Tuesday, October 10, 2006

Blood

Her baby had been born at 27 weeks gestation and was doing very well. She hadn't needed to be on a ventilator for long and now was cruising on nasal CPAP, which is when we blow air and oxygen into the nose and lungs with a little bit of pressure. The baby's hematocrit (the amount of red blood cells in the blood), though, had become quite low so we gave her a blood transfusion. The mother was a frequent visitor to the NICU and very knowledgeable about her baby's condition, but this day she was late and not there when we decided to transfuse. When she came in to find there had been a transfusion, she struggled to keep her composure but finally couldn't, her face cracking as she began sobbing.

This was a long time ago, at a different hospital where we didn't obtain consent before blood transfusions. Now we do and even if consent has been previously obtained I still try to contact the parents to let them know before a transfusion. Blood transfusions aren't that big of a deal to neonatologists. We do them frequently but not carelessly; they are simply part of our therapeutic armamentarium.

For parents, though, blood transfusions can stir an emotional reaction, even if they're not Jehovah's Witnesses. There's something about receiving another person's blood that really bothers some people. Part of it may be a fear of infections like HIV, but I think it's more than that. I think it's a very personal thing, taking another's blood into your own body. I don't understand it completely, but maybe it's sort of like chewing another person's already chewed gum, or licking their ice cream cone.

Over the past several years neonatologists have tended to be more and more conservative with transfusions, letting a baby's hematocrit drop lower and lower before transfusing them. I have done the same thing, although I have to admit that this practice wasn't always necessarily evidence based. In the past year approximately, two studies have examined the issue. One of them, from Iowa, suggests that this lower threshold for transfusing might not be good. The second study, from Canada and just published, suggests the opposite, that transfusing at lower levels is indeed safe.

Oh well, it's not like this is the first time we've had to deal with contradictory evidence in neonatal medicine. I'll keep transfusing when I think it's best, while all the while looking for better evidence to support my practices, and I'll definitely keep notifying parents before I do.

23 Comments:

Anonymous Anonymous said...

Interesting. When my daughter was born I don't remember giving consent for transfusions, but it's certainly possible that I did. She had many, both red blood and platelets (she was on ECMO). Maybe it was just the fact that she was on ECMO that gave the consent for the transfusions kind of by default. Obviously she needed extra blood to fill up the circuit.

The transfusion part was never upsetting. I guess in the grand scheme of things, that wasn't the thing to worry about.

Love your blog.

Megan

12:49 PM  
Anonymous Anonymous said...

can you provide the citation for the recent Canadian article? Thanks.

1:14 PM  
Anonymous Pine Baroness said...

Speaking as a parent whose child has had a transfusion, it is scary on a very elemental level. When someone is injured, the severity is usually determined by the amount of visible blood (to a layman). The more blood, the worse the injury.
This is something that is learned very young. Scrape your knee, no blood, no problem; scrape your knee lots of blood, cry a lot.

That emotion comes out when you hear your child needs blood. You think OMG it must be worse than I thought - he needs BLOOD!

You get over it, as new problems arise, but that first time - whew!

2:16 PM  
Blogger Laura said...

my son, an ex 24 weeker, received 16 blood transfusions during his 132 day stay. Back then (4+ years ago) the docs in our unit seemed to transfuse more and had a higher threshold hct which is why little man received so many.
For me the transfusions were not so scary...no, the fact that it took ten weeks and three failed attempts to get him off of the vent and those 9 surgeries he has had in his short little lifetime so far have scared me much, much more. Like Megan said, for me, in the grand scheme of things the transfusions were not so scary or upsetting.
Shortly after I noticed in my nursing practice that we were transfusing less and the docs had a more watch and see attitude. We also started giving epo more regularly. Where I am at now we don't give epo much at all and it eem that the thought is coming back to keeping the hct at a certain threshold. It is interesting how the pendulum swings back and forth isn't it?

2:36 PM  
Blogger PaedsRN said...

I'm glad the parents of one of my more recent patients weren't around when he came back from surgery, to be honest. Lots of blood from the airway, and I was giving red cells almost straight away.

We don't routinely obtain consent for transfusions, although during the operative and anaesthetic consents pre-op parents are warned that transfusion is likely (and of course, bypass involves quite a bit of extra blood.) Aside from parents who have clearly stated religious or ideological objections, we pretty much just say "We're going to give some blood now," and explain why.

3:11 PM  
Anonymous Dianne said...

Does epogen play a role in the treatment of anemia in premies or other infants? In adults it is considered safer and is certainly less emotionally laden than giving blood in cases where the indication is marginal.

3:41 PM  
Blogger Dream Mom said...

I don't know enough about neonates as it relates to blood transfusions but I do know I was totally against Dear Son getting a blood transfusion earlier this year when he was on the ventilator with the MRSA pneumonia. It had been a pretty long day when they requested the transfusion. I denied it repeatedly because I was afraid of what he might get from the transfusion. I realize they are "supposed" to be safe but as I told the PICU Attending, I didn't exactly win the gene lottery with Dear Son (referring to his ARX gene defect) so I didn't feel particularly lucky. I asked questions about the blood-where was it from, etc. and no one could answer me. That didn't make me feel any safer. I wanted to donate my own since prior to Dear Son I used to donate blood for neonatal surgeries (they'd call me the day before the surgery to donate) all the time. But that would take a few days to be tested.
I also have never taken any drugs of any kind nor am I on any medications of any kind so I would certainly prefer my own blood to that of a stranger.

The issue for me was that if he got HIV from the blood, then I was forever having to check the box that he had a blood transfusion on any medical questionnaire for the rest of his life. I did not want to live with the stigma of him having HIV or anything else from the blood. I have enough issues to deal with.

I also asked if they had any information on transfusions at Big Academic Medical Center. Nothing was available in the PICU. I would expect that if you want parents to agree to these, then perhaps a question/answer sheet would be helpful. I should point out that I didn't have any internet access in the PICU where I could get any of my concerns answered.

In the end, as he began failing, they begged me for consent and I finally agreed. I figured that although he "might" die from a transfusion, he would definitely die "without" one. I felt bullied into that decision.

In the end, there are things that you do every day. I don't do these things every day and it's difficult when you are in the middle of a serious illness, going without sleep, sleeping on a hospital cot, to make good decisions without any information.

4:15 PM  
Anonymous sarah Furlough said...

When my sons were in the NICU, I remember being upset by many things (though I always felt they were getting the best of care). I don't remember specifically being upset by transfusions (of which they had many), but at any time, any little thing could set me off.

I think as the mother of a premature baby, you feel so much guilt. Maybe this mother felt guilty that her baby had to have another transfusion, another IV, or maybe she just felt guilt about what she could have done to prevent this.

Guilt is a very funny thing, and I don't know if you can ever let it go.

Thanks, Neonatal Doc for letting me see things from the other side.

4:40 PM  
Blogger Bardiac said...

Just a word from the other side, maybe?

I gave blood regularly when I was young, then was deferred for a couple years (there was/is a five year precaution after taking malaria prophylactics). When my dad had heart surgery, I had the same blood type, and the Red Cross arranged to get some of my blood across country for his surgery. My donation was hugely important to me, and he said it meant lots to him as well.

That donation got me donating again regularly. I can't, of course, guarantee that every donor takes donation seriously, but the people I've seen do (lots of us are regulars, and run into each other multiple times), and I think the Red Cross people take testing seriously.

I empathize with the fear, but hope you remember the people who donate hoping to help someone.

5:43 PM  
Blogger Jen said...

Neonatal doc-

What bothered me the most about my Dear Daughter (former 27 weeker) getting her transfusions was that she was supposed to still be inside of me...living off of what I provided her...my blood. Transfusions, while I appreciated did give her much needed help, played on my mommy guilt over having a preemie in the first place.

For me, HIV, hepatitis or any other ailment didn't factor into issues with transfusing.

6:40 PM  
Blogger WendyLou said...

My post written the evening of my daughter's blood transfusion.

http://wendythejellybean.blogspot.com/2006/06/o.html

I agree very much with Jen. She should have still been inside of me. Up to that point I had provided her with everything she had needed for survival (with the exception of the HMF and antibiotics and jaundice lights) I as her mommy should be giving my baby what she needs, not some stranger.

The hospital policies really irked me. We knew for about a week that a transfusion was coming, and they would not let family members donate and go through the regular screening procedure. This includes Sydney's father who is O+. Sydney is A+. It felt like one more way that we were "less than" as a family. One more instance where we could not give her what she needs.

I sat and watched that foreign red substance flow into my precious little baby. I hoped we were doing the right thing. The comment the neo made while giving me informed consent did not help "It's not things like AIDS and Hep that worry me. It's the things that we don't know about that we will learn about in 10 years that worry me." I agree with him there. I'm educated enough to "hope" that the blood supply is safe, and that we are not at the beginning of a new blood born illness which we don't even know about yet.

I am guessing that our neo's subscribe to the "be more and more conservative with transfusions, letting a baby's hematocrit drop lower and lower before transfusing them. " camp. A large part of my mind wonders if DD had received her transfusion earlier, perhaps she would have had more energy to eat and we could have gotten out of the NICU sooner. From what I have read, 95% of babies born at her birth weight need a transfusion, may we should have had her's sooner. I mean, she was anemic from birth.

I also want to add, that I believe now, I got even more worried than I should have, because in my mind, only dying people get blood. The scene from ER where they are squeezing the blood in slower that it is running out comes to mind.

I sat there alone in the NICU that day, praying this transfusion would not harm her, praying the donor was honest, and thanking the Lord for the donor and for medicine to help my baby girl. She was so small, and it seemed like so much blood.

10:52 PM  
Blogger Awesome Mom said...

It is good that you notify parents. My son has recieved a number of tranfusions along with FFP. I never felt shocked. I felt grateful that someone donated blood for him to use. It made me want to give back in the same way and donate blood more often.

1:37 AM  
Blogger Nurse M said...

In our nicu the majority of babies are born via c-section and normally (if dad is involved) he comes down with the transporter with baby while the mom is being closed. In the nicu while the baby is being transferred to a warmer, the neonatologist who was at the delivery updates the dad and all of the consents are given/signed at this point (for blood, lines, ETT, etc).
I worked last night and there was actually an issue with blood donation. It it very typical for our babes to be transfused (of course). The dad was asking about direct donor blood donation and wanted the mother to be able to donate. It was explained to him that the mother can't donate since she just had a baby but if other people in the family were a [healthy] match, they could.
The dad left, with the blood consent signed, but if a direct donor was available then that would be ideal.
I have never run into this, but as a doctor what would your reaction be to a babe with symptomatic anemia (maybe not responding to Epo or Iron) whose family refused to transfuse?

10:02 AM  
Blogger WendyLou said...

This comment has been removed by the author.

3:43 PM  
Blogger WendyLou said...

My link cut off...

http://wendythejellybean.blogspot.
com/2006/06/o.html

No this is not a shameless plug for my website. I think my post has merit to the discussion here

3:45 PM  
Blogger neonataldoc said...

Thanks, everyone. It's fascinating to see the wide variety of thoughts and reactions re blood transfusions. I know guilt plays a big part in the feelings of mothers of NICU babies, but I didn't realize it affected their feeling re transfusions, too. I guess that I, too, think there are bigger things than blood transfusions to be worried about in the NICU.

Anonymous 1:14, the Canadian study is published in the September, 2006 Journal of Pediatrics, volume 149, page 301.

The point about having information re transfusions in the NICU is well taken. I'll have to check to see what we have about it.

Most NICU's I know of don't use epogen anymore. It didn't make that much of a difference, although it's probably a little more complicated thatn that.

8:13 PM  
Blogger Judy said...

We still use epogen with some of our babies, but in the majority of cases, transfusions are still necessary. Bottom line, we're taking samples from the sickest kids faster than the red cells can be replaced with or without epogen.

My husband had bypass surgery several years ago. When they presented him with a separate consent for transfusion, he wanted to refuse. I bullied him into signing. His platelet count was 30,000 at the time. They got it up over 100,000 prior to surgery, but it dropped again -- and his hematocrit was in the low 20's post op. They were very slow letting me into the ICU and when I finally managed to talk my way in, he was getting a transfusion. I got the feeling they didn't want me to see that. The surgical fellow was almost apologetic. I didn't understand that. I suppose some families would object, but I know the statistics for our blood supply. Volunteer donor blood is safer than directed donor blood.

10:59 PM  
Blogger Flea said...

Blood is a great drug. Like all drugs, we ought to be careful with it, but neither should we withhold it without a good reason.

Flea

10:27 AM  
Anonymous Leah said...

I was with my mother when my younger 6 mo sister needed a transfusion - I don't recall actual consent...just a no-nonsense discussion that "this baby needs a transfusion right away...there's risks, you may want to call clergy". And so, my youngest sister was baptised and blessed and then we were scooted out of the room as the crash cart came in. Freaked us out - but felt we had no choice...and we weren't resentful for the brisk words and were thankful for the care she received. Sister was a former 35 weeker that had grown tremendously in 6 months; according to the docs she'd outgrown her blood supply (I think) and was severaly anemic. They considered it a rare event, but 6 weeks later I noticed a memo out to GPs, Peds, etc. with the case profile just as an FYI on former preemies.

12:13 PM  
Anonymous Anonymous said...

The following website summarizes over 200 similar court cases involving Jehovah's Witness Parents who refused life-saving blood transfusions for their children:

DIVORCE, BLOOD TRANSFUSIONS, AND OTHER LEGAL ISSUES AFFECTING CHILDREN OF JEHOVAH'S WITNESSES

http://jwdivorces.bravehost.com/

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