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 2 nd Ed.” New RBC transfusion guideline was implemented from Jan 2001

4. 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 2 35-50% Hct < 27% or Hb < 8 g/dl Asymptomatic Hct  30% Respiratory disease requiring FiO 2 25-35% / 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

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 < 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 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

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 Student’s t tests for group means Linear regression for prediction estimation of transfusion Differences considered significant at a p value of < 0.05

10. Results No. of premature infants included TotalTransfused% Before Sep 1998 – Dec 200045 2862.2 After Jan 2001 – Aug 200125 832.0

11. Baseline Characteristics BW (g)  1000 1001 – 12501251 – 1500Total Number12141036 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)

12. Baseline Characteristics BeforeAfterp Number288- Mean birth weight (g)109011350.645 Mean gestation age (wks)27.828.50.288 Mean Hct at birth (%)52.348.70.151 Ventilation days (d)14.03.90.007 O 2 days (d)32.732.00.949 IVH (  G 3) (%) 3.600.778 BPD (%)39.337.50.631 ROP (  G 3) (%) 10.700.459 Phlebotomy blood loss (ml)55.932.80.002 Length of hospital stay (d)99.684.40.463 Age attaining weight 2200 g (d)63.159.60.629

13. 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 Before452862.21.3323.855.92.1 After25832.00.41.49.032.81.6 Reduct ion --30.20.91.614.923.10.5 p0.0860.0010.170.0020.132

14. Compliance with New Transfusion Guidelines Before (1998 – 2000)After (2001) No. of Transfusion Episodes 8516 % Compliance with Guideline 2001 50.693.8 % Compliance with Guideline 1998 95.3N/A Ordering of Transfusion % Pre MRCP15.312.5 % Post MRCP81.212.5 % FHKAM3.575 % 2 nd Round83.581.3

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

16. Transfusion & Phlebotomy Loss BW (g)  1000 1001 – 1250 1251 – 1500 NICHD 2001* (1251-1500) Total N1621315968 No. of Transfusion/patient Mean (range) 4 (2 – 7)3 (1-7)2 (1-7) 1.1  1.7 3 (1-7) Transfused % with 02533.367.79547.1 % with 1028.619.4317.6 % with 231.39.56.5213.2 % with  3 43.828.66.5022.1 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) 392319 26  15 28 Phlebotomy loss > Day 14 (ml/kg/patient) 38201125

17. Transfusion Indications BW (g)  1000 1001 – 1250 1251 – 1500 NICHD 2001 (1251-1500) Number of Transfusion Episodes50371459  Moderate ventilatory support % 3213.514.324.2 Ventilatory respiratory support %010.8022.6 No ventilatory supp O 2 or CPAP %148.101.6 Increased O 2 support %28.1014.5 Apnoea / Bradycardia %1613.521.46.5 Asymptomatic %007.10 Old guideline – Hct < 0.40 %205.421.4- Old guideline – Hct < 0.35 %1232.47.1- Old guideline – Hct < 0.27 %05.421.4- Non – compliance %42.77.129.0

18. Blood Investigations Performed Before (1998-2000)After (2001) BW (g)  1000 1001 – 1500  1000 1001 – 1500 N10 18 2266 Age (day)  14 > 14  14 > 14  14 > 14  14 > 14 CBP (n)3.89.54.49.63.372.73.3 Hct (n)14.69.17.42.69.37.75.33.2 RFT (n)16.118.914.710.9912.38.35.7 LFT (n)2.79.32.76.42.77.71.94.1 ABG (n)45.124.533.812.418.36.319.44.1 Blood Culture (n) 1.81.41.30.71.72.31.40.3 Phlebotomy loss (ml/kg) 41.541.122.918.223.621.516.811.9

19. Risk Factors for Total Volume of Transfusion R 2 = 0.870 Risk FactorSignificance (p) Total Phlebotomy blood loss< 0.001 Hct% at birth0.023 Ventilation Days0.025 Birth weight0.370 IVH0.712 BPD0.62 O 2 Days0.944

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

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 14Day 15 - Discharge  100041.541.1 1001-150022.918.2 After  100023.625.1 1001-150016.811.9 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  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

26. Thank you

27. 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 2 35-50% Hct  30% Respiratory disease requiring FiO 2 25- 35% / 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

28. Risk Factors for Volume of Transfusion  14 days

29. Risk Factors for Total Volume of Transfusion R 2 = 0.870 Risk FactorBetaSignificance Total Phlebotomy blood loss0.633< 0.001 Hct% at birth- 0.2190.023 Ventilation Days0.2630.025 Birth weight0.8910.370 IVH0.2920.712 BPD0.0790.62 O 2 Days0.6080.944

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