RBC storage and avoiding hyperkalemia from transfusions to neonates & infants.

A “benchmark” is a standard or measure by which others can be assessed and/or compared. Benchmarking is the process of gathering information (ie, data and/or expert opinions) to set the benchmark. The greater the care, precision and validation taken during the benchmarking process, the more accurately the benchmark will reflect the optimal practices/issues in question and, in turn, allow the best point of reference for comparing/judging/instructing/advising others. In this issue of Transfusion, Fung et al report results of a benchmarking survey performed by the University HealthSystem Consortium (UHC) to assess the acceptability of various RBC anticoagulant/storage solutions and to determine the existence, or lack thereof, of policies to avoid possible hyperkalemia during RBC transfusions given to infants at member institutions.(1) The authors state in the title that this is a “benchmarking study” — which by convention implies that the results will serve as a standard by which others may be measured and/or as a point of reference from which other measurements can be made. Although the need to establish benchmarks for the issues raised (ie, RBC anticoagulant/storage solutions for infant transfusions and policies to avoid potential problems with transfusion-induced hyperkalemia) are well stated in the introduction by Fung et al,(1) the limitations/shortcomings of the benchmarking survey are multiple (as pointed-out by the authors in the discussion section). Thus, the extent to which the findings, conclusions and recommendations of Fung et al should be directly applied to neonatal/infant transfusion practices can be questioned. The basis for my opinion pertaining to limitations/shortcomings, is summarized by the following critical points — many of which were mentioned by the authors themselves,(1) but warrant emphasis here. First, response to the survey by institutions surveyed was only modest (47 of 107 UHC members = 44% for the RBC anticoagulant/preservative section and 45 of 107 = 42% for the hyperkalemia section), with no explanation offered as to why nonresponders failed to reply — other than mentioning that only 77 UHC members are “benchmarking program members” and noting that “no attempt was made at increasing response rate” beyond a few modest efforts.(1) Because UHC members are academic medical centers, one might assume that their practices would be as “evidence-based” as possible. Accordingly, to avoid possible misinformation due to reporting bias, more efforts should have been made to increase response rates to get a complete and accurate picture of member practices — to establish benchmarks that most likely reflect best/optimal practices. Second, one should question whether the most knowledgeable people completed the survey. The respondents were not neonatologists/pediatricians and only 21% were transfusion/pathology physicians. The remaining 79% of respondents were supervisors/managers/administrators.(1) Although these non-physician respondents can review blood bank/laboratory policies/procedures to answer survey questions, it is likely that they will not have in depth knowledge of transfusion practice guidelines/policies of the Departments of Pediatrics and Neonatology Divisions or of the Departments of Nursing. Moreover, they likely will not be familiar with the preferences/practices of physicians prescribing RBC transfusions for infants — particularly pertaining to potassium concerns. Third, to extend the second point, collecting data for which RBC anticoagulant/preservative solutions are “acceptable” provides only limited benchmarking data. For purposes of planning educational programs and recommending evidence-based guidelines/practices, it would be much more informative to know which anticoagulant/preservative solutions are “preferred” and, in the many institutions accepting multiple solutions, what percentage of RBC transfusions are actually given with the “accepted” anticoagulant/preservative solutions. In 19 of 47 responding institutions, four or five different anticoagulant/preservative solutions were “acceptable” with no indication as to which one(s) the prescribing physicians preferred and/or to what extent RBCs stored in different solutions were transfused. Simply acknowledging a solution is “acceptable” does not mean it is preferred or even actually used at an institution. Fourth, no mention is made as to how, or even whether, the survey answers were validated for completeness or accuracy. The authors stated that although no formal validation was performed, all participating UHC members were given opportunities to review and make corrections after close of the survey.(1) It would have increased credibility to report the number/percentage of UHC members who actually did review the completed survey and made corrections — and, in particular, to document whether answers to the survey were ever reviewed by physicians and nurses actually involved in RBC transfusions given to infants. Regarding the acceptability of anticoagulant/preservative solutions, the authors state that the decision to transfuse RBCs stored in additive solutions (AS-1, AS-3, AS-5) should be made by the medical director of the transfusion service, in consultation with institutional neonatologists — a point with which all would agree. The authors then make a rather feeble case for recommending RBCs stored in additive solutions as the best practice for low volume (<20 mL/kg) transfusions given to infants and, then, mention the “boilerplate” comment that because there is not universal acceptance for this practice, there may be need for more education or more substantive evidence-based safety data. Were my mentor of years ago, at the Children’s Hospital Research Foundation in Cincinnati, to hear this last oft-used phrase about need for more education and data, he would exclaim “BALDERDASH!! Data are available, so educate!!” — a comment with which I fully agree. As previously reviewed(2–6), a great deal of data exist in peer-reviewed journals to establish both the efficacy and safety of transfusing RBCs stored in additive solutions for low/small volume transfusions (generally 10–15 mL/kg) to neonates/infants. Moreover, there are no definitive data to establish superior efficacy and/or safety of RBCs stored in CPD or CPDA (citrate-phosphate-dextrose-adenine) solutions — the ones often demanded by neonatologists — over RBCs in additive solutions for low/small volume transfusions. Accordingly, there is no scientific/medical justification for physicians to insist on RBCs stored in CPD or CPDA for low/small volume transfusions given to neonates/infants, and it is an unwarranted use of institutional resources for blood banks to maintain separate RBC inventories for infants needing such transfusions.