Iatrogenic blood loss in critical care: A prospective observational study conducted at Universitas Academic Hospital in the Free State Province, South Africa
Article Sidebar
Main Article Content
Abstract
Background. Prevention of iatrogenic blood loss is an essential component of patient blood management (PBM) in intensive care units (ICUs). The amount of iatrogenic blood loss from diagnostic phlebotomy in the ICUs at Universitas Academic Hospital, Free State Province, South Africa, is unknown.
Objective. To quantify diagnostic phlebotomy volumes, and volumes submitted in excess for diagnostic testing in the ICU.
Methods. We conducted a prospective descriptive observational study on adults who were admitted to ICUs at a single centre over a period of 14 days. The weight of each filled phlebotomy tube was calculated using the specific gravity of blood and averages of empty phlebotomy tubes, establishing the total volume.
Results. Data from 59 participants with a median length of stay at the ICU of 3 days were analysed. The median phlebotomy volume was 7.0 mL day and 13.6 mL/ICU admission. The volume of blood required for analysis daily and ICU admission was 0.7 mL and 2.2 mL, respectively. The median phlebotomy volume in excess of the amount required for analysis daily and ICU admission was 5.05 mL and 12.11 mL, respectively.
Conclusion. While the median excess daily phlebotomy volume in this present study may seem insignificant and underestimating the true excess of phlebotomy volume, interventions to reduce phlebotomy volumes and development of a PBM guideline for appropriate phlebotomy volumes and preventing wastage of patients’ blood in the ICU is required.
Article Details
Issue
Section
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
The SAJCC is published under an Attribution-Non Commercial International Creative Commons Attribution (CC-BY-NC 4.0) License. Under this license, authors agree to make articles available to users, without permission or fees, for any lawful, non-commercial purpose. Users may read, copy, or re-use published content as long as the author and original place of publication are properly cited.
Exceptions to this license model is allowed for UKRI and research funded by organisations requiring that research be published open-access without embargo, under a CC-BY licence. As per the journals archiving policy, authors are permitted to self-archive the author-accepted manuscript (AAM) in a repository.
How to Cite
References
Bodley T, Chan M, Levi O, et al. Patient harm associated with serial phlebotomy and blood waste in the intensive care unit: A retrospective cohort study. PLoS One 2021;16(1):e0243782. https:// doi.org/10.1371/journal.pone.0243782
Vincent JL, Baron JF, Reinhart K, et al. Anaemia and blood transfusion in critically ill patients. JAMA 2002;288(12):1499-1507. https://doi.org/10.1001/jama.288.12.1499
Corwin HL, Gettinger A, Pearl RG, et al. The CRIT Study: Anaemia and blood transfusion in the critically ill – current clinical practice in the United States. Crit Care Med 2004;32(1):39-52. https://doi.org/10.1097/01.ccm.0000104112.34142.79
Athar MK, Puri N, Gerber DR. Anaemia and blood transfusions in critically ill patients. J Blood Transf 2012;2012:629204. https://doi.org/10.1155/2012/629204
Shander A, Javidroozi M, Ozawa S, Hare GMT. What is really dangerous: Anaemia or transfusion? Br J Anaesth. 2011;107(Suppl 1):i41-i59. https://doi.org/10.1093/bja/aer350
Vincent JL. Which carries the biggest risk: Anaemia or blood transfusion? Transfus Clin Biol 2015;22(3):148-150. https://dx.doi.org/10.1016/j.tracli.2015.05.001
Isbister JP, Shander A, Spahn DR, Erhard J, Farmer SL, Hofmann A. Adverse blood transfusion outcomes: Establishing causation. Transfus Med Rev 2011;25(2):89-101. https://doi.org/10.1016/j. tmrv.2010.11.001
Roubinian NH, Escobar GJ, Liu V, et al. Trends in red blood cell transfusion and 30-day mortality among hospitalised patients. Transfusion 2014;54(10 Pt 2):2678-2686. https://doi.org/10.1111/ trf.12825
Chant C, Wilson G, Friedrich JO. Anaemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: A cohort study. Crit Care 2006;10(5).R140. https:// doi.org/10.1186/cc5054
Harber CR, Sosnowski KJ, Hegde RM. Highly conservative phlebotomy in adult intensive care – a prospective randomised controlled trial. Anaesth Intensive Care 2006;34(4):434-437. https://doi. org/10.1177/0310057X0603400414
Briggs EN, Hawkins DJ, Hodges AM, Monk AM. Small volume vacuum phlebotomy tubes: A controlled before-and-after study of a patient blood management initiative in an Australian adult intensive care unit. Crit Care Resusc 2019;21(4):251-257. https://ccr.cicm.org.au/file/download- article?id=1f8de85c-8374-424d-801f-70ab2b68f792&settings=litnzgC1RAsiHS43rCo4xrLtlEqu0 qUr8NMbjrCw2VY%3D (accessed 20 April 2022).
Leahy MF, Hofmann A, Towler S, et al. Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: A retrospective observational study in four major adult tertiary-care hospitals. Transfusion 2017;57(6):1347-1358. https://doi. org/10.1111/trf.1400617
Meybohm P, Richards T, Isbister J, et al. Patient blood management bundles to facilitate implementation. Transfus Med Rev 2017;31(1):62-71. https://doi.org/10.1016/j.tmrv.2016.05.012 14. Thomson J, Hofmann A, Barrett CA, et al. Patient blood management: A solution for South
Africa. S Afr Med J 2019;109(7):471-476. https://doi.org/10.7196/SAMJ.2019.v109i7.13859
Trudnowski RJ, Rico RC. Specific gravity of blood and plasma at 4 and 37 degrees. Clin Chem 1974;20(5):615-616. https://doi.org/10.1093/clinchem/20.5.615
Harris PA, Taylor R, Minor BL, et al. The REDCap Consortium: Building an international community of software platform partners. J Biomed Inform 2019;95:103208. https://doi.org/10.1016/j.jbi.2019.103208
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42(2):377-381. https://doi.org/10.1016/j. jbi.2008.08.010
Holland J, Peralta RM, Moss RL, Feane K, Uprichard J. A single-centre review of iatrogenic anaemia in adult intensive care. Transfus Med 2020;30(3):196-200. https://doi.org/10.1111/ tme.126740
Thavendiranathan P, Bagai A, Ebidia A, Detsky AS, Choudhry NK. Do blood tests cause anaemia in hospitalised patients? The effect of diagnostic phlebotomy on haemoglobin and haematocrit levels. J Gen Intern Med 2005;20(6):520-524. https://doi.org/10.1111/j.1525-1497.2005.0094.x
Tosiri P, Kanitsap N, Kanitsap A. Approximate iatrogenic blood loss in medical intensive care patients and the causes of anaemia. J Med Assoc Thai 2010;93(Suppl 7):S271-S276. https://www. semanticscholar.org/paper/Approximate-iatrogenic-blood-loss-in-medical-care-Tosiri-Kanitsap/ 31acaaf63b8eb4234377048f07de0ba1fa11c833 (accessed 24 January 2022).
Lyon AW, Chin AC, Slotsve GA, Lyon ME. Simulation of repetitive diagnostic blood loss and onset of iatrogenic anaemia in critical care patients with a mathematical model. Comput Biol Med 2013;43(2):84-90. https://doi.org/10.1016/j.compbiomed.2012.11.008
Yao R, Wu G, Xu L, et al. Diagnostic blood loss from phlebotomy and hospital acquired anaemia in patients with severe burns. Burns 2020;46(3):579-588. https://doi.org/10.1016/j. burns.2019.08.020
Jackson Chornenki NL, James TE, Barty R et al. Blood loss from laboratory testing, anaemia, and red blood cell transfusion in the intensive care unit: A retrospective study. Transfusion 2020;60(2):256-261. https://doi.org/10.1111/trf.1564930
Corwin HL, Parsonnet KC, Gettinger AG. RBC transfusion in the ICU. Is there a reason? Chest 1995;108(3):767-771. https://doi.org/10.1378/chest.108.3.767
Humble RM, Hounkponou HG, Krasowski MD. The ‘rainbow’ of extra blood tubes – useful or wasteful practice? JAMA Intern Med 2017;177(1):128-129. https://doi.org/10.1001/ jamainternmed.2016.6834
Sanchez-Giron F, Alvarez-Mora F. Reduction of blood loss from laboratory testing in hospitalised adult patients using small-volume (paediatric) tubes. Arch Pathol Lab Med 2008;132(12):1916- 1919. https://doi.org/10.5858/132.12.1916
Siegal DM, Belley-Cote E, Arnold DM, et al. Small-volume tubes to reduce anaemia and transfusion (STRATUS): A pragmatic stepped wedge cluster randomised trial. Blood 2019;134(Suppl 1):3685. https://doi.org/10.1182/blood-2019-130257
Wu Y, Spaulding AC, Borkar S, et al. Reducing blood loss by changing to small volume tubes for laboratory testing. Mayo Clin Proc Innov Qual Outcomes 2021;5(1):72-83. https://doi. org/10.1016/j.mayocpiqo.2020.08.007
Choosing Wisely, Critical Care Societies Collaborative – Critical Care. Five things physicians and patients should question (reviewed 2021). https://www.choosingwisely.org/societies/critical-care- societies-collaborative-critical-care/ (accessed 25 January 2022).