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Bolat F, Dursun M, Sarıaydın M. Packed Red Blood Cell Transfusion as a Predictor of Moderate-Severe Bronchopulmonary Dysplasia: A Comparative Cohort Study of Very Preterm Infants. Am J Perinatol 2024; 41:e1499-e1507. [PMID: 36898407 DOI: 10.1055/a-2051-8245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
OBJECTIVE Bronchopulmonary dysplasia (BPD) is a leading cause of morbidity and mortality in neonatal intensive care units. Our aim was to evaluate association between packed red blood cell transfusion and the development of BPD in very preterm infants. STUDY DESIGN This retrospective study of very preterm infants (mean gestational age: 27.1 ± 2.4 weeks, birth weight: 970 ± 271 g) was conducted at Biruni University (Turkey) between July 2016 and December 2020. RESULTS BPD developed in 107 of the 246 enrolled neonates, including 47 (43.9%), 27 (25.3%), and 33 (30.8%) diagnosed with mild, moderate, and severe BPD, respectively. A total of 728 transfusions were administered. The increased number (4 transfusions [2-7] vs. 1 [1-3], p = 0.001) and volume of transfusions (75 mL/kg volume [40-130] vs. 20 [15-43], p = 0.001) were significantly higher in infants with BPD compared to those without BPD. The transfusion volume cut-off for the prediction of BPD by receiver operating characteristic curve analysis was 42 mL/kg (sensitivity 73.6%; specificity 75%; area under the receiver-operating characteristic curve: 0.82). In multivariate analysis, multiple transfusions and larger transfusion volume were independent risk factors for moderate-severe BPD. CONCLUSION The increased number and volume of transfusions were associated with BPD in very preterm infants. A packed red blood cell transfusion volume ≥42 mL/kg was a statistically significant predictor of the development of BPD at a postmenstrual age of 36 weeks. KEY POINTS · Transfusions were found to be an important risk factor for BPD development in very premature infants.. · Number and volume of transfusion were associated with the severity of BPD.. · Optimal cut point volume of transfusion for prediction of BPD was 42 mL/kg body weight..
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Affiliation(s)
- Fatih Bolat
- Division of Neonatology, Department of Pediatrics, Istinye University Faculty of Medicine, Istanbul, Turkey
| | - Mesut Dursun
- Division of Neonatology, Department of Pediatrics, Biruni University Faculty of Medicine, Istanbul, Turkey
| | - Mehmet Sarıaydın
- Division of Neonatology, Department of Pediatrics, Biruni University Faculty of Medicine, Istanbul, Turkey
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2
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Bahr TM, Snow GL, Christensen TR, Davenport P, Henry E, Tweddell SM, Ilstrup SJ, Yoder BA, Ohls RK, Sola-Visner MC, Christensen RD. Can Red Blood Cell and Platelet Transfusions Have a Pathogenic Role in Bronchopulmonary Dysplasia? J Pediatr 2024; 265:113836. [PMID: 37992802 DOI: 10.1016/j.jpeds.2023.113836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/08/2023] [Accepted: 11/15/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVE To evaluate whether transfusions in infants born preterm contribute to the pathogenesis of bronchopulmonary dysplasia (BPD). STUDY DESIGN We conducted a multihospital, retrospective study seeking associations between red blood cell or platelet transfusions and BPD. We tabulated all transfusions administered from January 2018 through December 2022 to infants born ≤29 weeks or <1000 g until 36 weeks postmenstrual age and compared those with BPD grade. We performed a sensitivity analysis to assess the possibility of a causal relationship. We then determined whether each transfusion was compliant with restrictive guidelines, and we estimated effects fewer transfusions might have on future BPD incidence. RESULTS Eighty-four infants did not develop BPD and 595 did; 352 developed grade 1 (mild), 193 grade 2 (moderate), and 50 grade 3 (severe). Transfusions were given at <36 weeks to 7% of those who did not develop BPD, 46% who did, and 98% who developed severe BPD. For every transfusion the odds of developing BPD increased by a factor of 2.27 (95% CI, 1.59-3.68; P < .001). Sensitivity analyses suggested that transfusions might contribute to BPD. Fifty-seven percent of red blood cell transfusions and 68% of platelet transfusions were noncompliant with new restrictive guidelines. Modeling predicted that complying with restrictive guidelines could reduce the transfusion rate by 20%-30% and the moderate to severe BPD rate by ∼4%-6%. CONCLUSIONS Transfusions were associated with BPD incidence and severity. Lowering transfusion rates to comply with current restrictive guidelines might result in a small but meaningful reduction in BPD rates.
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Affiliation(s)
- Timothy M Bahr
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT; Department of Neonatology, Intermountain Health, Murray, UT.
| | | | - Thomas R Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Patricia Davenport
- Division of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Erick Henry
- Department of Neonatology, Intermountain Health, Murray, UT
| | - Sarah M Tweddell
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Sarah J Ilstrup
- Transfusion Services and Department of Pathology, Intermountain Health, Murray, UT
| | - Bradley A Yoder
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Robin K Ohls
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Martha C Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Robert D Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT; Department of Neonatology, Intermountain Health, Murray, UT
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3
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Salem A, Patel RM. Blood Donor Sex and Outcomes in Transfused Infants. Clin Perinatol 2023; 50:805-820. [PMID: 37866849 PMCID: PMC10688602 DOI: 10.1016/j.clp.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Red blood cell transfusion is common in neonatal intensive care. Multiple trials have evaluated different thresholds for when to administer red blood cell transfusion. In contrast, there has been less focus on studies of the characteristics of red blood cells transfused into neonates. In this review, the authors summarize the emerging literature on the potential impact of the sex of blood donors on outcomes in transfused neonates using a systematic search strategy. The authors review the uncertainty generated from studies with conflicting findings and discuss considerations regarding the impact of blood donor sex and other characteristics on neonatal outcomes.
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Affiliation(s)
- Anand Salem
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, Atlanta, GA 30322, USA
| | - Ravi Mangal Patel
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, Atlanta, GA 30322, USA.
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Alshaikh BN, Sproat TDR, Wood C, Spence JM, Knauff M, Hamilton C, Roy M. A Quality Improvement Initiative to Reduce Necrotizing Enterocolitis in Very Preterm Infants. Pediatrics 2023; 152:e2023061273. [PMID: 37920940 DOI: 10.1542/peds.2023-061273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2023] [Indexed: 11/04/2023] Open
Abstract
OBJECTIVE To reduce the incidence of necrotizing enterocolitis (NEC) among very preterm infants in the Calgary Health Region to ≤2% within 2 years. METHODS A multidisciplinary team developed key drivers for NEC. Targeted interventions included strategies to increase mothers' own milk (MOM), improve compliance with feeding regimens, standardize management of feeding intolerance, prevent intestinal microbial aberrations, and feed conservatively during blood transfusion and the treatment of patent ductus arteriosus. The outcome measure was NEC (≥ stage 2). Changes in NEC rates were examined among racial and ethnic groups. Process measures included MOM feeding at discharge, the difference between actual and expected time to reach full feeds, lowest hemoglobin, and the duration of empirical antibiotics. Growth, the rate of blood transfusion, and the duration of parenteral nutrition were balancing measures. The preintervention, intervention, and sustainment periods were January 2013 to June 2016, July 2016 to December 2018, and December 2018 to December 2021, respectively. RESULTS We included 2787 infants born at ≤326/7 weeks' gestation (1105 preintervention, 763 during intervention, and 919 in sustainment). NEC decreased from 5.6% to 1.9%. Process measures indicated increased MOM feeding at discharge, improved compliance with feeding regimens, increased lowest hemoglobin levels, and shorter durations of empirical antibiotics. Balancing measures revealed improved weight Z-scores, shorter durations on parenteral nutrition, and increased rates of blood transfusion. CONCLUSIONS Quality improvement initiatives to increase MOM, improve compliance with feeding regimens, feed conservatively during blood transfusion and treatment of patent ductus arteriosus, and prevent intestinal microbial aberrations were associated with reduced NEC.
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Affiliation(s)
- Belal N Alshaikh
- Neonatal Gastroenterology and Nutrition Program, Department of Pediatrics, Cumming School of Medicine
- Alberta Children's Hospital Research Institute
| | - Thomas D R Sproat
- Neonatal Gastroenterology and Nutrition Program, Department of Pediatrics, Cumming School of Medicine
| | - Christel Wood
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jill-Marie Spence
- Nutrition Services, Alberta Health Services, Calgary, Alberta, Canada
| | - Megan Knauff
- Nutrition Services, Alberta Health Services, Calgary, Alberta, Canada
| | - Claire Hamilton
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meagan Roy
- Alberta Health Services, Calgary, Alberta, Canada
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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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Chioma R, Ghirardello S, Włodarczyk K, Ulan-Drozdowska J, Spagarino A, Szumska M, Krasuska K, Seliga-Siwecka J, Philip RK, Al Assaf N, Pierro M. Association between the development of bronchopulmonary dysplasia and platelet transfusion: a protocol for a systematic review and meta-analysis. Front Pediatr 2023; 11:1049014. [PMID: 37360369 PMCID: PMC10289060 DOI: 10.3389/fped.2023.1049014] [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: 11/07/2022] [Accepted: 04/10/2023] [Indexed: 06/28/2023] Open
Abstract
Background There is a lack of consensus on the management of thrombocytopenia in preterm infants, and the threshold for prophylactic platelet transfusion varies widely among clinicians and institutions. Reports in animal models suggested that platelets may play a relevant role in lung alveolarization and regeneration. Bronchopulmonary dysplasia (BPD) is a severe respiratory condition with a multifactorial origin that affects infants born at the early stages of lung development. Recent randomized controlled trials on the platelets count threshold for prophylactic transfusions in preterm infants with thrombocytopenia suggest that a higher exposition to platelet transfusion may increase the risk of BPD. Here, we report a protocol for a systematic review, which aims to assist evidence-based clinical practice and clarify if the administration of platelet products may be associated with the incidence of BPD and/or death in preterm infants. Methods MEDLINE, Embase, Cochrane databases, and sources of gray literature for conference abstracts and trial registrations will be searched with no time or language restrictions. Case-control studies, cohort studies, and nonrandomized or randomized trials that evaluated the risk for BPD and/or death in preterm infants exposed to platelet transfusion will be included. Data from studies that are sufficiently similar will be pooled as appropriate. Data extraction forms will be developed a priori. Observational studies and nonrandomized and randomized clinical trials will be analyzed separately. Odds ratio with 95% confidence interval (CI) for dichotomous outcomes and the mean difference (95% CI) for continuous outcomes will be combined. The expected heterogeneity will be accounted for using a random-effects model. Subgroup analysis will be performed based on a priori-determined covariate of interest. In case of sufficient homogeneity of interventions and outcomes evaluated, results from subgroups of studies will be pooled together in a meta-analysis. Discussion This systematic review will investigate the association of BPD/death with platelet components administration in preterm infants, and, consequently, it will provide reliable indications for the evidence-based management of premature patients with thrombocytopenia.
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Affiliation(s)
- Roberto Chioma
- Department of Woman and Child Health and Public Health, Neonatology Unit, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Stefano Ghirardello
- Department of Woman and Child Health and Public Health, Neonatology Unit, Ospedale San Matteo, Pavia, Italy
| | - Krzysztof Włodarczyk
- Main Library, Medical University of Warsaw, Medical University of Warsaw, Warsaw, Poland
| | | | | | - Marta Szumska
- Neonatal and Intensive Care Department, Medical University of Warsaw, Warsaw, Poland
| | - Klaudia Krasuska
- Neonatal and Intensive Care Department, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Seliga-Siwecka
- Neonatal and Intensive Care Department, Medical University of Warsaw, Warsaw, Poland
| | - Roy K. Philip
- Division of Neonatology, Department of Pediatrics, University Maternity Hospital Limerick and Medical School University of Limerick, Limerick, Ireland
| | - Niazy Al Assaf
- Division of Neonatology, Department of Pediatrics, University Maternity Hospital Limerick and Medical School University of Limerick, Limerick, Ireland
| | - Maria Pierro
- M. Bufalini Hospital, AUSL Romagna, Cesena, Italy
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7
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Tang L, Zhu TT, Zhao J. Association between red blood cell transfusion and bronchopulmonary dysplasia: a systematic review and meta-analysis. Front Pediatr 2023; 11:1095889. [PMID: 37325359 PMCID: PMC10266411 DOI: 10.3389/fped.2023.1095889] [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: 11/11/2022] [Accepted: 04/21/2023] [Indexed: 06/17/2023] Open
Abstract
Background We aimed to determine the association between red blood cell transfusions (RBCT) and bronchopulmonary dysplasia (BPD) in neonates. Methods A systematic review and meta-analysis were conducted using data obtained from literature search of PubMed, Embase, and Web of Science from their inception till May 1, 2022. Two reviewers independently selected potentially relevant studies, and after data extraction, they assessed the methodological quality of the included studies using the Newcastle-Ottawa scale. Data were pooled using random-effects models in Review Manager 5.3. Subgroup-analysis was performed based on the number of transfusions and adjusted results. Results Of the 1,011 identified records, 21 total case-control, cross-sectional, and cohort studies were selected, which included a total of 6,567 healthy controls and 1,476 patients with BPD. The pooled unadjusted odds ratio ([OR], 4.01; 95% confidence interval [CI] 2.31-6.97) and adjusted OR (5.11; 95% CI 3.11-8.4) showed significant association between RBCT and BPD. A substantial heterogeneity was noted, which could be due to different variables controlled for in each study. The subgroup analysis showed that heterogeneity may be partially explained by the extent of transfusion. Conclusion The association between BPD and RBCT remains unclear based on the current data due to the substantial heterogeneity among the results. Well-designed studies are still needed in the future.
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Affiliation(s)
- Li Tang
- Department of Pediatrics Hematology and Oncology Nursing, West China Second University Hospital, Sichuan University, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Ting Ting Zhu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
| | - Jing Zhao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Sichuan University, Chengdu, China
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8
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Garcia MR, Comstock BA, Patel RM, Tolia VN, Josephson CD, Georgieff MK, Rao R, Monsell SE, Juul SE, Ahmad KA. Iron supplementation and the risk of bronchopulmonary dysplasia in extremely low gestational age newborns. Pediatr Res 2023; 93:701-707. [PMID: 35725917 PMCID: PMC9763546 DOI: 10.1038/s41390-022-02160-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/26/2022] [Accepted: 05/22/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to determine the relationship between iron exposure and the development of bronchopulmonary dysplasia (BPD). METHODS A secondary analysis of the PENUT Trial dataset was conducted. The primary outcome was BPD at 36 weeks gestational age and primary exposures of interest were cumulative iron exposures in the first 28 days and through 36 weeks' gestation. Descriptive statistics were calculated for study cohort characteristics with analysis adjusted for the factors used to stratify randomization. RESULTS Of the 941 patients, 821 (87.2%) survived to BPD evaluation at 36 weeks, with 332 (40.4%) diagnosed with BPD. The median cohort gestational age was 26 weeks and birth weight 810 g. In the first 28 days, 76% of infants received enteral iron and 55% parenteral iron. The median supplemental cumulative enteral and parenteral iron intakes at 28 days were 58.5 and 3.1 mg/kg, respectively, and through 36 weeks' 235.8 and 3.56 mg/kg, respectively. We found lower volume of red blood cell transfusions in the first 28 days after birth and higher enteral iron exposure in the first 28 days after birth to be associated with lower rates of BPD. CONCLUSIONS We find no support for an increased risk of BPD with iron supplementation. TRIAL REGISTRATION NUMBER NCT01378273. https://clinicaltrials.gov/ct2/show/NCT01378273 IMPACT: Prior studies and biologic plausibility raise the possibility that iron administration could contribute to the pathophysiology of oxidant-induced lung injury and thus bronchopulmonary dysplasia in preterm infants. For 24-27-week premature infants, this study finds no association between total cumulative enteral iron supplementation at either 28-day or 36-week postmenstrual age and the risk for developing bronchopulmonary dysplasia.
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Affiliation(s)
- Melissa R Garcia
- San Antonio Uniformed Services Health Education Consortium, San Antonio, TX, USA
| | | | - Ravi M Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Veeral N Tolia
- Pediatrix Medical Group, Dallas, TX, USA
- Baylor University Medical Center, Dallas, TX, USA
| | - Cassandra D Josephson
- Emory University School of Medicine and Center for Transfusion and Cellular Therapies, Atlanta, GA, USA
| | | | | | | | | | - Kaashif A Ahmad
- San Antonio Uniformed Services Health Education Consortium, San Antonio, TX, USA.
- Pediatrix Medical Group, San Antonio, TX, USA.
- Baylor College of Medicine, San Antonio, TX, USA.
- Pediatrix and Obstetrix Specialists of Houston, Houston, TX, USA.
- Methodist Children's Hospital, San Antonio, TX, USA.
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9
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Anand V, Pournami F, Prithvi AK, Nandakumar A, Prabhakar J, Jain N. Every treasured drop! Blood transfusion requirements in very preterm neonates after implementation of blood conservation strategies: an observational analytical study. J Trop Pediatr 2022; 68:6777800. [PMID: 36306125 DOI: 10.1093/tropej/fmac093] [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] [Indexed: 11/07/2022]
Abstract
BACKGROUND Certain morbidities are inevitable in preterm infants; the challenge lies in minimizing them. Anemia of prematurity is multifactorial. Therapy largely depends on adult red blood cell transfusions (RBCT); which inherently, are not without problems. Most literature in this respect are retrospective or evaluate individual stratagems to reduce RBCT. METHODS This observational analytical study was planned to compare need for RBCT, before and after institution of blood conservation strategies (BCS). All those ≤30 weeks gestation at birth during two-time epochs were included (Before BCS: retrospective; After BCS: prospective). BCS constituted of delayed cord clamping (DCC), strict sampling indications, micro-sampling with point-of-care testing (MS-POCT) and adherence to RBCT thresholds. RESULTS Of 45 enrolled neonates in each group, proportion of those requiring even 1 RBCT was significantly reduced after BCS [51.1% vs. 26.7%, p = 0.02, OR 0.35, 95%CI (0.14, 0.84)]. Calculated cumulative blood volume losses (35.3 ml vs. 21.9 ml) and loss per kilogram birth weight (35.3 ml/kg vs. 20.12 ml/kg) were significantly lower after BCS (p = 0.0036). Need for >1 RBCT, mean lowest Hb, mean maximum-hemoglobin drop, need for arterial lines were reduced. Adherence to RBCT thresholds were acceptably good in both time epochs. However, the compliance to DCC was low in both groups, identifying one area of focus with scope for massive improvement. CONCLUSIONS Need for RBCT transfusions largely attributable to reduced blood losses for lab analysis were reduced after BCS. Installation of in-house MS-POCT seemed to be the pivotal factor. Units that care for very preterm infants must make attempts to procure MS-POCT equipment.
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Affiliation(s)
- Vishnu Anand
- Department of Neonatology, Kerala Institute of Medical Sciences, Trivandrum, India
| | - Femitha Pournami
- Department of Neonatology, Kerala Institute of Medical Sciences, Trivandrum, India
| | - Ajai Kumar Prithvi
- Department of Neonatology, Kerala Institute of Medical Sciences, Trivandrum, India
| | - Anand Nandakumar
- Department of Neonatology, Kerala Institute of Medical Sciences, Trivandrum, India
| | - Jyothi Prabhakar
- Department of Neonatology, Kerala Institute of Medical Sciences, Trivandrum, India
| | - Naveen Jain
- Department of Neonatology, Kerala Institute of Medical Sciences, Trivandrum, India
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10
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Meyer MP, O'Connor KL, Meyer JH. Thresholds for blood transfusion in extremely preterm infants: A review of the latest evidence from two large clinical trials. Front Pediatr 2022; 10:957585. [PMID: 36204671 PMCID: PMC9530179 DOI: 10.3389/fped.2022.957585] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
There are two recently completed large randomized clinical trials of blood transfusions in the preterm infants most at risk of requiring them. Liberal and restrictive strategies were compared with composite primary outcome measures of death and neurodevelopmental impairment. Infants managed under restrictive guidelines fared no worse in regard to mortality and neurodevelopment in early life. The studies had remarkably similar demographics and used similar transfusion guidelines. In both, there were fewer transfusions in the restrictive arm. Nevertheless, there were large differences between the studies in regard to transfusion exposure with almost 3 times the number of transfusions per participant in the transfusion of prematures (TOP) study. Associated with this, there were differences between the studies in various outcomes. For example, the combined primary outcome of death or neurodevelopmental impairment was more likely to occur in the TOP study and the mortality rate itself was considerably higher. Whilst the reasons for these differences are likely multifactorial, it does raise the question as to whether they could be related to the transfusions themselves? Clearly, every effort should be made to reduce exposure to transfusions and this was more successful in the Effects of Transfusion Thresholds on Neurocognitive Outcomes (ETTNO) study. In this review, we look at factors which may explain these transfusion differences and the differences in outcomes, in particular neurodevelopment at age 2 years. In choosing which guidelines to follow, centers using liberal guidelines should be encouraged to adopt more restrictive ones. However, should centers with more restrictive guidelines change to ones similar to those in the studies? The evidence for this is less compelling, particularly given the wide range of transfusion exposure between studies. Individual centers already using restrictive guidelines should assess the validity of the findings in light of their own transfusion experience. In addition, it should be remembered that the study guidelines were pragmatic and acceptable to a large number of centers. The major focus in these guidelines was on hemoglobin levels which do not necessarily reflect tissue oxygenation. Other factors such as the level of erythropoiesis should also be taken into account before deciding whether to transfuse.
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Affiliation(s)
- Michael P Meyer
- Neonatal Unit, KidzFirst, Middlemore Hospital, Auckland, New Zealand.,Department of Paediatrics Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Kristin L O'Connor
- Neonatal Unit, KidzFirst, Middlemore Hospital, Auckland, New Zealand.,Department of Paediatrics Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Jill H Meyer
- Department of Biomedicine and Medical Diagnostics, Auckland University of Technology, Auckland, New Zealand
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11
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Cheema RK, Jain S, Bedi RK, Kaur G, Chawla D. Comparison of Hematocrit Change in Preterm Neonates with Birth Weight Based Versus Formula Based Packed Red Blood Cell Transfusion: A Randomized Control Trial. Indian J Hematol Blood Transfus 2022; 38:138-144. [PMID: 33814792 PMCID: PMC8005667 DOI: 10.1007/s12288-021-01420-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/24/2021] [Indexed: 11/26/2022] Open
Abstract
Conventionally the packed red blood cell (PRBC) transfusion volume given to neonates is 10 ml/kg to 20 ml/kg. The weight-based formulae underestimate the volume of PRBC required to achieve a target hematocrit (Hct) in preterm neonates. The study was done to compare the rise in Hct after transfusing PRBC volume calculated either based on body weight or using formula considering Hct of blood bag and Hct of preterm neonates. This prospective study included a total of 68 preterm neonates requiring transfusion for the first time having ≤ 34 weeks of gestational age. Neonates were randomized using block randomization, to receive 15 ml/kg of PRBC transfusion (group A) or transfusion based on the formula (group B). The primary outcome of interest was post-transfusion rise in hematocrit. The secondary outcome was the effect of transfusion on neonatal morbidities in terms of retinopathy of prematurity, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, and death. Baseline variables (birth weight, gestation age, APGAR score and score of neonatal acute physiology) pre-transfusion hemodynamics and hematocrit of the bag were comparable in both groups. The mean volume of PRBC in group A was 18.8 ± 4.9 ml, whereas in group B it was 29.6 ± 7.3 ml, p = 0.0001. Group B transfusions had a statistically significant change in 24 h post-transfusion hematocrit. Secondary outcomes were comparable in two groups. Post transfusion rise in Hct of the patient in group B was significant as compared to group A. The study needed huge sample size to establish a difference in the number of re-transfusions required across two groups. The trial was registered under the clinical trial registry of India (CTRI/2018/01/011,063). SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s12288-021-01420-1.
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Affiliation(s)
- Rajbir Kaur Cheema
- Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, 160030 India
| | - Suksham Jain
- Department of Neonatology, Government Medical College and Hospital, Chandigarh, 160030 India
| | - Ravneet Kaur Bedi
- Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, 160030 India
| | - Gagandeep Kaur
- Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, 160030 India
| | - Deepak Chawla
- Department of Neonatology, Government Medical College and Hospital, Chandigarh, 160030 India
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12
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Usuda H, Saito M, Ikeda H, Sato S, Kumagai Y, Saito Y, Kawamura S, Hanita T, Sakai H, Kure S, Yaegashi N, Newnham JP, Kemp MW, Watanabe S. Assessment of synthetic red cell therapy for extremely preterm ovine fetuses maintained on an artificial placenta life-support platform. Artif Organs 2021; 46:653-665. [PMID: 34932228 DOI: 10.1111/aor.14155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/29/2021] [Accepted: 12/15/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Artificial placenta therapy (APT) is an experimental care strategy for extremely preterm infants born at 21-24 weeks' gestation. In our previous studies, blood taken from the maternal ewe was used as the basis of priming solutions for the artificial placenta circuit. However, the use of maternal blood as a priming solution is accompanied by several challenges. We explored the use of synthetic red cells (hemoglobin vesicles; HbV) as the basis of a priming solution for APT used to manage extremely early preterm ovine fetuses. METHODS Six ewes with singleton pregnancies at 95 d gestation (term = 150 d) were adapted to APT and maintained with constant monitoring of key vital parameters. The target maintenance period was 72 h in duration. A synthetic red cell solution consisting of HbV, sheep albumin and electrolytes was used as priming solutions for the APT circuit. Fetuses were evaluated on gross appearance, physiological parameters and bleeding after euthanasia. RESULTS Two out of six APT fetuses were successfully maintained for the targeted 72 h experimental period with controllable anemia (>10 g/dl) and methemoglobinemia (<10%) using an infusion of blood transfusion and nitroglycerin delivered >1 h after APT commencement, a sufficient period of time to cross-match blood products and screen for viral agents of concern. CONCLUSIONS Extremely preterm sheep fetuses were maintained for a period of up to 72 h using APT in combination with circuit priming using a synthetic red cell (HbV) preparation. Although significant further refinements are required, these findings demonstrated the potential clinical utility of synthetic blood products in the eventual clinical translation of artificial placenta technology to support extremely preterm infants.
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Affiliation(s)
- Haruo Usuda
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia.,Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Masatoshi Saito
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia.,Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Hideyuki Ikeda
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Shinichi Sato
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yusaku Kumagai
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yuya Saito
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | | | - Takushi Hanita
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Hiromi Sakai
- Department of Chemistry, Nara Medical University, Nara, Japan
| | - Shigeo Kure
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Nobuo Yaegashi
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - John P Newnham
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia.,School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia.,Women and Infants Research Foundation, King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - Matthew W Kemp
- Division of Obstetrics and Gynecology, The University of Western Australia, Crawley, Western Australia, Australia.,Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan.,School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia.,Women and Infants Research Foundation, King Edward Memorial Hospital, Perth, Western Australia, Australia.,Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Shimpei Watanabe
- Center for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
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13
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Ming S, Zhang D, Chen L, Shi Y. Effects of anemia and red blood cell transfusion in preterm infants on the development of bronchopulmonary dysplasia: a propensity score analysis. ALL LIFE 2021. [DOI: 10.1080/26895293.2021.1972350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Shishi Ming
- Department of Neonatology, Children’s Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
| | - Dianlong Zhang
- Department of Neonatology, Children’s Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
| | - Long Chen
- Department of Neonatology, Children’s Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
| | - Yuan Shi
- Department of Neonatology, Children’s Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing Key Laboratory of Pediatrics, Chongqing, People’s Republic of China
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14
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Liao Z, Zhao X, Rao H, Kang Y. Analysis of correlative risk factors for blood transfusion therapy for extremely low birth weight infants and extreme preterm infants. Am J Transl Res 2021; 13:8179-8185. [PMID: 34377303 PMCID: PMC8340198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/10/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To analyze the related risk factors in blood transfusions for extremely low birth weight infants and extreme preterm infants, and to explore the prevention strategy of anemia. METHODS A total of 60 infants with gestational age < 28 weeks or birth weight < 1000 g admitted to our hospital from January 2017 to December 2020 were retrospectively analyzed. The infants with a birth weight of less than 1000 g were divided into the blood transfusion group and the non-blood transfusion group according to whether they received a blood transfusion. The general health situation, disease occurrence and treatment measures during hospitalization were compared between the two groups, and the risk factors of blood transfusion were analyzed. RESULTS There were significant differences in maternal anemia during pregnancy, birth weight, gestational age, hemoglobin and hematocrit at birth, blood collection within 2 weeks after birth, length of hospital stay, bronchopulmonary dysplasia and patent ductus arteriosus between the transfusion group and the non-transfusion group (P < 0.05). Multivariate logistic regression analysis and ROC curve analysis showed that the younger the gestational age (OR=0.385, 95% CI: 0.212~0.705, P=0.002), the lower the birth weight (OR=1.004, 95% CI: 0.967~0.998, P=0.001), the longer the hospitalization time (OR=2.178, 95% CI: 1.172~4.049, P=0.014) and a larger blood collection within 2 weeks after birth (OR=1.269, 95% CI: 1.084~1.489, P=0.003) would induce higher the blood transfusion rates. CONCLUSION The transfusion indications of extremely low birth weight infants and extreme preterm infants are affected by many factors, among which gestational age, length of hospital stay, blood collection within 2 weeks after birth and birth weight are independent predictors of transfusion. Blood transfusion in extremely low birth weight infants and extreme preterm infants is associated with an increased risk of apnea, neonatal respiratory distress syndrome, bronchopulmonary dysplasia and patent ductus arteriosus.
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Affiliation(s)
- Zhixing Liao
- Department of Neonatology and Neonatal Intensive Care Unit, Huizhou Municipal Central Hospital Huizhou 516001, Guangdong, China
| | - Xiang Zhao
- Department of Neonatology and Neonatal Intensive Care Unit, Huizhou Municipal Central Hospital Huizhou 516001, Guangdong, China
| | - Hongping Rao
- Department of Neonatology and Neonatal Intensive Care Unit, Huizhou Municipal Central Hospital Huizhou 516001, Guangdong, China
| | - Yanwen Kang
- Department of Neonatology and Neonatal Intensive Care Unit, Huizhou Municipal Central Hospital Huizhou 516001, Guangdong, China
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15
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Sharma A, Xin Y, Chen X, Sood BG. Early prediction of moderate to severe bronchopulmonary dysplasia in extremely premature infants. Pediatr Neonatol 2020; 61:290-299. [PMID: 32217025 DOI: 10.1016/j.pedneo.2019.12.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 11/15/2019] [Accepted: 12/16/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Bronchopulmonary Dysplasia (BPD) is the commonest morbidity in extremely preterm infants (PTIs). Risk factors for BPD have been described in the era before the widespread availability of non-invasive ventilation (NIV) in the delivery room (DR). The objective of this study is to identify risk factors for Moderate/Severe BPD in an era of widespread availability of NIV in the DR. METHODS Detailed antenatal and postnatal data were abstracted for PTIs, 230/7-276/7 weeks GA. Multivariate logistic regression and classification and regression tree analyses (CART) identified predictors for the primary outcome of Moderate/Severe BPD. RESULTS Of 263 eligible infants, 59% had Moderate/Severe BPD. Moderate/Severe BPD was significantly associated with birthweight, gender, DR intubation and surfactant compared to No/Mild BPD. Of infants not intubated in the DR, 40% with No/Mild BPD and 80% with Moderate/Severe BPD received intubation by 48 hours (p < 0.05). Infants with Moderate/Severe BPD received longer duration of oxygen and mechanical (MV). On logistic regression, birthweight, gender, oxygen concentration, cumulative duration of oxygen and MV, surfactant, and blood transfusions predicted Moderate/Severe BPD. Both CART analysis and logistic regression showed duration of oxygen and MV to be the most important predictors for Moderate/Severe BPD. CONCLUSIONS In an era of increasing availability of NIV in the DR, lower birthweight, male gender, surfactant treatment, blood transfusions and respiratory support in the first 2-3 weeks after birth predict Moderate/Severe BPD with high sensitivity and specificity. The majority of these infants received intubation within 48 hours of birth (97%). These data suggest that early failures of NIV represent opportunities for improvement of NIV techniques and of non-invasive surfactant to avoid intubation in the first 48 hours. Furthermore, these risk factors may allow earlier identification of infants most likely to benefit from interventions to prevent or decrease severity of BPD.
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Affiliation(s)
- Amit Sharma
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Wayne State University, Detroit, MI 48201, USA; Hutzel Women's Hospital, Detroit, MI 48201, USA; Children's Hospital of Michigan, Detroit, MI 48201, USA
| | - Yuemin Xin
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Wayne State University, Detroit, MI 48201, USA
| | - Xinguang Chen
- University of Florida College of Medicine, College of Public Health, USA
| | - Beena G Sood
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Wayne State University, Detroit, MI 48201, USA; Hutzel Women's Hospital, Detroit, MI 48201, USA; Children's Hospital of Michigan, Detroit, MI 48201, USA.
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16
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Lee EY, Kim SS, Park GY, Lee SH. Effect of red blood cell transfusion on short-term outcomes in very low birth weight infants. Clin Exp Pediatr 2020; 63:56-62. [PMID: 32024329 PMCID: PMC7029666 DOI: 10.3345/kjp.2019.00990] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/08/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Red blood cell (RBC) transfusion improves cardiorespiratory status of preterm infants by increasing circulating hemoglobin, improving tissue oxygenation, and reducing cardiac output. However, RBC transfusion itself has also been suggested to negatively affect short-term outcomes such as intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), and necrotizing enterocolitis (NEC) in premature infants. PURPOSE This study aimed to analyze the relationship between RBC transfusion and short-term outcomes in very low birth weight (VLBW) infants (birth weight, <1,500 g). METHODS We retrospectively reviewed the medical records of VLBW infants admitted to the Soonchunhyang University Bucheon Hospital between October 2010 and December 2017. Infants who died during hospitalization were excluded. The infants were divided into 2 groups according to RBC transfusion status. We investigated the relationship between RBC transfusion and short-term outcomes including BPD, ROP, NEC, and IVH. RESULTS Of the 250 enrolled VLBW infants, 109 (43.6%) underwent transfusion. Univariate analysis revealed that all shortterm outcomes except early-onset sepsis and patent ductus arteriosus were associated with RBC transfusion. In multivariate analysis adjusted for gestational age, birth weight and Apgar score at 1 minute, RBC transfusion was significantly correlated with BPD (odds ratio [OR], 5.42; P<0.001) and NEC (OR, 3.40; P= 0.009). CONCLUSION RBC transfusion is significantly associated with adverse clinical outcomes such as NEC and BPD in VLBW infants. Careful consideration of the patient's clinical condition and appropriate guidelines is required before administration of RBC transfusions.
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Affiliation(s)
- Eui Young Lee
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Sung Shin Kim
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Ga Young Park
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Sun Hyang Lee
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
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17
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Goldstein GP, Rao A, Ling AY, Ding VY, Chang IJ, Chock VY. Influence of enteral feeding and anemia on tissue oxygen extraction after red blood cell transfusion in preterm infants. Transfusion 2020; 60:466-472. [PMID: 31984520 DOI: 10.1111/trf.15680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 12/11/2019] [Accepted: 12/11/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Understanding factors that impact tissue oxygen extraction may guide red blood cell (RBC) transfusion decision making in preterm infants. Our objective was to assess the influence of enteral feeding and anemia on cerebral and mesenteric oxygen saturation (Csat and Msat) and fractional tissue oxygen extraction (cFTOE and mFTOE) over the entire time course of RBC transfusion. STUDY DESIGN AND METHODS Preterm, very low-birth-weight infants receiving RBC transfusions at a single center were enrolled. Near-infrared spectroscopy sensors measured Csat and Msat levels from an hour before transfusion to 24 hours after. During this period, changes in Csat, Msat, cFTOE, and mFTOE were described, and their association with enteral feeding status and pretransfusion degree of anemia were assessed using generalized estimating equations. RESULTS RBC transfusion data from 31 preterm infants were included. Infants receiving enteral feeds exhibited lower pretransfusion Msat. Infants with pretransfusion hematocrit greater than 30% exhibited higher pretransfusion Csat and lower pretransfusion cFTOE. Such differences in baseline measurements persisted through 24 hours after transfusion. However, no statistically significant differences in oxygenation measures over time by enteral feeding or anemia status were identified. CONCLUSION Compared to NPO, enteral feeding was associated with lower Msat; anemia (hematocrit ≤30%) was associated with lower Csat and higher cFTOE. Over the time course of RBC transfusion, trajectories of Csat, Msat, cFTOE and mFTOE did not differ by enteral feeding or anemia status.
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Affiliation(s)
- Gregory P Goldstein
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Anoop Rao
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Albee Y Ling
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Victoria Y Ding
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Irene J Chang
- Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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18
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Carroll PD, Zimmerman MB, Nalbant D, Gingerich EL, An G, Cress GA, Veng-Pedersen P, Widness JA. Neonatal Umbilical Arterial Catheter Removal Is Accompanied by a Marked Decline in Phlebotomy Blood Loss. Neonatology 2020; 117:294-299. [PMID: 32564030 PMCID: PMC7669694 DOI: 10.1159/000506907] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 03/02/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Umbilical arterial catheters (UACs) are frequently used in critically ill neonates. UAC are convenient, reliable, and allow for caregiver convenience in performing painless arterial blood sampling. We hypothesized that UAC removal in extremely low birth weight (ELBW) neonates will result in significantly less phlebotomy blood loss (PBL) after correcting for severity of illness. STUDY DESIGN AND METHODS PBL was measured at a single center in 99 ELBW infants who survived to day 28. Individual infant's paired daily PBL for the two 24-h periods before and after UAC removal were compared using the paired t test. Daily PBL up to 7 days before and 7 days after UAC removal were compared using a logistic regression with mixed model analysis for repeated measures. Cumulative 28-day phlebotomy loss was evaluated by multiple linear regression analysis. RESULTS PBL 24 h before and after UAC removal were 1.7 mL (95% CI 1.5-1.9) and 0.9 mL (95% CI 0.8-1.0; p < 0.0001), respectively. Cumulative 28-day PBL increased by 2.2 mL (±0.7) per day that a UAC was present with or without correction for severity of illness (p < 0.001). CONCLUSION UAC removal is independently associated with a marked decline in PBL. We speculate the ease and convenience of UAC blood sampling lead to more frequent blood testing and greater PBL.
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Affiliation(s)
- Patrick D Carroll
- Women and Newborn Clinical Program, Intermountain Healthcare, Dixie Regional Medical Center, St. George, Utah, USA
| | - M Bridget Zimmerman
- Department of Biostatistics, College of Public Health, The University of Iowa, Iowa City, Iowa, USA
| | - Demet Nalbant
- Stead Family Department of Pediatrics, Roy J. and Lucille A. Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Earl L Gingerich
- Stead Family Department of Pediatrics, Roy J. and Lucille A. Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Guohua An
- Department of Pharmaceutical Sciences and Experimental Therapeutics, University of Iowa College of Pharmacy, Iowa City, Iowa, USA
| | - Gretchen A Cress
- Stead Family Department of Pediatrics, Roy J. and Lucille A. Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Peter Veng-Pedersen
- Department of Pharmaceutical Sciences and Experimental Therapeutics, University of Iowa College of Pharmacy, Iowa City, Iowa, USA
| | - John A Widness
- Stead Family Department of Pediatrics, Roy J. and Lucille A. Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA,
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19
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Patel RM, Knezevic A, Yang J, Shenvi N, Hinkes M, Roback JD, Easley KA, Josephson CD. Enteral iron supplementation, red blood cell transfusion, and risk of bronchopulmonary dysplasia in very-low-birth-weight infants. Transfusion 2019; 59:1675-1682. [PMID: 30801736 DOI: 10.1111/trf.15216] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/29/2018] [Accepted: 01/08/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Enteral iron supplementation and RBC transfusions are routinely administered to very-low-birth-weight (VLBW) infants, although the potential risks of these exposures have not been adequately quantified. This study evaluated the association between the cumulative dose of enteral iron supplementation, total volume of RBCs transfused, and risk of bronchopulmonary dysplasia (BPD) in VLBW infants. STUDY DESIGN AND METHODS Retrospective, multicenter observational cohort study in Atlanta, Georgia. Cumulative supplemental enteral iron exposure and total volume of RBCs transfused were measured until the age at assessment of BPD. Multivariable generalized linear models were used to control for confounding, and the reliability of the factors was assessed in 1000 bootstrap models. RESULTS A total of 598 VLBW infants were studied. In multivariable analyses, a greater cumulative dose of supplemental enteral iron exposure was associated with an increased risk of BPD (adjusted relative risk per 50-mg increase, 1.07; 95% confidence interval [CI], 1.02-1.11; p = 0.002). Similarly, a greater volume of RBCs transfused was associated with a higher risk of BPD (adjusted relative risk per 20-mL increase, 1.05; 95% CI, 1.02-1.07; p < 0.001). Both factors were reliably associated with BPD (>50%). Volume of RBCs transfused was similar to gestational age in reliability as a risk factor for BPD (present in 100% of models) and was more reliable than mechanical ventilation at 1 week of age. CONCLUSION The cumulative dose of supplemental enteral iron exposure and total volume of RBC transfusion are both independently associated with an increased risk of BPD in VLBW infants.
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Affiliation(s)
- Ravi Mangal Patel
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Andrea Knezevic
- Biostatistics and Bioinformatics, Rollins School of Public Health, Atlanta, Georgia.,Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jing Yang
- Biostatistics and Bioinformatics, Rollins School of Public Health, Atlanta, Georgia.,Biostatistics and Research Decision Sciences, Merck & Co., Inc., Kenilworth, New Jersey
| | - Neeta Shenvi
- Biostatistics and Bioinformatics, Rollins School of Public Health, Atlanta, Georgia
| | | | - John D Roback
- Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia
| | - Kirk A Easley
- Biostatistics and Bioinformatics, Rollins School of Public Health, Atlanta, Georgia
| | - Cassandra D Josephson
- Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia.,Division of Hematology and Oncology, Aflac Cancer and Blood Disorders Center, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
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20
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Kim DH. Transfusion practice in neonates. KOREAN JOURNAL OF PEDIATRICS 2018; 61:265-270. [PMID: 30185018 PMCID: PMC6172519 DOI: 10.3345/kjp.2018.06849] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 09/06/2018] [Indexed: 11/29/2022]
Abstract
Neonates, especially extremely low birth weight infants, are among the groups of patients undergoing transfusion frequently. Since they are exposed to higher specific transfusion risks compared to the patients of other age groups, there are many special aspects that must be considered for transfusion therapy in neonates. The transfusion risks in neonates include adverse outcomes specific for preterm infants as well as increased metabolic, immunologic, and infectious complications. To reduce the risks of transfusion-transmitted cytomegalovirus infection and transfusion-associated graft-versus-host disease, leukoreduced and irradiated cellular blood products should be used for all neonates. This review summarizes the risks of neonatal transfusion therapy, specific methods to reduce risk, and current trends and practices of red blood cell and platelet transfusions in neonates, to facilitate decision-making for neonatal transfusion.
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Affiliation(s)
- Do-Hyun Kim
- Department of Pediatrics, Dongguk University Ilsan Hospital, Goyang, Korea
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21
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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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Kalhan TG, Bateman DA, Bowker RM, Hod EA, Kashyap S. Effect of red blood cell storage time on markers of hemolysis and inflammation in transfused very low birth weight infants. Pediatr Res 2017; 82:964-969. [PMID: 28738026 PMCID: PMC5685900 DOI: 10.1038/pr.2017.177] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/18/2017] [Indexed: 12/19/2022]
Abstract
BackgroundProlonged storage of transfused red blood cells (RBCs) is associated with hemolysis in healthy adults and inflammation in animal models. We aimed to determine whether storage duration affects markers of hemolysis (e.g., serum bilirubin, iron, and non-transferrin-bound iron (NTBI)) and inflammation (e.g., interleukin (IL)-8 and monocyte chemoattractant protein (MCP)-1) in transfused very low birth weight (VLBW) infants.MethodsBlood samples from 23 independent transfusion events were collected by heel stick before and 2-6 h after transfusion.ResultsSerum iron, total bilirubin, NTBI, and MCP-1 levels were significantly increased after transfusion of RBCs (P<0.05 for each comparison). The storage age of transfused RBCs positively correlated with increases in NTBI following transfusion (P<0.001; R2=0.44). No associations between storage duration and changes in the other analytes were observed.ConclusionTransfusion of RBCs into VLBW infants is associated with increased markers of hemolysis and the inflammatory chemokine MCP-1. RBC-storage duration only correlated with increases in NTBI levels following transfusion. NTBI was only observed in healthy adults following 35 days of storage; however, this study suggests that VLBW infants are potentially more susceptible to produce this pathological form of iron, with increased levels observed after transfusion of only 20-day-old RBCs.
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Affiliation(s)
- Tamara G. Kalhan
- Division of Neonatology, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York 10461
| | - David A. Bateman
- Division of Neonatology, Department of Pediatrics, College of Physicians & Surgeons, Columbia University, New York, New York 10032
| | - Rakhee M. Bowker
- Division of Neonatology, Department of Pediatrics, Rush University Medical Center, Chicago, IL
| | - Eldad A. Hod
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY 10032,Correspondence: Eldad A. Hod, M.D., Department of Pathology and Cell Biology, 630 West 168th St, Room P&S 14-434, Laboratory of Transfusion Biology, College of Physicians & Surgeons of Columbia University, New York, NY 10032; Phone: 212-342-5648;
| | - Sudha Kashyap
- Division of Neonatology, Department of Pediatrics, College of Physicians & Surgeons, Columbia University, New York, New York 10032
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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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24
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Duan J, Kong X, Li Q, Hua S, Zhang S, Zhang X, Feng Z. Association between anemia and bronchopulmonary dysplasia in preterm infants. Sci Rep 2016; 6:22717. [PMID: 26936610 PMCID: PMC4776173 DOI: 10.1038/srep22717] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 02/22/2016] [Indexed: 12/16/2022] Open
Abstract
Anemia is commonly seen in preterm infants. It may reduce the capacity of hemoglobin to transport oxygen throughout the body and may result in tissue and organ dysfunction. This study aimed to investigate the effect of anemia on the development of bronchopulmonary dysplasia (BPD) in preterm infants. 243 infants who were admitted to BaYi Children’s Hospital Affiliated to Clinical Medical College in Beijing Military General Hospital with gestational age (GA) less than 32 weeks from February, 2014 to February, 2015 were included in the study. Maternal and infant data were recorded. Multivarariate logistic regression analysis was performed to determine the association between anemia and BPD. Of 243 preterm infants, the incidence of anemia was higher in BPD patients than non-BPD patients (p < 0.001). Mean Hct in BPD patients was lower than non-BPD patients at different time points in 1d, 7d, 14d, and 21d. Controlling for other confounding factors, early anemia was associated with an increased risk of BPD. Number of transfusions is also a significant risk factor for BPD (p = 0.001). Therefore, prevention and treatment of early anemia is necessary and reducing number of transfusions may reduce the incidence of BPD in preterm infants.
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Affiliation(s)
- Jun Duan
- Department of Pediatrics, BaYi Children's Hospital Affiliated to Clinical Medical College in Beijing Military General Hospital of Southern Medical University, Beijing 100700, China
| | - Xiangyong Kong
- Department of Pediatrics, BaYi Children's Hospital Affiliated to Clinical Medical College in Beijing Military General Hospital of Southern Medical University, Beijing 100700, China
| | - Qiuping Li
- Department of Pediatrics, BaYi Children's Hospital Affiliated to Clinical Medical College in Beijing Military General Hospital of Southern Medical University, Beijing 100700, China
| | - Shaodong Hua
- Department of Pediatrics, BaYi Children's Hospital Affiliated to Clinical Medical College in Beijing Military General Hospital of Southern Medical University, Beijing 100700, China
| | - Sheng Zhang
- Department of Pediatrics, BaYi Children's Hospital Affiliated to Clinical Medical College in Beijing Military General Hospital of Southern Medical University, Beijing 100700, China
| | - Xiaoying Zhang
- Department of Pediatrics, BaYi Children's Hospital Affiliated to Clinical Medical College in Beijing Military General Hospital of Southern Medical University, Beijing 100700, China
| | - Zhichun Feng
- Department of Pediatrics, BaYi Children's Hospital Affiliated to Clinical Medical College in Beijing Military General Hospital of Southern Medical University, Beijing 100700, China
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