ANEMIA, BLOOD LOSS, and TRANSFUSIONS

in NORTH AMERICAN CHILDREN

in the INTENSIVE CARE UNIT

Sri Julyani

Patologi Klinik

ABSTRACT
Rationale: Minimizing exposure of children to
blood products is desirable.
Objectives: We aimed to understand anemia
development, blood loss, and red blood cell
(RBC) transfusions in the pediatric intensive
care unit (PICU).
Methods: Prospective, multicenter, 6-month
observational study in 30 PICUs. Data were
collected onconsecutive children (< 18 yr old)
in the PICU for 48 hours or more.

 Measurements and Main Results:

Anemia development, blood loss, and RBC
transfusions were measured. A total of 977
children were enrolled. Most (74%) children were
anemic in the PICU (33% on admission,41%
developed anemia). Blood draws accounted for
73% of daily blood loss; median loss was 5.0
ml/day. Forty-nine percent of children received
transfusions; 74% of first transfusions were on
Days 12.

After adjusting for age and illness severity,

compared with nontransfused children, children
who underwent transfusion had significantly
longer days of mechanical ventilation (2.1 d, P <
0.001) and PICU stay (1.8 d, P < 0.03), and had
increased mortality (odds ratio [OR], 11.6; 95%
confidence interval [CI], 1.4390.9; P = 0.02),
nosocomial infections (OR, 1.9; 95% CI, 1.23.0; P
< 0.004), and cardiorespiratory dysfunction (OR,
2.1; 95% CI, 1.53.0; P < 0.001).

High blood loss per kilogram body weight from

blood draws (OR, 1.11;95%CI, 1.031.2; P < 0.01)
was associated with RBC transfusion more than
48 hours after admission.
The most common indication for transfusion was
low hemoglobin (42%).
Pretransfusion hemoglobin values varied greatly
(mean, 9.7 2.7 g/dl).

Conclusions: Critically ill children are at

significant risk for developing anemia and
receiving blood transfusions.
Transfusion in the PICU was associated with
worse outcomes. It is imperative to minimize
blood loss from blood draws and to set clear
transfusion thresholds.

 Anemia critically ill children in PICU.

chronic anemia, overt and occult blood loss
underlying disease and treatments causing
bone marrow suppression.
Response Erythropoietin in adults and children is
described
RBC transfusions therapy in critically ill and injured
children.
Risks transfusion-transmitted infections,
transfusion-related acute lung injury
hemodynamic compromise,
intravascular volume overload
acute hemolysis,
immunosuppression

 In adults, RBC transfusions

prolongation of mechanical ventilation
diminished organ function, and even death
To date,
No data available on blood loss in children
admitted to the PICU
No multicenter prospective data on anemia
and transfusions in the PICU are available.

 In this study children with a longer PICU stay

interventions
blood conservation protocols
erythropoietin therapy
20% of PICU admissions stay greater than 48
hours but I sproportionately high PICU resource
utilization .
Aimed assess the epidemiology of anemia and RBC
transfusions in this population as well as to determine
the causes of blood loss in the PICU.
Outcomes and complications were captured to assess
any association with transfusions.

METHODS
Prospektif
Multicenter

30 PICUs

> 48 h in
the PICU

Sept 8 ,2004 March 29 , 2005

Children,
younger 18 y

Prematur

> 72 h in
PICU

Brain
death

Prior
participation

Exclution
criteria

Pregnancy

Related
research

Family
history

Blood loss
Prospectively
Data after

48 h

Data collected
Retrospectively

Data from the

first 48 h

Data on addmission

Demographics
Severity of
illness

Daily data
Lowest Hb level

RBC Transfusion

Reason for transfusion

Score :
PRISM III
PELOD
MODS

Blood loss
PELOD, MODS

Clinical event

Anemia
Cutof
value
Severity of
anemia

Hb concentration 2 SD below the

mean Hb concentration for each age
group

Neonatus :14,5 g / dl
2 months Dropping to 9 g /dl
6 months : rising to 10,5 g / dl
2 years : 11,5 g / dl
Females : 12 g/dl . Males 13 g/dl
Severe
Moderate
Mild

: < 7 g / dl
: 7 10 g / dl
: > 10 g / dl

Chi-square : outcomes
predictor

Analysis of varians : anemia

Logistic regressions : complication

for transfusion, risk for anemia
and transfusion

Result
5570

1.097 :
> 48 h

986 enrolled

9 : case report
incomplete

977 : analysis

TABLE 1. BASELINE CHARACTERISTICS OF THE CHILDREN ON

ADMISSION TO THE PEDIATRIC INTENSIVE CARE UNIT
All Children, n
(%)

Anemia on
Admission, n
(%)

Develop Anemia Any Transfusion Transfusion >48

>48 h after
in PICU, n (%) h after Admit, n
Admit, n (%)
(%)

(n = 977)

(n = 322)

(n = 176)

(n = 475)

(n = 162)

83 (8)

28 (9)

23 (13)

58 (12)

26 (16)

28 d to <2 yr

358 (37)

82 (25)

72 (41)

208 (44)

63 (39)

2 yr to <5 yr

137 (14)

38 (12)

28 (16)

57 (12)

19 (12)

5 yr to <12 yr

183 (19)

72 (22)

28 (16)

67 (14)

24 (15)

12 yr to <18 yr

216 (22)

102 (32)

25 (14)

85 (18)

30 (19)

575 (59)

203 (63)

102 (58)

276 (58)

88 (54)

Trauma

99 (10)

50 (16)

11 (6)

56 (12)

15 (9)

Surgical,
nontrauma

383 (39)

106 (33)

75 (43)

216 (45)

53 (33)

Medical,
nontrauma

495 (51)

166 (52)

90 (51)

203 (43)

94 (58)

Age group
<28 d

Male sex
Admitting type

Admitting category
Cardiovascular system

253 (26)

58 (18)

50 (28)

187 (39)

53 (33)

Nervous system
Digestive system

217 (22)
62 (6)

82 (26)
29 (9)

34 (19)
17 (10)

79 (17)
40 (8)

24 (15)
14 (9)

Endocrine system

17 (2)

3 (1)

4 (2)

6 (1)

4 (3)

Hematologic
Renal/urologic
Respiratory
Comorbid conditions*
None
Asthma
Cyanotic congenital heart disease

39 (4)
22 (2)
353 (36)

27 (8)
14 (4)
102 (32)

1 (1)
3 (2)
66 (37)

31 (7)
16 (3)
111 (23)

9 (6)
4 (3)
53 (33)

387 (40)
112 (12)
136 (14)

127 (39)
37 (11)
25 (8)

69 (39)
17 (10)
34 (19)

185 (39)
36 (8)
110 (23)

58 (36)
13 (8)
33 (20)

Nervous system
Renal and urologic

199 (20)
80 (8)

65 (20)
34 (11)

38 (22)
14 (8)

66 (14)
44 (9)

27 (17)
12 (7)

Other
PRISM III score
Mean (SD)
Median

128 (13)

46 (15)

18 (10)

73 (16)

19 (12)

4.2 (5.3)
2.0

5.3 (5.8)
4.0

3.6 (4.5)
2.0

5.6 (5.8)
4.0

4.5 (5.1)
3.0

7 d before : 15 %

Admission : 33%
Anemia
During : 41%
Never : 26%

Severity
of
illness Anemia on

Length
of stay Anemia in

admission
>> (5,35,8)

PICU
(10,47,8)

Became
anemia
(3,85,1)

Anemia on
admission
(8,97,0)

Never
anemia
(3,34,5)

Never
anemia
(6,65,9)

TABLE 2. PREDICTORS OF DEVELOPMENT OF ANEMIA AFTER PEDIATRIC

INTENSIVE CARE UNIT DAY 2 (n = 438)*

Effect
Age category
<28 d
28 d to <2 yr
2 yr to <5 yr
5 yr to <12 yr
12 yr to 18 yr
Female vs. male
Race
White
Asian
Black
Other

OR (95% Wald confidence limits)

P Value

4.9 (1.813.4)
0.9 (0.41.6)
1.1 (0.52.3)
Reference
1.2 (0.52.6)
1.1 (0.71.6)

<0.01
0.73

Reference
3.3 (0.714.4)
1.4 (0.63.0)
1.1 (0.62.0)

0.38

No transfusion ICU Days 12

Absence of shock on admission

Primary admission category

Respiratory
Cardiovascular system
Central nervous system
Other
PELOD score
0
110
11
Chronic conditions
Respiratory
Nonrespiratory

2.6 (1.44.8)
0.4 (0.21.0)

<0.01
0.04

Reference
0.7 (0.41.3)
0.9 (0.51.7)
4.5 (1.910.2)

<0.001

0.5 (0.30.9)
0.6 (0.31.0)
Reference

0.04

1.9
Reference

0.04

Blood loss from blood

draws

Prosedur 325
(33%)

0,25 ml / kg

Spontaneous
233 (24%)
2,56 ml / kg
Inverse relationship :
blood loss/kg and
age

RBC Transfusion
49%

received one or more RBC

transfusions during the PICU stay

6%

received a transfusion after PICU

discharge.

First
transfusion

22% : between Days 2 and 7

4% : > 7 d after admission to PICU

Conclusion
Anemia , blood loss, and transfusions in the PICU
significant.
Efforts to develop guidelines needed
Prospective studies taking into account the data
provided in this large multicenter epidemiologic study
should be undertaken to estimate the clinical impact of
measures aiming to decrease blood draws, to prevent
or treat anemia, and to decrease transfusions for
critically ill children.

Terima kasih