Changes in transfusion practice over time in the PICU

Abstract

Objectives: Recent randomized clinical trials have shown the efficacy of a restrictive transfusion strategy in critically ill children. The impact of these trials on pediatric transfusion practice is unknown. Additionally, long-term trends in pediatric transfusion practice in the ICU have not been described. We assessed transfusion practice over time, including the effect of clinical trial publication.

Design: Single-center, retrospective observational study.

Setting: A 10-bed PICU in an urban academic medical center.

Patients: Critically ill, nonbleeding children between the ages of 3 days and 14 years old, admitted to the University of Maryland Medical Center PICU between January 1, 1998, and December 31, 2009, excluding those with congenital heart disease, hemolytic anemia, and hemoglobinopathies.

Interventions: None.

Measurements and main results: During the time period studied, 5,327 patients met inclusion criteria. Of these, 335 received at least one RBC transfusion while in the PICU. The overall proportion transfused declined from 10.5% in 1998 to 6.8% in 2009 (p = 0.007). Adjusted for acuity, the likelihood of transfusion decreased by calendar year of admission. In transfused patients, the pretransfusion hemoglobin level declined, from 10.5 g/dL to 9.3 g/dL, though these changes failed to meet statistical significance (p = 0.09). Neonatal age, respiratory failure, shock, multiple organ dysfunction syndrome, and acidosis were associated with an increased likelihood of transfusion in both univariate and multivariable models.

Conclusions: The overall proportion of patients transfused between 1998 and 2009 decreased significantly. The magnitude of the decrease varied over time, and no additional change in transfusion practice occurred after the publication of a major pediatric clinical trial in 2007. Greater illness acuity and younger patient age were associated with an increased likelihood of transfusion.

Figure 1

Enrollment of study participants. Excluded patients may have met more than one exclusion criterion. PICU, pediatric intensive care unit

Figure 2

Percentage of patients transfused, by interval. The proportion of patients transfused decreased from 10.5% in 1998–1999 to 6.6% in 2009–2010 (linear regression, p=0.007).

Figure 3

Mean pre-transfusion hemoglobin (g/dL) for the first red cell transfusion event, by admission year. Mean hemoglobin decreased from 10.5 mg/dL in 1998–1999 to 9.3 mg/dL in 2009–2010 (linear regression, p=0.09).

Figure 4

Mean pre-transfusion hemoglobin (g/dL) for repeat red cell transfusion events, by admission year. Mean hemoglobin decreased from 11.8 mg/dL in 1998–1999 to 9.2 mg/dL in 2009–2010 (linear regression, p<0.001)