Pediatric blood transfusion practices at a regional referral hospital in Kenya

Abstract

BACKGROUNDSevere anemia in children is a major public health problem in sub‐Saharan Africa. In this study we describe clinical and operational aspects of blood transfusion in children admitted to Coast Provincial General Hospital, Kenya.STUDY DESIGN AND METHODSThis was an observational study where over a 2‐year period, demographic and laboratory data were collected on all children for whom the hospital blood bank received a transfusion request. Clinical data were obtained by retrospective review of case notes over the first year.RESULTSThere were 2789 requests for blood for children (median age, 1.8 years; interquartile range [IQR], 0.6‐6.6 years); 70% (1950) of the samples were crossmatched with 85% (1663/1950) issued. Ninety percent (1505/1663) were presumed transfused. Median time from laboratory receipt of request to collection of blood was 3.6 hours (IQR, 1.4‐12.8 hr). Case notes of 590 children were reviewed and median pretransfusion hemoglobin level was 6.0 g/dL (IQR, 4.2‐9.1 g/dL). Ninety‐four percent (186) were transfused “appropriately” while 52% (120) were transfused “inappropriately.” There was significant disagreement between the clinical and laboratory diagnosis of severe anemia (exact McNemar's test; p < 0.0001). Antimalarials were prescribed for 65% (259) of children who received blood transfusions but only 41% (106) of these had a positive blood film.CONCLUSIONIn this setting, clinicians often order blood based on the clinical impression of “severe anemia.” This has implications for laboratory workload and the blood supply itself. However, the majority of children with severe anemia were appropriately transfused. The use of antimalarials with blood transfusions irrespective of blood film results is common practice.

High rate of inappropriate blood transfusions in the management of children with severe anemia in Ugandan hospitals

“…Our findings are similar to those of a Kenyan study that retrospectively reviewed transfusion requests from the paediatric ward of a tertiary hospital to the blood bank [ 12 ]. The authors found that 52% of the blood transfusions were requested based on clinical judgement without laboratory confirmation of the anemia.…”

“…In this study laboratory results were disregarded and at least 16% of the patients were transfused inappropriately with pre-transfusion Hb > 6 g/dl. This was lower than the 46% reported in children transfused with Hb > 6 g/dl in the Kenyan study [ 12 ]. The main reason given by the clinicians for none-adherence to blood transfusion guidelines was that some of the SA children present late and in critical condition so they prioritised giving blood transfusion without waiting for Hb testing or Hb result.…”

“…However, adherence to the guidelines is variable [ 11 ]. Blood transfusions are often given without laboratory confirmation of Hb level [ 12 ] or documented indications [ 13 ], and patients with indications for transfusions are not given blood [ 14 ]. Most of the studies that examined clinical use of blood amongst children have done so in children with a known pre-transfusion Hb level [ 4 , 6 , 15 ] usually under controlled research settings [ 11 ].…”

Adherence to clinical guidelines for use of blood components at a tertiary hospital in Ghana

“…These data need to be interpreted cautiously since it is difficult to gauge the appropriateness of clinical decisions from patients notes due to limited detail; however, these results are similar to those from a study in Malawi that used an independent clinician‐observer to judge the appropriateness of transfusion decisions against guidelines in real‐time, where 44% of transfusion decisions were not in accordance with guidelines . Inappropriate transfusions may arise from problems with speed or accuracy of laboratory haemoglobin results , but in our study, the accuracy and turnaround time of haemoglobin tests was perceived as satisfactory. Despite the majority of clinicians stating that they were reasonably knowledgeable and confident in their transfusion practice, there were wide variations in the haemoglobin triggers they used to guide transfusion practice which were at variance with those in the national guidelines.…”

Blood Transfusion Delay and Outcome in County Hospitals in Kenya

“…In Kenyan health facilities, blood transfusion is mostly performed to treat malaria-associated anemia, severe acute malnutrition, and sickle cell anemia patients and to replenish massive blood loss in the course of childbirth, accident, or surgery. 14 , 28 Our analysis focused on inpatient pediatric wards with information collected on admissions' symptoms and signs, orders for blood transfusion, date blood transfusion prescribed, date blood transfusion given, hemoglobin results, admission diagnoses, and final outcome at discharge. In these settings, transfusion orders are for whole blood or much less commonly packed red cell.…”