A Simple “Blood-Saving Bundle” Reduces Diagnostic Blood Loss and the Transfusion Rate in Mechanically Ventilated Patients

Abstract

IntroductionAim of this study was to reduce blood loss caused by diagnostic blood sampling and to minimize the development of anemia in a high-risk group of mechanically ventilated medical intensive care patients. We therefore implemented a “blood-saving bundle” (BSB) combining a closed-loop arterial blood sampling system, smaller sampling tubes, reduced frequency of blood drawings, and reduced sample numbers.MethodsThe study included all patients from our medical ICU who were ventilated for more than 72 hours. Exclusion criteria were: acute or chronic anemia on admission, bleeding episode(s) during the ICU stay, or end-of-life therapy. The BSB was introduced in 2009 with training and educational support. Patients treated in 2008, before the introduction of the BSB, served as a control group (n = 41, 617 observation days), and were compared with patients treated in 2010 after the introduction of the BSB (BSB group, n = 50, 559 observation days). Primary endpoints were blood loss per day, and development of anemia. Secondary endpoints were numbers of blood transfusions, number of days on mechanical ventilation, and length of the ICU stay.ResultsMean blood loss per ICU day was decreased from 43.3 ml (95% CI: 41.2 to 45.3 ml) in the controls to 15.0 ml (14.3 to 15.7 ml) in the BSB group (P < 0.001). The introduction of a closed-loop arterial blood sampling system was the major contributor to this effect. Mean hemoglobin concentrations showed no significant differences in both groups during the ICU stay. Hemoglobin values <9 g/dl, however, were recorded in 21.2% of observation days in the controls versus 15.4% in the BSB group (P = 0.01). Units of transfused red blood cells per 100 observation days decreased from 7 to 2.3 (P < 0.001). The mean number of ventilation days was 7.1 days (6.1 to 8.3 days) in the controls and 7.5 days (6.6 to 8.5 days) in the BSB group (P = NS). In total, patients in the BSB group stayed in ICU for a mean of 9.9 days (8.6 to 11.3 days), compared to a mean ICU stay of 13.0 days (10.9 to 15.4 days) in the control group (P = 0.014). Due to the longitudinal study design, however, we cannot exclude uncontrolled confounders affecting the transfusion frequency and mean ICU stay.ConclusionOur BSB could be easily implemented and was able to reduce diagnostic blood loss.

Interventions to prevent iatrogenic anemia: a Laboratory Medicine Best Practices systematic review

“…Four studies [36–39], all rated as fair quality, examined the impact of implementing multiple interventions at once (bundled interventions). The study population was adult ICU patients for three studies [36, 38, 39] and children with parapneumonic effusion for the fourth study [37].…”

“…Four studies [36–39], all rated as fair quality, examined the impact of implementing multiple interventions at once (bundled interventions). The study population was adult ICU patients for three studies [36, 38, 39] and children with parapneumonic effusion for the fourth study [37]. The intervention bundles observed in the evidence base were:Small volume tubes, a closed blood sampling device, and decision tools, such as flow charts providing the amount of blood to draw for various tests [36];Small volume tubes, a closed blood sampling device, and non-invasive testing methods [39];Small volume tubes and a closed blood sampling device [38]; andA policy to minimize phlebotomy, microsample blood collection tubes, and reinfusion of blood drawn prior to obtaining a sample [37].…”

Factors influencing the bias between blood gas analysis versus central laboratory hemoglobin testing. A secondary analysis of a randomized controlled trial

“…Prior to RBC transfusion, the physician evaluates if there are possible transfusion triggers such as low Hb values, hypotension, tachycardia or lactatemia. In these settings, particularly in intensive care units where Hb is frequently determined [ 23 , 24 ], measurements with BGA is recommended since less blood volume is required, turn-around time is faster, and stable results for Hb can be observed. Blood sparing methods consequently lead to fewer RBC transfusions and shorter duration of stay in the intensive care unit [ 23 ].…”

“…In these settings, particularly in intensive care units where Hb is frequently determined [ 23 , 24 ], measurements with BGA is recommended since less blood volume is required, turn-around time is faster, and stable results for Hb can be observed. Blood sparing methods consequently lead to fewer RBC transfusions and shorter duration of stay in the intensive care unit [ 23 ]. Unfortunately, noninvasive methods tended to be inferior to invasive BGA [ 8 , 24 ].…”

Implementation of a Blood-Saving Program in a Pediatric Intensive Care Unit to Reduce Diagnostic Blood Loss

“…PICU patients with central venous catheters or arterial lines in place had a higher number of blood draws than children with peripheral venous lines only [1]. In high-risk patients, who require central venous catheters or arterial lines for monitoring purpose, blood conservation devices which limit discarded blood by a port integrated into the arterial or venous line should be used instead of taking blood from stopcocks [18,21,22].…”