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In a recent study published in the journal Pediatric Critical Care Medicine Showed that a pediatric intensive care unit (PICU) was associated with anemia during discharge from the diagnostic blood collection unit. The study concluded that 25% of the sample lost blood loss and increased volume for patients with sepsis, shock or cardiac surgery, and for patients with vascular access or ventilator support.
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More than 50% of PICU survivors suffer from anemia after a serious illness. Anemia has well-known negative effects on neurocognitive development and quality of life, and its etiology is multifaceted. Blood collection is a variable contributing factor for diagnostic testing. Based on this information, the objectives of the study were to describe the practice of blood collection in PICU, to determine the causes of the patient associated with the increase in these collections and to evaluate the relationship between blood collection, anemia PICU discharge and hemoglobin change (Hb) discharge from unit to PICU. Until.
The potential observational integrated study was conducted at the PICU of St.-Justin University Hospital in Montreal, Canada. All children enrolled in a four-month period (September 13, 2019 to January 15, 2020) were included.
The following exclusion criteria were applied: premature neonates (gestational age less than 37 weeks at the time of admission to PICU), adult patients (over 18 years of age) and pregnant or immediately after delivery. Patients with anemia or known clotting disorders were not excluded. Redemption within 48 hours at PICU was considered as a single admission. Finally, patients who were re-admitted after 48 hours were considered new admissions.
A total of 423 admissions were made during the study period, of which 314 had sufficient data to be included in the multivariate analysis. Male patients represented 54% of the sample. Respiratory failure was the most common clinical diagnosis in admissions, when one-third of patients were admitted after surgery. Sixteen patients underwent surgery at the PICU and four died before discharge. The average length of hospital stay was 2.1 days, average time 4.5 days. Invasive mechanical ventilation (IMV) was used in 30% of patients and non-invasive ventilator support (NIV) in 50% of patients. About 40% had access to the central vein, with an average catheter duration of 8.5 and 3.7 days, respectively.
Overall, patients received two blood transfusions per day. About 10% of patients had no blood sample and only 14% of patients had a blood sample. Blood volume was recorded for 57% of all blood samples.
The average volume of blood collected for the sample was 5.3 (± 6.3) mL / patient / day. The average amount of blood sampled per PICU admission was 3.9 (± 19.0) mL / kg, which corresponds to about 5% of the total blood volume performed (TVSC). In 30 of the 423 patients (7.1%), the total amount of blood collected at VTSC was more than 10%. On average, 1.0 (± 5.9) mL / kg of blood was discarded per PICU admission, representing 26% of the total blood collected.
Patients admitted after cardiac surgery and those with sepsis or shock who had the highest blood samples (11.0 ± 4.5 and 8.7 ± 8.8 ml / day, respectively; p <0.001). Patients diagnosed with early respiratory disease collected less blood (2.1 ± 3.4 ml / patient / day). Patients with ventilation support had significantly higher blood samples than those without blood samples (38.0 ± 116.5 mL vs. 10.5 ± 16.9 mL / admission; p <0.001).
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The total amount of blood collected was significantly higher than in patients with vascular access (8.2 ± 6.4 vs. 3.1 ± 5.3 mL / patient / d; p <0.001). Blood volume was significantly higher in patients with central venous access (14.4 ± 35 vs. 2.1 ± 6.9 ml / admission; p <0.001). We did not detect a correlation between increased blood sample and disease severity (worst daily PELOD-2) (p = 0.43) (PELOD-2 = Dysfunction of pediatric logistical organs-2 scores).
Children without anemia at the time of admission to PICU and non-transfused patients were at higher risk of Hb loss during PICU:
- No anemia at admission: average ΔHb –9.73 g / L;
- No transfer: Hb -10.5 g / L;
- Children over 120 months of age were also more likely to have Hb (ΔHb, –6.4 g / L).
The researchers also reported that 43 patients (10%) received at least one RBC transfusion while in their PICU, the highest number of transfusions reported among septic and cardiac surgery patients. The overall proportion of transplanted patients was low: most children received their transfers within the first 24 to 48 hours (moderate, 11.8 hours) of admission to PICU. More than half of the patients suffered from anemia during PICU discharge (177/315, 56%), 16% had severe anemia (Hb <9.0 g / dL) and 18% (57/314) had recurrent anemia during discharge. PICU Children who developed new anemia during PICU discharge had higher Hb levels in PICU discharge (p <0.001) than PICU admission. No statistically significant relationship was found between blood volume and Hb reduction.
Diagnostic blood draw is responsible for about 5% of SCTV in children. A significant portion of the collected blood is wasted on the bedside, mainly related to the collection technique. The amount of blood sampled is significantly associated with an increased risk of anemia during PICU discharge, especially when the volume collected exceeds 1.0 mL / kg. Therefore, intensive care requires daily assessment of the need for diagnostic blood tests for the care of children and improvement of clinical practice and collection techniques.
This study reinforces the importance of daily discussion of patients’ clinical conditions (for example, in a round format) at PICU, so that all members of the interdepartmental group can discuss whether or not to collect unnecessarily. In practice, we think: “Since we are going to collect X, we are going to take advantage and also Y is going to harvest”. But the question is: with the best intentions to reach the patient as much as possible, aren’t we also at risk of itrogenic events? This discussion should be done with parents, who often insist on frequent collection for various reasons. Finally, it is always important to keep up to date with the practices and techniques of professional collection.
I further emphasize that, in the study, the researchers described that the unit follows the proposed limited transfusion guidelines. The researchers noted that they typically avoid red blood cell transfusions for hemodynamically stable, non-cyanotic patients with hemoglobin above 7.0 g / dL, although the decision is at the discretion of the treating physician. However, I have adopted these recommendations in my daily practice and I find that there is a current tendency for pediatric intensive care physicians to be more conservative in this regard. However, how many frequent and large-volume collections cannot evolve in the need to move with all the complexities that can follow?
I totally recommend reading this incredible study.
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