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Blood Conservation: Identifying Factors to Reduce Phlebotomy Induced Blood
Loss in the PICU
Stacey Valentine, MD MPHInstructor, Division of Critical Care Medicine
Children’s Hospital BostonCRIT Collaborative
May 29, 2012
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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
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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
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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.
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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
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Patient Demographics
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Blood Draw Demographics
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Percent Volume Blood Overdraw by Blood Draw Site
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Percent Volume Blood Overdraw by Number of Tests Per Draw
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Percent Volume Blood Overdraw by Patient Weight
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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 < 10 kg had a greater amount of blood loss per kilogram per PICU stay compared to 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
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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