1. Blood Conservation: Identifying Factors to Reduce Phlebotomy Induced Blood Loss in the PICU Stacey Valentine, MD MPH Instructor, Division of Critical Care Medicine Children’s Hospital Boston CRIT Collaborative May 29, 2012

2. Phlebotomy Induced Blood Loss In Adult Critically Ill Patients Vincent et al. 2002 Phlebotomy frequency in adult critically ill patients varies between 5 – 24 samples per day, with a mean volume of 41 ml/day Daily phlebotomy volumes have been independently associated with the likelihood of transfusion in adult critically ill patients Fowler et al. 2003 Patients treated with a restrictive diagnostic phlebotomy and blood conservation strategy were less likely to receive a packed red cell blood transfusion during their ICU stay The use of a closed system for blood draws demonstrated a 50% reduction in phlebotomy volumes compared to standard phlebotomy practices Vincent et al. 2002. JAMA Fowler et al. 2003. Crit Care

3. Anemia and Blood Loss in the PICU: Epidemiology: Bateman et al. 2008 977 patients from 2004 to 2005 Blood draws occurred in 96% of critically ill pediatric patients Phlebotomy accounted for 73% of blood loss Blood loss from phlebotomy was associated with increased odds of transfusion Bateman et al. 2008. Am J Respir Crit Care Med

4. Study Aim: Aim: To identify avoidable factors associated with phlebotomy induced blood loss. Hypothesis: Phlebotomy overdraw significantly contributes to phlebotomy induced blood loss and can be avoided. Blood draws taken from an indwelling catheter without a closed system result in significantly greater blood overdraw volumes.

5. Methods Prospective observational study from September 2004 to January 2005 All blood draws, including draw volume, site and tests ordered were recorded The minimum amount of blood needed for each blood draw was calculated Blood overdraw was defined as the percentage of blood drawn in excess of phlebotomy requirements

6. Patient Demographics

7. Blood Draw Demographics

8. Percent Volume Blood Overdraw by Blood Draw Site *

9. Percent Volume Blood Overdraw by Number of Tests Per Draw **

10. Percent Volume Blood Overdraw by Patient Weight

11. Conclusions Blood overdraw volumes ranged from 55% to 375% the needed volume to perform the laboratory test Blood overdraw accounted for >50% of the total phlebotomy blood loss Patients 10kg Blood draws sent from central venous catheters were associated with increased phlebotomy overdraw Blood draws sent for single laboratory evaluations were associated with increased phlebotomy overdraw

12. References 1. Bateman ST, Lacroix J, Boven K, et al: Anemia, blood loss, and blood transfusions in North American children in the intensive care unit. Am J Respir Crit Care Med 2008; 178:26-33 2. Vincent JL et al. ABC (Anemia and Blood Transfusion in Critical Care) Investigators. Anemia and blood transfusion in critically ill patients. JAMA. 2002 Sep 25;288(12):1499-507 2. Corwin HL et al. The CRIT Study: Anemia and blood transfusion in the critically ill-- current clinical practice in the United States. Crit Care Med. 2004 Jan;32(1):39-52. 3. Fowler RA et al. Blood conservation for critically ill patients. Crit Care Clin. 2004 Apr;20(2):313-24 4. Lin JC et al. Phlebotomy overdraw in the neonatal intensive care nursery. Pediatrics. 2000 Aug;106(2):E19. 5. Barie PS et al. Phlebotomy in the intensive care unit: strategies for blood conservation. Crit Care. 2004;8 Suppl 2:S34-6 6. Chant C, Wilson G, Friedrich JO: Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study. Crit Care 2006; 10:R140 7. MacIssac CM, Presneill JJ, Boyce CA, et al: The influence of a blood conserving device on anaemia in intensive care patients. Anaesth Intensive Care 2003; 31:653- 657