VARIATIONS IN TRANSFUSION PRACTICE IN NEONATAL INTENSIVE-CARE

Objective. To compare the transfusion practices between two neonatal i ntensive care units (NICUs) to assess the impact of local practice sty les on the timing, number, and total volume of packed red cell transfu sions in very low birth weight infants. To derive multivariate models to describe practice and to identify potential areas for improvement i n the future. Methodology. We reviewed phlebotomy losses and transfusi on rates between two NICUs (A and B) for 270 consecutive admissions of birth weight <1500 g. We stratified for birth weight and for illness severity by the Score for Neonatal Acute Physiology (SNAP). Measures o f short-term outcome were compared. We derived multivariate models to describe and compare the practices in the two NICUs. Results. Patients in NICU A had smaller phlebotomy losses than those in NICU B. A lower percentage of the patients in NICU A (65% vs 87%) received transfusio ns, but they tended to receive a greater total volume per kg per patie nt (67 mL/kg vs 54.8 mL/kg). Transfusion timing differed between the N ICUs; in NICU A only approximately one-half of their transfusions occu rred in the first 2 weeks, whereas in NICU B almost 70% of the transfu sions were given in this time period. Multivariate models showed that phlebotomy losses were significantly related to lower gestational age (GA) and higher SNAP. Hospitalization in NICU B resulted in 10.7 cc of additional losses relative to NICU A for a comparable GA and illness severity score. The volume of blood transfused per kilogram of body we ight was a function of GA, SNAP, and hospital. Care practices in NICU A added an additional 19 cc of transfused volume in the first 14 days of life, and an additional 26 cc thereafter when adjusted for GA and S NAP. These differences in phlebotomy and transfusion were not associat ed with differences in the days of oxygen therapy or mechanical ventil ation, the oxygen requirement at 28 days, the incidence of chronic lun g disease, or the rate of growth by day 28. Conclusions. We identified significant differences in phlebotomy and transfusion practices betwe en two NICUs. We found no differences in short-term outcome, suggestin g that the additional use of blood in one of the NICUs was discretiona ry rather than necessary. Our multivariate models can be used to chara cterize and quantify transfusion and phlebotomy practices. By predicti ng which patients are likely to require multiple transfusions, clinici ans can target patients for erythropoietin therapy and identify those patients for whom donor exposure can be reduced by a unit of blood for multiple use. The models may help in monitoring changes in practice a s they occur.