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Anemia, Blood Loss, and Blood Transfusions in North American Children in the Intensive Care Unit

¹ University of Massachusetts Medical Center, Worcester, Massachusetts; ² CHU Sainte-Justine, Montreal, Canada; ³ Johnson and Johnson Pharmaceutical, Research and Development, Raritan, New Jersey; ⁴ Children's Hospital, Boston, Massachusetts; ⁵ Children's Hospital of Saint Francis, Tulsa, Oklahoma; ⁶ Penn State Children's Hospital, Hershey, Pennsylvania; ⁷ Children's National Medical Center, Washington, DC; ⁸ Children's Hospital of Los Angeles, Los Angeles, California; ⁹ Novo Nordisk, Inc., Princeton, New Jersey; and ¹⁰ Children's Hospital and Research Center Oakland, Oakland, California

Correspondence and requests for reprints should be addressed to Scot T. Bateman, M.D., University of Massachusetts Medical Center, Department of Pediatrics, H5-524, 55 Lake Avenue, North Worcester, MA 01655. E-mail: batemans{at}ummhc.org

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 on consecutive 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 1–2. 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], 1.43–90.9; P = 0.02), nosocomial infections (OR, 1.9; 95% CI, 1.2–3.0; P = 0.004), and cardiorespiratory dysfunction (OR, 2.1; 95% CI, 1.5–3.0; P < 0.001). High blood loss per kilogram body weight from blood draws (OR, 1.11; 95% CI, 1.03–1.2; 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.

Key Words: blood loss • anemia • transfusions • pediatric • intensive care • red blood cells

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject Recent emphasis directed toward minimizing anemia and decreasing transfusions in critically ill adult patients has led to a significant need to better understand the burden of anemia and transfusions in critically ill children. What This Study Adds to the Field Critically ill children are at significant risk for developing anemia and receiving blood transfusions. Transfusion in the PICU was associated with worse outcomes.