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Chan Poon KTC, Li L, Pittman R, Hornik CD, Tanaka DT, Katakam L, Goldberg RN, Cotten CM, Athavale KV. Decreasing Blood Transfusions in Premature Infants Through Quality Improvement. Pediatrics 2024:e2023063728. [PMID: 39015101 DOI: 10.1542/peds.2023-063728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 04/26/2024] [Accepted: 05/02/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Packed red blood cell transfusions (pRBCT) in preterm infants have been associated with significant morbidity. Although infants <26 weeks' gestational age typically require several pRBCT, preterm infants born between 26 and 34 weeks' gestational age may also require pRBCT during their hospitalization that are potentially preventable. We aimed to reduce pRBCT in this population by 20%. METHODS This quality improvement project was conducted in the Duke University Hospital NICU between July 2018 and February 2023. Interventions included the implementation of evidence-based transfusion thresholds, supporting bone marrow erythropoiesis, and reducing laboratory specimen volumes by increasing capillary test panels. The rates per 1000 patient days for pRBCT (outcome measure), number of new patients initiated on erythropoietin (process measure), number of basic metabolic panels (process measure), and total capillary panels (process measure) were monitored during the project period. Statistical process control charts were used to observe trends over time. RESULTS Among infants born between 26 0/7 and 34 6/7 weeks' gestational age, the rate of pRBCT decreased from an average of 23.8 to 12.7 transfusions per 1000 patient days, which is a 46.6% decrease. Increases in the use of erythropoietin and capillary panels were observed, along with a decrease in the use of basic metabolic panels. There was no change in mortality or the rate of necrotizing enterocolitis. Improvement was sustained for 24 months after implementation. CONCLUSIONS pRBCT can be decreased in preterm infants born between 26 and 34 completed weeks' gestation through a combination of strategies utilizing quality improvement methodology.
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Affiliation(s)
- Kwai Tei C Chan Poon
- Department of Pediatrics, Division of Neonatology, Duke University Hospital, Durham, North Carolina
| | - Lusia Li
- Department of Pediatrics, Division of Neonatology, Duke University Hospital, Durham, North Carolina
| | - Rick Pittman
- Department of Pediatrics, Division of Neonatology, Duke University Hospital, Durham, North Carolina
| | - Chi Dang Hornik
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - David T Tanaka
- Department of Pediatrics, Division of Neonatology, Duke University Hospital, Durham, North Carolina
| | - Lakshmi Katakam
- Department of Pediatrics, Division of Neonatology, Duke University Hospital, Durham, North Carolina
| | - Ronald N Goldberg
- Department of Pediatrics, Division of Neonatology, Duke University Hospital, Durham, North Carolina
| | - C Michael Cotten
- Department of Pediatrics, Division of Neonatology, Duke University Hospital, Durham, North Carolina
| | - Kamlesh V Athavale
- Department of Pediatrics, Division of Neonatology, Duke University Hospital, Durham, North Carolina
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Diwan N, Kumar M, Tripathi S. Postexchange transfusion-related acute lung injury in a term neonate. BMJ Case Rep 2024; 17:e259748. [PMID: 38702072 PMCID: PMC11085716 DOI: 10.1136/bcr-2024-259748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2024] Open
Abstract
We report a successful case where a newborn with transfusion-related acute lung injury following an exchange transfusion was effectively treated using conservative methods, eliminating the need for surfactant therapy. Very few instances of this complication have been documented globally. A low birth weight, small for gestational age, term neonate, diagnosed with hyperbilirubinaemia due to Rh incompatibility, experienced sudden respiratory distress in the form of severe retractions, tachypnoea and cyanosis 3 hours after the procedure. Neonate required mechanical ventilation on the grounds of mixed acidosis and diffuse alveolar infiltrates on the chest radiograph. The medical team suspected and treated the baby for transfusion-related acute lung injury through conservative measures. Transfusion-related acute lung injury, an acute life-threatening complication of blood component transfusion, can exhibit symptoms in neonates that are frequently misinterpreted as sepsis. The baby was discharged in good health after successful management after 19 days.
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Affiliation(s)
- Nikita Diwan
- Paediatrics, King George's Medical College, Lucknow, Uttar Pradesh, India
| | - Mala Kumar
- Paediatrics, King George's Medical College, Lucknow, Uttar Pradesh, India
| | - Shalini Tripathi
- Paediatrics, King George's Medical College, Lucknow, Uttar Pradesh, India
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3
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Ma T, Sun Y, Wang Q, Liu F, Hua K, Wang L, Song A, Wang W, Xie X, Yang J, Li X. Retrospective cohort study of neonatal blood transfusion in China. BMC Pediatr 2023; 23:621. [PMID: 38066456 PMCID: PMC10709978 DOI: 10.1186/s12887-023-04225-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/02/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Blood transfusion therapy is extremely important for certain neonatal diseases, but the threshold for neonatal blood transfusion is not the same in different countries. Until now, clinical studies to determine the suitable threshold for newborns in China are lacking. Therefore, it is of high importance to establish a multi-center cohort study to explore appropriate transfusion thresholds for newborns in China. METHODS This retrospective cohort study investigated neonatal blood transfusion therapy administered from January 1, 2017 to June 30, 2018, with the aim of evaluating the effect of restricted and nonrestricted blood transfusion on neonatal health. The subjects were enrolled in 46 hospitals in China. A total of 5669 neonatal cases were included in the study. Clinical diagnosis and transfusion treatment of these neonates were collected and the data were retrospectively analyzed. The neonates were followed up 1 week and 1 month after leaving the hospital. The newborns' and their mothers' data were collected containing 280 variables in the database. The primary outcome of the study was mortality, and the secondary outcomes were complications, hospital stays, NICU hospital stays and hospital costs. RESULTS Results from the < 1500 g group showed that there was a higher mortality rate in the restricted transfusion group (11.41%) when compared with the non-restricted transfusion group (5.12%) (P = 0.000). Among the secondary outcomes, the restricted transfusion group had fewer costs. Results from the 1500-2500 g group showed that the mortality rates of the restricted and non-restricted transfusion groups were 3.53% and 4.71%, respectively, however there was no statistical significance between the two groups (P = 0.345). Among the secondary outcomes, the restricted transfusion group had fewer hospital stays, NICU hospital stays and hospital costs. The incidence of necrotizing enterocolitis was lower in the restricted transfusion group (OR, 2.626; 95% confidence interval [CI], 1.445 to 4.773; P = 0.003). The results from the ≥ 2500 g restricted transfusion group suggested that the mortality rate of (3.02%) was significantly lower than that of non-restricted transfusion group (9.55%) (P = 0.000). Among the secondary outcomes, the restricted transfusion group had fewer hospital stays and hospital costs. The incidence of retinopathy of prematurity was lower in the restricted transfusion group (OR, 4.624; 95% confidence interval [CI], 2.32 to 9.216; P = 0.000). CONCLUSIONS Current transfusion protocols for newborns weighing less than 1500 g may be inappropriate and lead to higher mortality. The current transfusion threshold performed better for the other two weight groups.
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Affiliation(s)
- Ting Ma
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, 256 Youyi West Road, Xi'an, 710068, China
| | - Yang Sun
- Department of Data Center, Shaanxi Provincial People's Hospital, Xi'an, 710068, China
| | - Qiushi Wang
- Department of Transfusion Medicine, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Fenghua Liu
- Department of Transfusion Medicine, The Fisrt Affiliated Hospital of Harbin Medical University, Harbin, 150000, China
| | - Kai Hua
- College of Life Sciences, Northwest University, Xi'an, 710068, China
| | - Liqin Wang
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, 256 Youyi West Road, Xi'an, 710068, China
| | - Aowei Song
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, 256 Youyi West Road, Xi'an, 710068, China
| | - Wenhua Wang
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, 256 Youyi West Road, Xi'an, 710068, China
| | - Xinxin Xie
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, 256 Youyi West Road, Xi'an, 710068, China
| | - Jiangcun Yang
- Department of Transfusion Medicine, Shaanxi Provincial People's Hospital, 256 Youyi West Road, Xi'an, 710068, China.
| | - Xiling Li
- Department of Transfusion Medicine, Children's Hospital Of ShanXi, Xinmin North Street, 13, Xinghualing District, Taiyuan, 030013, China.
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4
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Kitsommart R, Limrungsikul A, Tongsawang N, Thamwiriyakul N, Deesomchok A, Pithakton N, Paes B. Impact of level of neonatal care on phlebotomy and blood transfusion in extremely low birthweight infants: a prospective, multicenter, observational study. Front Pediatr 2023; 11:1238402. [PMID: 37724088 PMCID: PMC10505442 DOI: 10.3389/fped.2023.1238402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/21/2023] [Indexed: 09/20/2023] Open
Abstract
Objectives To explore the level of neonatal care on cumulative phlebotomy loss (cPL) and red cell transfusions in extremely low birthweight [ELBW; birthweight (BW) <1,000 g] infants, up to 40 weeks post-conceptual age (PCA). The secondary objective was to determine the associations between cPL and number of transfusions and between transfusions and hospital outcomes. Methods A prospective, comparative, observational study was conducted in two level IV and two level III neonatal intensive care units (NICUs) in Thailand. Daily cPL volume and number of blood tests were recorded. Descriptive data are reported as frequency and percentage for categorical variables and median [25th percentile (P25), 75th percentile (P75)] for continuous data according to the data distribution. A p-value <0.05 was considered statistically significant. Results 210 ELBW infants were included; 99 and 111 were admitted to level IV and level III NICUs, respectively. Birth weight of level IV infants was lower 780.0 [660.0, 875.0] vs. 865.0 [723.0, 930.0] g; p < 0.001]. Initial group hematocrits were similar (43.1% vs. 44.0%, p = 0.47). cPL for each infant was 28.1 [16.5, 46.4] ml. Level IV infants had more tests (n = 89 [54, 195] vs. 59 [37, 88], p < 0.001). Counterintuitively, there was a lower cPL trend in level IV infants, but this was insignificant (19.6 [12.3, 52.3] vs. 28.9 [19.3, 45.3] ml; p = 0.06). The number of transfusions in both NICUs was similar 4 [2, 6], with a strong correlation between cPL and number of transfusions (r = 0.79, p < 0.001). Transfusions were significantly associated with bronchopulmonary dysplasia [BPD; adjusted RR (95% CI): 2.6 (1.2, 5.3), p = 0.01]. Conclusions Level IV NICUs conducted more blood tests in ELBW infants without a difference in cPL, and number of transfusions. Cumulative PL correlated with number of transfusions and was associated with BPD risk. Minimizing cPL by point-of-care tests and restrictive transfusion criteria, may reduce need for transfusion.
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Affiliation(s)
- Ratchada Kitsommart
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anchalee Limrungsikul
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Numtip Tongsawang
- Department of Pediatric Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Areeya Deesomchok
- Department of Pediatrics, Buddhachinaraj Hospital, Phitsanulok, Thailand
| | - Nuttanan Pithakton
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Bosco Paes
- Department of Pediatrics (Neonatal Division), McMaster University, Hamilton, ON, Canada
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5
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Paul J, Kaiser T, Dalldorf DA, Chenoweth B, Williams E, Sisk JM. Constriction Band Release in a Neonatal Ischemic Limb: A Pediatric Anesthesiology Case Report. Cureus 2023; 15:e36895. [PMID: 37128543 PMCID: PMC10148239 DOI: 10.7759/cureus.36895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 05/03/2023] Open
Abstract
A 1.1 Kg, four-hour-old, 29-weeks-gestation male patient presented with right upper extremity ischemia secondary to neonatal constriction band syndrome. Emergency constriction band release was deemed necessary to facilitate limb salvage. The anesthetic management of this patient required close communication with the surgical team and meticulous attention to the risks of post-reperfusion syndrome and blood loss in this fragile neonate. Limb salvage was ultimately successful, and the patient demonstrated full neurologic recovery at his two-year follow-up visit.
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Affiliation(s)
- James Paul
- Anesthesiology, Emory University, Atlanta, USA
| | - Taylor Kaiser
- Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Delaney A Dalldorf
- Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Brian Chenoweth
- Orthopedic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, USA
| | - Eddison Williams
- Anesthesiology, Tufts University School of Medicine, Boston, USA
| | - Joseph M Sisk
- Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, USA
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6
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Scrivens A, Reibel NJ, Heeger L, Stanworth S, Lopriore E, New HV, Dame C, Fijnvandraat K, Deschmann E, Aguar M, Brække K, Cardona FS, Cools F, Farrugia R, Ghirardello S, Lozar J, Matasova K, Muehlbacher T, Sankilampi U, Soares H, Szabo M, Szczapa T, Zaharie G, Roehr CC, Fustolo-Gunnink S. Survey of transfusion practices in preterm infants in Europe. Arch Dis Child Fetal Neonatal Ed 2023:archdischild-2022-324619. [PMID: 36653173 DOI: 10.1136/archdischild-2022-324619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 12/10/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Preterm infants commonly receive red blood cell (RBC), platelet and fresh frozen plasma (FFP) transfusions. The aim of this Neonatal Transfusion Network survey was to describe current transfusion practices in Europe and to compare our findings to three recent randomised controlled trials to understand how clinical practice relates to the trial data. METHODS From October to December 2020, we performed an online survey among 597 neonatal intensive care units (NICUs) caring for infants with a gestational age (GA) of <32 weeks in 18 European countries. RESULTS Responses from 343 NICUs (response rate: 57%) are presented and showed substantial variation in clinical practice. For RBC transfusions, 70% of NICUs transfused at thresholds above the restrictive thresholds tested in the recent trials and 22% below the restrictive thresholds. For platelet transfusions, 57% of NICUs transfused at platelet count thresholds above 25×109/L in non-bleeding infants of GA of <28 weeks, while the 25×109/L threshold was associated with a lower risk of harm in a recent trial. FFP transfusions were administered for coagulopathy without active bleeding in 39% and for hypotension in 25% of NICUs. Transfusion volume, duration and rate varied by factors up to several folds between NICUs. CONCLUSIONS Transfusion thresholds and aspects of administration vary widely across European NICUs. In general, transfusion thresholds used tend to be more liberal compared with data from recent trials supporting the use of more restrictive thresholds. Further research is needed to identify the barriers and enablers to incorporation of recent trial findings into neonatal transfusion practice.
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Affiliation(s)
- Alexandra Scrivens
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Lisanne Heeger
- Neonatology, Leiden University Medical Centre, Leiden, The Netherlands.,Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
| | - Simon Stanworth
- Department of Haematology, National Health Service, Blood and Transplant, Oxford University Hopsitals NHS Foundation Trust, Oxford, UK
| | - Enrico Lopriore
- Neonatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Helen V New
- Paediatric Transfusion Medicine, National Health Service, Blood and Transplant, London, UK
| | - Christof Dame
- Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Karin Fijnvandraat
- Sanquin Blood Supply Foundation, Amsterdam, The Netherlands.,Pediatrics, Emma Children's Hospital, Pediatric Hematology, University of Amsterdam, Amsterdam, The Netherlands
| | - Emöke Deschmann
- University Hospital, Stockholm, Karolinska Institute, Stockholm, Sweden
| | - Marta Aguar
- Servicio de Neonatologia, University & Polytechnic Hospital La Fe, Valencia, Spain
| | - Kristin Brække
- Women and Children's division, Department of Neonatal Intensive Care, Ullevål, Oslo University Hospital, Oslo, Norway
| | - Francesco Stefano Cardona
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Intensive Care and Pediatric Neurology, Medical University of Vienna, Wien, Austria
| | - Filip Cools
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Stefano Ghirardello
- Neonatal Intensive Care and Neonatology Unit, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Jana Lozar
- Neonatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Katarina Matasova
- Jessenius Faculty of Medicine in Martin, University Hospital Martin, Martin, Slovakia
| | | | - Ulla Sankilampi
- Department of Pediatrics, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Henrique Soares
- Neonatology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Miklos Szabo
- Division of Neonatology 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Tomasz Szczapa
- II Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical Sciences, Poznan, Poland
| | - Gabriela Zaharie
- Neonatology, University of Medicine and Pharmacy Iuliu Hatieganu Cluj, Cluj Napoca, Romania
| | - Charles Christoph Roehr
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Oxford Population Health, Medical Sciences Division, University of Oxford, Oxford, UK .,Women and Children's, Neonatal Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
| | - Suzanne Fustolo-Gunnink
- Sanquin Blood Supply Foundation, Amsterdam, The Netherlands.,Department of Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Pediatric Hematology, Amsterdam University Medical Center, Amsterdam, Netherlands
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7
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Bellach L, Eigenschink M, Hassanein A, Savran D, Salzer U, Müllner EW, Repa A, Klebermass-Schrehof K, Wisgrill L, Giordano V, Berger A. Packed red blood cell transfusion in preterm infants. Lancet Haematol 2022; 9:e615-e626. [PMID: 35901846 DOI: 10.1016/s2352-3026(22)00207-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 06/15/2023]
Abstract
Premature infants commonly receive adult packed red blood cells (pRBCs) during their hospital stay. As adult erythrocytes differ substantially from those of preterm infants, transfusion of adult pRBCs into preterm infants can be considered inappropriate for the physiology of a preterm infant. An absence of standardisation of transfusion protocols makes it difficult to compare and interpret pertinent clinical data, as reflected by unclear associations between pRBC transfusion and complications related to prematurity, such as bronchopulmonary dysplasia, neurodevelopmental impairment, retinopathy of prematurity, or necrotising enterocolitis. The difficulty in interpreting clinical data is further increased by differences in study designs that either overestimate pRBC-associated complications of prematurity or have not yet been designed to directly link pRBC transfusions to their respective complications. Thus, neonatal transfusion practice has become an ongoing difficulty, in which differences in transfusion guidelines hinder the ability to generate comparable clinical data, and heterogeneity in clinical data prevents the implementation of standardised transfusion protocols. To overcome these issues, novel approaches with biochemical-clinical translational designs could enable clinicians to gather causal evidence instead of circumstantial correlation.
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Affiliation(s)
- Luise Bellach
- Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Michael Eigenschink
- Center for Medical Biochemistry, Max Perutz Labs, Medical University of Vienna, Vienna, Austria
| | - Abtin Hassanein
- Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Danylo Savran
- Center for Medical Biochemistry, Max Perutz Labs, Medical University of Vienna, Vienna, Austria
| | - Ulrich Salzer
- Center for Medical Biochemistry, Max Perutz Labs, Medical University of Vienna, Vienna, Austria
| | - Ernst W Müllner
- Center for Medical Biochemistry, Max Perutz Labs, Medical University of Vienna, Vienna, Austria
| | - Andreas Repa
- Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Katrin Klebermass-Schrehof
- Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Lukas Wisgrill
- Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Vito Giordano
- Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Angelika Berger
- Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria.
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8
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Crawford TM, Andersen CC, Hodyl NA, Robertson SA, Stark MJ. Effect of washed versus unwashed red blood cells on transfusion-related immune responses in preterm newborns. Clin Transl Immunology 2022; 11:e1377. [PMID: 35284073 PMCID: PMC8907378 DOI: 10.1002/cti2.1377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/04/2022] [Accepted: 02/04/2022] [Indexed: 12/22/2022] Open
Abstract
Objectives Transfusion with washed packed red blood cells (PRBCs) may be associated with reduced transfusion‐related pro‐inflammatory cytokine production. This may be because of alterations in recipient immune responses. Methods This randomised trial evaluated the effect of transfusion with washed compared with unwashed PRBCs on pro‐inflammatory cytokines and endothelial activation in 154 preterm newborns born before 29 weeks’ gestation. Changes in plasma cytokines and measures of endothelial activation in recipient blood were analysed after each of the first three transfusions. Results By the third transfusion, infants receiving unwashed blood had an increase in IL‐17A (P = 0.04) and TNF (P = 0.007), whereas infants receiving washed blood had reductions in IL‐17A (P = 0.013), TNF (P = 0.048), IL‐6 (P = 0.001), IL‐8 (P = 0.037), IL‐12 (P = 0.001) and IFN‐γ (P = 0.001). The magnitude of the post‐transfusion increase in cytokines did not change between the first and third transfusions in the unwashed group but decreased in the washed group for IL‐12 (P = 0.001), IL‐17A (P = 0.01) and TNF (P = 0.03), with the difference between the groups reaching significance by the third transfusion (P < 0.001 for each cytokine). Conclusion The pro‐inflammatory immune response to transfusion in preterm infants can be modified when PRBCs are washed prior to transfusion. Further studies are required to determine whether the use of washed PRBCs for neonatal transfusion translates into reduced morbidity and mortality.
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Affiliation(s)
- Tara M Crawford
- The Women's and Children's Hospital Adelaide SA Australia.,The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Chad C Andersen
- The Women's and Children's Hospital Adelaide SA Australia.,The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Nicolette A Hodyl
- The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Sarah A Robertson
- The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Michael J Stark
- The Women's and Children's Hospital Adelaide SA Australia.,The Robinson Research Institute The University of Adelaide Adelaide SA Australia
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9
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Jani P, Balegarvirupakshappa K, Moore JE, Badawi N, Tracy M. Regional Oxygenation and Perfusion Monitoring to Optimize Neonatal Packed Red Blood Cell Transfusion Practices: A Systematic Review. Transfus Med Rev 2021; 36:27-47. [PMID: 34702614 DOI: 10.1016/j.tmrv.2021.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 07/25/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
Contemporary packed red blood cell transfusion practices in anaemic preterm infants are primarily based on measurement of hemoglobin or haematocrit. In neonatal intensive care units, most preterm infants receive at least 1 packed red cell transfusion as standard treatment for anaemia of prematurity. Clinicians are faced with a common question "at what threshold should anaemic preterm infants receive packed red blood cell transfusion?". While evidence from interventional trials offers a range of haemoglobin levels to clinicians on thresholds to initiate red cell transfusion, it does not offer identification of exact haemoglobin level at which regional oxygenation and perfusion gets compromised. Assessment of regional oxygenation using near infrared spectroscopy and perfusion using ultrasound could offer a personalized transfusion medicine approach to optimize transfusion practices. We conducted a systematic review of the literature to identify the role of both regional oxygenation and/or ultrasound-based perfusion monitoring as a potential trigger to initiate packed red blood cell transfusion in anaemic preterm infants. MEDLINE, Embase, Maternity and Infant Care database were searched up to March 2021. Publications identified were screened and relevant data was extracted. Changes to regional oxygenation and/or perfusion monitoring before and after packed red blood cell transfusion were the primary outcomes. 44 out of 755 studies met the inclusion criteria and were included in the final analysis. Most were prospective, observational studies in stable preterm infants. Overall, studies reported an improvement in regional oxygenation and/or ultrasound-based perfusion after packed red blood cell transfusion. These changes were more consistently observed when hemoglobin <9.6g/dL or hematocrit was <0.30. Significant variation was found for patient characteristics, postnatal age at the time of monitoring, criteria for diagnosis of anaemia, and period of monitoring as well as regional oxygenation monitoring methodology. Regional oxygenation and/or perfusion monitoring can identify at-risk anaemic preterm infants and are promising tools to individualize packed red blood cell transfusion practices. However, there is lack of evidence for incorporating this monitoring, in their present form, into standard clinical practice. Additionally, consistency in reporting of study methodology should be improved.
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Affiliation(s)
- Pranav Jani
- Department of Neonatology, Westmead Hospital, Westmead, Australia; The University of Sydney, Sydney, Australia.
| | - Kiran Balegarvirupakshappa
- Neonatal Intensive Care Unit, Nepean Hospital, Penrith, Australia; The University of Sydney, Sydney, Australia
| | - James E Moore
- Division of Neonatal-Perinatal Medicine, Connecticut Children's Medical Center, Connecticut Children's, Hartford, CT, USA; UCONN School of Medicine Farmington, CT, USA
| | - Nadia Badawi
- The University of Sydney, Sydney, Australia; Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Westmead, Australia; Cerebral Palsy Alliance Research Institute, Sydney, Australia
| | - Mark Tracy
- Department of Neonatology, Westmead Hospital, Westmead, Australia; The University of Sydney, Sydney, Australia
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10
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Cibulskis CC, Maheshwari A, Rao R, Mathur AM. Anemia of prematurity: how low is too low? J Perinatol 2021; 41:1244-1257. [PMID: 33664467 DOI: 10.1038/s41372-021-00992-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 01/20/2021] [Accepted: 02/04/2021] [Indexed: 12/11/2022]
Abstract
Anemia of prematurity (AOP) is a common condition with a well-described chronology, nadir hemoglobin levels, and timeline of recovery. However, the underlying pathophysiology and impact of prolonged exposure of the developing infant to low levels of hemoglobin remains unclear. Phlebotomy losses exacerbate the gradual decline of hemoglobin levels which is insidious in presentation, often without any clinical signs. Progressive anemia in preterm infants is associated with poor weight gain, inability to take oral feeds, tachycardia and exacerbation of apneic, and bradycardic events. There remains a lack of consensus on treatment thresholds for RBC transfusion which vary considerably. This review elaborates on the current state of the problem, its implication for the premature infant including association with subphysiologic cerebral tissue oxygenation, necrotizing enterocolitis, and retinopathy of prematurity. It outlines the impact of prophylaxis and treatment of anemia of prematurity and offers suggestions on improving monitoring and management of the condition.
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Affiliation(s)
- Catherine C Cibulskis
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Akhil Maheshwari
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rakesh Rao
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Amit M Mathur
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA.
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11
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Acute lung injury after exchange transfusion in two newborns with Glucose-6-phosphate dehydrogenase deficiency. Transfus Apher Sci 2021; 60:103133. [PMID: 33846094 DOI: 10.1016/j.transci.2021.103133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/01/2021] [Indexed: 11/21/2022]
Abstract
Transfusion-related lung injury (TRALI) is a condition that develops suddenly within the first six hours after a blood transfusion and it is one of the most important causes of blood transfusion-related mortality. There are few data in the literature about TRALI in the neonatal period. We present two newborn patients who developed TRALI after exchange transfusion due to high bilirubin levels. Our first case was a late preterm LGA baby and was on CPAP. The baby was intubated due to sudden deterioration after the exchange transfusion. Our second case was born at term and, an exchange transfusion was performed on the 5th day of life. He developed respiratory distress unexpectedly soon after the exchange transfusion and was intubated. Glucose-6- phosphate dehydrogenase (G6PD) deficiency was detected in both of our cases. We wanted to emphasize that TRALI should be considered in the differential diagnosis of respiratory distress that develops soon after a transfusion in the newborn period and to draw attention to that TRALI may develop more frequently in patients with G6PD deficiency.
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12
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Piersigilli F. Transfusions and neurodevelopmental outcomes in extremely low gestation neonates: to transfuse or not to transfuse, that is the question…. Pediatr Res 2021; 90:16-17. [PMID: 33927344 PMCID: PMC8511854 DOI: 10.1038/s41390-021-01470-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 12/15/2020] [Accepted: 03/04/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Fiammetta Piersigilli
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Bruxelles, Belgium.
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13
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Bruno AM, Rosenbloom JI, Woolfolk C, Conner SN, Tuuli MG, Macones GA, Cahill AG. Neonatal outcomes after percutaneous umbilical cord blood sampling †. J Matern Fetal Neonatal Med 2020; 33:3984-3989. [PMID: 30905236 DOI: 10.1080/14767058.2019.1593960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objectives: While percutaneous umbilical cord blood sampling (PUBS) and intrauterine transfusion (IUT) are the standards of care for the management of significant fetal anemia, the neonatal complications resultant from these procedures remain poorly understood. Thus, we aimed to compare neonatal outcomes of the patients undergoing percutaneous umbilical cord blood sampling (PUBS) for intrauterine transfusion (IUT) to gestational age- and sex-matched controls with no indication for and not undergoing PUBS.Methods: This was a retrospective matched cohort study at a single institution from 2000 to 2017. Clinical and demographic data were abstracted from the medical record of patients undergoing PUBS. Neonatal outcomes from pregnancies undergoing PUBS for suspected fetal anemia and from randomly selected gestational age- and sex-matched controls were collected. Neonatal outcomes were compared using matched pairs analysis.Results: There were 64 patients who underwent a total of 178 PUBS with 157 IUT. The most common etiology of fetal anemia was anti-D alloimmunization. On an average, patients undergoing PUBS underwent two procedures (IQR 1,4). There were available neonatal outcomes in 40 patients. The median gestational age at delivery was 34 weeks in both neonates who underwent PUBS and controls. In matched pairs analysis, neonates who underwent PUBS were at higher risk for neonatal complications compared to control neonates (92.5 vs. 55%, OR 4.5, 95% CI 4.5, ∞) . Specifically, neonates who underwent PUBS were more likely to experience respiratory complications compared to controls despite a higher uptake of antenatal corticosteroids.Conclusions: We found that neonates who underwent PUBS experience a higher occurrence of complications which does not appear to be secondary to prematurity alone. Despite higher uptake of antenatal corticosteroids in neonates who underwent PUBS as compared to control neonates, neonates who underwent PUBS had a higher risk of respiratory complications. This study can help to inform patients undergoing PUBS/IUT on the anticipated neonatal outcomes and anticipate needed neonatology resources. While PUBS/IUT is the best treatment known to date for management of fetal anemia, our study highlights the need for further research into the subsequent neonatal complications and how to prevent them.
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Affiliation(s)
- Ann M Bruno
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St. Louis, MO, USA
| | - Joshua I Rosenbloom
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St. Louis, MO, USA
| | - Candice Woolfolk
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St. Louis, MO, USA
| | - Shayna N Conner
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St. Louis, MO, USA
| | - Methodius G Tuuli
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St. Louis, MO, USA
| | - George A Macones
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St. Louis, MO, USA
| | - Alison G Cahill
- Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St. Louis, MO, USA
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14
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Villeneuve A, Arsenault V, Lacroix J, Tucci M. Neonatal red blood cell transfusion. Vox Sang 2020; 116:366-378. [PMID: 33245826 DOI: 10.1111/vox.13036] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 10/06/2020] [Accepted: 11/05/2020] [Indexed: 02/06/2023]
Abstract
Transfusions are more common in premature infants with approximately 40% of low birth weight infants and up to 90% of extremely low birth weight infants requiring red blood cell transfusion. Although red blood cell transfusion can be life-saving in these preterm infants, it has been associated with higher rates of complications including necrotizing enterocolitis, bronchopulmonary dysplasia, retinopathy of prematurity and possibly abnormal neurodevelopment. The main objective of this review is to assess current red blood cell transfusion practices in the neonatal intensive care unit, to summarize available neonatal transfusion guidelines published in different countries and to emphasize the wide variation in transfusion thresholds that exists for red blood cell transfusion. This review also addresses certain issues specific to red blood cell processing for the neonatal population including storage time, irradiation, cytomegalovirus (CMV) prevention strategies and patient blood management. Future research avenues are proposed to better define optimal transfusion practice in neonatal intensive care units.
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Affiliation(s)
- Andréanne Villeneuve
- Division of Neonatology, CHU Sainte-Justine, Montréal, QC, Canada.,Department of Pediatrics, Université de Montréal, Montréal, QC, Canada
| | - Valérie Arsenault
- Department of Pediatrics, Université de Montréal, Montréal, QC, Canada.,Division of Haematology, CHU Sainte-Justine, Montréal, QC, Canada
| | - Jacques Lacroix
- Department of Pediatrics, Université de Montréal, Montréal, QC, Canada.,Division of Pediatric Intensive Care, CHU Sainte-Justine, Montréal, QC, Canada
| | - Marisa Tucci
- Department of Pediatrics, Université de Montréal, Montréal, QC, Canada.,Division of Pediatric Intensive Care, CHU Sainte-Justine, Montréal, QC, Canada
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15
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Iron Homeostasis Disruption and Oxidative Stress in Preterm Newborns. Nutrients 2020; 12:nu12061554. [PMID: 32471148 PMCID: PMC7352191 DOI: 10.3390/nu12061554] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/24/2020] [Accepted: 05/25/2020] [Indexed: 02/06/2023] Open
Abstract
Iron is an essential micronutrient for early development, being involved in several cellular processes and playing a significant role in neurodevelopment. Prematurity may impact on iron homeostasis in different ways. On the one hand, more than half of preterm infants develop iron deficiency (ID)/ID anemia (IDA), due to the shorter duration of pregnancy, early postnatal growth, insufficient erythropoiesis, and phlebotomy losses. On the other hand, the sickest patients are exposed to erythrocytes transfusions, increasing the risk of iron overload under conditions of impaired antioxidant capacity. Prevention of iron shortage through placental transfusion, blood-sparing practices for laboratory assessments, and iron supplementation is the first frontier in the management of anemia in preterm infants. The American Academy of Pediatrics recommends the administration of 2 mg/kg/day of oral elemental iron to human milk-fed preterm infants from one month of age to prevent ID. To date, there is no consensus on the type of iron preparations, dosages, or starting time of administration to meet optimal cost-efficacy and safety measures. We will identify the main determinants of iron homeostasis in premature infants, elaborate on iron-mediated redox unbalance, and highlight areas for further research to tailor the management of iron metabolism.
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16
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Knee D, Knoop S, Davis AT, Rawson B, DiCarlo A, Olivero R. Outcomes after implementing restrictive blood transfusion criteria in extremely premature infants. J Perinatol 2019; 39:1089-1097. [PMID: 31222156 DOI: 10.1038/s41372-019-0408-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/11/2019] [Accepted: 04/29/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess mortality and morbidities in very low birthweight (VLBW) infants before and after changing to a restrictive blood transfusion guideline (RTG). STUDY DESIGN This is a large retrospective study comparing outcomes of a liberal transfusion guideline (LTG) and RTG in VLBW infants admitted to a large single neonatal intensive care unit. Blood and platelet transfusion details, mortality, and diagnoses of frequently diagnosed morbidities were collected for each infant. RESULTS Mortality was similar between RTG and LTG groups (6.8% vs. 6.3%, p = 0.755). Rates of periventricular leukomalacia (PVL), retinopathy of prematurity (ROP), sepsis and the diagnosis of necrotizing enterocolitis (NEC) within 48 h of a PRBC transfusion were significantly lower with RTG (p < 0.05). Chronic lung disease was similar between groups. CONCLUSION RTG are safe compared to LTG, and are associated with lower rates of PVL, ROP, transfusion-associated cases of NEC and sepsis.
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Affiliation(s)
- Daniel Knee
- Neonatal Associates, PHC and Helen DeVos Children's Hospital of Spectrum Health Hospital Group, Grand Rapids, MI, USA.
| | - Serena Knoop
- Helen DeVos Children's Hospital of Spectrum Health Hospital Group, Grand Rapids, MI, USA
| | - Alan T Davis
- Spectrum Health Office of Medical Education Scholarly Activity Support, Grand Rapids, MI, USA.,Department of Surgery, Michigan State University, Grand Rapids, MI, USA
| | - Brenda Rawson
- Helen DeVos Children's Hospital of Spectrum Health Hospital Group, Grand Rapids, MI, USA
| | - Anna DiCarlo
- Spectrum Health/Michigan State University/Helen DeVos Children's Hospital Pediatric Residency Program, Grand Rapids, MI, USA
| | - Rosemary Olivero
- Department of Pediatrics and Human Development, Helen DeVos Children's Hospital of Spectrum Health and Michigan State College of Human Medicine, Grand Rapids, MI, USA
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17
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Crawford TM, Andersen CC, Hodyl NA, Robertson SA, Stark MJ. The contribution of red blood cell transfusion to neonatal morbidity and mortality. J Paediatr Child Health 2019; 55:387-392. [PMID: 30737849 DOI: 10.1111/jpc.14402] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 11/29/2018] [Accepted: 01/20/2019] [Indexed: 12/19/2022]
Abstract
Anaemia of prematurity will affect 90% of all very preterm infants, resulting in at least one red blood cell (RBC) transfusion. A significant proportion of preterm infants require multiple transfusions over the course of hospital admission. Growing evidence supports an association between transfusion exposure and adverse neonatal outcomes. In adults, transfusion-associated sepsis, transfusion-related acute lung injury and haemolytic reactions are the leading causes of transfusion-related morbidity and mortality; however, these are seldom recognised in newborns. The association between transfusion and adverse outcomes remains inconclusive. However, the evidence from preclinical studies demonstrates that RBC products can directly modulate immune cell function, a pathway termed transfusion-related immunomodulation (TRIM), which may provide a mechanism linking transfusion exposure with neonatal morbidities. Finally, we discuss the impact of TRIM on transfusion medicine, how we may address these issues and the emerging areas of research aimed at improving the safety of transfusions in this vulnerable population.
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Affiliation(s)
- Tara M Crawford
- Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Chad C Andersen
- Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Department of Neonatal Medicine, Women's and Children's Hospital Adelaide, Adelaide, South Australia, Australia
| | - Nicolette A Hodyl
- Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Sarah A Robertson
- Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Michael J Stark
- Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Department of Neonatal Medicine, Women's and Children's Hospital Adelaide, Adelaide, South Australia, Australia
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18
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Nitzan I, Hammerman C, Mimouni FB, Bin-Nun A. Packed red blood cells transfusion in neonates: effect on FiO 2 and PaO 2/SaO 2 ratio, and implications for neonatal saturation targeting. J Perinatol 2018; 38:693-695. [PMID: 29467516 DOI: 10.1038/s41372-018-0079-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/07/2018] [Accepted: 01/29/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the effect of blood transfusions in neonates on partial pressure of oxygen in arterial blood (PaO2), arterial hemoglobin oxygen saturation (SaO2) and arterial hemoglobin oxygen saturation as measured by pulse oximetry (SpO2). STUDY DESIGN Retrospective study of neonates that received a first blood transfusion while having an indwelling arterial line. We compared PaO2, SaO2, SpO2, SaO2/PaO2 ratio and fraction of inspired oxygen (FiO2) 12 h before and after blood transfusion. RESULTS Post-transfusion neonates had higher PaO2 and SaO2, had lower SaO2/PaO2 ratio, and received higher FiO2 with no change in SpO2. CONCLUSIONS Post-transfusion, neonates had lower hemoglobin oxygen affinity. They received higher FiO2 and had higher PaO2 at the same SpO2. We speculate that FiO2 was increased in order to maintain SpO2. Larger prospective trials are needed to confirm our findings.
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Affiliation(s)
- Itamar Nitzan
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel.
| | - Cathy Hammerman
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel
- The Faculty of Medicine of the Hebrew University, Jerusalem, Israel
| | - Francis B Mimouni
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel
- Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Alona Bin-Nun
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel
- The Faculty of Medicine of the Hebrew University, Jerusalem, Israel
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19
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Safety of umbilical cord milking in very preterm neonates: a randomized controlled study. Obstet Gynecol Sci 2017; 60:527-534. [PMID: 29184860 PMCID: PMC5694726 DOI: 10.5468/ogs.2017.60.6.527] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 05/04/2017] [Accepted: 05/24/2017] [Indexed: 12/24/2022] Open
Abstract
Objective To investigate the safety of umbilical cord milking on both the mother and neonate among very preterm deliveries of less than 33 weeks of gestation. Methods Pregnant women who were expected to deliver at between 24 0/7 and 32 6/7 weeks of gestation were randomized to either the umbilical cord milking or immediate cord clamping group. Maternal and neonatal data associated with delivery, in addition to neonatal morbidity and mortality data, were collected and analyzed. Results Of the 66 preterm deliveries included in the study, 34 were randomized into the milking and 32 into the clamping group. Differences between maternal pre- and post-partum hemoglobin levels were 1.35 g/dL in the milking and 1.58 g/dL in the clamping group (P=0.451). Neonatal Apgar scores at both 1 and 5 minutes, initial blood gas analysis results, body temperature at admission, need for early intubation, and maximum bilirubin levels were all similar between the 2 groups. However, neonatal hemoglobin levels at birth (15.79 vs. 14.69 g/dL; P<0.05) and at 24 hours of age (14.83 vs. 13.29 g/dL; P<0.05) were significantly higher in the milking group. Neonates in the clamping group required more blood transfusion (1.78 vs. 0.93; P=0.049), and a higher percentage of neonates in the clamping group required inotropic drugs (63% vs. 29%; P=0.007). The mortality rate was significantly lower in the milking group (6% vs. 28%; P=0.015). Conclusion Umbilical cord milking can be a safe and beneficial procedure for both the mother and the neonate in deliveries of less than 33 weeks of gestation.
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20
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Outcomes of a Quality Improvement Initiative to Prevent Unnecessary Packed Red Blood Cell Transfusions Among Extremely Low Birth-Weight Neonates. Adv Neonatal Care 2016; 16:E3-9. [PMID: 26734813 DOI: 10.1097/anc.0000000000000249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Extremely low birth-weight (ELBW) infants frequently receive packed red blood cell (PRBC) transfusions. Recent studies have shown that more restrictive PRBC transfusion guidelines limit donor exposure and reduce transfusion-related costs without any increase in adverse clinical outcomes. PURPOSE We developed and implemented an evidence-based PRBC transfusion guideline for ELBW infants treated in our unit and then measured provider adherence to this guideline. METHODS/SEARCH STRATEGY We performed a retrospective review of all PRBC transfusions given to ELBW infants in 2012 (preguideline) and the first half of 2014 (postguideline). We identified the indication for each transfusion by reviewing physiological/laboratory data and the daily clinical note. We then determine whether each transfusion met criteria according to our new evidence-based guideline. FINDINGS/RESULTS When extrapolating the newly developed protocol to 2012 data, less than 15% of transfusions among ELBW infants would have met the current evidence-based standard. Conversely, during the first 6 months of 2014, 61% of transfusions were administered in adherence to the guideline (P < 001). Using current cost estimates, this represents a projected cost savings of $31,000 in that 6-month period. IMPLICATIONS FOR PRACTICE A multidisciplinary approach to improving PRBC transfusion practices results in potentially safer, more cost-effective care for ELBW infants. IMPLICATIONS FOR RESEARCH Given the frequency, potential harms, and costs associated with PRBC transfusions in ELBW infants, it seems both feasible and important to pursue prospective clinical trials comparing permissive and restrictive approaches to transfusion in this vulnerable population.
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21
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Keir AK, Wilkinson D, Andersen C, Stark MJ. Washed versus unwashed red blood cells for transfusion for the prevention of morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2016; 2016:CD011484. [PMID: 26788664 PMCID: PMC8733671 DOI: 10.1002/14651858.cd011484.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Infants born very preterm often receive multiple red blood cell (RBC) transfusions during their initial hospitalisation. However, there is an increasing awareness of potential adverse effects of RBC transfusions in this vulnerable patient population. Modification of RBCs prior to transfusion, through washing with 0.9% saline, may reduce these adverse effects and reduce the rate of significant morbidity and mortality for preterm infants and improve outcomes for this high-risk group. OBJECTIVES To determine whether pre-transfusion washing of RBCs prevents morbidity and mortality in preterm infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 7), MEDLINE via PubMed (31 July 2015), EMBASE (31 July 2015), and CINAHL (31 July 2015). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised, cluster randomised, and quasi-randomised controlled trials including preterm infants (less than 32 weeks gestation) or very low birth weight infants (less than 1500 g), or both, who received one or more washed packed RBC transfusions. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of the trials. We identified four studies from the initial search. After further review of the full-text studies, we found one study meeting the selection criteria. MAIN RESULTS We included a single study enrolling a total of 21 infants for analysis in this review and reported on all-cause mortality during hospital stay, length of initial neonatal intensive care unit (NICU) stay (days), and duration of mechanical ventilation (days). There was no significant difference in mortality between the washed versus the unwashed RBCs for transfusion groups (risk ratio 1.63, 95% confidence interval (CI) 0.28 to 9.36; risk difference 0.10, 95% CI -0.26 to 0.45). There was no significant difference in the length of initial NICU stay between the washed versus the unwashed RBCs for transfusion groups (mean difference (MD) 25 days, 95% CI -21.15 to 71.15) or the duration of mechanical ventilation between the washed versus the unwashed RBCs for transfusion groups (MD 9.60 days, 95% CI -1.90 to 21.10). AUTHORS' CONCLUSIONS We identified a single small study. The results from this study show a high level of uncertainty, as the confidence intervals are consistent with both a large improvement or a serious harm caused by the intervention. Consequently, there is insufficient evidence to support or refute the use of washed RBCs to prevent the development of significant neonatal morbidities or mortality. Further clinical trials are required to assess the potential effects of pre-transfusion washing of RBCs for preterm or very low birth weight infants, or both, on short- and long-term outcomes.
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Affiliation(s)
- Amy K Keir
- University of AdelaideRobinson Research Institute72 King William RoadAdelaideAustralia
- Women's and Children's HospitalDepartment of Neonatal Medicine72 King William RoadNorth AdelaideAustralia
| | - Dominic Wilkinson
- University of AdelaideRobinson Research Institute72 King William RoadAdelaideAustralia
- University of OxfordOxford Uehiro Centre for Practical EthicsOxfordUK
| | - Chad Andersen
- University of AdelaideRobinson Research Institute72 King William RoadAdelaideAustralia
- Women's and Children's HospitalDepartment of Neonatal Medicine72 King William RoadNorth AdelaideAustralia
| | - Michael J Stark
- University of AdelaideRobinson Research Institute72 King William RoadAdelaideAustralia
- Women's and Children's HospitalDepartment of Neonatal Medicine72 King William RoadNorth AdelaideAustralia
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22
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Respiratory Dysfunction Associated With RBC Transfusion in Critically Ill Children: A Prospective Cohort Study. Pediatr Crit Care Med 2015; 16:325-34. [PMID: 25647237 DOI: 10.1097/pcc.0000000000000365] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Respiratory complications associated with RBC transfusions may be underestimated in PICUs because current definitions exclude patients with preexisting respiratory dysfunction. This study aims to determine the prevalence and characterize the risk factors and outcomes of new or progressive respiratory dysfunction observed after RBC transfusion in critically ill children. DESIGN Prospective cohort study of all children admitted over a 1-year period. SETTING A multidisciplinary PICU in a tertiary pediatric university hospital. PATIENTS Patients who received a RBC transfusion while in PICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two independent adjudicators established the diagnosis of respiratory dysfunction. A respiratory dysfunction associated with transfusion was considered new if it appeared after the first RBC transfusion in PICU. A progressive respiratory dysfunction associated with transfusion was diagnosed if the respiratory dysfunction was present before the transfusion and the PaO2/FIO2 or the SpO2/FIO2 ratio dropped by at least 20% thereafter. Among 842 children admitted into the PICU, 136 received at least one RBC transfusion and were analyzed. Fifty-eight cases of respiratory dysfunction associated with transfusion (43% of transfused patients) were detected, including nine new respiratory dysfunction associated with transfusion (7%) and 49 progressive respiratory dysfunction associated with transfusion (36%). Higher severity of illness, multiple organ dysfunction syndrome prior to transfusion, and volume (mL/kg) of RBC transfusion were independently associated with respiratory dysfunction associated with transfusion. A dose-response relationship was observed between transfusion volume (mL/kg) and the prevalence of respiratory dysfunction associated with transfusion. Patients with respiratory dysfunction associated with transfusion had more progressive multiple organ dysfunction and less ventilation-free and PICU-free days at day 28. CONCLUSIONS Development of respiratory dysfunction associated with transfusion is frequent in PICU and occurs mainly in patients with prior respiratory dysfunction, who would not be identified using current definitions for transfusion-associated complications. A cause-effect relationship cannot be confirmed. However, the high prevalence and the serious adverse outcomes associated with respiratory dysfunction associated with transfusion suggest that this complication should be further studied.
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23
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Keir AK, Yang J, Harrison A, Pelausa E, Shah PS. Temporal changes in blood product usage in preterm neonates born at less than 30 weeks' gestation in Canada. Transfusion 2015; 55:1340-6. [PMID: 25652740 DOI: 10.1111/trf.12998] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 11/24/2014] [Accepted: 12/01/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND Knowledge of neonatal transfusion practices remains limited to local cohorts or survey-based studies. This study evaluated the pattern and temporal changes in the types and frequency of blood product use among preterm neonates born at less than 30 weeks' gestation in Canada. STUDY DESIGN AND METHODS A retrospective cohort study of preterm neonates born at less than 30 weeks' gestation and admitted to participating neonatal intensive care units in the Canadian Neonatal Network from 2004 to 2012 was conducted to evaluate blood product usage. The temporal change in red blood cell (RBC) use was evaluated by dividing the study period into three epochs: 2004 to 2006, 2007 to 2009, and 2010 to 2012. RESULTS Of 14,868 eligible neonates admitted to participating units in Canada during the overall study period, 8252 (56%) received RBCs, 2151 (15%) platelets, 1556 (11%) fresh-frozen plasma, 915 (6%) albumin, and 302 (2%) cryoprecipitate. Temporal evaluation over three epochs revealed a trend toward fewer RBC transfusions among neonates born at 26 to 29 weeks' gestation (p = <0.01-0.04) but use remained unchanged or increased for neonates born at 23 to 25 weeks' gestation (p = 0.02-0.54). CONCLUSION Blood product use remains at a very high frequency in preterm neonates born at less than 30 weeks' gestation. Evolutionary practice changes and relative high tolerance for anemia may be associated with a reduction in RBC usage in recent years in neonates born at at least 26 weeks' gestation. This contrasts with the ongoing higher usage of blood products observed at extremely low gestational ages.
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Affiliation(s)
- Amy K Keir
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, South Australia, Australia
| | - Junmin Yang
- Maternal-Infant Care Research Centre (MiCare), Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Adele Harrison
- Department of Paediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Prakesh S Shah
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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Henry E, Christensen RD, Sheffield MJ, Eggert LD, Carroll PD, Minton SD, Lambert DK, Ilstrup SJ. Why do four NICUs using identical RBC transfusion guidelines have different gestational age-adjusted RBC transfusion rates? J Perinatol 2015; 35:132-6. [PMID: 25254330 DOI: 10.1038/jp.2014.171] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 07/29/2014] [Accepted: 08/04/2014] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To compare neonatal red blood cell (RBC) transfusion rates in four large Intermountain Healthcare NICUs, all of which adhere to the same RBC transfusion guidelines. STUDY DESIGN This retrospective analysis was part of a transfusion-management quality-improvement project. De-identified data included RBC transfusions, clinical and laboratory findings, the anemia-prevention strategies in place in each NICU, and specific costs and outcomes. RESULT Of 2389 NICU RBC transfusions given during the 4-year period studied, 98.9 ± 2.1% (mean ± S.D.) were compliant with our transfusion guidelines, with no difference in compliance between any of the four NICUs. However, RBC transfusion rates varied widely between the four, with averages ranging from 4.6 transfusions/1000 NICU days to 21.7/1000 NICU days (P < 0.00001). Gestational age-adjusted transfusion rates were correspondingly discordant (P < 0.00001). The lower-transfusing NICUs had written anemia-preventing guidelines, such as umbilical cord milking at very low birth weight delivery, use of cord blood for admission laboratory studies, and darbepoetin dosing for selected neonates. Rates of Bell stage ⩾ 2 necrotizing enterocolitis and grade ⩾ 3 intraventricular hemorrhage were lowest in the two lower-transfusing NICUs (P < 0.0002 and P < 0.0016). Average pharmacy costs for darbepoetin were $84/dose, with an average pharmacy cost of $269 per transfusion averted. With a cost of $900/RBC transfusion, the anemia-preventing strategies resulted in an estimated cost savings to Intermountain Healthcare of about $6970 per 1000 NICU days, or about $282,300 annually. CONCLUSION Using transfusion guidelines has been shown previously to reduce practice variability, lower transfusion rates and diminish transfusion costs. Based on our present findings, we maintain that even when transfusion guidelines are in place and adhered to rigorously, RBC transfusion rates are reduced further if anemia-preventing strategies are also in place.
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Affiliation(s)
- E Henry
- The Women and Newborn's Clinical Program, Salt Lake City, UT, USA
| | - R D Christensen
- The Women and Newborn's Clinical Program, Salt Lake City, UT, USA
| | - M J Sheffield
- The Women and Newborn's Clinical Program, Salt Lake City, UT, USA
| | - L D Eggert
- The Women and Newborn's Clinical Program, Salt Lake City, UT, USA
| | - P D Carroll
- The Women and Newborn's Clinical Program, Salt Lake City, UT, USA
| | - S D Minton
- The Women and Newborn's Clinical Program, Salt Lake City, UT, USA
| | - D K Lambert
- The Women and Newborn's Clinical Program, Salt Lake City, UT, USA
| | - S J Ilstrup
- The Transfusion Medicine Program, Intermountain Healthcare, Salt Lake City, UT, USA
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Placental transfusion strategies in very preterm neonates: a systematic review and meta-analysis. Obstet Gynecol 2014; 124:47-56. [PMID: 24901269 DOI: 10.1097/aog.0000000000000324] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate the effects of interventions promoting placental transfusion at delivery (delayed cord clamping or umbilical cord milking) compared with early cord clamping on outcomes among premature neonates of less than 32 weeks of gestation. DATA SOURCES A systematic search was conducted of PubMed, Embase, and ClinicalTrials.gov databases (January 1965 to December 2013) for articles relating to placental transfusion strategies in very preterm neonates. METHODS OF STUDY SELECTION Literature searches returned 369 articles with 82 considered in full. We only included data from studies with an average gestational age of less than 32 weeks of gestation enrolled in randomized trials of enhanced placental-fetal transfusion interventions (delayed cord clamping or umbilical cord milking) compared with early cord clamping. TABULATION, INTEGRATION, AND RESULTS We identified 12 eligible studies describing a total of 531 neonates with an average gestation of 28 weeks. Benefits of greater placental transfusion were decreased mortality (eight studies, risk ratio 0.42, 95% confidence interval [CI] 0.19-0.95, 3.4% compared with 9.3%, P=.04), lower incidence of blood transfusions (six studies, risk ratio 0.75, 95% CI 0.63-0.92, 49.3% compared with 66%, P<.01), and lower incidence of intraventricular hemorrhage (nine studies, risk ratio 0.62, 95% CI 0.43-0.91, 16.7% compared with 27.3%, P=.01). There was a weighted mean difference of -1.14 blood transfusions (six studies, 95% CI -2.01-0.27, P<.01) and a 3.24-mmHg increase in blood pressure at 4 hours of life (four studies, 95% CI 1.76-4.72, P<.01). No differences were observed between the groups across all available safety measures (5-minute Apgar scores, admission temperature, incidence of delivery room intubation, peak serum bilirubin levels). CONCLUSIONS Results of this meta-analysis suggest that enhanced placental transfusion (delayed umbilical cord clamping or umbilical cord milking) at birth provides better neonatal outcomes than does early cord clamping, most notably reductions in overall mortality, lower risk of intraventricular hemorrhage, and decreased blood transfusion incidence. The optimal umbilical cord clamping practice among neonates requiring immediate resuscitation remains uncertain.
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Keir A, Pal S, Trivella M, Lieberman L, Callum J, Shehata N, Stanworth S. Adverse effects of small-volume red blood cell transfusions in the neonatal population. Syst Rev 2014; 3:92. [PMID: 25143009 PMCID: PMC4149676 DOI: 10.1186/2046-4053-3-92] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 08/13/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adverse transfusion reactions in the neonatal population are poorly understood and defined. The incidence and pattern of adverse effects due to red blood cell (RBC) transfusion are not well known, and there has been no systematic review of published adverse events. RBC transfusions continue to be linked to the development of morbidities unique to neonates, including chronic lung disease, retinopathy of prematurity, intraventricular haemorrhage and necrotising enterocolitis. Uncertainties about the exact nature of risks alongside benefits of RBC transfusion may contribute to evidence of widespread variation in neonatal RBC transfusion practice.Our review aims to describe clinical adverse effects attributed to small-volume (10-20 mL/kg) RBC transfusions and, where possible, their incidence rates in the neonatal population through the systematic identification of all relevant studies. METHODS A comprehensive search of the following bibliographic databases will be performed: MEDLINE (PubMed/OVID which includes the Cochrane Library) and EMBASE (OVID). The intervention of interest is small-volume (10-20 mL/kg) RBC transfusions in the neonatal population.We will undertake a narrative synthesis of the evidence. If clinical similarity and data quantity and quality permit, we will also carry out meta-analyses on the listed outcomes. DISCUSSION This systematic review will identify and synthesise the reported adverse effects and associations of RBC transfusions in the neonatal population. We believe that this systematic review is timely and will make a valuable contribution to highlight an existing research gap. TRIAL REGISTRATION PROSPERO, CRD42013005107http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013005107.
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Affiliation(s)
- Amy Keir
- School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide 5005, Australia
- Department of Neonatal Medicine, Level 1 Queen Victoria Building, Women's and Children's Hospital, 72 King William Road, North Adelaide, South Australia 5006, Australia
| | - Sanchita Pal
- Rosie Neonatal Unit, Cambridge University Hospitals NHS Foundation Trust Cambridge, Cambridge CB2 0QQ, UK
| | - Marialena Trivella
- Centre for Statistics in Medicine, University of Oxford, Oxford OX2 6UD, UK
| | - Lani Lieberman
- Transfusion Medicine, University Health Network, Toronto M5G 2N2, Canada
- Department of Clinical Pathology, University of Toronto, Toronto M5G 2M9, Canada
| | - Jeannie Callum
- Transfusion Medicine and Tissue Banks, Sunnybrook Health Sciences Centre, Toronto M4N 3M5, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto M5S 1A1, Canada
| | - Nadine Shehata
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto M5S 1A1, Canada
- Department of Medicine, Mount Sinai Hospital, Toronto M5G 1X5, Canada
| | - Simon Stanworth
- National Health Service Blood and Transplant/Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK
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Effects of non-leukocyte-reduced and leukocyte-reduced packed red blood cell transfusions on oxygenation of rat spinotrapezius muscle. Microvasc Res 2013; 91:30-6. [PMID: 24189119 DOI: 10.1016/j.mvr.2013.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 10/18/2013] [Accepted: 10/24/2013] [Indexed: 11/21/2022]
Abstract
Leukoreduction of blood used for transfusion alleviates febrile transfusion reactions, graft versus host disease and alloimmunization to leukocyte antigen. However, the actual clinical benefit of leukoreduction in terms of microcirculatory tissue O2 delivery after packed red blood cell (pRBC) transfusion has not been investigated. As such, the aim of this study was to determine the effects of non-leukoreduced (NLR) and leukoreduced (LR) fresh pRBC transfusion on interstitial oxygenation in anesthetized male Sprague-Dawley rats. Interstitial fluid PO2 and arteriolar diameters in spinotrapezius muscle preparations were monitored before and after transfusion with NLR- or LR-pRBCs. The major findings were that (1) transfusion of NLR-pRBCs significantly decreased interstitial oxygenation whereas transfusion of LR-pRBCs did not, and (2) transfusion with LR-pRBCs elicited a substantially greater increase in arterial blood pressure (ABP) than did transfusion with NLR-pRBCs. These changes in PO2 and ABP were not associated with changes in the diameters of resistance arterioles in the spinotrapezius muscle. These data suggest that transfusion of fresh NLR-pRBCs may negatively affect tissue oxygenation via enhanced leukocyte influx and decreased O2 delivery. They also suggest that leukocytes diminish the capability of transfused pRBCs to increase cardiac output. As such, transfusion of LR-pRBCs may be less deleterious on tissue PO2 levels than NLR-pRBCs although a concomitantly greater increase in ABP may accompany transfusion of LR-pRBCs.
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