Indian J Pediatr DOI 10.1007/s12098-014-1370-2

ORIGINAL ARTICLE

Audit of Pediatric Transfusion Practices in a Tertiary Care Hospital Shalini Bahadur & Neha Sethi & Sangeeta Pahuja & Chintamani Pathak & Manjula Jain

Received: 6 April 2013 / Accepted: 3 February 2014 # Dr. K C Chaudhuri Foundation 2014

Abstract Objective To perform a retrospective audit of transfusion practices, in order to study the appropriate and inappropriate usage of different blood components in pediatric population. Methods The present study, conducted over a period of 3 mo analyzed all the episodes of transfusions and divided them into appropriate and inappropriate according to the type of blood components, the requesting departments and the clinical indication of transfusion. Data was reviewed according to the British Committee for Standards in Hematology and American Association of Blood Bank guidelines. Results A total of 2,145 units of hemocomponents were transfused to children, including 1,181 units of red cell concentrates, 566 units of platelet concentrates/platelet rich plasma, 118 units of whole blood and 280 units of fresh frozen plasma in 1,819 episodes. Appropriate usage of blood components was 59.65 %. Whole blood was most appropriately transfused (82.9 %). Appropriate indications outnumbered inappropriate requisitions in Department of Pediatric Medicine (70.38 %), Nursery (82.54 %) and Thalassemia day care centre (55.63 %). Red cell concentrate was most appropriately indicated in anemias (73.14 %) and inappropriately in cases of surgeries (53.6 %). Platelets were used more appropriately in all clinical indications. Whole blood was transfused most appropriately (100 %) in double venous exchange therapy. Most appropriate indication of fresh frozen plasma usage was coagulopathy (42.57 %). Conclusions As the appropriate usage (59.65 %) of blood components was low in the present study, regular auditing of transfusion practices from time to time is indicated. This not S. Bahadur : N. Sethi : S. Pahuja : C. Pathak : M. Jain Department of Pathology and Blood Bank, Lady Hardinge Medical College, New Delhi, India N. Sethi (*) 10-C, DDA Flats, Phase 1( Masjid Moth( New Delhi 110048, India e-mail: [email protected]

only helps guide their judicious use but also serves to evaluate and decrease their inappropriate usage. Keywords Audit . Pediatric . Blood . Transfusion

Introduction Audit of blood transfusion practices is essential to monitor appropriate use of blood components. Blood transfusions are essential and life saving, however associated with risk of transfusion transmitted diseases and other adverse reactions. Moreover, blood is an invaluable and scarce human resource. Hence, the judicious use of blood components is essential especially in the setting of a tertiary care hospital in a developing country like ours with limited resources. By doing audits, we can see through various nondesirable aspects where the use of blood components is not according to the guidelines. This would help in saving this already deficient and precious human resource so that right component can be used for right indication at right time for person in need. Many of the studies related to audit of blood components are based on adult population [1, 2]. There are very few studies addressing the audit of transfusion practices exclusively in pediatric population [3, 4]. The present study was conducted in one of the largest child care hospital in India and is based on retrospective transfusion practices involving transfusion of whole blood (WB), red cell concentrates (RCCs), fresh frozen plasma (FFP) and platelet concentrates/platelet rich plasma (PCs/PRP) in a cohort of pediatric population (up to 18 y of age).

Material and Methods This retrospective study was conducted over a period of 3 mo at the regional blood transfusion centre of a tertiary care

Indian J Pediatr

teaching institute. The study cohort of pediatric population included thalassemics, patients with aplastic anemia, idiopathic thrombocytopenic purpura and others upto 18 y of age who received RCCs, WB, FFP or platelets. Data was analysed retrospectively according to the information given in the transfusion requisition forms. All requisitions were properly screened. The patient variables including age, sex, blood group and clinical diagnosis, indication for transfusion, requesting department and type of blood component requested were noted. All the indications were analyzed and divided into appropriate and inappropriate according to the type of blood components and according to the requesting departments. Appropriate requests are those which conform to the guidelines of transfusion practices. Inappropriate requests on the other hand are ones which do not follow the guidelines. Requisitions with incomplete information about the indication of transfusion and laboratory findings, were retrieved from the case files. Further division was done according to the clinical indication of transfusion. If different components were requested in the same requisition form, they were regarded as different episodes. Different authors have described different inappropriate percentage of transfusion requests for different blood components [1, 2, 4–8] (Table 1). Indications of transfusion were reviewed according to the British Committee of Standards of Hematology (BCSH) guidelines for transfusion in neonates and infants up to 4 mo of age and older children up to 18 y of age [9]. The transfusion of whole blood was analyzed according to the American Association of Blood Bank (AABB) guidelines [10].

Results A total 2,145 units of hemocomponents were transfused to children in the study period, including 1,181 units of RCCs, 566 units of PCs/PRPs, 118 units of WB and 280 units of FFP in 1,819 episodes. These 2,145 units were transfused to 845 patients with a male to female ratio of 1.72:1. Appropriate usage of blood components was found to be 59.65 %. Table 1 Studies by different authors on audit of different blood components

RBC Red blood cell; FFP Fresh frozen plasma

RCC, PCs/PRP and WB were most appropriately transfused as compared to FFP in which 69.07 % of episodes were inappropriately indicated (Table 2). WB was most appropriately transfused (82.9 %) followed by PCs/PRP (66.7 %), and RCC (61.35 %) (Fig. 1). While dividing the episodes according to different requesting departments (Table 3), maximum requisitions were received from department of Pediatric Medicine (PM) (71.4 %), followed by Thalassemia day care centre (TDCC) (55.63 %). Appropriate indications outnumbered inappropriate requisitions in department of PM (70.38 %), Nursery (82.54 %) and TDCC (55.63 %) while requisitions were more inappropriate in Pediatric intensive care unit (PICU) (69.39 %), Pediatric Surgery (53.49 %) and Orthopedics (100 %). When categorizing data according to individual blood components, appropriate requisition of RCC outnumbered inappropriate indications in all departments. Usage of platelets and WB was appropriate in all departments except pediatric surgery. FFP however, were inappropriately utilized in all departments. When dividing the episodes according to the clinical indication (Table 4), it was observed that RCC’s were mostly transfused for hemoglobinopathies (57.88), followed by anemias (24.52 %), bleeding and coagulopathies (9.18 %) and surgeries (8.4 %). RCC’s were most appropriately indicated in anemias (73.14 %) and inappropriately in cases of surgeries (53.6 %) (Fig. 2). Most common indication of platelet transfusion was thrombocytopenia (55.03 %) followed by coagulopathies (23.58 %), surgery (12.26 %) and bleeding (9.12 %). Platelets were appropriately used in all clinical indications like surgery (74.36 %) followed by thrombocytopenia (68 %), coagulopathy (64 %) and bleeding (55.17 %). WB was found to be transfused most commonly (67.57 %) and appropriately (100 %) in double venous exchange transfusion (DVET). WB was inappropriately (75 %) used as a substitute in the setting of blood loss. FFP was transfused most commonly in cases of coagulopathy (42.79 %). It was used inappropriately when transfused for indications of anemia (100 %), DVET (100 %) and surgeries (83.05 %). In the present study, authors found episodes whereby FFP was used alone

Author

Blood component

% of inappropriate requests/units

Mozes et al. [1] Tuckfield et al. [2] Hume et al. [4]

All blood components All blood components All blood components

83 31 58

Carvajal et al. [5] Jamal et al. [6] Ghali et al. [7] Makroo et al. [8]

All blood components Platelet concentrate/PRP RBC FFP

39 17.5 55.3 30.2

Indian J Pediatr Table 2 Division of episodes of different hemocomponents into appropriate and inappropriate

RCCs Red cell concentrates; PLT/ PRP Platelet concentrate/platelet rich plasma; WB Whole blood; FFP Fresh frozen plasma

Blood components

Units

Episodes

Appropriate no. of episodes (%)

Inappropriate no. of episodes (%)

RCCs PLT/PRP WB Total FFP Total

1,181 566 118 280 2,145

1,154 318 111 236 1,819

708 (61.35) 212 (66.7) 92 (82.9) 73 (30.93) 1085 (59.65)

446 (38.64) 106 (33.3) 19 (17.1) 163 (69.07) 734 (40.35)

without any combination with RCC, while performing DVET. This accounted for inappropriate usage. Most appropriate indication of FFP usage was coagulopathy (42.57 %).

Discussion Studies based on audit of pediatric transfusion practices are very few in comparison to adult patients. The present audit showed 59.65 % of transfusion episodes to be appropriate. Transfusion of blood products is an essential and potentially life saving measure. However, it is a double edged sword as it may not always be beneficial to patients. Associated hazards like transfusion transmitted infections, transfusion reactions etc., require careful consideration to be given regarding decision to transfuse this invaluable resource. Individual blood products will be discussed separately. In the present study, 61.35 % of episode of red cells were appropriately transfused. This was low as compared to Marti-Carvazal et al. [5] who found 76 % appropriate indications of RCC transfusions in their study. Hamoudi et al. [3] (89 %) and Hume et al. [4] (80 %) also found a higher rate of appropriate transfusion of RCC. The possible explanation for the low rate of appropriate transfusion of RCC in the present study is that all Fig. 1 Division of different number of hemocomponents into appropriate and inappropriate percentage of episodes. RCCs Red cell concentrates; PLT/PRP Platelet concentrate/platelet rich plasma; WB Whole blood; FFP Fresh frozen plasma

incomplete requests (that is insufficient clinical details, indications not specified) were considered inappropriate. It is important for clinician to consider patient’s signs, symptoms and functional capacities, presence or absence of other diseases and availability of alternate therapies apart from the hemoglobin (Hb) levels in making a decision for RCC transfusions [11]. It has also been stated that it is impossible to produce a clear evidence based criteria for the administration of red cells in the neonatal period, hence a liberal approach is being considered for neonates [12]. This can be an explanation for the most appropriate RCC transfusions (88.9 %) among nursery patients. In surgeries RCC’s were most inappropriately transfused (53.6 %). This is because of the improper use of RCC as volume expanders. It is therefore important that patient’s need for blood components and fluid replacements should be as specific as possible to ensure that the blood is prescribed rationally. In cases of beta thalassemia, regular transfusions of RCC are given to suppress erythropoiesis, inhibit increased gastrointestinal absorption of iron and to correct anemia. For this Hb concentration is maintained at 9.5 g/dL before transfusion. This provides adequate bone marrow suppression and lower rates of iron overload [13]. The present study showed 66.7 % of platelet transfusion requests to be appropriate as compared to Marti-Carvazel et al. [5] and Hume et al. [4] who found 52.6 % and 64.7 % appropriate requests in their respective studies. According to

100 80 60 40

82.9 61.35 38.64

69.07

66.7

59.65 40.35

33.3 17.1 30.93

20 0

l ta To

Appropriate no. of episodes (%) Inappropriate no. of episodes (%)

No. % No. % No. % No. % No. %

No. % No. %

Platelet/PRP

WB

FFP

Total

49 51.04 16 88.90 316 55.63 – – 708 61.35

300 71.4 27 54

47 48.90 2 11.10 252 44.37 2 100 446 38.64

120 28.6 23 46 96 – 18 – 568 – 2 – 1154 –

420 – 50 – 7 46.7 11 73.3 – – – – 212 66.7

187 67.7 7 58.3 8 53.3 4 26.7 – – – – 106 33.3

89 32.2 5 41.7 15 – 15 – – – – – 318 –

276 – 12 – 4 40 22 95 – – – – 92 82.9

54 90 12 66.7 6 60 1 4.3 – – – – 19 17.1

6 10 6 33.3 10 – 23 – – – – – 111 –

60 – 18 –

75 58.59 76 81.72 8 100 4 57.14 – – – – 163 69.07

53 41.4 17 18.27 – – 3 42.86 – – – – 73 30.93

8 – 7 – – – – – 236 –

128 – 93 –

60 46.51 52 82.54 316 55.63 – – 1085 59.65

594 70.38 53 30.63

69 53.49 11 17.46 252 44.37 2 – 734 40.35

290 34.36 120 69.36

Appropriate Inappropriate Total Appropriate Inappropriate Total Appropriate Inappropriate Total Appropriate Inappropriate Total Appropriate Inappropriate

RCC

RCC Red cell concentrate; PLT/PRP Platelet concentrate/platelet rich plasma; WB Whole blood; FFP Fresh frozen plasma; PM Pediatric medicine; PICU Pediatric intensive care unit; TDCC Thalassemia day care centre

Total

Ortho

TDCC

Nursery

Ped surgery

PICU

PM

Department

Table 3 Division of episodes of different hemocomponents according to requesting departments

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No. % No. % No. % No. % No. % No. % No. % No. 446



– 708





1154





212

48 64 119 68 –

16 55.17 29 74.36 –

106

27 36 56 32 –

13 44.83 10 25.64 –



283 24.52 106 9.18 97 8.4 668 57.88 –



76 26.8 41 38.7 52 53.6 277 41.5 –

207 73.14 65 61.3 45 46.4 391 58.5 –

Inappropriate

Appropriate

Total

Appropriate

Inappropriate

Platelet/PRP

RCC

318

75 23.58 175 55.03 –

29 9.12 39 12.26 –



Total

75 100 92

0 0 23





– –

12 75 9 45 –



Inappropriate

4 25 11 55 –



Appropriate

WB

75 67.57 111





16 14.4 20 18.02 –



Total

RCC Red cell concentrate; PLT/PRP Platelet concentrate/platelet rich plasma; WB Whole blood; FFP Fresh frozen plasma; DVET Double venous exchange transfusion

Total

DVET

Thrombocytopenia

Coagulopathy

Hemoglobinopathies

Surgeries (liver and billiary)

Bleeding

Anemia

Clinical indications

Table 4 Division of episodes of different hemocomponents according to indication of transfusion

0 0 73

43 42.57 –

0 0 20 38.46 10 16.95 –

Appropriate

FFP

4 100 163

58 57.42 –

20 100 32 61.53 49 83.05 –

Inappropriate

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Indian J Pediatr Fig. 2 Division of episodes of different hemocomponents according to inappropriate indication of transfusion

120 100 80 60 40 20 0 %

%

%

%

%

%

%

Anemia

Bleeding

Surgeries

Hbpathy

Coagulopathy

Thrombocytopenia

DVET

RCC

a study by Jamal et al. [6] a much higher percentage (82.5 %) of platelet transfusion was found appropriate. This may be attributed to the prospective nature of audit conducted by them. From the department of nursery, indications for platelet transfusion were most appropriate (74.36 %). This is because of higher cut off levels of platelet transfusion in newborn and premature infants. Premature infants are at greater risk of intracranial hemorrhage and multiple abnormalities of hemostasis. The risk of these complications relate to the severity of thrombocytopenia [14]. Platelets were inappropriately (44.83 %) used in cases of bleeding, which can be explained by the erroneous use of platelets as an alternative to fluid replacement. Moreover, it has been recommended that in cases of acute bleeding, platelets should be transfused only when the platelet count is 1.5) and with associated significant risk of bleeding (preterm, intubated, previous periventricular hemorrhage) or who are about to undergo invasive procedures should receive FFP [16]. In the present study, in all cases (100 %) of anemia and DVET, FFP was used inappropriately. Both anemia and DVET are not indications for FFP transfusion.

Platlet/PRP

WB

FFP

The authors found 82.9 % requests of whole blood appropriate in the present study. Fresh whole blood was requested mostly for DVET in cases of hemolytic disease of newborn (HDN). In HDN, the aim is to remove both antibody coated red cells and excess bilirubin [17]. Inappropriate usage of whole blood was found to be as high as 75 % in the present study in cases of massive bleeding requiring massive transfusion. Authors support the use by Counts et al. who suggest the use of whole blood in cases of acute bleeding only when replacement of losses with red blood cells and crystalloids and colloids would dilute coagulation factors to levels insufficient to ensure homeostasis [17]. Verma et al. has discussed in detail the use of various blood components for transfusion support in pediatric population. They have described that a thorough understanding of various blood components and indications for each is critical when making the decision for transfusion in children [18]. Audits help in evaluating and improving transfusion practice. It is necessary to remember that to reap maximum benefits from audits; documentation needs to be judiciously maintained. All pertinent patient details must be entered for both prospective and retrospective audits. Clinicians should adhere to guidelines and not be swayed by clinical backdrop of patients. Where necessary they should reassess patients in between transfusions to prevent injudicious transfusion episodes. Interaction and regular education of clinicians from time to time is required by conducting workshops/ seminars and upholding regular Hospital Blood Transfusion Committee meetings. This helps to reinforce appropriate blood usage and provide a platform to discuss the lacunae regarding blood demand and supply. To conclude it is important to remember that whatever deficits get highlighted in an audit they should be interpreted constructively and mark the starting point of the end of inappropriate blood usage.

Indian J Pediatr Contributions SB and NS: Analysed the data and wrote the paper; SP, CP and MJ: Reviewed the paper and made necessary corrections. MJ will act as guarantor for this paper. Conflict of Interest None. Role of Funding Source None.

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8. Makroo RN, Raina V, Kumar P, Thakur UK. A prospective audit of transfusion request in a tertiary care hospital for the use of fresh frozen plasma. Asian J Transf Sci. 2007;1:59–61. 9. Gibson BE, Todd A, Roberts I, Pamphilon D, Rodeck C, BoltonMaggs P, et al; British Committee for Standards in Haematology Transfusion Task Force: Writing group. Transfusion guidelines for neonates and older children. Br J Haematol. 2004;124:433–53. 10. Strauss RG, Blanchette VS, Hume H, Levy GJ, Scholz L, Blazina JF, et al. National acceptability of American Association of Blood Bank Pediatric Hemotherapy Committee guidelines for auditing pediatric transfusion practices. Transfusion. 1993;33:168–71. 11. Blanchette VS, Hume HA, Levy GJ, Luban NL, Strauss RG. Guidelines for auditing pediatric blood transfusion practices. Am J Dis Child. 1991;145:787–96. 12. Strauss RG. Practical issues in neonatal transfusion practice. Am J Clin Pathol. 1997;107:S57–63. 13. Cazzola M, Borgna-Pignatti C, Locatelli F, Ponchio L, Beguin Y, De Stefano P. A moderate transfusion regimen may reduce iron loading in b-thalassaemia major without producing excessive expansion of erythropoiesis. Transfusion. 1997;37:135–40. 14. Cahill MR, Lilleyman JS. The rational use of platelet transfusions in children. Semin Thromb Hemost. 1998;24:567–75. 15. British Committee for Standards in Haematology, Blood Transfusion Task Force. Guidelines for platelet transfusions. Br J Haematol. 2003;122:10–23. 16. O’Shaughnessy DF, Atterbury C, Bolton Maggs P, Murphy M, Thomas D, Yates S, et al; British Committe for Standards in Haematology, Blood Transfusion Task Force. Guidelines for use of fresh-frozen plasma, cryoprecipitate and cryosupernatant. Br J Haematol. 2004;126:11–28. 17. Counts RB, Haisch C, Simon TL, Maxwell NG, Heimbach DM, Carrico CJ. Hemostasis in massively transfused trauma patients. Ann Surg. 1979;190:91–9. 18. Verma A, Hemlata. Blood component therapy. Indian J Pediatr. 2008;75:717–22.

Audit of pediatric transfusion practices in a tertiary care hospital.

To perform a retrospective audit of transfusion practices, in order to study the appropriate and inappropriate usage of different blood components in ...
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