Abstract
BackgroundIntensive care unit (ICU) patients are at high risk of anemia, and phlebotomy is a potentially modifiable source of blood loss. Our objective was to quantify daily phlebotomy volume for ICU patients, including blood discarded as waste during vascular access, and evaluate the impact of phlebotomy volume on patient outcomes.MethodsThis was a retrospective observational cohort study between September 2014 and August 2015 at a tertiary care academic medical-surgical ICU. A prospective audit of phlebotomy practices in March 2018 was used to estimate blood waste during vascular access. Multivariable logistic regression was used to evaluate phlebotomy volume as a predictor of ICU nadir hemoglobin < 80 g/L, and red blood cell transfusion.ResultsThere were 428 index ICU admissions, median age 64.4 yr, 41% female. Forty-four patients (10%) with major bleeding events were excluded. Mean bedside waste per blood draw (144 draws) was: 3.9 mL from arterial lines, 5.5 mL central venous lines, and 6.3 mL from peripherally inserted central catheters. Mean phlebotomy volume per patient day was 48.1 ± 22.2 mL; 33.1 ± 15.0 mL received by the lab and 15.0 ± 8.1 mL discarded as bedside waste. Multivariable regression, including age, sex, admission hemoglobin, sequential organ failure assessment score, and ICU length of stay, showed total daily phlebotomy volume was predictive of hemoglobin <80 g/L (p = 0.002), red blood cell transfusion (p<0.001), and inpatient mortality (p = 0.002). For every 5 mL increase in average daily phlebotomy the odds ratio for nadir hemoglobin <80 g/L was 1.18 (95% CI 1.07–1.31) and for red blood cell transfusion was 1.17 (95% CI 1.07–1.28).ConclusionA substantial portion of daily ICU phlebotomy is waste discarded during vascular access. Average ICU phlebotomy volume is independently associated with ICU acquired anemia and red blood cell transfusion which supports the need for phlebotomy stewardship programs.
Highlights
In the intensive care unit (ICU) blood testing guides diagnosis, monitoring, and titration of invasive therapies
Multivariable regression, including age, sex, admission hemoglobin, sequential organ failure assessment score, and ICU length of stay, showed total daily phlebotomy volume was predictive of hemoglobin
For every 5 mL increase in average daily phlebotomy the odds ratio for nadir hemoglobin
Summary
In the intensive care unit (ICU) blood testing guides diagnosis, monitoring, and titration of invasive therapies. Two studies from inpatient populations show that hospital acquired anemia is a predictor of inpatient mortality [4, 10], suggesting clinicians may inadvertently cause harm through phlebotomy if it contributes to low hemoglobin. Interventions to reduce phlebotomy are generally not linked to patient specific outcomes, fueling the controversy as to whether there is a modifiable link between phlebotomy and harm among hospitalized patients [24,25,26]. Better understanding the drivers of ICU phlebotomy, the potential for patient harm, and developing realistic targets for patient specific outcomes is important for planning, implementing, and evaluating stewardship interventions. Intensive care unit (ICU) patients are at high risk of anemia, and phlebotomy is a potentially modifiable source of blood loss. Our objective was to quantify daily phlebotomy volume for ICU patients, including blood discarded as waste during vascular access, and evaluate the impact of phlebotomy volume on patient outcomes
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