Commitfee Report

Blood component therapy during the neonatal period: a national survey of red cell transfusion practice, 1985 R.A. SACHER, R.G. STRAUSS, N.L.C. LUBAN,M. FEIL,H.B. ANSTALL,A. BARNES, JR., V.S. BLANCHEITE, S.H. BUTCH,H.A. HUME,S.V. KEW, G.J. LEVY,A. MCMICAN,K. STARLING, A N D A.K. WILLIAMS A questionnaire to determine patterns of neonatal red cell transfusion practice during 1985 was mailed to 2200 blood banks of American Association of Blood Banks (AABB) institutional members and children’s hospitals. There were 915 responses 41.6% ; 785 responses (86%) contained sufficient data for analysis. The majority 70.6% of 785 responding hospitals were community/urban institutions. However, more highly specialized, pediatric hospitals were also represented by 92 university/ tertiary-care hospitals (11.7% of respondents) and 29 children’s hospitals (3.7% of respondents). Two-thirds of hospitals performed a major antiglobulin crossmatch (rather than an abbreviated one) before all neonatal red cell transfusions. The red cell preparation most frequently selected for small-volume transfusions was ABO and Rh group-specific red cell concentrates. When performing only large-volume exchange transfusions, 19.2 percent of hospitals used whole blood; all others prepared reconstituted units of red cells plus fresh-frozen plasma, a practice that frequently causes exposure to two donors per unit. Another practice likely leading to multiple donor exposure is the use of fresh-frozen plasma to adjust the hematocrit of red cell reparations to a predetermined value prior to a small-volume transfusion. Over one! t alf of hospitals adjusting hematocrits used plasma, presumably from one donor, to dilute packed red cells from another donor, a practice that has no apparent medical benefit. Most hospitals (63.4%) provided red cells with a reduced risk of transmitting cytomegalovirus; blood from seronegative donors was selected b 65 percent of hospitals. The majority of hospitals, including most of the communityhrban hospitals, did not irradiate blood products before transfusion. Thus, neonatal red cell transfusion practices during 1985 were widely diverse, some of which are judged to be less than ideal. The data in this report offer a resource for comparative studies and provide a basis for education, peer review, and research. TRANSFUSION 1990;30:271-276.

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NEONATALPATIENTS MANAGED in intensive care settings receive many red cell transfusions. However, little information exists as to the precise details of transfusion practice during the neonatal period. The limited data available suggest that red cell usage for neonatal patients i s substantial, i s probably increasing, and results, particularly for those with birth weight ~ 1 5 0 0 g, in exposure to an alarmingly high number of donors.’ The efficacy of red cell transfusions in many neonatal settings has not been proven by sound scientific studies. Moreover, the indications for and risks of red cell transfusions, the optimal red cell preparations to be selected

for neonatal transfusions, and the need for special blood banking procedures are not defined adequately.’J Accordingly, we report the results of a survey conducted during 1986 and 1987 to analyze neonatal transfusion practice in the United States during 1985. The intent i s to obtain basic information about red cell transfusion policies. The data can be used to estimate the quality of transfusion practice, to compare trends throughout the country during 1985, and to note changes in the future. The documentation here of diverse practices, some of which are not ideal, emphasizes the need for continued research, education, and peer review of a l l neonatal transfusion practices.

From the Departments of Medicine, Pathology and Laboratory Medicine, Georgetown University Medical Center, Washington, DC; the Departments of Pathology and Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa; the Departments of Pediatrics and Laboratory Medicine, Children’s Hospital National Medical Center, Washington, DC; Moshman Associates, Bethcsda, Maryland; and the Pediatric Hcmotherapy Committee, American Association of Blood Banks. This report is the opinion of the authors and does not represent the policy of the American Associalion of Blood Banks. Receivcd for publication August 11, 1989; revision rcccivcd October 12, 1989, and accepted October 16, 1989.

Materials and Methods We collected data via a questionnaire mailed to institutional members of the American Association of Blood Banks (AABB) and to blood banks of children’s hospitals. Children’s hospitals with neonatal patient care units were selected for the survey from directories of the National Association of Children’s Hospitals and Related Institutions and the American Board of Pediatrics’ Neonatal Training Programs. We crossreferenced lists to ensure that duplication did not occur and that each response provided data from only one hospital. Only institutions in the

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United States were eligible, and each was sent a questionnaire designed to obtain institutional demographic information and data about many aspects of neonatal transfusion practice during the interval between January 1 and December 31, 1985. The completed questionnaires were returned to the AABB National Office and were analyzed without further alteration (i.e., no attempts were made to contact nonresponders or to finish partially completed questionnaires). As a consequence, the number (N) of institutions responding to different questions varied, and the N on all tables and figures is, therefore, not identical. The questionnaire addressed many aspects of neonatal and general pediatric transfusion practice and consisted of 35 closed and 7 open questions requiring specific numeric responses. Data from 18 categorical variables from the questionnaire that pertained specifically to neonatal red cell transfusions and to closely related issues are reported here. Respondents classified hospitals as being community/urban, children’s, or university/ tertiary-care institutions. Respondents also estimated the level of neonatal intensive care offered (Level 1 through Level 4) according to the American Academy of Pediatrics classifications.’ We used a standardized coding protocol to encode the responses to questions and key-entered the data using a software package (WYL-BUR/pc, On-line Business System, San Francisco, CA) on a personal computer (IBM, Boca Raton, FL).4 We used data-editing programs to verify the consistency within each responding institution’s data record and then transmitted data to a main-frame computer (System 370, IBM) using a software package (KERMIT, Columbia University Center for Computing, New York, NY).5We used the frequency procedure of a statistical analysis software system (SAS, SAS Institute, Cary, NC)6 to cross-classify the responses to each question by the type of hospital. Statistical methods included the calculation of Pearson’s chisquare to test the null hypothesis of equal proportions of responses for each type of hospital. We also partitioned each table of responses to questions by the type of hospital, to isolate differences in the likelihood that each type of hospital would follow different patterns of neonatal transfusions.’ The principle of Bonferroni inequality was used to adjust p values to account for multiple comparisons.8 The level of significance was 0.05.

Results

Demographic data We mailed 2200 questionnaires, and 915 were returned (41.6% response). Of the 915 responses, 785 (86% of respondents, 36% of questionnaires mailed) contained sufficient data for analysis. The majority (70.6%) of the 785 respondents were community/urban hospitals. Twenty-nine hospitals (3.7%) were children’s hospitals and 92 (1 1.7%) were university/tertiarycare hospitals. Respondents from the remaining 110 hospitals classified themselves as miscellaneous, presumably because they had characteristics of more than one category. Because the miscellaneous group could not be defined clearly, data from this group will be neither presented nor compared to that from the other types of hospitals. The distribution of the number of beds is shown in Fig. 1. Most responding hospitals were, at least, medium in size (>200 beds), and 22.3 percent had >500 total beds. Seventy-five percent of responding hospitals had 11 to 100 pediatric beds, and 72.4 percent had a neonatal special care unit. Only a very few hospitals with neonatal special care units were limited to Level 1 care. In community/urban hospitals reporting the level of care provided, 64 percent classified their care capability as

Vol. 30. Nn. 3-1990

N-272

35UI e

6 30-

hd

25-

“178

B 20-

E

N.125

15-

1 lo5-

N.32

Number of Hospilal Beds

FIG. 1. Thc size of responding hospilals t h a t provided sufficicnl data for analysis.

Level 2 and 29 percent as Level 3 or 4. In general, the degree of management in children’s hospitals was more complex, with 11 percent offering only Level 2 care and 89 percent providing Levels 3 and 4. Fourteen percent of university/tertiary-care hospitals provided Level 2 care, and 84 percent provided Level 3 or 4.

RBC transfusion data In 1985, 66 percent of hospitals performed a major antiglobulin crossmatch before an initial red cell (RBC) transfusion was given to any neonatal patient. Twenty-eight percent of hospitals were more selective in testing and performed a major antiglobulin crossmatch only if the pretransfusion antibody screen was positive. When performing subsequent, rather than initial, RBC transfusions, 33.8 percent of hospitals did not repeat pretransfusion testing providing that the initial antibody screen was negativeg and the neonatal patient exhibited no evidence of hemolysis. In 81.6 percent of responding hospitals, maternal blood was available and could have been used, instead of neonatal blood, for pretransfusion testing. The majority of community/urban hospitals selected ABO, Rh group-specific RBCs, whereas children’s and university/ tertiary-care institutions frequently chose group 0 cells that were either Rh compatible or Rh negative (Fig. 2). RBC preparations selected for transfusion are ranked by percentage in Fig. 3. The purpose of most RBC transfusions is to provide small volumes of blood with a high hematocrit, and 72.8 percent of hospitals used concentrated RBCs for this purpose. Washed RBCs were the second most frequently selected component (12% of hospitals), largely as a result of their use at children’s hospitals (used in 40% of transfusions given at children’s hospitals). Other RBC preparations were selected only occasionally (frozen-deglycerolized RBCs by 6.1% of hospitals, whole blood by 3%, RBCs with buffy coats removed by 0.9%, and combinations by 5.2%). The component of choice for large-volume exchange transfusions (55.2% of hospitals) was reconstituted whole blood (i.e., an RBC concentrate centrifuged with plasma and/or preservative solution removed and fresh-frozen plasma [FFP] added). An additional 13.7 percent of institutions, using reconstituted blood, washed RBC concentrates before resuspending them in FFP. The second choice for exchange transfusion was whole blood (19.2% of hospitals). A few hospitals (3.9%) used frozen-deglycerolized RBCs suspended in plasma, RBCs with b u Q coat removed plus plasma (l.l%), or a combination of products (7.9%).

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0 Community/Urban, N.546 Childrsnk N.28

n 0 Rh neg

0 Rh neglpos

ABO Rh specific

munityhrban and university/tertiary-care hospitals and by nearly 50 percent of children’s hospitals. The source of plasma was not precisely identified, but it was presumed that, in many instances, units of plasma and RBCs from the same donor were not available simultaneously. Thus, i t was probably necessary to combine units from two different donors to prepare the standardized product. Hospitals employed a number of systems to collect, store, and dispense small-volume RBC transfusions to neonatal patients. Multiple. connected bags such as quadruple and quintuple packs were the most popular mini-transfusion systems (44.1% of hospitals). The “cow” system (i.e., use of 1 unit as a source of blood for multiple neonatal patients) was used by 10.3 percent of respondents. A variety of other systems, including syringes or local modifications of other techniques, were reported by 11.3 percent of hospitals.

Use of specially prepared RLIC components Red Cell Types Selected

FIG.2. Rcd cell products, sclcctcd by antigen types, for transfusion by different hospitals. Comrnunity/urban hospitals werc morc likely to use ABO, Rh group-specificred cells than group 0 cells (p ~0.001).

Children’s and university/rcrtiar)i-care hospitals wcrc morc likcly 10 sclcct group 0,Rh-compatible cells than werc communitylurban hospitals (p

Blood component therapy during the neonatal period: a national survey of red cell transfusion practice, 1985.

A questionnaire to determine patterns of neonatal red cell transfusion practice during 1985 was mailed to 2200 blood banks of American Association of ...
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