Blood Conservation: Identifying Factors
to Reduce Phlebotomy Induced Blood
Loss in the PICU
Stacey Valentine, MD MPH
Instructor, Division of Critical Care Medicine
Children’s Hospital Boston
CRIT Collaborative
May 29, 2012
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
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
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.
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
Patient Demographics
Blood Draw Demographics
Percent Volume Blood Overdraw by Blood Draw Site
*
Percent Volume Blood Overdraw by Number of Tests
Per Draw
300
**
Mean Percent Blood Overdraw
250
200
150
100
50
0
1
2
3
Number of Tests Ordered Per Draw
4
5
Percent Volume Blood Overdraw by Patient Weight
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
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; 31:653657