Haemolysis in adult and neonatal erythrocytes caused by autoxidation of lipid emulsion (Intralipid)

Macronutrients and Micronutrients in Parenteral Nutrition for Preterm Newborns: A Narrative Review

Preterm neonates display a high risk of postnatal malnutrition, especially at very low gestational ages, because nutritional stores are less in younger preterm infants. For this reason nutrition and growth in early life play a pivotal role in the establishment of the long-term health of premature infants. Nutritional care for preterm neonates remains a challenge in clinical practice. According to the recent and latest recommendations from ESPGHAN, at birth, water intake of 70–80 mL/kg/day is suggested, progressively increasing to 150 mL/kg/day by the end of the first week of life, along with a calorie intake of 120 kcal/kg/day and a minimum protein intake of 2.5–3 g/kg/day. Regarding glucose intake, an infusion rate of 3–5 mg/kg/min is recommended, but VLBW and ELBW preterm neonates may require up to 12 mg/kg/min. In preterm infants, lipid emulsions can be started immediately after birth at a dosage of 0.5–1 g/kg/day. However, some authors have recently shown that it is not always possible to achieve optimal and recommended nutrition, due to the complexity of the daily management of premature infants, especially if extremely preterm. It would be desirable if multicenter randomized controlled trials were designed to explore the effect of early nutrition and growth on long-term health.

Daytime Evaluation of Oxidative Stress and Behavioural Parameters of Donkeys (Equus asinus) During The Hot-Dry and Cold-Dry (Harmattan) Season in a Tropical Savannah

The aim of the study was to evaluate oxidative stress and behavioural responses of donkeys during the cold-dry and hot-dry seasons. Thirty donkeys divided into three groups of ten donkeys each according to their age served as experimental subjects. During each season, behavioural and blood parameters of the donkeys were evaluated three times with an interval of one week at 06:00 h, 12:00 h and 18:00 h (GMT+1). During the hot-dry season, the peak dry-bulb temperature (DBT) value of 36.00 ± 1.00°C was recorded at 12:00 h, indicating that the season induced heat stress. The time spent feeding demonstrated diurnal fluctuations in adult, yearling and foal donkeys, with the highest time occurring at 12:00 h in both seasons. The malondialdehyde (MDA) concentrations in adults (2.34 ± 0.14 nMol/L), yearlings (2.28 ± 0.19 nMol/L) and foals (3.48 ± 0.17 nMol/L) during the hot-dry season were significantly (P < 0.05) higher, when compared to the corresponding values (0.96 ± 0.09, 1.18 ± 0.10 and 1.82 ± 0.10 nMol/L, respectively) recorded during the cold-dry season. At 0.3% NaCl-concentration, the percentage haemolysis obtained during the hot-dry season in adult (90.33 ± 0.49%), yearling (91.24 ± 0.88%) and foal (97.44 ± 0.24%) donkeys were significantly (P < 0.05) higher than the corresponding values (78.53 ± 0.98, 78.67 ± 0.58 and 88.23 ± 0.47%, respectively), recorded during the cold-dry season. In conclusion, the hot-dry season induced heat stress in the donkeys, resulting in a decrease in time spent on feeding and oxidative stress, as evidenced by high erythrocyte MDA concentration and percentage haemolysis.

Oxidative injury in neonatal erythrocytes

Erythrocytes are continuously exposed to free radicals (FR) injury due to their high cellular oxygen concentration and heme iron. The autoxidation of oxyhaemoglobin to methaemoglobin, generating superoxide anion radical, represents the main source of FR in erythrocytes. The erythrocyte membrane is particularly sensitive to oxidative damage due to its high polyunsaturated fatty acid content, and hence, it represents an important system to evaluate the effect of oxidative stress (OS). Information on how red cells OS is triggered and mechanisms of erythrocytes oxidative pressure from plasma may provide a partial answer to questions about the causes of the anaemia of prematurity and about red cell involvement in hypoxia. The recent insights about the mechanism of oxidative injury of red cells and the evidence of relationships between erythrocyte, OS and hypoxia suggest that increased haemolysis is induced by severe hypoxia and acidosis in the perinatal period.

Lipaemic plasma induces haemolysis in resuspended red cell concentrate

INTRODUCTION

We investigated whether haemolysis in red cells suspended in plasma was affected by the lipid content and/or methylene blue (MB) treatment of fresh-frozen plasma (FFP). We also investigated whether haemolysis was affected by the conditions under which lipaemic plasma was stored.

METHODS

Study 1: Visibly lipaemic (n = 22) or nonlipaemic FFP (n = 24) units were thawed, pooled and split into identical pairs, one of which was MB treated. These units were used to resuspend red cell concentrates (RCC) and tested for haemolysis immediately and after 24 and 48 h of storage at 2-6°C. Study 2: Fresh plasma was aliquoted into 15-ml tubes and stored in one of four ways as follows: room temperature; 2-6°C; frozen and thawed; or twice frozen and thawed. A sample of RCC was resuspended in each of these plasmas and haemolysis measured after 2 h. Study 3: Plasma was divided into 15-ml tubes and stored as in study 2 followed by storage left standing upright in a refrigerator (2-6°C) for 24 h (with the exception of the room temperature sample). Plasma was separated into top, middle and bottom fractions and used to resuspend RCC that were assessed for haemolysis after 2 h.

RESULTS

The levels of haemolysis in RCC were immediately greater when suspended in lipaemic plasma (0·70 ± 0·53% v 0·05 ± 0·06% for nonlipaemic plasma), which increased further on subsequent storage for 48 h (1·22 ± 0·40% v 0·15 ± 0·14% for nonlipaemic plasma). This was irrespective of whether plasma was MB treated. Lipaemic plasma stored frozen and then thawed resulted in the greatest haemolysis. In lipaemic plasma stored at 2-6°C, the chylomicron-rich top fraction caused the highest level of haemolysis.

CONCLUSION

Haemolysis in red cells is increased in those suspended in lipaemic plasma and is dependent upon the storage conditions of that plasma prior to suspension. These data are relevant to the choice of plasma used to suspend red cells for neonatal exchange transfusion.

Influence of shielding TPN from photooxidation on the number of early blood transfusions in ELBW premature neonates

OBJECTIVES

The smallest premature neonates often receive blood transfusions early in life. Nonrestrictive transfusion policies are linked to deleterious outcomes. Exposure of total parenteral nutrition (TPN) to ambient light generates oxidation products associated with haemolysis in vitro. Shielding TPN from light limits oxidation. Our hypothesis was protecting TPN from light decreases haemolysis and therefore the need for early blood transfusions.

METHODS

Comparison of haemolysis between animals fed enterally and those receiving TPN, and exploratory case-control retrospective analysis of transfusion counts in premature infants receiving light-exposed or light-protected TPN. The statistical analysis was analysis of variance and longitudinal binomial regression model adjusting for potential covariables of transfusion counts.

RESULTS

In animals, TPN is associated with higher (P<0.05) haemolysis compared with enteral feeds; photoprotection induces lower peroxide load with no effect on the level of haemolysis. In premature infants, light-exposed (n=76) or light-protected (n=57) populations exhibited similar clinical characteristics. Initial haematocrit, gestational age, and index of disease severity had a significant effect on the number of transfusions. When adjusting for these covariables, photoprotection was no longer significant.

CONCLUSIONS

Even though peroxides are associated in vitro with haemolysis, shielding TPN from light to reduce infused peroxides does not significantly decrease the need for early transfusions in premature infants.

A summary of NICU fat emulsion medication errors and nursing services: data from MEDMARX

Intralipid infusions remain a critical part of ensuring adequate nutritional supplement and growth in premature and term infants. Managing intralipid therapy requires great care to prevent metabolic and physiological side effects. The authors sought to systematically study medication errors associated with intralipid administration in the neonatal intensive care unit (NICU). A descriptive quantitative and qualitative analysis incorporating secondary data was used. Medication error data were drawn from 54 institutions that voluntarily participated with MEDMARX, a national, Internet-accessible medication error reporting program owned and operated by the United States Pharmacopeia. These errors were associated with NICUs, and each medication error record identified nursing staff as making the initial error. A total of 257 errors were reviewed, with 3.9% resulting in harm. The mean age of the neonate was 7 days, and more errors occurred on Mondays than any other day of the week. Errors disproportionately occurred between 6 pm and midnight, with a significant difference between errors near 7 am and 7 pm (P = .002). Wrong dose errors occurred in 69% of the sample. Nearly one quarter of the errors resulted from misprogramming infusion devices (either pumps or syringes). Qualitative findings revealed that many of the errors were the result of the nurse's misinterpretation of the modes (ie, time, volume, or rate) on the infusion device or by not recognizing the decimal point on the device's display panel. Several errors involved switching the rate of infusion with total parenteral nutrition and that of intralipids. Voluntary medication error reporting offers valuable insights into intralipid errors occurring in NICUs. Secondary analysis is an ethical, economic means of studying the occurrence of such errors. MEDMARX data suggest that some of the serious errors are the result of complex care and equipment needed for these vulnerable infants.

Intralipid medication errors in the neonatal intensive care unit

These findings suggest that most intralipids errors occur during the administration phase. This complex process can generate high opportunities for error directly related to the use of IV pumps. Nursing staff members are prone to making dosing errors while accurately programming the infusion devices, especially during times of high workload. The evening hours around shift change appeared most vulnerable to such errors occurring. A further analysis to include error rates as a function of error opportunities is critical. The tracking and tallying of such opportunity for error can be accomplished using smart pump technology. A detailed analysis of the existing intralipid administration workflow process will guide the overall strategy of an error prevention plan. Understanding the nursing workload as a function of time of day and census is essential. These mission-critical tasks often require the hard work of a dedicated task force, the commitment of the hospital leadership, and cooperation from the health care providers.

Oxidant and antioxidant levels in preterm newborns with idiopathic hyperbilirubinaemia

OBJECTIVES

Newborns, particularly preterm infants, have limited antioxidant protective capacity. The organism's defence system against reactive oxygen species including vitamins A, E and C, trace element selenium (Se) and enzymes, such as catalase (CAT), superoxide dismutase (SOD), and glutathione peroxidase (GSH-Px) are essential components of the antioxidant system against the oxidative injury to the cellular membranes of erythrocytes. In this study, our aim was to compare the oxidant nitric oxide (total plasma nitrite level as an indicator of nitric oxide (NO)), antioxidant vitamins and selenium and erythrocyte antioxidant enzymes in premature babies with hyperbilirubinaemia with healthy preterms.

METHODS

Twenty preterm infants with newborn jaundice were included in the study group, while 15 preterm infants without jaundice were enrolled in the control group. We evaluated the mean plasma levels of, respectively, the total nitrite as an indicator of NO, bilirubin, vitamins A, E, C and selenium, and the activity of erythrocyte antioxidant enzymes such as CAT, SOD and GSH-Px of preterm infants with idiopathic hyperbilirubinaemia and compared to those of the control group.

RESULTS

The mean plasma total nitrite and total serum bilirubin levels and blood reticulocyte counts of the study group were found to be significantly higher than those of the control group (P < 0.001, P < 0.001 and P < 0.05, respectively). Furthermore, the activity of erythrocyte antioxidant enzymes (all P < 0.001) and the mean plasma levels of the antioxidant vitamins A, E, and C (P < 0.05, P < 0.05 and P < 0.001, respectively) and selenium (P < 0.001) of the study group were all found to be significantly lower than those of the control group.

CONCLUSION

We hypothesize that low antioxidants in pretem babies may predispose them to increased oxidative stress, and cause hyperbilirubinaemia.

Oxidant injury in neonatal erythrocytes during the perinatal period

It has been known for many decades that oxidative stress leads to oxidation of hemoglobin and damage to the erythrocyte membrane. More recently, the factors involved in denaturating of membrane proteins and lipid peroxidation have been investigated in detail, as well as the mechanism of reactive oxygen species formation in red cells. Oxidative stress depletes adenosine triphosphate (ATP) and adenine nucleotides, whereas adenosine monophosphate (AMP) deaminase seems to depress energy metabolism by blocking the salvage pathway of purine nucleotides. Depletion of ATP and activation of AMP deaminase are related to calcium ion concentrations. Denaturating of membrane proteins generally precedes lipid peroxidation and consequent phagocytosis due to caspase activation. Extensive investigations demonstrated the key role of oxidative stress and iron release in a reactive form causing membrane protein damage via the Fenton reaction and hydroxyl radical production. In the absence of efficient protection by antioxidant factors and other molecules such as flavonoids, oxidative stress is responsible for the release of iron in reactive form, predisposing red cells to hemolysis through the formation of senescence antigen. Other well-known sources of oxidative stress in red cells are free radical production outside the red cell by activated phagocytes, endothelial metabolism, hyperoxia, ischemia-reperfusion and the arachidonic acid cascade.

CONCLUSION

The recent insight into the mechanism of oxidative injury of red cells and evidence of relationships between erythrocyte oxidative stress and hypoxia suggest that increased hemolysis is induced by severe hypoxia and acidosis in the fetus as well as the newborn.

Interaction between erythrocytes from three different animals and emulsions prepared with various lecithins and oils

The hemolysis of various animal erythrocytes in emulsions prepared with various emulsifying agents (lecithins) and oils was examined. In the emulsions stabilized with different emulsifying agents, the degree of hemolysis increased in the order soybean lecithin<egg yolk lecithin<hydrogenated egg yolk lecithin<hydrogenated soybean lecithin. In the emulsions stabilized with phospholipids with different iodine values that describe the degree of unsaturation in the fatty acyl groups of phospholipids, the percentage hemolysis decreased with increasing iodine value. In addition, in emulsions prepared with various triglycerides as the oil phase the percentage hemolysis increased with increasing triglyceride acyl chain length. The percentage hemolysis of the different animal erythrocytes increased in the order sheep<rabbit<guinea pig according to phosphatidylcholine contents in erythrocyte membrane of each animal. These results suggested that hemolysis caused by the interaction between erythrocytes and emulsions was involved in phospholipid dispersal such as liposome-like vesicles in the water phase, and was dependent on the phosphatidylcholine contents in both the emulsions and the erythrocyte membrane. Moreover, sphingomyelin in the erythrocyte membrane was found to be an important component for stabilization of erythrocyte membranes against hemolysis induced by intravenous fat or lipid emulsions.

Characterization of a subpopulation of mouse red blood cells as preferential target for malarial invasion

Cell electrophoresis was used to study a distinct subpopulation of murine red blood cells (RBC). These RBC are normally found in the spleen and bone marrow. They appear in the peripheral blood when mice are mildly bled or sucked by mosquitos. These cells have been characterized as having larger size, light density, lower electrophoretic mobility, and being more resistant to lysis with unsaturated fatty acids and in glycerol-containing medium than mature erythrocytes. All their features suggest that their differentiation status represents an intermediate stage between reticulocytes and adult RBC. In vitro Plasmodium invasion tests showed their increased sensitivity to invasion by the parasites. The extent of their spreading in the blood was found to be strain-dependent, being more pronounced in C57B1/6 mice, highly susceptible to developing cerebral malaria after infection with Plasmodium berghei, as compared to Balb/c, a nonsusceptible strain of mice.

Paradoxical role of ascorbic acid and riboflavin in solutions of total parenteral nutrition: implication in photoinduced peroxide generation

In the presence of light, a multivitamin preparation is the main source of peroxides in solutions of total parenteral nutrition (TPN). This preparation contains two photosensitive products, 5'-phosphate flavin mononucleotide (FMN) and polysorbates (PS), as well as electron donors such as ascorbate (AH). We hypothesized that the admixture of FMN or PS with electron donors generates peroxides in TPN and alters the quality of nutrients. Using xylenol orange, peroxide concentrations were measured in solutions containing AH, FMN, and/or PS in water, a dextrose solution, an amino acid preparation, and a lipid emulsion. Thiol functions were evaluated by reduction of 5,5-dithiobis(2-nitrobenzoic acid) in the amino acid preparation. After 24-h light exposure, dextrose solutions with admixtures of AH + FMN or AH + FMN + PS generated peroxides at concentrations similar to those observed in a 1% multivitamin solution, and over three times higher than those observed with FMN, PS, or AH alone. However, in the presence of amino acids, FMN alone induced a generation of peroxides comparable to that observed with FMN + AH. In the lipid emulsion, peroxides increased over 3-fold in the presence of FMN or FMN + AH. The addition of catalase suggested that lipid peroxides and H2O2 were produced, and the loss of thiol function suggested that an oxidation of amino acids occurred. When exposed to light, FMN induces reactions with amino acids, polyunsaturated fatty acids, and even AH, altering the quality of nutrients. Paradoxically, AH without FMN has a protective effect on peroxide generation in TPN.

Chain-breaking antioxidants and ferriheme-bound drugs are synergistic inhibitors of erythrocyte membrane peroxidation

Induced erythrocyte membrane peroxidation (EMP) is considered as an accurate model of reperfusion injuries and as such was used to investigate protective effects of various drugs. EMP was induced by an azo initiator and monitored by oxygen uptake. Both hydrophilic (ascorbic acid) and lipophilic (alpha-tocopherol, probucol, nicanartine) chain-breaking antioxidants as well as ferriheme-bound drugs (deferoxamine, chloroquine) inhibited EMP. When antioxidants and ferriheme-bound drugs were combined, synergistic effects were observed. It is proposed that ferriheme compounds which catalyse peroxide induced lipid peroxidation were blocked by deferoxamine and/or chloroquine. So these drugs inhibited at least partly the membrane peroxidation process and added their effects to the ones of chain-breaking antioxidants.

In vitro oxidation of i.v. lipid emulsions in different all-in-one admixture bags assessed by an iodometric assay and gas-liquid chromatography

Polyunsaturated fatty acids (FAs) of intravenous (IV) lipid emulsions can peroxidize to potentially harmful lipid hydroperoxides. In order to assess in vitro peroxidation of IV fat emulsions in all-in-one (AIO) admixture bags, an iodometric titration to determine lipid hydroperoxide content expressed by the peroxide value (PV) and a gas-liquid chromatographic (GLC) assay to determine changes of the FA pattern were established. A long-chain triglyceride (LCT) and medium-chain triglyceride-LCT emulsion were compared for the PV and the pH during storage at room temperature and daylight in AIO bags made of ethylvinylacetate (EVA) and polypropylene:polyamide 7:3 (V90). In contrast to storage in glass bottles, significant peroxidation was detected in both emulsions with 0.5-3.4 mmol peroxides/L after 28 d (150 times the control PV). A pH drop of at least 0.3 (EVA) and 1.2 (V90) units was measured. Initial PVs and peroxidation kinetics of the emulsions were different; V90 material showed better barrier properties against oxygen. PV was increased by higher temperature and light exposure. The FA pattern of an LCT emulsion with a PV > 6 (storage: 40 degrees C in a dark room for 28 d in AIO bags) assayed by GLC remained unchanged. The iodometric peroxide and the GLC assay were reproducible and easy to handle. Only the iodometric method was sensitive enough to detect peroxidation effects (detection limit: 0.02 mmol peroxides/L). IV fat emulsions can be checked for lipid hydroperoxide content with the rapid iodometric assay to guarantee optimal quality of IV lipids used for AIO admixtures. To prevent peroxidation, lipids in AIO bags should be stored light-protected in a refrigerator an oxygen-tight overwrap is mandatory for extended periods.