Routine Versus On-Demand Blood Sampling in Critically Ill Patients: A Systematic Review*

Abstract

OBJECTIVES: We aimed to provide an overview of the current evidence on routine versus on-demand blood sampling in critical care. We assessed the reported proportion of patients exposed to daily routine blood sampling, the tests performed, characteristics associated with more frequent blood sampling, and the reported benefits and harms of routine blood sampling compared with on-demand sampling. DATA SOURCES: We systematically searched the Cochrane Library, the Excerpta Medica Database, and the Medical Literature Analysis and Retrieval System Online for studies assessing routine versus on-demand blood testing in critically ill patients from inception to September 2022. STUDY SELECTION: Abstracts and full texts were assessed independently and in duplicate by two reviewers. STUDY EXTRACTION: Data were extracted independently and in duplicate by two reviewers using predefined extraction forms. DATA SYNTHESIS: Of 12,212 records screened, 298 full-text articles were assessed for eligibility. We included 70 studies; 50 nonrandomized interventional studies and 20 observational studies. Exposure to routine blood testing was 52–100% (very low certainty of evidence). Blood testing seemed to occur more frequently in medical intensive care settings with a median of 18 blood tests per patient day (interquartile range, 10–33) (very low certainty of evidence). Mixed biochemistry seemed to be the most frequently performed blood tests across all settings (five tests per patient day; interquartile range, 2–10) (very low certainty of evidence). Reductions in routine blood testing seemed to be associated with reduced transfusion rates and costs without apparent adverse patient outcomes (low certainty of evidence). CONCLUSIONS: In this systematic review, routine blood testing in critically ill patients was common and varied considerably. A reduction in routine blood testing appeared to be associated with reduced transfusion rates and costs without adverse effects, but the evidence was very uncertain.

It Is Time to Effectively Address Unnecessary Laboratory Testing*

“…Basic Bayesian reasoning supports the concept that diagnostic testing should be done only when there is a clinical suspicion of a problem, as in the on-demand arm of the study by Hjortsø et al (1). By definition, 5% of reported test results outside of the reference range (usually, but incorrectly called the "range of normal") are not actually abnormal.…”

“…In this issue of Critical Care Medicine , Hjortsø et al (1) report a systematic review of 70 studies comparing routine (daily) with on-demand diagnostic blood testing in critically ill patients. None were randomized trials, and they had important limitations the authors felt precluded performing meta-analysis, including highly variable outcomes, quality generally rated as very low, and differing definitions of what constitutes a single laboratory evaluation.…”