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Perrone S, Dell'Orto V, Beretta V, De Bernardo G, Giordano M, Petrolini C, Boscarino G, Sodini C, Titolo A, Costa F, Esposito SMR. Predictive Role of Reticulocyte Fluorescence for Late Red Blood Cell Transfusion in Very Low Birth Weight Infants. Arch Med Res 2024; 55:103066. [PMID: 39098113 DOI: 10.1016/j.arcmed.2024.103066] [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: 02/12/2024] [Revised: 06/15/2024] [Accepted: 07/24/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Nearly 58% of very low birth weight (VLBW) infants receive at least one red blood cell transfusion, which is not without risk. Reticulocyte fluorescence (RF) indicates the degree of cell maturation. The greater the fluorescence, the greater the immaturity of the reticulocytes. AIM To evaluate RF as a marker of reticulocyte maturity and to investigate its predictive value for transfusion requirement in VLBW infants. METHODS Complete blood count was performed at 1, 7, 14, 21, and 28 d of age in 104 VLBW infants at the University Hospital of Parma. Iron supplementation was started at 15 d of life. The infants were divided into two groups: those who required transfusion after 28 d of life. (Tr) and those who did not (NTr). RESULTS Twenty-seven of 104 newborns required a red blood cell transfusion after 28 d of life (Tr group). At 14 d of life, the percentage of high fluorescence reticulocyte (HFR) was significantly higher in the r group than in infants who did not receive any transfusion (NTr groups): 18.5 vs. 5%, p = 0.002. The ROC curve (AUC 74%) revealed an HFR cut-off value of 16.5% as a predictor of the need for red blood cell (RBC) transfusion. CONCLUSIONS Reticulocyte maturation at 14 d of life is clinically useful for estimating the qualitative impairment of erythropoiesis and predicts the risk of RBC transfusion in VLBW infants. The data suggest the need for tailored iron integration in VLBW infants to improve the quality of hematopoiesis and reduce the risk of blood transfusion.
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Affiliation(s)
- Serafina Perrone
- Neonatology Unit, Department of Medicine and Surgery, University of Parma, Pietro Barilla Children's Hospital, Parma, Italy.
| | - Valentina Dell'Orto
- Neonatology Unit, Department of Medicine and Surgery, University of Parma, Pietro Barilla Children's Hospital, Parma, Italy
| | - Virginia Beretta
- Neonatology Unit, Department of Medicine and Surgery, University of Parma, Pietro Barilla Children's Hospital, Parma, Italy
| | - Giuseppe De Bernardo
- Department of Woman and Child, Ospedale Buon Consiglio Fatebenefratelli, Naples, Italy
| | - Maurizio Giordano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Chiara Petrolini
- Neonatology Unit, Department of Medicine and Surgery, University of Parma, Pietro Barilla Children's Hospital, Parma, Italy
| | - Giovanni Boscarino
- Neonatology Unit, Department of Medicine and Surgery, University of Parma, Pietro Barilla Children's Hospital, Parma, Italy
| | - Chiara Sodini
- Neonatology Unit, Department of Medicine and Surgery, University of Parma, Pietro Barilla Children's Hospital, Parma, Italy
| | - Annachiara Titolo
- Neonatology Unit, Department of Medicine and Surgery, University of Parma, Pietro Barilla Children's Hospital, Parma, Italy
| | - Federico Costa
- Neonatology Unit, Department of Medicine and Surgery, University of Parma, Pietro Barilla Children's Hospital, Parma, Italy
| | - Susanna Maria Roberta Esposito
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Heeger LE, Koster MIJ, Caram-Deelder C, Bekker V, van der Bom JG, Lopriore E. Umbilical Cord Blood as an Alternative to Neonatal Blood for Complete Blood Count: A Comparison Study. J Pediatr 2024; 271:114059. [PMID: 38636783 DOI: 10.1016/j.jpeds.2024.114059] [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: 02/07/2024] [Revised: 04/08/2024] [Accepted: 04/14/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE To assess concordance between umbilical cord blood (UCB) and neonatal blood (NB) laboratory test results at birth. STUDY DESIGN This retrospective study considered very preterm neonates (<32 weeks' gestational age) admitted to a tertiary neonatal intensive care unit from 2012 to 2023. Inclusion criteria required neonates with a complete blood count measured in both UCB and NB drawn within 2 hours after birth. Median hemoglobin (Hb) and hematocrit (Hct) concentrations were compared between UCB (venous samples) and NB (venous, arterial, or capillary samples). RESULTS A total of 432 neonates with paired UCB and NB values were included in the study. Hb concentration in UCB was 14.7 g/dL (IQR 13.5-16.1 g/dL) compared with 14.8 g/dL (IQR 12.6-19.3 g/dL) in venous NB samples, 13.9 g/dL (IQR 12.9-15.3 g/dL) in arterial NB and 18.7 g/dL (IQR 16.6-20.8 g/dL) in capillary NB. The regression equation showed a correction factor of 1.08 for converting Hb values from UCB to venous NB. Median Hct concentration in UCB was 0.45 L/L (IQR: 0.41-0.49 L/L) compared with 0.48 L/L (IQR 0.43-0.54 L/L) in venous NB, 0.42 L/L (IQR 0.38-0.45 L/L) in arterial NB and 0.57 L/L, (IQR 0.51-0.63 L/L) in capillary NB. CONCLUSIONS Hb and Hct concentrations measured in UCB are similar to those measured in venous blood in very preterm infants and are valid alternatives for NB tests at birth. Hb and Hct concentrations in arterial and capillary NB are respectively lower and higher compared with UCB measurements.
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Affiliation(s)
- Lisanne E Heeger
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands; Sanquin Blood Supply Foundation, Clinical Center for Transfusion Research, Amsterdam, The Netherlands
| | - Myrthe I J Koster
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Camila Caram-Deelder
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vincent Bekker
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna G van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands.
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Balasubramanian H, Bhanushali M, Tripathi V, Srinivasan L, Sakharkar S, Pillai A, Kabra NS. Effect of Minimization of Early Blood Sampling Losses Among Extremely Premature Neonates: A Randomized Clinical Trial. J Pediatr 2024; 269:114002. [PMID: 38447757 DOI: 10.1016/j.jpeds.2024.114002] [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: 12/11/2023] [Revised: 02/08/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE To evaluate the effect of blood sampling stewardship on transfusion requirements among infants born extremely preterm. STUDY DESIGN In this single-center, randomized controlled trial (RCT), infants born at <28 weeks of gestation and birth weight of <1000 g were randomized at 24 hours of age to two different blood sampling approaches: restricted sampling (RS) vs conventional sampling (CS). The stewardship intervention in the RS group included targeted reduction in blood sampling volume and frequency and point of care testing methods in the first 6 weeks after birth. Both groups received early recombinant erythropoietin from day three of age. Primary outcome was the rate of early red blood cell (RBC) transfusions in the first six postnatal weeks. RESULTS A total of 102 infants (mean gestational age: 26 weeks; birth weight: 756 g) were enrolled. Fidelity to the sampling protocol was achieved in 95% of the infants. Sampling losses in the first 6 weeks were significantly lower in the RS group (16.8 ml/kg vs 23.6 ml/kg, P < .001). The RS group had a significantly lower rate of early postnatal RBC transfusions (41% vs 73%, RR: 0.56 [0.39-0.81], P = .001). The hazard of needing a transfusion during neonatal intensive care unit (NICU) stay was reduced by 55% by RS. Mortality and neonatal morbidities were similar between the two groups. CONCLUSION Minimization of blood sampling losses by approximately one-third in the first 6 weeks after birth leads to substantial reduction in the early red blood cell transfusion rate in infants born extremely preterm and weighing <1000 g at birth. TRIAL REGISTRATION http://www.ctri.nic.in (CTRI/2020/01/022 964).
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Affiliation(s)
| | - Mayuri Bhanushali
- Department of Neonatology, Surya Children's Hospital, Mumbai, Maharashtra, India
| | - Vimmi Tripathi
- Department of Neonatology, Surya Children's Hospital, Mumbai, Maharashtra, India
| | | | - Sachin Sakharkar
- Department of Neonatology, Surya Children's Hospital, Mumbai, Maharashtra, India
| | - Anish Pillai
- Department of Neonatology, Surya Children's Hospital, Mumbai, Maharashtra, India
| | - Nandkishor S Kabra
- Department of Neonatology, Surya Children's Hospital, Mumbai, Maharashtra, India
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4
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Huang HB, Lin YB, Chen JH, Zhu M, Chen LJ, Ye W, Luo LH, Ye HM. Management of refined and personalized newborn blood specimen collection. Pract Lab Med 2024; 40:e00408. [PMID: 38883564 PMCID: PMC11180333 DOI: 10.1016/j.plabm.2024.e00408] [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: 04/13/2024] [Revised: 05/15/2024] [Accepted: 05/24/2024] [Indexed: 06/18/2024] Open
Abstract
Background Iatrogenic blood loss is an important cause of neonatal anemia. In this study, a spreadsheet tool was developed to reduce blood collection, providing a new idea for the prevention of iatrogenic blood loss in newborns. Methods Based on hematocrit, minimum test volume and dead volume, a new tool was to calculate the minimum blood collection volume and the number of containers required for the test portfolio. We collected data from October 2022 to October 2023 from Xiamen Maternal and Child Health Hospital for analysis and validation. Results During this year, there were 16,434 patients and 13,696 plasma/serological samples in the neonatology department. Among them, there were 8 test combinations of greater than 1%, and 9490 samples in total. According to the hospital manual, the recommended amount of blood collection is 27,534 ml and 9490 containers. Through the analysis of this tool, total blood collection was 8864.77 ml, marked qnantity of upward containers (closest level to the calculated blood collection volume) was 10301 ml, and the amount of containers was 8835, which decreased by 67.8%, 62.58% and 6.9% respectively. Besides, if the hematocrit information cannot be obtained in advance and the high hematocrit is calculated as 0.8, the recommended amount of blood collection is 14334.3 ml, and the marked amount of the upward container markering is 17340 ml, decreasing by 47.9% and 37.02% respectively. Conclusion We have developed an auxiliary tool that can manage neonatal blood specimen collection in a fine and personalized way and can be applied among different laboratory instruments by parameters modification.
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Affiliation(s)
- Hui-Bin Huang
- Department of Laboratory Medicine, Fujian Key Clinical Specialty of Laboratory Medicine, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Yu-Bin Lin
- Department of Laboratory Medicine, Fujian Key Clinical Specialty of Laboratory Medicine, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Jin-Hua Chen
- Department of Clinical Laboratory, Fujian Provincial hospital, Shengli Clinical Medical College of Fujian Medical University, 350001, Fujian, China
| | - Min Zhu
- Department of Laboratory Medicine, Fujian Key Clinical Specialty of Laboratory Medicine, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Li-Jin Chen
- Department of Laboratory Medicine, Fujian Key Clinical Specialty of Laboratory Medicine, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Wang Ye
- Department of Laboratory Medicine, Fujian Key Clinical Specialty of Laboratory Medicine, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Lin-Hua Luo
- Department of Laboratory Medicine, Fujian Key Clinical Specialty of Laboratory Medicine, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Hui-Ming Ye
- Department of Laboratory Medicine, Fujian Key Clinical Specialty of Laboratory Medicine, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China
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5
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Jung N, Kim C, Kim H, Seo Y, Hwang J, Yang M, Ahn SY, Sung SI, Chang YS. Changes to Blood-Sampling Protocol to Reduce the Sampling Amount in Neonatal Intensive Care Units: A Quality Improvement Project. J Clin Med 2023; 12:5712. [PMID: 37685781 PMCID: PMC10488476 DOI: 10.3390/jcm12175712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/21/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
(1) Background: This study aimed to evaluate whether the implementation of a modified blood-sampling protocol, which focused on need-based laboratory testing and minimized venous sampling by replacing it with point-of-care testing (POCT) via capillary puncture, successfully reduced iatrogenic blood loss, incidence of anemia, and the frequency of blood transfusion among extremely low-birth-weight infants (ELBWIs) without negatively affecting neonatal outcomes. (2) Methods: A retrospective analysis was conducted on 313 ELBWIs with a gestational age (GA) of between 23 and 28 weeks and born between 2013 and 2019. The infants were divided into two groups corresponding to the periods before (period I) and after (period II) the implementation of the modified blood-sampling protocol in January 2016. Propensity score matching was conducted to minimize selection bias. Clinical data, including the frequency and amount of blood sampling, the frequency and volume of blood transfusion, and clinical characteristics, such as gestational age, birth weight, and neonatal outcome data, were collected and compared between the two groups. (3) Results: No significant differences in GA or birth weight between the two periods were observed. The total sampling volume a month after birth (16.7 ± 4.1 mL vs. 15.6 ± 4.4 mL, p = 0.03) and the total sampling volume during hospitalization days (51.4 ± 29.7 mL vs. 44.3 ± 27.5 mL, p = 0.04) in period II were significantly lower than those in period I. There were no differences in terms of anemia (hemoglobin 10.8 ± 2.2 vs. 11.0 ± 1.9, p = 0.43) and mortality or morbidity, such as intraventricular hemorrhage, retinopathy of prematurity, bronchopulmonary dysplasia, necrotizing enterocolitis, and sepsis, between the two periods. Although the transfusion frequency and amount did not present significant differences between the periods, we observed a positive correlation between the transfusion frequency and sampling volume (coefficient: 0.09, 95% CI: 0.08-0.11). (4) Conclusions: The modified blood-sampling protocol effectively reduced the level of iatrogenic blood loss without negatively affecting the neonatal outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | - Se In Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (N.J.); (C.K.); (H.K.); (Y.S.); (J.H.); (M.Y.); (S.Y.A.); (Y.S.C.)
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6
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Stone SB, Bisaccia E, Zakhary MS, Bashqoy F, Wagner D, Stoops C. Implementation Strategies for Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action) to Prevent Neonatal Medication-Induced Kidney Injury. J Pediatr Pharmacol Ther 2023; 28:287-296. [PMID: 37795277 PMCID: PMC10547052 DOI: 10.5863/1551-6776-28.4.287] [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: 01/31/2022] [Accepted: 12/27/2022] [Indexed: 10/06/2023]
Abstract
Acute kidney injury (AKI) is a common complication among patients admitted to the neonatal intensive care unit. Nephrotoxic medications (NTMs) are known to increase the incidence of AKI, but the use of these -medications is often unavoidable. Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action) is a -quality improvement (QI) project that may be implemented at individual institutions and aims to systematically identify AKI in neonates and infants receiving NTMs. The purpose of this review is to describe nephrotoxic AKI in the neonatal population, introduce the Baby NINJA QI project and its potential to reduce neonatal AKI, and outline strategies for effective implementation of Baby NINJA.
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Affiliation(s)
- Sadie B. Stone
- Department of Pharmacy (SBS), Children’s of Alabama, Birmingham, AL
| | | | | | - Ferras Bashqoy
- Department of Pharmacy (FB), Hassenfeld Children’s Hospital at NYU Langone Health, New York, NY
| | - Deborah Wagner
- Department of Pharmacy (DW), Michigan Medicine, Ann Arbor, MI
| | - Christine Stoops
- Department of Pediatrics (CS), University of Alabama at Birmingham, Birmingham, AL
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7
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Hansen AP, Haischer-Rollo GD, Shapiro JB, Aden JK, Abadie JM, Mu TS. The Novel Use of Umbilical Cord Blood to Obtain Complete Blood Counts for Critical Neonatal Assessment. Cureus 2022; 14:e28009. [PMID: 36134078 PMCID: PMC9470209 DOI: 10.7759/cureus.28009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Neonates undergoing clinical evaluations are often subjected to potentially painful phlebotomy for laboratory tests. The use of cord blood laboratory values for admission has been suggested as a means to decrease the risk of painful venipuncture and anemia. Methods: Peripheral and umbilical cord blood complete blood count (CBC) results were obtained from infants who required a CBC. Results were compared using the Sysmex XN heme analyzer (Sysmex, Kobe, Japan). Results: White blood cell (WBC) and hemoglobin (HgB) values were significantly higher in peripheral samples than in cord samples. The mean cord WBC count was 14.1 × 103/mm3 versus 15.6 × 103/mm3 peripherally (p < 0.001). The mean cord HgB was 15.8 g/dL versus 16.8 g/dL peripherally (p < 0.001). Cord platelet (Plt) counts were, conversely, lower in peripheral samples than in cord samples (264.8 × 103/mm3 versus 242.3 × 103/mm3, respectively; p < 0.001). Although statistically different, the mean CBC values from both samples were within the reference ranges. Delayed cord clamping (DCC) increased peripheral versus cord HgB difference nearly threefold (0.6-1.7 g/dL; p = 0.01). Conclusions: Cord blood is an acceptable source for CBC blood sampling in newborn infants and can be used for clinical decisions. CBC laboratory values for cord blood remained within the peripheral blood reference range, with slight variability between the two samples.
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8
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Hajjaj OI, Clarke G, Lieberman L. Immunohematology testing using umbilical cord blood: review of the literature, survey of practice and guidance development. Transfusion 2022; 62:871-886. [PMID: 35322408 DOI: 10.1111/trf.16834] [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: 10/29/2021] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Following delivery, blood tests are performed on umbilical cord blood (CB) to avoid neonatal venipuncture. Despite widespread and longstanding CB testing, no guidelines exist to suggest which immunohematology tests should be performed on CB. STUDY DESIGN AND METHODS We performed a scoping review, surveyed national practice, and developed guidance statements concerning CB testing. Database searches identified relevant articles. A survey was sent to all Canadian hospitals and transfusion laboratories that perform perinatal testing. A national panel of experts was convened to develop guidance statements. RESULTS A total of 116 articles met the inclusion criteria and were summarized. Literature on CB testing is limited; few studies have investigated laboratory testing methodologies or validated CB test results with peripheral samples. The survey was completed by 580/597 institutions (97%); 85% were community hospitals and 16% had a neonatal intensive care unit. There is diversity in the types of CB tests performed and variability in practice. While most centers order appropriately, some laboratories routinely perform CB tests that are not clinically indicated (e.g., direct antiglobulin testing for all neonates) and other do not perform CB tests when results would be beneficial (e.g., phenotype on CB when mother has a clinically significant antibody). Fifteen guidance statements were developed. DISCUSSION This study highlights variability in CB testing, likely reflecting evidence gaps, methodology differences between studies, and lack of guidelines. CB tests should only be performed when indicated and validated on this sample type. The presented guidance statements aim to standardize practice and encourage judicious CB sampling.
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Affiliation(s)
- Omar I Hajjaj
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada
| | - Gwen Clarke
- Canadian Blood Services, Laboratory Services, Ottawa, Ontario, Canada.,Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) Research Program, Toronto, Ontario, Canada.,Department of Clinical Pathology, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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9
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Ikuta T, Iwatani S, Okutani T, Yoshimoto S. Gestational Age-Dependent Reference Ranges for Albumin Levels in Cord Serum. Neonatology 2022; 119:327-333. [PMID: 35294949 DOI: 10.1159/000522502] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 02/08/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND To diagnose hypoalbuminemia in newborns, it is essential to establish a definition applicable to those with a different gestational age (GA) and clinical conditions. A positive correlation between serum albumin levels and GA has been reported, but the study was limited to small numbers of newborns. We therefore investigated the GA-dependent reference ranges for serum albumin levels using cord venous blood (UC-Alb levels) from a large number of newborns delivered at a tertiary perinatal center. METHODS Albumin levels were assessed in 2,917 newborns at 22-41 weeks of GA after exclusion of those with congenital disorders. Linear regression analysis was used to correlate GA and UC-Alb levels. After calculation of the percentile values of UC-Alb levels for each week of GA, the distributions were approximated by the least-squares method. To validate the determined linear approximation of the 5%ile value, the UC-Alb levels in newborns with hydrops fetalis and gastroschisis were used. RESULTS A significant positive correlation between GA and UC-Alb levels was found (rs = 0.701, p < 0.001, respectively). The distribution of the 5%ile of UC-Alb levels (Y) by GA (X) was approximated as a straight line (Y = 0.062 × X + 0.326, R2 = 0.951). Among the 59 and 18 newborns with hydrops fetalis and gastroschisis, 51 (86.4%) and 15 (83.3%), respectively, were below the line. CONCLUSIONS We established GA-dependent reference ranges for serum albumin levels, which may be useful to accurately diagnose hypoalbuminemia in newborns.
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Affiliation(s)
- Toshihiko Ikuta
- Department of Neonatology, Hyogo Prefectural Kobe Children's Hospital Perinatal Center, Kobe, Japan
| | - Sota Iwatani
- Department of Neonatology, Hyogo Prefectural Kobe Children's Hospital Perinatal Center, Kobe, Japan
| | - Takahiro Okutani
- Department of Pediatrics, Saiseikai Hyogo-ken Hospital, Kobe, Japan
| | - Seiji Yoshimoto
- Department of Neonatology, Hyogo Prefectural Kobe Children's Hospital Perinatal Center, Kobe, Japan
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10
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Mizuno Y, Sato T, Shimura K, Ishii T, Hasegawa T. One microliter of blood for SRY testing in a neonate with atypical genitalia. Pediatr Int 2022; 64:e15345. [PMID: 36163638 DOI: 10.1111/ped.15345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Yasuaki Mizuno
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Sato
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.,The Center for Differences of Sex Development, Keio University Hospital, Tokyo, Japan
| | - Kazuhiro Shimura
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Tomohiro Ishii
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.,The Center for Differences of Sex Development, Keio University Hospital, Tokyo, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan.,The Center for Differences of Sex Development, Keio University Hospital, Tokyo, Japan
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11
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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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12
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Mu TS, Prescott AC, Haischer-Rollo GD, Aden JK, Shapiro JB. Umbilical Cord Blood Use for Admission Blood Tests of VLBW Preterm Neonates: A Randomized Control Trial. Am J Perinatol 2021. [PMID: 34407547 DOI: 10.1055/s-0041-1733781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Umbilical cord blood (UCB) for admission laboratories is an approach to decrease anemia risk in very low birth weight (VLBW) neonates. We hypothesized that UCB use results in higher hemoglobin concentration [HgB] around 24 hours of life. STUDY DESIGN A randomized control trial among VLBW infants whose admission laboratories were drawn from UCB (n = 39) or the infant (n = 41) in three U.S. military NICUs (clinicaltrials.gov#NCT02103296). RESULTS No demographic differences were observed between groups. UCB infants had higher [HgB] at 12 to 24 hours of life (15.5 vs. 14.0 g/dL, p = 0.02). The median time to first transfusion was 17 days longer in the experimental group (p = 0.04), and at discharge, their number of donor exposures was lower (1.1 vs. 1.8, p = 0.04). CONCLUSION In the first 24 hours of life that is a period of higher risk for hemodynamic instability, UCB utilization for admission bloodwork in VLBW infants results in higher [HgB]. KEY POINTS · Umbilical cord blood laboratory work in preterm infants is feasible.. · Cord blood use for admission laboratories results in increased hemoglobin in the first 24 hours of life.. · Cord blood use for admission laboratories delays time to first transfusion in preterm infants..
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Affiliation(s)
- Thornton S Mu
- Department of Pediatrics, Brooke Army Medical Center, San Antonio, Texas
| | - Alicia C Prescott
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, Hawaii
| | | | - James K Aden
- Department of Graduate Education, Brooke Army Medical Center, San Antonio, Texas
| | - Jonathan B Shapiro
- Department of Pediatrics, Brooke Army Medical Center, San Antonio, Texas
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13
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Placental transfusion: may the "force" be with the baby. J Perinatol 2021; 41:1495-1504. [PMID: 33850284 DOI: 10.1038/s41372-021-01055-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 02/26/2021] [Accepted: 03/29/2021] [Indexed: 12/14/2022]
Abstract
Placental transfusion results in a significant decrease in the risk of death for extremely preterm infants. With immediate cord clamping (ICC), these infants can leave up to one-half of their normal circulating in utero blood volume in the placenta. Extremely preterm infants are at highest risk of harm from ICC yet are currently the most likely to receive ICC. Receiving a placenta transfusion provides infants with life-saving components and enhanced perfusion. We present some lesser-known but important effects of placental transfusion. New research reveals that enhanced vascular perfusion causes an organ's endothelial cells to release angiocrine responses to guide essential functions. High progesterone levels and pulmonary artery pressure in the first few hours of life assist with neonatal adaptation. We propose that lack of essential blood volume may be a major factor contributing to inflammation, morbidities, and mortality that preterm infants frequently encounter.
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14
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Matveeva TM, Singh G, Gisslen TA, Gewirtz JC, Georgieff MK. Sex differences in adult social, cognitive, and affective behavioral deficits following neonatal phlebotomy-induced anemia in mice. Brain Behav 2021; 11:e01780. [PMID: 33605555 PMCID: PMC7994701 DOI: 10.1002/brb3.1780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Anemia is common in prematurely born infants due to blood loss resulting from frequent phlebotomies and may contribute to their neurobehavioral deficits. Preclinical models of phlebotomy-induced anemia (PIA) have revealed metabolic and genomic changes in multiple brain structures of young mice, yet the impact of neonatal PIA on early-life and adult behavior has not been assessed. METHODS The present study employed a range of behavioral measures in phlebotomized anemic neonatal mice to investigate short- and long-term neurodevelopmental effects. PIA from postnatal (P) days 3 to 14 caused sex-specific changes in social behavior, novelty preference, and anxiety at P17 that persisted into adulthood. RESULTS Our preclinical model suggests that PIA may contribute to acute and long-term behavioral and affective deficits and warrants further substantiation of the observed behavioral phenomena in larger samples. CONCLUSIONS We conclude that this model is a useful tool for beginning to better understand the lasting effect that early-life PIA might have on the developing brain. The differential impact of PIA on male and female subjects warrants further exploration for the development of appropriately targeted interventions.
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Affiliation(s)
| | - Garima Singh
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Tate A Gisslen
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Jonathan C Gewirtz
- Department of Psychology, University of Minnesota, Minneapolis, MN, USA.,Department of Neuroscience, University of Minnesota, Minneapolis, MN, USA
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15
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Keir A, Grace E, Stanworth S. Closing the evidence to practice gap in neonatal transfusion medicine. Semin Fetal Neonatal Med 2021; 26:101197. [PMID: 33541808 DOI: 10.1016/j.siny.2021.101197] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Significant resources are directed towards world-class research projects, but the findings are not necessarily translated into better healthcare outcomes, either at all or in a sustained way. There is a clear need to dedicate further resources to understanding how to promote the uptake of evidence and effectively change neonatal transfusion practice to improve outcomes. Approaching blood transfusion behaviour change more systematically, and working across disciplines and involving families, holds the potential to increase the rate of uptake of emerging evidence in clinical practice. This approach holds the potential to save costs, conserve resources, and improve clinical outcomes. Our paper focuses on the use of quality improvement to bridge the gap between evidence-based knowledge and transfusion practice in neonatal units around the world.
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Affiliation(s)
- Amy Keir
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, South Australia, Australia; Adelaide Medical School and the Robinson Research Institute, The University of Adelaide, South Australia, Australia; Women's and Babies Division, Women's and Children's Hospital, North Adelaide, South Australia, Australia.
| | - Erin Grace
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, South Australia, Australia; Adelaide Medical School and the Robinson Research Institute, The University of Adelaide, South Australia, Australia; Women's and Babies Division, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Simon Stanworth
- National Health Service (NHS) Blood and Transplant/Oxford University Hospitals NHS Trust, Oxford, United Kingdom
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16
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Sanghavi A, Desai S, Nanavati R, Prabhat D. Correlation of haematological parameters and C-reactive protein between cord blood and first post-natal blood sample in preterm neonates: A prospective observational study. J Paediatr Child Health 2020; 56:922-927. [PMID: 31943504 DOI: 10.1111/jpc.14776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 11/18/2019] [Accepted: 12/15/2019] [Indexed: 01/10/2023]
Abstract
AIM There is some recent evidence on the utility of the cord blood as a reliable source for admission complete blood count in preterm neonates. However, there is a need to validate other laboratory parameters from the cord blood such as C-reactive protein (CRP) to rule out neonatal sepsis. The present study was carried out to evaluate the correlation between haematological parameters and CRP obtained from the cord blood to the first post-natal blood sample, for it to be considered as a reliable alternative. METHODS A total of 89 paired cord blood and first post-natal blood samples were prospectively analysed to assess the haematological parameters (complete blood count) and CRP. Pearson's coefficient was calculated to assess the correlation between the cord blood and the first post-natal blood sample. RESULTS When Pearson's correlation coefficient was calculated for various haematological parameters, it showed good correlation coefficient of 0.84 for total leukocyte count, 0.84 for absolute neutrophil count count, 0.87 for immature to total neutrophil ratio and 0.95 for CRP. The correlation coefficient was 0.64 for haemoglobin and 0.36 for platelet count. CONCLUSION There is a strong correlation between the majority of haematological parameters and CRP obtained from the cord blood with the first post-natal blood sample in preterm neonates, except the platelet count. Hence, umbilical cord blood is a feasible and reliable alternative source for assessment of haematological parameters and CRP for the first post-natal blood sample, thereby avoiding a painful prick in these fragile preterm neonates.
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Affiliation(s)
- Avi Sanghavi
- Neonatology Department, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Saumil Desai
- Neonatology Department, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Ruchi Nanavati
- Neonatology Department, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Daksha Prabhat
- Pathology Department, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
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17
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Hellström W, Forssell L, Morsing E, Sävman K, Ley D. Neonatal clinical blood sampling led to major blood loss and was associated with bronchopulmonary dysplasia. Acta Paediatr 2020; 109:679-687. [PMID: 31505053 PMCID: PMC7155086 DOI: 10.1111/apa.15003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 01/23/2023]
Abstract
AIM Studies indicate that reduced foetal haemoglobin levels are related to increased neonatal morbidity rates. This study investigated the relationships between sampling-related blood loss and adult blood transfusions administered during postnatal days 1-14 and the development of severe neonatal morbidities in extremely preterm infants born before 28 weeks of gestation. METHODS The medical files of 149 extremely preterm infants born at two university hospitals in Sweden from 2013 to 2018 were investigated. RESULTS Blood sampling resulted in a 58% depletion of the endogenous blood volume postnatal days 1-14 (median 40.4 mL/kg, interquartile range 23.9-53.3 mL/kg) and correlated with the adult erythrocyte transfusion volume (rS = 0.870, P < .001). Sampling-related blood loss on postnatal days 1-7, adjusted for gestational age at birth and birth weight standard deviation score, was associated with the development of bronchopulmonary dysplasia (BPD) (odds ratio by a 10-unit increase 2.4, 95% confidence interval 1.1-5.4) (P = .03). No associations were found between blood sampling and intraventricular haemorrhage or necrotising enterocolitis in the full statistical model. The largest proportion of sampling-related blood was used for blood gas analyses (48.7%). CONCLUSION Diagnostic blood sampling led to major endogenous blood loss replaced with adult blood components and was associated with the development of BPD.
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Affiliation(s)
- William Hellström
- Department of Paediatrics Institute of Clinical Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Linnéa Forssell
- Department of Clinical Sciences Lund Paediatrics Lund University Skåne University Hospital Lund Sweden
| | - Eva Morsing
- Department of Clinical Sciences Lund Paediatrics Lund University Skåne University Hospital Lund Sweden
| | - Karin Sävman
- Department of Paediatrics Institute of Clinical Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Region Västra Götaland Department of Neonatology The Queen Silvia Children's Hospital Sahlgrenska University Hospital Gothenburg Sweden
| | - David Ley
- Department of Clinical Sciences Lund Paediatrics Lund University Skåne University Hospital Lund Sweden
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18
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Falck AJ, Medina AE, Cummins-Oman J, El-Metwally D, Bearer CF. Mercury, lead, and cadmium exposure via red blood cell transfusions in preterm infants. Pediatr Res 2020; 87:677-682. [PMID: 31649339 DOI: 10.1038/s41390-019-0635-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/26/2019] [Accepted: 10/05/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Mercury, lead, and cadmium are developmental neurotoxicants. We predict that preterm newborns requiring packed red blood cell (PRBC) transfusions may be exposed to neurotoxic doses. We explored the relationship between donor concentration, number of donors, number of transfusions and mercury, lead and cadmium exposure. METHODS Single-donor PRBCs were analyzed for mercury, lead and cadmium concentration. Dose per transfusion was calculated and compared to intravenous reference doses (IVRfDs). Linear regression analyses were performed to correlate donor and infant exposure. RESULTS Thirty-six infants received 268 transfusions from 94 donors. Number of donors and transfusions were significantly correlated with birthweight and gestational age. All three metals were detected in ≥95% of donor PRBCs. Number of donors was significantly associated with cumulative dose, and there was a significant correlation between mercury and lead doses/transfusion. IVRfDs were exceeded for mercury and lead in 8.6% and 38% of transfusions, respectively. None exceeded the IVRfD for cadmium. For lead, infants exposed to three donors had more transfusions exceeding IVRfD than those exposed to 1-2 donors. CONCLUSIONS Preterm infants are exposed to heavy metals via transfusions. Doses exceeded the IVRfDs for mercury and lead. Cadmium did not pose a risk. Prescreening donor blood could reduce exposure risk.
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Affiliation(s)
- Alison J Falck
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, 110 South Paca, 8th Floor, Baltimore, MD, 21201, USA.
| | - Alexandre E Medina
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, 110 South Paca, 8th Floor, Baltimore, MD, 21201, USA
| | - Justine Cummins-Oman
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, 110 South Paca, 8th Floor, Baltimore, MD, 21201, USA
| | - Dina El-Metwally
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, 110 South Paca, 8th Floor, Baltimore, MD, 21201, USA
| | - Cynthia F Bearer
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, 110 South Paca, 8th Floor, Baltimore, MD, 21201, USA
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19
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Puia-Dumitrescu M, Tanaka DT, Spears TG, Daniel CJ, Kumar KR, Athavale K, Juul SE, Smith PB. Patterns of phlebotomy blood loss and transfusions in extremely low birth weight infants. J Perinatol 2019; 39:1670-1675. [PMID: 31582812 PMCID: PMC7331095 DOI: 10.1038/s41372-019-0515-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 07/25/2019] [Accepted: 08/13/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Characterize frequency and volume of blood draws and transfusions in extremely low birth weight infants in the first 10 weeks of life. STUDY DESIGN We included infants with a birth weight <1000 g born 23 0/7-29 6/7 weeks gestational age (GA) and with a length of stay ≥10 weeks, admitted between 2014 and 2016 to a single neonatal intensive care unit. RESULTS Of 54 infants, median (25th, 75th percentile) GA and birth weight were 25 weeks (24, 26) and 665 g (587, 822), respectively. Median number of blood draws per infant decreased from 57 (49, 65) in week 1 to 12 (8, 22) in week 10. Median volume of blood extracted was 83 mL (70, 97), and median number of blood transfusions was 8 (5, 10). CONCLUSIONS This cohort experienced a high number and volume of blood draws. Draw frequency and transfusions decreased over the first 10 weeks of life.
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Affiliation(s)
- Mihai Puia-Dumitrescu
- Department of Pediatrics, University of Washington, Seattle, WA, USA,Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - David T. Tanaka
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | | | | | - Karan R. Kumar
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA,Duke Clinical Research Institute, Durham, NC, USA
| | - Kamlesh Athavale
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Sandra E. Juul
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - P. Brian Smith
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA,Duke Clinical Research Institute, Durham, NC, USA
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20
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Balasubramanian H, Srinivasan L, Kabra N. Reply. J Pediatr 2019; 215:284. [PMID: 31542157 DOI: 10.1016/j.jpeds.2019.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/06/2019] [Indexed: 11/24/2022]
Affiliation(s)
| | - Lakshmi Srinivasan
- The Children's Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, Pennsylvania
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21
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Balasubramanian H, Srinivasan L. Reply. J Pediatr 2019; 214:242-243. [PMID: 31377037 DOI: 10.1016/j.jpeds.2019.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/02/2019] [Indexed: 11/30/2022]
Affiliation(s)
| | - Lakshmi Srinivasan
- The Children's Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, Pennsylvania
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22
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Counsilman CE, Heeger LE, Tan R, Bekker V, Zwaginga JJ, Te Pas AB, Lopriore E. Iatrogenic blood loss in extreme preterm infants due to frequent laboratory tests and procedures. J Matern Fetal Neonatal Med 2019; 34:2660-2665. [PMID: 31588840 DOI: 10.1080/14767058.2019.1670800] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the cumulative amount of iatrogenic blood loss in extreme preterm infants during the first month of life. STUDY DESIGN We performed an observational cohort study in 20 extreme preterm infants (gestational age <28 weeks). We recorded the amount of blood drawn for laboratory testing during the first 4 weeks of life, the number of punctures for phlebotomy and intravenous access and the amount of blood loss associated with these procedures. We compared the cumulative blood loss to the estimated total blood volume (85 ml/kg body weight) and to the total volume of red blood cell (RBC) transfusions administered during the same study period. RESULTS The median cumulative iatrogenic blood loss was 24.2 ml/kg (interquartile range (IQR) 15.8-30.3 ml/kg) per patient, which equals a median of 28.5% (IQR 18.6-35.6%) of the total blood volume. Blood loss was higher in the most extreme preterm infants (30.2 ml/kg at 24 weeks versus 15.9 ml/kg at 27 weeks). The median number of punctures per infant was 47 (IQR 26-56) during the first 4 weeks of life. The median volume of RBC transfusions administered during the study period was 30 ml/kg, slightly more than the cumulative blood loss (24.2 ml/kg). CONCLUSIONS Extreme preterm infants lose almost one-third of their total blood volume in the first month of life as a result of blood loss due to multiple blood draws for laboratory investigations, and procedures.
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Affiliation(s)
- Clare E Counsilman
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lisanne E Heeger
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ratna Tan
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vincent Bekker
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaap Jan Zwaginga
- Department of Immuno-Hematology and Blood Transfusion, Leiden University Medical Center, Leiden, Netherlands
| | - Arjan B Te Pas
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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23
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Abstract
Pre-term infants have one of the highest transfusion requirements within the hospital-setting. The vast majority of blood transfusions performed in Neonatal Intensive Care Units (NICUs) are for medically stable pre-term infants with anaemia of prematurity, with the aim of improving oxygen delivery to the vital organs during the crucial phase of growth and development. However, despite the frequency of transfusion in this population, the potential benefits and harms of 'top up' transfusion are not fully understood, leading to practice variation between clinicians, institutions and countries. Significant advances have been made in the prevention of anaemia of prematurity, with recent emphasis on optimising infants' circulatory volume at birth via placental transfusion and preserving infants' own blood volume through innovative minimal sampling techniques. More research is urgently needed to establish optimal transfusion thresholds for these high-risk pre-term infants, for whom benefits as well as adverse outcomes may have consequences that extend for decades throughout the recipients' life-course. In this review, we will discuss some of the consensus and controversies regarding optimal management of anaemia in pre-term infants and highlight potential areas for future research.
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Affiliation(s)
- Maria Saito-Benz
- Neonatal Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand.,Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand
| | | | - Mary J Berry
- Neonatal Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand.,Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand.,Centre for Translational Physiology, University of Otago, Wellington, New Zealand
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24
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Fustolo-Gunnink SF, Roehr CC, Lieberman L, Christensen RD, Van Der Bom JG, Dame C, Del Vecchio A, Keir AK, Curley A, Stanworth SJ, Lopriore E. Platelet and red cell transfusions for neonates: lifesavers or Trojan horses? Expert Rev Hematol 2019; 12:797-800. [PMID: 31423859 DOI: 10.1080/17474086.2019.1657824] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Suzanne F Fustolo-Gunnink
- Sanquin Research, Center for Clinical Transfusion Research, Plesmanlaan 1A , Leiden , the Netherlands.,Department of Pediatric Hematology, Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Pediatric Hematology , Amsterdam , Netherlands
| | - Charles C Roehr
- Medical Sciences Division, Dept. Paediatrics, University of Oxford , Oxford , UK.,Newborn Services, John Radcliffe Hospital , Oxford , UK
| | - Lani Lieberman
- Department of Clinical Pathology, University Health Network, University of Toronto , Toronto , Canada
| | - Robert D Christensen
- Women and Newborn's Clinical Program, Intermountain Healthcare , Salt Lake City , UT , USA
| | - Johanna G Van Der Bom
- Sanquin Research, Center for Clinical Transfusion Research, Plesmanlaan 1A , Leiden , the Netherlands.,Department of Epidemiology, Leiden University Medical Center , Leiden , the Netherlands
| | - Christof Dame
- Department of Neonatology, Charité-Universitätsmedizin Berlin , Berlin , Germany
| | - Antonio Del Vecchio
- Neonatal Intensive Care Unit, Department of Women's and Children's Health, "Di Venere" Hospital of Bari , Bari , Italy
| | - Amy K Keir
- Robinson Research Institute, Adelaide Medical School, University of Adelaide , Adelaide , Australia.,Department of Neonatal Medicine, Women's and Children's Hospital , Adelaide , Australia.,Healthy Mothers, Babies and Children, South Australian Medical and Research Institute , Adelaide , Australia
| | - Anna Curley
- Department of Neonatology, National Maternity Hospital , Dublin , Ireland
| | - Simon J Stanworth
- Transfusion Medicine, National Health Service (NHS) Blood and Transplant , Oxford , UK.,Department of Haematology, Oxford University Hospitals, NHS Foundation Trust , Oxford , UK.,Radcliffe Department of Medicine, University of Oxford, and Oxford BRC Haematology Theme , Oxford , UK
| | - Enrico Lopriore
- Department of Pediatrics, Division of neonatology, Leiden University Medical Center , Leiden , the Netherlands
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25
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Whitehead NS, Williams LO, Meleth S, Kennedy SM, Ubaka-Blackmoore N, Geaghan SM, Nichols JH, Carroll P, McEvoy MT, Gayken J, Ernst DJ, Litwin C, Epner P, Taylor J, Graber ML. Interventions to prevent iatrogenic anemia: a Laboratory Medicine Best Practices systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:278. [PMID: 31399052 PMCID: PMC6688222 DOI: 10.1186/s13054-019-2511-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 06/10/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND As many as 90% of patients develop anemia by their third day in an intensive care unit (ICU). We evaluated the efficacy of interventions to reduce phlebotomy-related blood loss on the volume of blood lost, hemoglobin levels, transfusions, and incidence of anemia. METHODS We conducted a systematic review and meta-analysis using the Laboratory Medicine Best Practices (LMBP) systematic review methods for rating study quality and assessing the body of evidence. Searches of PubMed, Embase, Cochrane, Web of Science, PsychINFO, and CINAHL identified 2564 published references. We included studies of the impact of interventions to reduce phlebotomy-related blood loss on blood loss, hemoglobin levels, transfusions, or anemia among hospital inpatients. We excluded studies not published in English and studies that did not have a comparison group, did not report an outcome of interest, or were rated as poor quality. Twenty-one studies met these criteria. We conducted a meta-analysis if > 2 homogenous studies reported sufficient information for analysis. RESULTS We found moderate, consistent evidence that devices that return blood from flushing venous or arterial lines to the patient reduced blood loss by approximately 25% in both neonatal ICU (NICU) and adult ICU patients [pooled estimate in adults, 24.7 (95% CI = 12.1-37.3)]. Bundled interventions that included blood conservation devices appeared to reduce blood loss by at least 25% (suggestive evidence). The evidence was insufficient to determine if these devices reduced hemoglobin decline or risk of anemia. The evidence suggested that small volume tubes reduced the risk of anemia, but was insufficient to determine if they affected the volume of blood loss or the rate of hemoglobin decline. CONCLUSIONS Moderate, consistent evidence indicated that devices that return blood from testing or flushing lines to the patient reduce the volume of blood loss by approximately 25% among ICU patients. The results of this systematic review support the use of blood conservation systems with arterial or venous catheters to eliminate blood waste when drawing blood for testing. The evidence was insufficient to conclude the devices impacted hemoglobin levels or transfusion rates. The use of small volume tubes may reduce the risk of anemia.
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Affiliation(s)
| | - Laurina O Williams
- Division of Laboratory Systems, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, 1600 Clifton Road, NE, MS G25, Atlanta, GA, 30333, USA.
| | | | | | | | - Sharon M Geaghan
- Department of Pathology, Pediatrics Division, Stanford University School of Medicine, Stanford, CA, USA
| | - James H Nichols
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Patrick Carroll
- Division of Neonatology, Intermountain Healthcare , St. George, UT, USA
| | | | - Julie Gayken
- Julie Gayken Laboratory Consulting, St. Cloud, MN, USA
| | | | - Christine Litwin
- Clinical Immunology and Referral Testing, Medical University of South Carolina, Columbia, SC, USA
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26
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Effect of Umbilical Cord Blood Sampling versus Admission Blood Sampling on Requirement of Blood Transfusion in Extremely Preterm Infants: A Randomized Controlled Trial. J Pediatr 2019; 211:39-45.e2. [PMID: 31113718 DOI: 10.1016/j.jpeds.2019.04.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/12/2019] [Accepted: 04/16/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the effect of blood sampling from the placental end of the umbilical cord compared with initial blood sampling from neonates, on the need for first packed red blood cell transfusion in extremely preterm infants. We hypothesized that cord blood sampling could delay the time to first blood transfusion. STUDY DESIGN In this single-center, assessor blind, randomized controlled trial, we included extremely low birth weight neonates <28 weeks of gestational age at birth. Five milliliter of blood for initial laboratory investigations was collected either from the placental end of the umbilical cord (study group) or from the neonate upon neonatal intensive care unit admission (control group). Both groups received similar anemia prevention strategies. The primary outcome was the time (in days) to the first packed red blood cell transfusion, and was compared using survival analysis. RESULTS Eighty neonates were enrolled. The time to first transfusion was significantly delayed in the cord sampling group (30 vs 14 days, hazard ratio: 0.44, [95% CI 0.27-0.72], P < .001). Fewer neonates in the cord sampling group were transfused in the first 28 days of life (30% vs 75%, P < .001). Overall transfusion requirements and other clinical outcomes were similar in the groups. CONCLUSIONS Initial blood sampling from placental end of umbilical cord, when combined with anemia prevention strategies, significantly prolonged the time to first transfusion and reduced the need for early transfusions among extremely premature neonates. TRIAL REGISTRATION Ctri.nic.in/ (CTRI/2017/04/008320).
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27
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D'Cunha R, Schmidt R, Widness JA, Mock DM, Yan X, Cress GA, Kuruvilla D, Veng-Pedersen P, An G. Target-mediated disposition population pharmacokinetics model of erythropoietin in premature neonates following multiple intravenous and subcutaneous dosing regimens. Eur J Pharm Sci 2019; 138:105013. [PMID: 31340188 DOI: 10.1016/j.ejps.2019.105013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/16/2019] [Accepted: 07/18/2019] [Indexed: 01/09/2023]
Abstract
Routine erythropoietin (Epo) therapy for neonatal anemia is presently controversial due to its modest response. We speculate that an important contributor to this modest response is that previous clinical study designs were not driven by rigorous mechanistic and kinetic insights into the complex pharmacokinetics (PK) and pharmacodynamics (PD) of Epo in this population. To address this therapeutic opportunity, we conducted a prospective clinical study to investigate the PK of Epo in very-low-birth-weight (VLBW) premature neonates using a unique Epo dosing algorithm that accounts for complex neonatal erythropoietic physiology. Twenty-seven subjects received up to 10 intravenous or subcutaneous exogenous doses of Epo (600 or 1200 U/kg) during the first 4 weeks of life. Subjects were administered two doses of Epo 1200 U/kg on days 2 and 16, and eight doses of Epo 600 U/kg on days 4, 5, 6, 7, 9, 14, 15, and 28 following birth. We have developed for the first time a mechanistic, target-mediated disposition model that provides novel insights into the mechanisms driving Epo PK in VLBW neonates. Epo association rate, kon, was estimated to be 0.00610 pM-1h-1, and the dissociation rate koff was 0.112 h-1. Internalization of the Epo-target complex (kint) and the total receptor concentration (Rmax) were estimated to be 0.118 h-1 and 133 pM, respectively. Following s.c. administration, the absorption rate (ka) of Epo was 0.0738h-1 and bioavailability was 78.0%. Our mechanism-based population pharmacokinetic analysis provided quantitative insight into Epo kinetics in VLBW neonates; the information gained will assist in deriving dosing strategies for neonatal anemia and for neuroprotection efficacy studies.
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Affiliation(s)
- Ronilda D'Cunha
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA
| | - Robert Schmidt
- Department of Pediatrics Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - John A Widness
- Department of Pediatrics Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Donald M Mock
- Department of Biochemistry and Molecular Biology, University of Arkansas for Medical Sciences, USA
| | - Xiaoyu Yan
- School of Pharmacy, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong
| | - Gretchen A Cress
- Department of Pediatrics Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Denison Kuruvilla
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA; MedImmune, LLC., San Francisco, CA, USA
| | - Peter Veng-Pedersen
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA
| | - Guohua An
- Division of Pharmaceutics and Translational Therapeutics, College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA.
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Aucott SW, Maheshwari A. To transfuse or not transfuse a premature infant: the new complex question. J Perinatol 2019; 39:351-353. [PMID: 30651578 DOI: 10.1038/s41372-018-0306-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 12/10/2018] [Indexed: 01/28/2023]
Affiliation(s)
- Susan W Aucott
- The Charlotte R. Bloomberg Children's Center/Room 8530, 1800 Orleans Street, Baltimore, MD, 21287, USA
| | - Akhil Maheshwari
- The Charlotte R. Bloomberg Children's Center/Room 8530, 1800 Orleans Street, Baltimore, MD, 21287, USA.
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Bianchi M, Papacci P, Valentini CG, Barbagallo O, Vento G, Teofili L. Umbilical cord blood as a source for red-blood-cell transfusion in neonatology: a systematic review. Vox Sang 2018; 113:713-725. [PMID: 30328121 DOI: 10.1111/vox.12720] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/28/2018] [Accepted: 09/20/2018] [Indexed: 02/06/2023]
Abstract
The prevention and treatment of anaemia in newborn patients made tremendous progress in the last decades. However, red-blood-cell (RBC) transfusions remain unavoidable in many neonates candidate to surgery and especially in preterm infants. In particular, anaemia occurring in neonates born at extremely low gestational age is actually severe and frequently requires transfusions. Several approaches have been explored to prevent or even to reduce the threshold and the frequency of RBC transfusions. Among these, umbilical cord blood (UCB) collection and processing to obtain RBC components for autologous or allogeneic transfusion have been extensively investigated. In this systematic review, we revised the literature concerning the use of UCB for either autologous or allogeneic transfusion purposes and we illustrated the rationale for a transfusion therapy tailored to extremely preterm neonates, based on RBC concentrates from allogeneic UCB donations.
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Affiliation(s)
- Maria Bianchi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Banca del sangue di cordone ombelicale UNICATT, Rome, Italy
| | - Patrizia Papacci
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
- Terapia Intensiva Neonatale, Rome, Italy
| | - Caterina Giovanna Valentini
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Banca del sangue di cordone ombelicale UNICATT, Rome, Italy
| | - Ombretta Barbagallo
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Banca del sangue di cordone ombelicale UNICATT, Rome, Italy
| | - Giovanni Vento
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
- Terapia Intensiva Neonatale, Rome, Italy
| | - Luciana Teofili
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Banca del sangue di cordone ombelicale UNICATT, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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Aysola AE, Duque MA, Williams P, Alissa R. Comparison of heel stick sample with placental blood sample for pretransfusion testing. Transfusion 2018; 58:2227-2231. [PMID: 30153354 DOI: 10.1111/trf.14792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/09/2018] [Accepted: 03/25/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Published studies demonstrate that placental blood samples provide acceptable results for various laboratory tests, but these studies did not include pretransfusion testing. The aim of this study was to show concordance between heel stick and placental blood sample pairs for pretransfusion testing and to validate tube and gel method for placental samples. Using placental blood samples for pretransfusion testing potentially reduces the amount of blood collected from newborns for initial laboratory tests. STUDY DESIGN AND METHODS Placental samples were collected for pretransfusion tests at birth from 32 newborns with less than 2000 g birthweight and less than 35 weeks to compare the results with the heel stick samples from the same newborns. ABO and D typing, direct antiglobulin test (DAT) with IgG, and antibody screen tests were performed on these sample pairs. For ABO and D typing both tube and gel methods were used to validate both methods for the placental samples. RESULTS This study shows 100% concordance in 32 sample pairs for ABO, D, and DAT tests. Antibody screen results were compared on 29 sample pairs. All 28 sample pairs were concordant, but one placental blood sample was more sensitive to detect a weak maternal antibody than its corresponding heel stick sample was. CONCLUSION The results of this study validated that placental blood samples can be used in place of heel stick samples and are suitable for pretransfusion testing. This study also validated ABO and D typing by tube and gel methods for placental samples.
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Affiliation(s)
- Agnes E Aysola
- Department of Pathology and Laboratory Medicine, Department of Pediatrics, University of Florida, College of Medicine, Jacksonville, Florida
| | - Miriam Andrea Duque
- Department of Pathology and Laboratory Medicine, Department of Pediatrics, University of Florida, College of Medicine, Jacksonville, Florida
| | - Patty Williams
- Department of Pathology and Laboratory Medicine, Department of Pediatrics, University of Florida, College of Medicine, Jacksonville, Florida
| | - Rana Alissa
- Department of Pathology and Laboratory Medicine, Department of Pediatrics, University of Florida, College of Medicine, Jacksonville, Florida
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Cervantes LL, Zuñiga JA. Strategies to Avoid Neonatal Blood Transfusions for Families of the Jehovah's Witness Faith. Nurs Womens Health 2018; 22:332-337. [PMID: 30077239 DOI: 10.1016/j.nwh.2018.05.006] [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] [Received: 12/12/2017] [Revised: 02/14/2018] [Accepted: 03/01/2018] [Indexed: 06/08/2023]
Abstract
Beliefs and restrictions regarding acceptance of blood products by members of the Jehovah's Witness faith often provoke discussion among health care professionals regarding alternative interventions. Establishing and maintaining an open dialog with women and families of the Jehovah's Witness faith regarding their beliefs on the use of blood and blood products are vital in creating a therapeutic relationship between families and the health care team. Such rapport facilitates the discussion of strategies to avoid blood transfusions for newborns and provides women and families multiple opportunities to develop of a holistic birth plan congruent with their beliefs.
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Comparison of Placental and Neonatal Admission Complete Blood Cell Count and Blood Cultures. Adv Neonatal Care 2018; 18:215-222. [PMID: 29578894 DOI: 10.1097/anc.0000000000000482] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The utilization of placental blood for neonatal admission laboratory tests, specifically the complete blood cell (CBC) count and blood culture, has the potential to delay the onset of anemia of prematurity and intraventricular hemorrhage, frequency of blood transfusions and associated complications, and painful procedures related to laboratory sampling. PURPOSE To determine the feasibility of drawing neonatal admission laboratory tests from the placenta rather than the neonate and to compare CBC count and blood culture results. METHODS All infants less than 35 weeks' gestational age and all term infants with a maternal history of chorioamnionitis or untreated, positive group B Streptococcus status were eligible to participate. Participating infants had paired CBC count and blood cultures obtained from the placenta and the infant. RESULTS All CBC count outcomes were significantly, positively correlated between placental and infant blood (all Ps < .05). The paired white blood cells, neutrophils, and lymphocytes were strongly correlated (r = 0.761, r = 0.797, and r = 0.815, respectively), whereas the hemoglobin, hematocrit, platelet, and eosinophils were moderately correlated (r = 0.554, r = 0.545, r = 0.563, and r = 0.478, respectively). Monocytes and basophils were only weakly correlated (r = 0.373 and r = 0.217, respectively). There were 13 (93%) pairs where placental blood culture was positive but the direct infant draw blood culture was negative, and 1 (7%) pair where the placental culture was negative but the direct infant draw blood culture was positive. IMPLICATIONS FOR PRACTICE The results of this and other studies suggest that placental blood can be reliably used to obtain neonatal admission CBC count and blood cultures. IMPLICATIONS FOR RESEARCH Further research is needed regarding the prevention of blood culture contamination, especially in vaginally delivered placentas. Institutions that adopt this procedure should perform quality improvement initiatives to monitor outcomes and add to the growing body of literature on the utilization of placental blood for neonatal admission laboratory tests.
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Moore SP, Newberry DM, Jnah AJ. Use of Placental/Umbilical Blood Sampling for Neonatal Admission Blood Cultures: Benefits, Challenges, and Strategies for Implementation. Neonatal Netw 2018; 36:152-159. [PMID: 28494827 DOI: 10.1891/0730-0832.36.3.152] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Placental blood remains an underused resource for early neonatal care despite ample evidence that placental blood provides the same clinical decision making information without the need for painful, invasive blood sampling procedures. Potential benefits of placental/umbilical blood sampling (PUBS) for neonatal admission labs include decreases in pain reactivity, rates of anemia, need for blood transfusions, use of vasopressors, and rates of intraventricular hemorrhage. Here, we present a unique case study of a critically ill infant with contradictory blood culture results from PUBS and direct infant sampling. A negative admission direct sample blood culture result compared with a positive admission PUBS blood culture result suggests that infection may have been missed in the direct infant sample. Relevant placental embryology and circulation is also described, as well as the benefits of PUBS for neonatal admission labs (with focus on the blood culture), challenges associated with PUBS practice, and strategies for implementation of PUBS.
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Carroll PD, Livingston E, Baer VL, Karkula K, Christensen RD. Evaluating Otherwise-Discarded Umbilical Cord Blood as a Source for a Neonate's Complete Blood Cell Count at Various Time Points. Neonatology 2018; 114:82-86. [PMID: 29719291 DOI: 10.1159/000488024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 02/28/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous studies have reported the use of cord blood for admission laboratory complete blood counts (CBCs). However, no studies have investigated its stability for the first 30 min after delivery. OBJECTIVES We quantified blood cells drawn from the umbilical vein to determine the effect of (1) the time after placental delivery, and (2) the site of blood sampling (umbilical vein on an isolated cord segment vs. umbilical vein on the placental surface). METHODS Timed phlebotomies were drawn at 2, 10, and 30 min from (1) the umbilical vein on an isolated, double-clamped cord segment, and (2) the umbilical vein near or on the placental surface. Leukocyte count, hemoglobin, platelet count, and fibrinogen were measured on each phlebotomy sample. RESULTS Blood drawn from the isolated umbilical cord segments had leukocyte count, hemoglobin, platelet count, and fibrinogen that remained unchanged between the phlebotomies at 2, 10, and 30 min after delivery. However, blood drawn from the umbilical vein on the placental surface had, at 30 min, a leukocyte count (p = 0.002), hemoglobin (p = 0.01), and platelet count (p = 0.001) that were statistically different from the values at 2 and 10 min after delivery. There was no difference in fibrinogen at 2, 10, or 30 min. CONCLUSIONS If cord blood is used for a neonate's initial CBC, the blood should be drawn within 10 min of the placental delivery when it is taken from the umbilical vein on or near the placenta. If an umbilical cord segment is obtained, the phlebotomy can be delayed for up to 30 min.
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Affiliation(s)
- Patrick D Carroll
- Women and Newborn's Clinical Program, Intermountain Healthcare, Salt Lake City, Utah, USA.,Dixie Regional Medical Center, St. George, Utah, USA
| | | | - Vickie L Baer
- Women and Newborn's Clinical Program, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Kerby Karkula
- Dixie Regional Medical Center, St. George, Utah, USA
| | - Robert D Christensen
- Women and Newborn's Clinical Program, Intermountain Healthcare, Salt Lake City, Utah, USA.,Divisions of Neonatology and Hematology/Oncology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
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35
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Cure P, Bembea M, Chou S, Doctor A, Eder A, Hendrickson J, Josephson CD, Mast AE, Savage W, Sola-Visner M, Spinella P, Stanworth S, Steiner M, Mondoro T, Zou S, Levy C, Waclawiw M, El Kassar N, Glynn S, Luban NLC. 2016 proceedings of the National Heart, Lung, and Blood Institute's scientific priorities in pediatric transfusion medicine. Transfusion 2017; 57:1568-1581. [PMID: 28369923 DOI: 10.1111/trf.14100] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/30/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Pablo Cure
- Division of Blood Diseases and Resources, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Melania Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Stella Chou
- Department of Hematology and the Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Allan Doctor
- Department of Pediatrics, St Louis Children's Hospital, St Louis, Missouri
| | - Anne Eder
- National Institutes of Health, Bethesda, Maryland
| | - Jeanne Hendrickson
- Department of Laboratory Medicine, Yale University, New Haven, Connecticut
| | | | - Alan E Mast
- Blood Research Institute, Blood Center of Wisconsin, and the Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Martha Sola-Visner
- Department of Newborn Medicine, Children's Hospital, Boston, Massachusetts
| | | | - Simon Stanworth
- NHS Blood and Transplant, John Radcliffe Hospital, and Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - Marie Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | | | - Shimian Zou
- Division of Blood Diseases and Resources, NHLBI/NIH
| | | | - Myron Waclawiw
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - Simone Glynn
- Division of Blood Diseases and Resources, NHLBI/NIH
| | - Naomi L C Luban
- Division of Laboratory Medicine, Children's National Health System, Washington, DC
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Abstract
Procedural distress is a common occurrence in the NICU and is tied to attempts to support the life and development of vulnerable premature infants. We discuss the epidemiology of procedural distress and the potential negative consequences on infant neurodevelopment. We define procedural distress in the NICU and outline three approaches to limit or to reduce its detrimental effects including minimizing the number of procedures, instituting measures for developmentally supportive care, and using preemptively pharmacologic and nonpharmacologic analgesia. Despite the pervasiveness of procedural distress in the NICU, clinical and administrative measures are available to ameliorate possible harmful outcomes.
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Research Opportunities to Improve Neonatal Red Blood Cell Transfusion. Transfus Med Rev 2016; 30:165-73. [PMID: 27424006 DOI: 10.1016/j.tmrv.2016.06.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 06/28/2016] [Indexed: 01/23/2023]
Abstract
Red blood cell (RBC) transfusion is a common and lifesaving therapy for anemic neonates and infants, particularly among those born prematurely or undergoing surgery. However, evidence-based indications for when to administer RBCs and adverse effects of RBC transfusion on important outcomes including necrotizing enterocolitis, survival, and long-term neurodevelopmental impairment remain uncertain. In addition, blood-banking practices for preterm and term neonates and infants have been largely developed using studies from older children and adults. Use of and refinements in emerging technologies and advances in biomarker discovery and neonatal-specific RBC transfusion databases may allow clinicians to better define and tailor RBC transfusion needs and practices to individual neonates. Decreasing the need for RBC transfusion and developing neonatal-specific approaches in the preparation of donor RBCs have potential for reducing resource utilization and cost, improving outcomes, and assuring blood safety. Finally, large donor-recipient-linked cohort studies can provide data to better understand the balance of the risks and benefits of RBC transfusion in neonates. These studies may also guide the translation of new research into best practices that can rapidly be integrated into routine care. This review highlights key opportunities in transfusion medicine and neonatology for improving the preparation and transfusion of RBCs into neonates and infants. We focus on timely, currently addressable knowledge gaps that can increase the safety and efficacy of preterm and term neonatal and infant RBC transfusion practices.
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38
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Lemyre B, Sample M, Lacaze-Masmonteil T. Minimizing blood loss and the need for transfusions in very premature infants. Paediatr Child Health 2016; 20:451-62. [PMID: 26744559 DOI: 10.1093/pch/20.8.451] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Reducing blood loss and the need for blood transfusions in extremely preterm infants is part of effective care. Delayed cord clamping is well supported by the evidence and is recommended for infants who do not immediately require resuscitation. Cord milking may be an alternative to delayed cord clamping; however, more research is needed to support its use. In view of concerns regarding the increased risk for cognitive delay, clinicians should avoid using hemoglobin transfusion thresholds lower than those tested in clinical trials. Higher transfusion volumes (15 mL/kg to 20 mL/kg) may decrease exposure to multiple donors. Erythropoietin is not recommended for routine use due to concerns about retinopathy of prematurity. Elemental iron supplementation (2 mg/kg/day to 3 mg/kg/day once full oral feeds are achieved) is recommended to prevent later iron deficiency anemia. Noninvasive monitoring (eg, for carbon dioxide, bilirubin) and point-of-care testing reduce the need for blood sampling. Clinicians should strive to order the minimal amount of blood sampling required for safe patient care, and cluster samplings to avoid unnecessary skin breaks.
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40
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Carroll PD, Ridout RE. Contemporary Bloodletting--An Opportunity for Collaboration With the Neonatal Intensive Care Unit. Ann Thorac Surg 2015; 100:1976-7. [PMID: 26522571 DOI: 10.1016/j.athoracsur.2015.05.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 04/30/2015] [Accepted: 05/07/2015] [Indexed: 11/24/2022]
Affiliation(s)
- Patrick D Carroll
- Department of Pediatrics, Intermountain Healthcare, Dixie Regional Medical Center, 544 S 400 E, St. George, UT 84770.
| | - R Erick Ridout
- Department of Pediatrics, Intermountain Healthcare, Dixie Regional Medical Center, 544 S 400 E, St. George, UT 84770
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41
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Lemyre B, Sample M, Lacaze-Masmonteil T. Limiter les pertes de sang et le recours aux transfusions chez les grands prématurés. Paediatr Child Health 2015. [DOI: 10.1093/pch/20.8.457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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42
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Umbilical Cord Blood-An Untapped Resource: Strategies to Decrease Early Red Blood Cell Transfusions and Improve Neonatal Outcomes. Clin Perinatol 2015; 42:541-56. [PMID: 26250916 DOI: 10.1016/j.clp.2015.04.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Umbilical cord blood is a resource that is available to all neonates. Immediately after delivery of the fetus, cord blood can be used for the direct benefit of the premature infant. Delayed cord clamping and milking of the umbilical cord are 2 methods of transfusing additional fetal blood into the neonate after vaginal or cesarean delivery. Additionally, umbilical cord blood can be utilized for neonatal admission laboratory testing rather than direct neonatal phlebotomy. Together these strategies both increase initial neonatal total blood volume and limit immediate loss through phlebotomy.
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43
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Osterholm EA, Georgieff MK. Chronic inflammation and iron metabolism. J Pediatr 2015; 166:1351-7.e1. [PMID: 25684086 PMCID: PMC4446233 DOI: 10.1016/j.jpeds.2015.01.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 12/03/2014] [Accepted: 01/07/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Erin A. Osterholm
- Assistant Professor of Pediatrics Division of Neonatology University of Minnesota Children’s Hospital
| | - Michael K. Georgieff
- Professor of Pediatrics Division of Neonatology University of Minnesota Children’s Hospital
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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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ANALYSIS OF PHLEBOTOMY BLOOD LOSSES IN NEONATES IN A TERTIARY CARE HOSPITAL. INDIAN JOURNAL OF CHILD HEALTH 2014. [DOI: 10.32677/ijch.2014.v01.i01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Pharmacodynamically optimized erythropoietin treatment combined with phlebotomy reduction predicted to eliminate blood transfusions in selected preterm infants. Pediatr Res 2014; 75:336-42. [PMID: 24216541 PMCID: PMC4418561 DOI: 10.1038/pr.2013.213] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 06/18/2013] [Indexed: 11/08/2022]
Abstract
BACKGROUND Preterm very-low-birth-weight (VLBW) infants weighing <1.5 kg at birth develop anemia, often requiring multiple red blood cell transfusions (RBCTx). Because laboratory blood loss is a primary cause of anemia leading to RBCTx in VLBW infants, our purpose was to simulate the extent to which RBCTx can be reduced or eliminated by reducing laboratory blood loss in combination with pharmacodynamically optimized erythropoietin (Epo) treatment. METHODS Twenty-six VLBW ventilated infants receiving RBCTx were studied during the first month of life. RBCTx simulations were based on previously published RBCTx criteria and data-driven Epo pharmacodynamic optimization of literature-derived RBC life span and blood volume data corrected for phlebotomy loss. RESULTS Simulated pharmacodynamic optimization of Epo administration and reduction in phlebotomy by ≥ 55% predicted a complete elimination of RBCTx in 1.0-1.5 kg infants. In infants <1.0 kg with 100% reduction in simulated phlebotomy and optimized Epo administration, a 45% reduction in RBCTx was predicted. The mean blood volume drawn from all infants was 63 ml/kg: 33% required for analysis and 67% discarded. CONCLUSION When reduced laboratory blood loss and optimized Epo treatment are combined, marked reductions in RBCTx in ventilated VLBW infants were predicted, particularly among those with birth weights >1.0 kg.
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Abstract
The physiology of the neonate is ideally suited to the transition to extrauterine life followed by a period of rapid growth and development. Intravenous fluids and electrolytes should be prescribed with care in the neonate. Sodium and water requirements in the first few days of life are low and should be increased after the postnatal diuresis. Expansion of the extracellular fluid volume prior to the postnatal diuresis is associated with poor outcomes, particularly in preterm infants. Newborn infants are prone to hypoglycemia and require a source of intravenous glucose if enteral feeds are withheld. Anemia is common, and untreated is associated with poor outcomes. Liberal versus restrictive transfusion practices are controversial, but liberal transfusion practices (accompanied by measures to minimize donor exposure) may be associated with improved long-term outcomes. Intravenous crystalloids are as effective as albumin to treat hypotension, and semi-synthetic colloids cannot be recommended at this time. Inotropes should be used to treat hypotension unresponsive to intravenous fluid, ideally guided by assessment of perfusion rather than blood pressure alone. Noninvasive methods of assessing cardiac output have been validated in neonates. More studies are required to guide fluid management in neonates, particularly in those with sepsis or undergoing surgery. A balanced salt solution such as Hartmann's or Plasmalyte should be used to replace losses during surgery (and blood or coagulation factors as indicated). Excessive fluid administration during surgery should be avoided.
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Affiliation(s)
- Frances O'Brien
- Department of Paediatrics, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Headington, Oxford, UK
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Ohls RK, Christensen RD, Kamath-Rayne BD, Rosenberg A, Wiedmeier SE, Roohi M, Lacy CB, Lambert DK, Burnett JJ, Pruckler B, Schrader R, Lowe JR. A randomized, masked, placebo-controlled study of darbepoetin alfa in preterm infants. Pediatrics 2013; 132:e119-27. [PMID: 23776118 PMCID: PMC3691539 DOI: 10.1542/peds.2013-0143] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A novel erythropoiesis stimulating agent (ESA), darbepoetin alfa (Darbe), increases hematocrit in anemic adults when administered every 1 to 3 weeks. Weekly Darbe dosing has not been evaluated in preterm infants. We hypothesized that infants would respond to Darbe by decreasing transfusion needs compared with placebo, with less-frequent dosing than erythropoietin (Epo). METHODS Preterm infants 500 to 1250 g birth weight and ≤48 hours of age were randomized to Darbe (10 μg/kg, 1 time per week subcutaneously), Epo (400 U/kg, 3 times per week subcutaneously) or placebo (sham dosing) through 35 weeks' gestation. All received supplemental iron, folate, and vitamin E, and were transfused according to protocol. Transfusions (primary outcome), complete blood counts, absolute reticulocyte counts (ARCs), phlebotomy losses, and adverse events were recorded. RESULTS A total of 102 infants (946 ± 196 g, 27.7 ± 1.8 weeks' gestation, 51 ± 25 hours of age at first dose) were enrolled. Infants in the Darbe and Epo groups received significantly fewer transfusions (P = .015) and were exposed to fewer donors (P = .044) than the placebo group (Darbe: 1.2 ± 2.4 transfusions and 0.7 ± 1.2 donors per infant; Epo: 1.2 ± 1.6 transfusions and 0.8 ± 1.0 donors per infant; placebo: 2.4 ± 2.9 transfusions and 1.2 ± 1.3 donors per infant). Hematocrit and ARC were higher in the Darbe and Epo groups compared with placebo (P = .001, Darbe and Epo versus placebo for both hematocrit and ARCs). Morbidities were similar among groups, including the incidence of retinopathy of prematurity. CONCLUSIONS Infants receiving Darbe or Epo received fewer transfusions and fewer donor exposures, and fewer injections were given to Darbe recipients. Darbepoetin and Epo successfully serve as adjuncts to transfusions in maintaining red cell mass in preterm infants.
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Affiliation(s)
| | | | - Beena D. Kamath-Rayne
- Cincinnati Children’s Hospital, Cincinnati, Ohio;,Department of Pediatrics, University of Colorado, Aurora, Colorado; and
| | - Adam Rosenberg
- Department of Pediatrics, University of Colorado, Aurora, Colorado; and
| | | | | | | | | | | | - Barbara Pruckler
- Department of Pediatrics, University of Colorado, Aurora, Colorado; and
| | - Ron Schrader
- Clinical Translational Research Center, University of New Mexico, Albuquerque, New Mexico
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Baer VL, Lambert DK, Carroll PD, Gerday E, Christensen RD. Using umbilical cord blood for the initial blood tests of VLBW neonates results in higher hemoglobin and fewer RBC transfusions. J Perinatol 2013; 33:363-5. [PMID: 23047426 DOI: 10.1038/jp.2012.127] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We previously described a method for reducing early phlebotomy losses from very low birth weight (VLBW) neonates by obtaining the initial blood tests from otherwise discarded fetal blood from the placenta. In the present study we sought to; (1) measure the feasibility of performing this method in actual practice, (2) test the hypothesis that this method would result in higher hemoglobin concentrations and lower erythrocyte transfusion rates in the first week after birth. METHODS We conducted two studies in three Intermountain Healthcare NICUs. The first was a feasibility analysis involving 96 VLBW neonates, measuring the success of obtaining the NICU admission laboratory blood tests this way. The second study used case-control methodology to test the hypothesis that this method would result in a higher blood hemoglobin 12 to 24 h after birth, and a lower proportion receiving an erythrocyte transfusion in the first week. RESULT In 91 of 96 VLBW neonates (95%) the initial blood tests were successfully obtained with this method. The success rate was not diminished by delayed cord clamping or cord milking, as it was successful in 35 of 36 (97%) such instances. Cases and controls were well matched on demographic and level of illness comparisons. Among cases the hemoglobin generally increased between birth and 12 to 24 h later, but among controls the hemoglobin generally decreased (P<0.05). In the week following birth fewer cases received vasopressors (P<0.01) and erythrocyte transfusions (P<0.001). CONCLUSION We judge that it is feasible to collect the initial blood tests of VLBW neonates using otherwise discarded umbilical cord/placental blood, in that this can be accomplished in about 95% of VLBW deliveries. This method, which can be used in addition to either delayed clamping of the umbilical cord or cord milking, results in higher hemoglobin concentrations, less vasopressor use and fewer transfusions in the first week.
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Affiliation(s)
- V L Baer
- Women and Newborns Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
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Rosebraugh MR, Widness JA, Nalbant D, Veng-Pedersen P. A mathematical modeling approach to quantify the role of phlebotomy losses and need for transfusions in neonatal anemia. Transfusion 2012; 53:1353-60. [PMID: 23033916 DOI: 10.1111/j.1537-2995.2012.03908.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Very preterm infants commonly develop anemia requiring multiple red blood cell transfusions (RBCTx). This is in part attributable to heavy laboratory phlebotomy loss. Quantification of the extent to which laboratory blood loss contributes to anemia sufficient to prompt RBCTx has not been examined. STUDY DESIGN AND METHODS Twenty-six preterm infants weighing less than 1500 g at birth requiring ventilator support who received one or more RBCTx were intensively studied during the first month of life. Hemoglobin (Hb) loss via laboratory blood loss and RBC senescence and Hb gain from RBCTx were precisely accounted for in a Hb mass balance mathematical model developed to assess the impact of phlebotomy on RBCTx when restrictive RBCTx criteria were applied. RESULTS Study subjects had a birth weight of 880 ± 240 g (mean ± SD) and a Hb level of 14.4 ± 2.4 g/dL at birth and received 3.81 ± 2.15 RBCTx during the study period. Modeling indicated that even with the total elimination of laboratory phlebotomy loss, a reduction of 41% to 48% in RBCTx was achievable. CONCLUSION The present modeling results indicate that while phlebotomy reduction can significantly decrease the number of RBCTx administered to preterm infants, total elimination of all RBCTx will likely require other approaches, for example, stimulation of erythropoiesis with erythropoiesis-stimulating agents.
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Affiliation(s)
- Matthew R Rosebraugh
- College of Pharmacy and College of Medicine, University of Iowa, Iowa City, Iowa 52242, USA
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