97), use of umbilical catheter (1.86; 1.35-2.57), parenteral nutrition (2.06; 1.27-3.33), >60 days of hospitalization (5.29; 4.02-6.95) and the neonatal unit where the neonate was born. Conclusions: The frequency of RBC transfusions varied among neonatal intensive care units. Even after adjusting for adverse health conditions and therapeutic interventions, the neonatal unit continued to influence transfusion practices in very-low birth-weight infants.
    Full-text · Article · Sep 2015 · BMC Pediatrics
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