Blood transfusion in neonates- An audit study

Authors : Pradip R Butale, Pradip R Butale, Balawant Kove, Balawant Kove, Shubhangi Jibhakate, Shubhangi Jibhakate

DOI : 10.18231/2581-3706.2019.0003

Volume : 4

Issue : 1

Year : 2019

Page No : 16-21

Introduction

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Fig. 1: Sex distribution among cases with and without transfusion

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Fig. 2: Distribution in transfused and non-transfused

The request for PC was 344 out of which 142 units were utilized, this helped us calculate the cross match to transfusion ratio (CTR) which was found to be 2.42. This falls under the optimum range and is an indicator of
optimum utilization of blood. Table 2 show the distribution of cases according to diagnosis in transfused and non-transfused group.

The total prevalence of blood group in the mothers that were studied reveals O positive as the most frequent blood group (30.3%) followed by B positive (24.5%), A positive (21.7%) and AB positive (11%). The Rh- negative groups were O negative (4.5%), B negative (2.8%), A negative (2.8%) and AB negative (0.7%) in decreasing order of prevalence. In the neonates studied there were equal number
of O positive and A positive (30.1%) followed by B positive (26.3%) and AB positive (9.7%) while the Rh- negative blood groups were O negative (2.8%) followed by A negative (1%) and B negative (0.3%).Table 3 shows the distribution of mothers and neonates according to blood group in transfused and non-transfused group.

The appropriateness of transfusion for packed red cells was observed to be 87.5% which is an indicator of optimum utilization of blood. For platelets the appropriateness of
utilization was 78.9% which is an excellent number in comparison to other studies. The appropriateness of transfusion was statistically significant as shown inFig. 3.

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Fig. 3: Appropriateness of PC and platelet transfusion

There were 7 instances of Rh incompatibility 2.4 %, all of them required transfusion. There were 43 instances of
ABO (14.8%) incompatibility out of which 5 required exchange transfusion. The outcomes of patients who were transfused or not transfused was noted and depicted in Fig.
4. The mortality in the patients that were transfused was much higher (43.2%) than those who did not receive any transfusion at all (8.6%).There was only one minor transfusion reaction (0.37%) reported in the duration of study period which was an allergic and non-hemolytic reaction.

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Fig. 4: Outcomes in transfused and non-transfused neonates

Discussion

The availability of blood and blood component as compared to earlier times have become easier and the advances in technology have made it easier to collect, store, separate and dispense blood. Wastage of   whole blood and blood component are on the rise globally as a result of increase availability. Audit can help to curb this wastage to an extent and save a lot of expenses of the hospital as well as maintain an economy and optimum utilization of blood banking services. Regular audit can provide us with a timely trend of the pattern of utilization of the blood in a specific time period and can help the blood bank identify the need of changes in the inventory. This data can be utilized to outline policies of usage, frequency of blood donation camps to be arranged and number of components to be prepared from collected blood. Audit also help us to prevent undue over utilization of blood, wastage and reduced the number of inappropriate transfusion. Inappropriate transfusion exposes the patient being transfused to multiple donors and in turn to a variety of antigens and also the risk of transfusion transmitted diseases. Most of the audit done earlier include the overall some of the population of patients across all age groups and specialties.

But this was a specific study targeted towards neonates in the specialty of NICU; hence the sample size was smaller as compared to various other studies.^[5],^[6]A lot of guidelines and previous studies^[5],^[6]have taken into account neonates, but under 4 months and not under age group of 28 days as included in present study. There was only a minimal variation when it comes to the distribution of sex of patients admitted in NICU. But, there does exist a male predominance when it comes to the severity and mortality of diseases. The rate of transfusions, complications and death has been reported to higher in males than females in the neonatal population.

The grand total of the entire component required from the NICU was 503 inclusive of all the products including PC, Platelets and FFP. Out of which PC had the highest request (344 patients) followed by platelets (140 patients) and FFP (19 patients). Various other studies had similar finding with respect to pediatric patient except for FFP.^[6],^[7]

The overall instance of single transfusion of a blood product was 52% which was less than found in Deb et al study^[8] while instances of multiple transfusions were 48 % and it is comparable with the study done by Marti-Carvajal et al.^[5]

The cross match to transfusion ratio is an excellent numerical which reflects the efficiency of coordination between the blood banking service and the various clinical departments of the hospital. The present audit study reveals that the cross match to transfusion ratio which was calculated as 2.41 is within the target ratio of ?2.5. This substantiates that there is indeed an optimum utilization of PC in the NICU; this finding was comparable with previous studies.^[9],^[10]Measuring the appropriateness of transfusions involves major constituents of performing an audit. This gives us a measure of the exact instances and percentage of whether the transfusions were given in accordance with the guidelines for transfusion or not. In current study, the appropriateness of transfusions for PC and platelets was 87.5% and 78.9% respectively which was a significantly higher number and is an indicator of optimum transfusion practice by the NICU. Also,   our values of appropriateness/inappropriateness fall within the range as compared to found in various literatures^[6],^[7],^[11]

Individual laboratory investigations which includes hemoglobin, hematocrit, platelet count and bilirubin levels, all had a statistically significant rise after post transfusion indicative of achieving the desirable effect and fulfillment of the purpose for which the transfusions were carried out, be it correction of anemia, thrombocytopenia or reducing bilirubin levels to prevent kernicterus by means of exchange transfusion. There was only one (0.34%) transfusion reaction reported which was a minor allergic, non-hemolytic and non-febrile and is less than reported in various studies.^[12],^[13]There were 7 instances of Rh incompatibility (2.4%); all of them required transfusion with whole blood which was comparable with the study done by Narang et al.^[14] There were 43 instances of ABO (14.8%) incompatibility out of which 5 required exchange transfusion with whole blood and this was compared with the study done by Yigit et al.^[15]

Out of the 69 patients who have received PC in spite of not falling in the recommended guidelines, there were28 deaths (40.57%) this high number can be attributed to the severe degree of illness including sepsis, respiratory distress syndrome (RDS) and birth asphyxia which are associated with high rates of mortality. Most of the neonates which were included in this category did not survive even after transfusion was carried out. Thus we can conclude that these patients who fell under the not needing transfusion category according to the transfusion guidelines ideally cannot be considered as inappropriate. This is because the cross match requests were honored and PC units were issued all the times, but due to associated severity of illness and mortality of the conditions for which requests were made resulted in death even though PC was issued. The mortality in patients who were transfused platelets was 36.84% whereas the death in patients who did not receive platelets was 17.02%. These finding of mortality are consistent with the findings of other authors.^[16],^[17],^[18] Thus the rate of mortality in patients who require transfusion will always be higher as compared to those who do not require transfusion.

Conclusion

The symbiotic relationship between the blood bank and NICU is highlighted in this study. Both the blood bank and NICU are utilizing the available resources for adequate and timely treatment of patients which leads to demonstrable betterment in the clinical outcome and are following the national and the international guidelines for transfusion.

This audit study can be used as a basis for further studies in other tertiary hospitals to establish the Indian data on the same. Such promising figures show adherence to the acceptable national and international guidelines for blood transfusion. It also provides an important tool for the future studies regarding the transfusion practices in an institute at a given point in time and contributes towards the data which can be utilized by transfusion committee to revise and update their transfusion guidelines from time to time.

Conflict of Interest: None.

 

 

 

 

 

 

 

 

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