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Patterson JA, Bowen JR, Francis S, Ford JB. Comparison of neonatal red cell transfusion reporting in neonatal intensive care units with blood product issue data: a validation study. BMC Pediatr 2018; 18:86. [PMID: 29475432 PMCID: PMC5824461 DOI: 10.1186/s12887-018-1005-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 01/23/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Infants in Neonatal Intensive Care Units represent a heavily transfused population, and are the focus of much research interest. Such research commonly relies on custom research databases or routinely collected data. Knowledge of the accuracy of transfusion recording in these databases is important. This study aims to assess the reporting of red blood cell transfusion neonatal intensive care unit data compared with routinely collected hospital blood bank ("Blood Watch") data. METHODS Blood Watch data was linked with the NICUS Data Collection, and with routinely collected birth and hospital data for births between 2007 and 2010. The sensitivity, specificity, and positive and negative predictive values for transfusion were calculated, compared to the Blood Watch data. The agreement between the NICUS and Blood Watch datasets on quantity transfused was also assessed. RESULTS Data was available on 3934 infants, of which 16.2% were transfused. Transfusion was reported in the NICUS Data Collection with high specificity (98.3%, 95% confidence interval (97.8%,98.7%)), but with some under-enumeration (sensitivity 89.2% (95% CI 86.5%,91.5%)). There was excellent agreement between the NICUS and Blood Watch datasets on quantity transfused (Kappa 0.90, 95% CI (0.88,0.92)). Transfusion reporting in the hospital data for these infants was also reliably reported (Sensitivity 83.7% (95% CI 80.6%,86.5%), specificity 99.1% (95% CI 98.7%,99.4%)). CONCLUSIONS Transfusion is reliably reported in the neonatal intensive care unit data, with some under-reporting, and quantity transfused is well recorded. The NICUS Data Collection provides useful information on blood transfusions, including quantity of blood transfused in a high risk population.
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Affiliation(s)
- Jillian A Patterson
- Clinical and Population Perinatal Health Research, Kolling Institute, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia. .,Sydney Medical School Northern, University of Sydney, Sydney, Australia.
| | - Jennifer R Bowen
- Sydney Medical School Northern, University of Sydney, Sydney, Australia.,Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
| | - Sally Francis
- BloodWatch Program, NSW Clinical Excellence Commission, Sydney, NSW, 2000, Australia
| | - Jane B Ford
- Clinical and Population Perinatal Health Research, Kolling Institute, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia.,Sydney Medical School Northern, University of Sydney, Sydney, Australia
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Howarth C, Banerjee J, Aladangady N. Red Blood Cell Transfusion in Preterm Infants: Current Evidence and Controversies. Neonatology 2018; 114:7-16. [PMID: 29550819 DOI: 10.1159/000486584] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/04/2018] [Indexed: 01/21/2023]
Abstract
The current evidence regarding the indication, advantages and risks of red blood cell transfusion (RBCT) for preterm infants is discussed. This is an important area in Neonatology to be examined given that 90% of extremely low birth weight infants receive RBCT and many controversies remain regarding when to transfuse and the risks of RBCT. The various treatment thresholds and guidelines used are presented and we compare the short-term clinical benefits of liberal and restrictive RBCT in preterm infants; the majority of these are equivocal and sadly long-term outcome data is limited. The latest evidence on how anaemia and blood transfusion affect organ perfusion in preterm infants is presented. This is important when trying to establish the optimal trigger threshold for RBCT in preterm infants, especially because the knowledge about the adaptive physiological responses to anaemia in very low birth weight infants and the effects of RBCT at various levels of anaemia is also inadequate. Further research into the physiological adaptive response to anaemia of varying degrees and to RBCT at different levels of anaemia in preterm infants of different gestational and post-natal ages is needed before we can conclusively guide the optimal timing and trigger thresholds for RBCT in preterm infants.
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Affiliation(s)
- Claire Howarth
- Homerton University Hospital NHS Foundation Trust, London, United Kingdom
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53
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Andersen CC, Hodyl NA, Kirpalani HM, Stark MJ. A Theoretical and Practical Approach to Defining "Adequate Oxygenation" in the Preterm Newborn. Pediatrics 2017; 139:peds.2016-1117. [PMID: 28325811 DOI: 10.1542/peds.2016-1117] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2016] [Indexed: 11/24/2022] Open
Abstract
John Scott Haldane recognized that the administration of supplemental oxygen required titration in the individual. Although he made this observation in adults, it is equally applicable to the preterm newborn. But how, in practice, can the oxygen requirements in the preterm newborn be determined to avoid the consequences of too little and too much oxygen? Unfortunately, the current generation of oxygen saturation trials in preterm newborns guides saturation thresholds rather than individual oxygen requirements. For this reason, we propose an alternate model for the description of oxygen sufficiency. This model considers the adequacy of oxygen delivery relative to simultaneous consumption. We describe how measuring oxygen extraction or the venous oxygen reservoir could define a physiologically based definition of adequate oxygen. This definition would provide a clinically useful reference value while making irrelevant the absolute values of both oxygen delivery and consumption. Additional trials to test adjunctive, noninvasive measurements of oxygen status in high-risk preterm newborns are needed to minimize the effects of both insufficient and excessive oxygen exposure.
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Affiliation(s)
- Chad C Andersen
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia; .,Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia; and
| | - Nicolette A Hodyl
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia.,Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia; and
| | - Haresh M Kirpalani
- Neonatal Division, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael J Stark
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia.,Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia; and
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54
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Dani C, Poggi C, Gozzini E, Leonardi V, Sereni A, Abbate R, Gori AM. Red blood cell transfusions can induce proinflammatory cytokines in preterm infants. Transfusion 2017; 57:1304-1310. [PMID: 28295397 DOI: 10.1111/trf.14080] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/28/2016] [Accepted: 01/06/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The risk of developing red blood cell (RBC) transfusion-associated necrotizing enterocolitis (TANEC) in preterm infants has recently been emphasized. Our aim was to assess changes in cytokine serum levels after RBC transfusions in a cohort of very preterm infants to evaluate their possible proinflammatory effect. STUDY DESIGN AND METHODS We carried out a prospective observational study. One transfusion event was studied in infants less than 32 weeks' gestation and more than 7 days old (n = 20) admitted to a tertiary neonatal intensive care unit. Interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor-α, interferon-γ (IFN-γ), IL-17, monocyte chemoattractant protein-1 (MCP-1), interferon-γ-induced protein 10 (IP-10), intracellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule serum levels were measured in enrolled patients within 120 minutes before (T0 ) the RBC transfusion and then within 120 minutes (T1 ), 12 ± 3 hours (T2 ), 24 ± 6 hours (T3 ), and 48 ± 6 hours (T4 ) after the end of RBC transfusion. RESULTS Infants received 19.8 ± 3.0 mL of RBCs at the mean age of 50 ± 18 days. Their hematocrit level increased from 24.1 ± 1.2% to 39.4 ± 2.9%. IL-1β, IL-8, IFN-γ, IL-17, MCP-1, IP-10, and ICAM-1 increased significantly after RBC transfusions. CONCLUSION Proinflammatory cytokines are increased after RBC transfusion. These findings may contribute to explaining the pathogenesis of TANEC and suggest the opportunity of adopting wise transfusion guidelines that would help to avoid detrimental risks of transfusion-related immunomodulation and of undertransfusion.
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Affiliation(s)
- Carlo Dani
- Department of Neurosciences, Psychology, Drug Research and Child Health
| | | | | | | | - Alice Sereni
- Department of Experimental and Clinical Medicine, University of Florence-Atherothrombotic Diseases Centre, Careggi University Hospital of Florence, Florence, Italy
| | - Rosanna Abbate
- Department of Experimental and Clinical Medicine, University of Florence-Atherothrombotic Diseases Centre, Careggi University Hospital of Florence, Florence, Italy
| | - Anna Maria Gori
- Department of Experimental and Clinical Medicine, University of Florence-Atherothrombotic Diseases Centre, Careggi University Hospital of Florence, Florence, Italy
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Keir A, Pal S, Trivella M, Lieberman L, Callum J, Shehata N, Stanworth SJ. Adverse effects of red blood cell transfusions in neonates: a systematic review and meta-analysis. Transfusion 2016; 56:2773-2780. [PMID: 27600435 DOI: 10.1111/trf.13785] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 04/28/2016] [Accepted: 06/26/2016] [Indexed: 02/11/2024]
Abstract
BACKGROUND Controversy exists regarding the contribution of blood transfusions to a range of adverse clinical outcomes in neonates. The aim of our systematic review was to identify the broader literature on harmful effects and associations potentially attributable to red blood cell (RBC) transfusions. STUDY DESIGN AND METHODS A comprehensive search of MEDLINE (PubMed) and EMBASE was undertaken. Eligible studies included both randomized controlled trials (RCTs) and nonrandomized studies examining the effects of small volume (10-20 mL/kg) RBC transfusions on neonates. Primary outcomes of interest were mortality, chronic lung disease, retinopathy of prematurity, necrotizing enterocolitis, and intraventricular hemorrhage. Two independent authors conducted a review of abstracts and then of full-text article reviews as well as data extraction and quality assessments. RESULTS Sixty-one studies were eligible for inclusion, including 16 (26%) randomized studies. The majority of studies were nonrandomized (n = 45; 74%), which included 32 observational studies with and 13 studies without a comparator group. There was no evidence that rates of mortality differed between restrictive and liberal strategies for transfusion (eight RCTs: risk ratio, 1.24; 95% confidence interval, 0.89-1.672, heterogeneity = 0%) or for necrotizing enterocolitis (five RCTs: risk ratio, 1.45; 95% confidence interval, 0.91-2.33; heterogeneity = 0%). A liberal strategy also was not superior to restrictive transfusion practice in the pooled randomized studies for rates of retinopathy of prematurity, chronic lung disease, or intraventricular hemorrhage. CONCLUSIONS Statistically significant differences in a range of harmful outcomes between neonates exposed to restrictive and liberal RBC transfusion practice were not found. However, the risks of bias identified in many studies and the lack of consistent reporting and definitions of events limits our conclusions.
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Affiliation(s)
- Amy Keir
- Robinson Research Institute and the School of Medicine, University of Adelaide, Adelaide, Australia
| | - Sanchita Pal
- Rosie Neonatal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Lani Lieberman
- Department of Clinical Pathology, University Health Network, Toronto, Canada
- Department of Clinical Pathology, Toronto, Canada
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Canada
| | - Jeannie Callum
- Transfusion Medicine and Tissue Banks, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Nadine Shehata
- Departments of Medicine, and Laboratory Medicine & Pathobiology, University of Toronto and Mount Sinai Hospital, Institute of Health Policy Management and Evaluation, Toronto, Canada
| | - Simon J Stanworth
- NHS Blood & Transplant/Oxford University Hospitals NHS Trust, Oxford, United Kingdom
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56
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Keir AK, Stanworth SJ. Neonatal Plasma Transfusion: An Evidence-Based Review. Transfus Med Rev 2016; 30:174-82. [PMID: 27473518 DOI: 10.1016/j.tmrv.2016.07.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 07/04/2016] [Accepted: 07/04/2016] [Indexed: 01/31/2023]
Abstract
Several clinical scenarios for plasma transfusion are repeatedly identified in audits, including treatment of bleeding in association with laboratory evidence of coagulopathy, correction of disseminated intravascular coagulation, prevention of intraventricular hemorrhage, management of critically ill neonates (eg, during sepsis or as a volume expander), or correction of markers of prolonged coagulation in the absence of bleeding. The findings of at least one national audit of transfusion practice indicated that almost half of plasma transfusions are given to neonates with abnormal coagulation values with no evidence of active bleeding, despite the limited evidence base to support the effectiveness of this practice. Plasma transfusions to neonates should be considered in the clinical context of bleeding (eg, vitamin K dependent), disseminated intravascular coagulation, and very rare inherited deficiencies of coagulation factors. There seems to be no role for prophylactic plasma to prevent intraventricular hemorrhage or for use as a volume expander.
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Affiliation(s)
- Amy K Keir
- Robinson Research Institute and the School of Medicine, University of Adelaide, Adelaide, Australia; Women's and Children's Health Network, North Adelaide, South Australia, Australia.
| | - Simon J Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS Trust, Oxford, United Kingdom.
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57
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Research Opportunities to Improve Neonatal Red Blood Cell Transfusion. Transfus Med Rev 2016; 30:165-73. [PMID: 27424006 DOI: 10.1016/j.tmrv.2016.06.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 06/28/2016] [Indexed: 01/23/2023]
Abstract
Red blood cell (RBC) transfusion is a common and lifesaving therapy for anemic neonates and infants, particularly among those born prematurely or undergoing surgery. However, evidence-based indications for when to administer RBCs and adverse effects of RBC transfusion on important outcomes including necrotizing enterocolitis, survival, and long-term neurodevelopmental impairment remain uncertain. In addition, blood-banking practices for preterm and term neonates and infants have been largely developed using studies from older children and adults. Use of and refinements in emerging technologies and advances in biomarker discovery and neonatal-specific RBC transfusion databases may allow clinicians to better define and tailor RBC transfusion needs and practices to individual neonates. Decreasing the need for RBC transfusion and developing neonatal-specific approaches in the preparation of donor RBCs have potential for reducing resource utilization and cost, improving outcomes, and assuring blood safety. Finally, large donor-recipient-linked cohort studies can provide data to better understand the balance of the risks and benefits of RBC transfusion in neonates. These studies may also guide the translation of new research into best practices that can rapidly be integrated into routine care. This review highlights key opportunities in transfusion medicine and neonatology for improving the preparation and transfusion of RBCs into neonates and infants. We focus on timely, currently addressable knowledge gaps that can increase the safety and efficacy of preterm and term neonatal and infant RBC transfusion practices.
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58
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Anaemia in the Premature Infant and Red Blood Cell Transfusion: New Approaches to an Age-Old Problem. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s40746-015-0021-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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