We have all heard the phrase “it’s the principle of the thing.” This phrase reminds us that in everything we do, including the clinical management of patients, there are both precedents and principles to guide our decision making processes. The principle of “doing the right thing” should be utilized in pediatric blood management and in making evidence based transfusion decisions.
Most of us are familiar with, and may well already be using, a Computerized Provider Order Entry (CPOE) system; which incorporates evidenced based practice (EBP) guidelines in an electronic order entry format. This EBP function is crucial in supporting the clinician’s decision to transfuse, and how much, if any, blood product is appropriate. Decision support systems can also help in areas such as pediatric blood volume management and anemia management. Some pediatric blood conservation centers utilize Electronic Medical Record (EMR) systems to monitor other blood management considerations such as intake and output, utilizing the output feature to monitor lab waste and sampling volumes. The EMR alerts the clinician when, based on the child’s body weight, and a 24-hour time period, the patient has reached maximum blood volume depletion due to sampling. Other centers have created a unique set of guidelines for pediatric lab sampling by which only the amount absolutely indicated is taken, lab tests are batched, and add-ons are encouraged. These strategies work together to promote blood conservation, maintain limited blood volume reserves, and conserve a very precious resource.
As mentioned, another important area where decision making support systems can be helpful is pediatric anemia management. A compelling yet disturbing fact is that red blood cells (RBCs) are the most frequently transfused blood component in children and the primary driver is “frequent blood loss, and iatrogenic losses from repeated phlebotomy” (AABB Technical Manual. 2011, p.665). A too common scenario is the hospitalized child with the Hb/Hct trending down for days and nothing proactive being done to assess and manage the anemia. As the proverbial needle on the gas tank goes down more and more each day, the clinician is ultimately left with only one viable solution: transfusion. What if we were able to utilize the tools at hand, e.g. EMR, to support anemia identification and to manage the anemic patient with erythropoietin stimulating agents or repleting children that are simply iron deficient, with the appropriate strategy, iron supplementation.
A thought leader in pediatric transfusion, Dr. Susan Roseff (2009) commented that “RBCs are not indicated for patients who can be appropriately treated with alternative therapies such as iron for iron–deficient patients” (p.5). EMR based transfusion guidelines can be built to alert clinicians when patients are reaching a critical lab value, the alert is not a trigger for the clinician to transfuse, but a reminder that someone needs to do something to manage the anemia. The track and trend features some EMRs offer can monitor Hb and Hct trends, thus allowing identification, diagnosis, and rapid management of anemia.
As we are all well aware, blood components are not benign intravenous fluids or red colored colloids; blood transfusions are a liquid transplant performed at the patient’s bedside. When we transfuse children we expose them to immune modulatory effects, and for better or for worse, these patients have a lifetime to live through that transfusion exposure. We must carefully weigh the risks and the benefits when considering transfusion therapy; review the evidence that supports appropriate product use, implement pharmacologic options to support red cell growth and build up depleted iron stores, and employ blood conservation strategies to preserve finite and precious blood volumes.
- Roback, J. AABB Technical Manual. 2011 Bethesda, Maryland: AABB.
- Roseff, S. Pediatric Transfusion: A Physician’s Handbook. 2009 Bethesda, Maryland: AABB.