Results
In this retrospective cohort study, data was abstracted from the electronic medical record of patients who are between ages 1 and 18, diagnosed with thalassemia, and received PRBC red transfusions at Children’s Minnesota during 2021 as part of their health maintenance. The study was approved by the Institutional Review Board at Children’s Minnesota and a waiver of consent was provided. Demographic and clinical characteristics including organ function were collected. For each transfusion day, total volume infused per kilogram, and total time for transfusion were calculated. Vital signs at 15 minutes and at end of transfusion (temperature, heart rate, blood pressure, and respiratory rate) were reviewed for all transfusions; frequency of vital sign measurements was determined by institutional policy. The number of times vital signs were outside normal limits for age were identified according to the American Heart Association’s Pediatric Advanced Life Support course manual.5 Additionally the percentage that the vital sign was over the norm for age was also calculated.
Twenty-one patients met the study criteria and are summarized in Table 1. All patients had a diagnosis of either alpha or beta transfusion dependent thalassemia requiring at least 8 transfusions per year. Transfusions were given every 3-5 weeks as part of their chronic transfusion program when they were at their baseline health status in our infusion center, not in an acute care setting. Institutional thalassemia care guidelines used in the ongoing care and monitoring of patients with thalassemia at Children’s Minnesota are based on guidelines from both the Northern California Comprehensive Thalassemia Center6 and the Thalassaemia International Federation7. Results of organ function monitoring are summarized in Table 1.
As seen in Table 2, there was a mean of 13.1 transfusions per patient during 2021. Transfusion time each transfusion day averaged just over 2 hours with a mean transfusion volume of 18.7 mL/kg. Among the 21 patients included in this cohort, there was a total of 276 transfusions that were reviewed. The number of times that heart rate, blood pressure, or respiratory rate were outside of the parameters for age, as defined by the American Heart Association,6 were low (Table 2). When vital signs were elevated, the average percentage over the norm for age was also low at approximately 4% (Table 2). One patient experienced hives as a reaction during one PRBC transfusion. All patients were stable throughout their outpatient transfusions and were discharged to home.
The AABB mandates that PRBC transfusions be completed with a 4 hour time period and the rate of infusion can be as rapid as the patient can tolerate.4 To our knowledge, we are the first to report that children or adolescents with thalassemia, who is otherwise medically well, can safely tolerate infusion rates of 10 mL/kg/hr. Implementation of this clinical practice promotes the effective utilization of the patients’, families’, and institution’s time and resources. Clinical sites implementing this changes as a quality improvement project, may consider measuring the patient and/or family’s quality of life and resource utilization pre and post clinical change. While this recommendation should not be applied broadly to children who are acutely ill, have unclear etiology for their anemia, or have underlying cardiac or pulmonary conditions, when used in appropriate patient population this change can decrease the burden of living with a chronic illness for patients and their families.