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Siebenaler L, Masciola R, Sayre C, Sharpe E. Implementation of a Standardized Red Blood Cell Transfusion Policy in a Level IV Neonatal Intensive Care Unit: A Quality Improvement Project. Adv Neonatal Care 2024:00149525-990000000-00132. [PMID: 38986137 DOI: 10.1097/anc.0000000000001175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
BACKGROUND Within the neonatal intensive care unit (NICU), infants frequently receive packed red blood cell (PRBC) transfusions. Although medically necessary, potential negative long- and short-term outcomes exist following PRBC transfusions in very low birth-weight (VLBW) infants (<1500 g). Synthesis of the literature demonstrates that the use of a restrictive PRBC transfusion policy can lead to a decreased number of transfusions administered with no increase in long-term neurodevelopmental outcomes. Blood transfusions have also been linked to the diagnosis of necrotizing enterocolitis (NEC) or intraventricular hemorrhage (IVH) in VLBW infants. PURPOSE For this quality improvement project, a restrictive PRBC transfusion policy was implemented in a level IV NICU to promote consistent care and evaluate changes in PRBC administration. METHODS The data were collected both pre- and post-policy implementation including: the number of blood transfusions, diagnosis of NEC, and diagnosis of IVH among infants <1500 g. RESULTS The data showed no significant change in the number of PRBC transfusions administered. Likewise, few infants were diagnosed with NEC or IVH during this same time period with minimal change between pre- and post-policy implementation data. IMPLICATIONS FOR PRACTICE AND RESEARCH Following policy implementation, there was a significant improvement in communication among providers regarding transfusion ordering and the inclusion of hematocrit thresholds in daily progress notes. This unintended outcome has helped to promote sustainability and enhance patient care within the NICU where this policy was implemented. Continued data collection may be beneficial in indicating whether a standardized PRBC transfusion policy will impact the administration of transfusions and diagnosis of NEC or IVH.
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Bolat F, Dursun M, Sarıaydın M. Packed Red Blood Cell Transfusion as a Predictor of Moderate-Severe Bronchopulmonary Dysplasia: A Comparative Cohort Study of Very Preterm Infants. Am J Perinatol 2024; 41:e1499-e1507. [PMID: 36898407 DOI: 10.1055/a-2051-8245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
OBJECTIVE Bronchopulmonary dysplasia (BPD) is a leading cause of morbidity and mortality in neonatal intensive care units. Our aim was to evaluate association between packed red blood cell transfusion and the development of BPD in very preterm infants. STUDY DESIGN This retrospective study of very preterm infants (mean gestational age: 27.1 ± 2.4 weeks, birth weight: 970 ± 271 g) was conducted at Biruni University (Turkey) between July 2016 and December 2020. RESULTS BPD developed in 107 of the 246 enrolled neonates, including 47 (43.9%), 27 (25.3%), and 33 (30.8%) diagnosed with mild, moderate, and severe BPD, respectively. A total of 728 transfusions were administered. The increased number (4 transfusions [2-7] vs. 1 [1-3], p = 0.001) and volume of transfusions (75 mL/kg volume [40-130] vs. 20 [15-43], p = 0.001) were significantly higher in infants with BPD compared to those without BPD. The transfusion volume cut-off for the prediction of BPD by receiver operating characteristic curve analysis was 42 mL/kg (sensitivity 73.6%; specificity 75%; area under the receiver-operating characteristic curve: 0.82). In multivariate analysis, multiple transfusions and larger transfusion volume were independent risk factors for moderate-severe BPD. CONCLUSION The increased number and volume of transfusions were associated with BPD in very preterm infants. A packed red blood cell transfusion volume ≥42 mL/kg was a statistically significant predictor of the development of BPD at a postmenstrual age of 36 weeks. KEY POINTS · Transfusions were found to be an important risk factor for BPD development in very premature infants.. · Number and volume of transfusion were associated with the severity of BPD.. · Optimal cut point volume of transfusion for prediction of BPD was 42 mL/kg body weight..
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Affiliation(s)
- Fatih Bolat
- Division of Neonatology, Department of Pediatrics, Istinye University Faculty of Medicine, Istanbul, Turkey
| | - Mesut Dursun
- Division of Neonatology, Department of Pediatrics, Biruni University Faculty of Medicine, Istanbul, Turkey
| | - Mehmet Sarıaydın
- Division of Neonatology, Department of Pediatrics, Biruni University Faculty of Medicine, Istanbul, Turkey
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Mohammad K, Molloy E, Scher M. Training in neonatal neurocritical care: A case-based interdisciplinary approach. Semin Fetal Neonatal Med 2024:101530. [PMID: 38670881 DOI: 10.1016/j.siny.2024.101530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Interdisciplinary fetal-neonatal neurology (FNN) training strengthens neonatal neurocritical care (NNCC) clinical decisions. Neonatal neurological phenotypes require immediate followed by sustained neuroprotective care path choices through discharge. Serial assessments during neonatal intensive care unit (NICU) rounds are supplemented by family conferences and didactic interactions. These encounters collectively contribute to optimal interventions yielding more accurate outcome predictions. Maternal-placental-fetal (MPF) triad disease pathways influence postnatal medical complications which potentially reduce effective interventions and negatively impact outcome. The science of uncertainty regarding each neonate's clinical status must consider timing and etiologies that are responsible for fetal and neonatal brain disorders. Shared clinical decisions among all stakeholders' balance "fast" (heuristic) and "slow" (analytic) thinking as more information is assessed regarding etiopathogenetic effects that impair the developmental neuroplasticity process. Two case vignettes stress the importance of FNN perspectives during NNCC that integrates this dual cognitive approach. Clinical care paths evaluations are discussed for an encephalopathic extremely preterm and full-term newborn. Recognition of cognitive errors followed by debiasing strategies can improve clinical decisions during NICU care. Re-evaluations with serial assessments of examination, imaging, placental-cord, and metabolic-genetic information improve clinical decisions that maintain accuracy for interventions and outcome predictions. Discharge planning includes shared decisions among all stakeholders when coordinating primary care, pediatric subspecialty, and early intervention participation. Prioritizing social determinants of healthcare during FNN training strengthens equitable career long NNCC clinical practice, education, and research goals. These perspectives contribute to a life course brain health capital strategy that will benefit all persons across each and successive lifespans.
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Affiliation(s)
| | | | - Mark Scher
- Pediatrics/Neurology, Case Western Reserve University, Cleveland, USA.
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Ngonzi J, Tibaijuka L, Mwanje Kintu T, Kihumuro RB, Ahabwe O, Byamukama O, Salongo W, Adong J, Boatin AA, Bebell LM. Prevalence and Risk Factors for Newborn Anemia in Southwestern Uganda: A Cross-Sectional Study. Anemia 2024; 2024:5320330. [PMID: 38596653 PMCID: PMC11003795 DOI: 10.1155/2024/5320330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/11/2024] Open
Abstract
Introduction The global prevalence of maternal anemia is about 42%, and in sub-Saharan Africa, the prevalence of newborn anemia ranges from 25% to 30%. Anemia in newborn babies may cause complications such as delayed brain maturation and arrested growth. However, there is limited data on the prevalence of newborn anemia and its risk factors in people living in resource-limited settings. Objectives We determined the prevalence and risk factors for newborn anemia and its correlation with maternal anemia in southwestern Uganda. Methods This was a cross sectional study of 352 pregnant women presenting to the Mbarara Regional Referral Hospital for delivery. We collected maternal blood in labor and umbilical cord blood from the placental vein. We measured hemoglobin using a point-of-care Hemocue machine. We used summary statistics to characterize the study participants and compared demographic characteristics and outcomes using chi-square, t-test, and Wilcoxon rank sum analyses. We defined newborn anemia as umbilical cord hemoglobin <13 g/dl and measured the relationship between maternal and umbilical cord hemoglobin using linear regression analysis. Results The prevalence of newborn anemia was 17%. Maternal parity was significantly higher for anemic than nonanemic newborns (3 versus 2, P=0.01). The mean age in years (SD) was significantly lower for participants with umbilical cord hemoglobin <13 g/dl than those ≥13 g/dl (26 years [5.6] versus 28 [6.3], P=0.01). In multivariable linear regression analysis, a 1-point decrease in maternal hemoglobin was associated with a 0.14-point decrease in umbilical cord hemoglobin (P=0.02). Each one-unit increase in parity was associated with a 0.25-point decrease in umbilical cord hemoglobin (P=0.01). Cesarean delivery was associated with a 0.46-point lower umbilical cord hemoglobin level compared with vaginal delivery (P=0.03). Conclusions We found a significant association between maternal and newborn hemoglobin, underscoring the importance of preventing and correcting maternal anemia in pregnancy. Furthermore, maternal anemia should be considered a risk factor for neonatal anemia.
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Affiliation(s)
- Joseph Ngonzi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Leevan Tibaijuka
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Timothy Mwanje Kintu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Raymond Bernard Kihumuro
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Onesmus Ahabwe
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Onesmus Byamukama
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Wasswa Salongo
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Julian Adong
- Department of Paediatrics and Child Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Adeline A. Boatin
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - Lisa M. Bebell
- Harvard Medical School, Department of Medicine, Center for Global Health and Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, USA
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Pérez-Pérez A, González-Pacheco N, Arriaga-Redondo M, Ramos-Navarro C, Rodríguez-Corrales E, de la Blanca ARS, González-Navarro P, Santos-González M, Sánchez-Luna M. Impact on cerebral hemodynamics of the use of volume guarantee combined with high frequency oscillatory ventilation in a neonatal animal respiratory distress model. Eur J Pediatr 2024; 183:157-167. [PMID: 37851085 DOI: 10.1007/s00431-023-05245-0] [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: 08/24/2023] [Revised: 09/22/2023] [Accepted: 09/28/2023] [Indexed: 10/19/2023]
Abstract
High-frequency oscillatory ventilation (HFOV) is an alternative to conventional mechanical ventilation (CMV). Recently, the use of volume guarantee (VG) combined with HFOV has been suggested as a safe strategy capable of reducing the damage induced by ventilation in immature lungs. However, the possible impact of this new ventilation technique on cerebral hemodynamics is unknown. To evaluate the cerebral hemodynamics effect of HFOV combined with VG in an experimental animal model of neonatal respiratory distress syndrome (RDS) due to surfactant deficiency compared with HFOV and CMV+VG (control group). Eighteen newborn piglets were randomized, before and after the induction of RDS by bronchoalveolar lavage, into 3 mechanical ventilation groups: CMV, HFOV and HFOV with VG. Changes in cerebral oxygen transport and consumption and cerebral blood flow were analyzed by non-invasive regional cerebral oxygen saturation (CrSO2), jugular venous saturation (SjO2), the calculated cerebral oxygen extraction fraction (COEF), the calculated cerebral fractional tissue oxygen extraction (cFTOE) and direct measurement of carotid artery flow. To analyze the temporal evolution of these variables, a mixed-effects linear regression model was constructed. After randomization, the following statistically significant results were found in every group: a drop in carotid artery flow: at a rate of -1.7 mL/kg/min (95% CI: -2.5 to -0.81; p < 0.001), CrSO2: at a rate of -6.2% (95% CI: -7.9 to -4.4; p < 0.001) and SjO2: at a rate of -20% (95% CI: -26 to -15; p < 0.001), accompanied by an increase in COEF: at a rate of 20% (95% CI: 15 to 26; p < 0.001) and cFTOE: at a rate of 0.07 (95% CI: 0.05 to 0.08; p < 0.001) in all groups. No statistically significant differences were found between the HFOV groups. CONCLUSION No differences were observed at cerebral hemodynamic between respiratory assistance in HFOV with and without VG, being the latter ventilatory strategy equally safe. WHAT IS KNOWN • Preterm have a situation of fragility of cerebral perfusion wich means that any mechanical ventilation strategy can have a significant influence. High-frequency oscillatory ventilation (HFOV) is an alternative to conventional mechanical ventilation (CMV). Recently, the use of volume guarantee (VG) combined with HFOV has been suggested as a safe strategy capable of reducing the damage induced by ventilation in immature lungs. Several studies have compared CMV and HFOV and their effects at hemodynamic level. It is known that the use of high mean airway pressure in HFOV can cause an increase in pulmonary vascular resistance with a decrease in thoracic venous return. WHAT IS NEW • The possible impact of VAFO + VG on cerebral hemodynamics is unknown. Due the lack of studies and the existing controversy, we have carried out this research project in an experimental animal model with the aim of evaluating the cerebral hemodynamic repercussion of the use of VG in HFOV compared to the classic strategy without VG.
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Affiliation(s)
- Alba Pérez-Pérez
- Neonatology Department, Hospital General Universitario Gregorio Marañón, c/ O'Donnell, 48, CP 28009, Madrid, Spain.
| | - Noelia González-Pacheco
- Neonatology Department, Hospital General Universitario Gregorio Marañón, c/ O'Donnell, 48, CP 28009, Madrid, Spain
| | - María Arriaga-Redondo
- Neonatology Department, Hospital General Universitario Gregorio Marañón, c/ O'Donnell, 48, CP 28009, Madrid, Spain
| | - Cristina Ramos-Navarro
- Neonatology Department, Hospital General Universitario Gregorio Marañón, c/ O'Donnell, 48, CP 28009, Madrid, Spain
| | - Elena Rodríguez-Corrales
- Neonatology Department, Hospital General Universitario Gregorio Marañón, c/ O'Donnell, 48, CP 28009, Madrid, Spain
| | | | - Pablo González-Navarro
- Unidad de Investigación Materno Infantil Fundación Familia Alonso (UDIMIFFA) - Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Martín Santos-González
- Medical and Surgical Research Unit, Instituto de Investigación Sanitaria Puerta de Hierro, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Manuel Sánchez-Luna
- Neonatology Department, Hospital General Universitario Gregorio Marañón, c/ O'Donnell, 48, CP 28009, Madrid, Spain
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Salem A, Patel RM. Blood Donor Sex and Outcomes in Transfused Infants. Clin Perinatol 2023; 50:805-820. [PMID: 37866849 PMCID: PMC10688602 DOI: 10.1016/j.clp.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Red blood cell transfusion is common in neonatal intensive care. Multiple trials have evaluated different thresholds for when to administer red blood cell transfusion. In contrast, there has been less focus on studies of the characteristics of red blood cells transfused into neonates. In this review, the authors summarize the emerging literature on the potential impact of the sex of blood donors on outcomes in transfused neonates using a systematic search strategy. The authors review the uncertainty generated from studies with conflicting findings and discuss considerations regarding the impact of blood donor sex and other characteristics on neonatal outcomes.
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Affiliation(s)
- Anand Salem
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, Atlanta, GA 30322, USA
| | - Ravi Mangal Patel
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, Atlanta, GA 30322, USA.
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Chen R, Lai SH, Xiu WL, Cai WH, Chen ZQ, Xie YL. Cerebral and intestinal oxygen saturation of different volumes of red blood cell transfusion in preterm infants. Transfus Apher Sci 2023; 62:103839. [PMID: 37891133 DOI: 10.1016/j.transci.2023.103839] [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: 05/25/2023] [Revised: 09/19/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023]
Abstract
OBJECTIVES The purpose of this study was to investigate and compare the effects of 20 ml/kg and 15 ml/kg red blood cell transfusion (RBCT) on cerebral and intestinal tissue oxygenation, the number of administered transfusions, and neonatal complications in premature infants with anemia. METHODS This prospective, randomized, partially blinded observational study investigated anemic neonates of gestational age < 32 weeks (Registration ID: ChiCTR 1,900,026,672). The infants were randomly assigned to receive 15 or 20 ml/kg red blood cell transfusion. Cerebral and intestinal tissue oxygen saturation (cer rSO2 and int rSO2) were collected 2 h before transfusion, 2, 4, 6, 12, 24, and 48 h after the beginning of transfusion by Near-infrared spectroscopy (NIRS). We also collected vital signs including heart rate (HR), peripheral oxygen saturation (SpO2), and mean arterial blood pressure (MABP) 2 h before infusion, 2 h, and 6 h after the beginning of transfusion. Then we analyzed and compared regional oxygen saturation(rSO2), fractional tissue oxygen extraction (FTOE), and other outcome readouts (blood transfusion numbers, changes in hematocrit and hemoglobin, hospitalization days, HR, SpO2, MABP, and complications) between the two groups. The intraindividual comparisons of the above readouts before transfusion and those after transfusion were also evaluated within each group. RESULT 73 newborns received 20 ml/kg (large volume group) and 78 newborns received 15 ml/kg transfusion (small volume group). There was no significant difference in cer rSO2, int rSO2, Cerebral fractional tissue oxygen extraction (cFTOE), and intestinal fractional tissue oxygen extraction (iFTOE) between the two groups. rSO2, MABP, and SpO2 increased; HR, cFTOE, and iFTOE decreased following transfusion in both groups. The transfusion number of the large volume group is significantly less than that of the small volume group (1.9 ± 0.3 vs. 2.6 ± 0.9, p < 0.01) and hospitalization days were also less than those in the low volume group (44.3 ± 8.2 vs. 47.6 ± 9.8, p < 0.05). The increases in hematocrit and hemoglobin were higher in the large volume group than those in small volume (hematocrit increment (%),10.7 ± 4.2 vs. 10.1 ± 5.9, p = 0.015; Hb concentration after blood transfusion (g/L) 132.3 ± 11.1 vs. 127.4 ± 15.4, p = 0.028). CONCLUSION After the transfusion, cer rSO2 and int rSO2 increased significantly, FTOE decreased and vital signs improved in both the 15 ml/kg and 20 ml/kg groups, and these changes were not significantly different between the two groups. However, the larger group showed a more pronounced increase in hematocrit and hemoglobin, a reduction in the total number of transfusions, and a shorter duration of hospitalization after transfusion in preterm infants without increasing complications.
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Affiliation(s)
- Rong Chen
- Department of Neonatology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Shu-Hua Lai
- Department of Neonatology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Wen-Long Xiu
- Department of Neonatology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.
| | - Wen-Hong Cai
- Department of Neonatology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Zhi-Qin Chen
- Department of Neonatology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Ying-Ling Xie
- Department of Neonatology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
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Noroozi-Clever MB, Liao SM, Whitehead HV, Vesoulis ZA. Preterm Infants off Positive Pressure Respiratory Support Have a Higher Incidence of Occult Cerebral Hypoxia. J Pediatr 2023; 262:113648. [PMID: 37517651 PMCID: PMC10822026 DOI: 10.1016/j.jpeds.2023.113648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To use cerebral near-infrared spectroscopy (NIRS) to quantify occult cerebral hypoxia across respiratory support modes in preterm infants. STUDY DESIGN In this prospective, longitudinal, observational study, infants ≤32 weeks gestation underwent serial pulse oximetry (oxygen saturation [SpO2]) and cerebral NIRS monitoring (4-6 hours per session) following a standardized recording schedule (daily for 2 weeks, every other day for 2 weeks, then weekly until 35 weeks corrected gestational age). Four calculations were made: median cerebral saturation, median cerebral hypoxia burden (proportion of NIRS samples below the hypoxia threshold [<67%]), median systemic saturation, and median systemic hypoxia burden (proportion of SpO2 samples below the desaturation threshold [<85%]). During each recording session, respiratory support mode was noted (room air, low-flow nasal cannula, high-flow nasal cannula, noninvasive positive pressure ventilation, continuous positive airway pressure, and invasive ventilation). RESULTS There were 1013 recording sessions made from 174 infants with a median length of 6.9 hours. Although the systemic (SpO2) hypoxia burden was significantly greater for infants on the highest respiratory support (invasive and noninvasive positive pressure ventilation), the cerebral hypoxia burden was significantly greater during recording sessions made on the lowest respiratory support (8% for room air; 29% for low-flow nasal cannula). CONCLUSIONS Premature infants on the highest levels of respiratory support have less cerebral hypoxia than those on lower respiratory support. These results raise concern about unrecognized cerebral hypoxia during lower acuity periods of neonatal intensive care unit hospitalization and adverse outcomes.
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Affiliation(s)
- Mona B Noroozi-Clever
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Steve M Liao
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Halana V Whitehead
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Zachary A Vesoulis
- Division of Newborn Medicine, Edward Mallinckrodt Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO.
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Jefferson L, Ramanan AV, Cummins M, Roderick M. Tailing growth, neonatal jaundice and anaemia. Arch Dis Child Educ Pract Ed 2023; 108:377-384. [PMID: 37263765 DOI: 10.1136/archdischild-2022-324990] [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: 10/11/2022] [Accepted: 05/11/2023] [Indexed: 06/03/2023]
Abstract
At medical school, there is a phrase to help us remember that common things are common: 'If you hear hooves think horses, not zebras'. However, zebras do exist, and from time to time in general paediatric and neonatal practice, we will encounter these rare diagnoses, more of which we can now accurately diagnose through the ever-expanding field of genomics. Our case demonstrates how a rare diagnosis can present with common features of growth restriction, jaundice and anaemia. Paediatricians therefore require a high index of suspicion and increasing knowledge of the logistics of genetic testing.
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Affiliation(s)
- Lucy Jefferson
- Paediatrics, Bristol Royal Hospital for Children, Bristol, UK
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - Michelle Cummins
- Paediatric Haematology, Bristol Royal Hospital for Children, Bristol, UK
| | - Marion Roderick
- Paediatric Infectious Diseases and Immunology, Bristol Royal Hospital for Children, Bristol, UK
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Kitsommart R, Limrungsikul A, Tongsawang N, Thamwiriyakul N, Deesomchok A, Pithakton N, Paes B. Impact of level of neonatal care on phlebotomy and blood transfusion in extremely low birthweight infants: a prospective, multicenter, observational study. Front Pediatr 2023; 11:1238402. [PMID: 37724088 PMCID: PMC10505442 DOI: 10.3389/fped.2023.1238402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/21/2023] [Indexed: 09/20/2023] Open
Abstract
Objectives To explore the level of neonatal care on cumulative phlebotomy loss (cPL) and red cell transfusions in extremely low birthweight [ELBW; birthweight (BW) <1,000 g] infants, up to 40 weeks post-conceptual age (PCA). The secondary objective was to determine the associations between cPL and number of transfusions and between transfusions and hospital outcomes. Methods A prospective, comparative, observational study was conducted in two level IV and two level III neonatal intensive care units (NICUs) in Thailand. Daily cPL volume and number of blood tests were recorded. Descriptive data are reported as frequency and percentage for categorical variables and median [25th percentile (P25), 75th percentile (P75)] for continuous data according to the data distribution. A p-value <0.05 was considered statistically significant. Results 210 ELBW infants were included; 99 and 111 were admitted to level IV and level III NICUs, respectively. Birth weight of level IV infants was lower 780.0 [660.0, 875.0] vs. 865.0 [723.0, 930.0] g; p < 0.001]. Initial group hematocrits were similar (43.1% vs. 44.0%, p = 0.47). cPL for each infant was 28.1 [16.5, 46.4] ml. Level IV infants had more tests (n = 89 [54, 195] vs. 59 [37, 88], p < 0.001). Counterintuitively, there was a lower cPL trend in level IV infants, but this was insignificant (19.6 [12.3, 52.3] vs. 28.9 [19.3, 45.3] ml; p = 0.06). The number of transfusions in both NICUs was similar 4 [2, 6], with a strong correlation between cPL and number of transfusions (r = 0.79, p < 0.001). Transfusions were significantly associated with bronchopulmonary dysplasia [BPD; adjusted RR (95% CI): 2.6 (1.2, 5.3), p = 0.01]. Conclusions Level IV NICUs conducted more blood tests in ELBW infants without a difference in cPL, and number of transfusions. Cumulative PL correlated with number of transfusions and was associated with BPD risk. Minimizing cPL by point-of-care tests and restrictive transfusion criteria, may reduce need for transfusion.
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Affiliation(s)
- Ratchada Kitsommart
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anchalee Limrungsikul
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Numtip Tongsawang
- Department of Pediatric Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Areeya Deesomchok
- Department of Pediatrics, Buddhachinaraj Hospital, Phitsanulok, Thailand
| | - Nuttanan Pithakton
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Bosco Paes
- Department of Pediatrics (Neonatal Division), McMaster University, Hamilton, ON, Canada
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11
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Ashoori M, O'Toole JM, O'Halloran KD, Naulaers G, Thewissen L, Miletin J, Cheung PY, El-Khuffash A, Van Laere D, Straňák Z, Dempsey EM, McDonald FB. Machine Learning Detects Intraventricular Haemorrhage in Extremely Preterm Infants. CHILDREN (BASEL, SWITZERLAND) 2023; 10:917. [PMID: 37371150 DOI: 10.3390/children10060917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/16/2023] [Accepted: 05/16/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVE To test the potential utility of applying machine learning methods to regional cerebral (rcSO2) and peripheral oxygen saturation (SpO2) signals to detect brain injury in extremely preterm infants. STUDY DESIGN A subset of infants enrolled in the Management of Hypotension in Preterm infants (HIP) trial were analysed (n = 46). All eligible infants were <28 weeks' gestational age and had continuous rcSO2 measurements performed over the first 72 h and cranial ultrasounds performed during the first week after birth. SpO2 data were available for 32 infants. The rcSO2 and SpO2 signals were preprocessed, and prolonged relative desaturations (PRDs; data-driven desaturation in the 2-to-15-min range) were extracted. Numerous quantitative features were extracted from the biosignals before and after the exclusion of the PRDs within the signals. PRDs were also evaluated as a stand-alone feature. A machine learning model was used to detect brain injury (intraventricular haemorrhage-IVH grade II-IV) using a leave-one-out cross-validation approach. RESULTS The area under the receiver operating characteristic curve (AUC) for the PRD rcSO2 was 0.846 (95% CI: 0.720-0.948), outperforming the rcSO2 threshold approach (AUC 0.593 95% CI 0.399-0.775). Neither the clinical model nor any of the SpO2 models were significantly associated with brain injury. CONCLUSION There was a significant association between the data-driven definition of PRDs in rcSO2 and brain injury. Automated analysis of PRDs of the cerebral NIRS signal in extremely preterm infants may aid in better prediction of IVH compared with a threshold-based approach. Further investigation of the definition of the extracted PRDs and an understanding of the physiology underlying these events are required.
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Affiliation(s)
- Minoo Ashoori
- INFANT Research Centre, University College Cork, T12 AK54 Cork, Ireland
- Department of Physiology, School of Medicine, College of Medicine and Health, University College Cork, T12 XF62 Cork, Ireland
| | - John M O'Toole
- INFANT Research Centre, University College Cork, T12 AK54 Cork, Ireland
- Department of Paediatrics and Child Health, School of Medicine, College of Medicine and Health, University College Cork, T12 DC4A Cork, Ireland
| | - Ken D O'Halloran
- INFANT Research Centre, University College Cork, T12 AK54 Cork, Ireland
- Department of Physiology, School of Medicine, College of Medicine and Health, University College Cork, T12 XF62 Cork, Ireland
| | - Gunnar Naulaers
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Herestraat 49, 3000 Leuven, Belgium
- Neonatal Intensive Care, Katholieke Universiteit Hospital Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Liesbeth Thewissen
- Neonatal Intensive Care, Katholieke Universiteit Hospital Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Jan Miletin
- Paediatric and Newborn Medicine, Coombe Women's Hospital, D08 XW7X Dublin, Ireland
| | - Po-Yin Cheung
- Department of Paediatrics, University of Alberta, Edmonton, AB T6G 1C9, Canada
| | - Afif El-Khuffash
- Faculty of Medicine and Health Sciences, Royal College of Surgeons in Ireland, D02 P796 Dublin, Ireland
| | - David Van Laere
- Neonatale Intensive Care Unit, Universitair Ziekenhuis, (UZ) Antwerp, Drie Eikenstraat 655, 2650 Antwerp, Belgium
| | - Zbyněk Straňák
- Institute for the Care of Mother and Child, Third Faculty of Medicine, Charles University, 100 00 Prague, Czech Republic
| | - Eugene M Dempsey
- INFANT Research Centre, University College Cork, T12 AK54 Cork, Ireland
- Department of Paediatrics and Child Health, School of Medicine, College of Medicine and Health, University College Cork, T12 DC4A Cork, Ireland
| | - Fiona B McDonald
- INFANT Research Centre, University College Cork, T12 AK54 Cork, Ireland
- Department of Physiology, School of Medicine, College of Medicine and Health, University College Cork, T12 XF62 Cork, Ireland
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12
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Fu X, Zhao X, Weng A, Zhang Q. Comparative efficacy and safety of restrictive versus liberal transfusion thresholds in anemic preterm infants: a meta-analysis of 12 randomized controlled trials. Ann Hematol 2023; 102:283-297. [PMID: 36542102 PMCID: PMC9889497 DOI: 10.1007/s00277-022-05072-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
The comparative efficacy and safety of restrictive with liberal transfusion thresholds remain controversial in anemic preterm infants. This meta-analysis aimed to compare the efficacy and safety of these two transfusion thresholds for anemic preterm infants. We searched PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure (CNKI) for relevant randomized controlled trials (RCTs) comparing restrictive with liberal transfusion thresholds in anemic preterm infants through April 30, 2022. Two independent investigators screened literature, extracted data, and appraised the methodological quality of eligible studies. Meta-analysis was conducted using RevMan version 5.3.5. Twelve RCTs with 4380 preterm infants were included. Liberal transfusion threshold significantly increased the level of hemoglobin after transfusion (mean difference (MD): -10.03; 95% confidence interval (CI): -15.98 to -4.08; p=0.001; I2=94%) and hematocrit (MD: -3.62; 95%CI: -6.78 to -0.46; p=0.02; I2=80%) compared with restrictive transfusion. Infants' age at first transfusion in restrictive transfusion group was higher than that of infants in liberal transfusion group (MD: 5.08; 95%CI: 2.27 to7.89; p=0.004; I2=54%); however, restrictive transfusion was associated with more time on supplemental oxygen (MD: 3.56; 95%CI: 1.93 to 5.18; p<0.001; I2=62%) and ventilator or CPAP (MD: 3.31; 95%CI: 1.42 to 5.20; p=0.006; I2=75%). For the remaining outcomes, two transfusion strategies were comparable. Furthermore, a series of sensitivity analyses confirmed the robustness of the level of hemoglobin after transfusion, age at first transfusion, time on ventilator or CPAP, and safety outcomes. Evidence with substantial heterogeneity indicates that liberal and restrictive transfusion thresholds are effective and safe blood cell transfusion strategies in anemic preterm infants, but the liberal strategy may be more effective in shortening the length of necessary respiratory support.
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Affiliation(s)
- Xiaoling Fu
- Department of Blood Transfusion, Hainan Women and Children’s Medical Center, Haikou, 570000 Hainan Province China
| | - Xingdan Zhao
- Department of Blood Transfusion, Hainan Women and Children’s Medical Center, Haikou, 570000 Hainan Province China
| | - Aihan Weng
- Department of Blood Transfusion, Hainan Women and Children’s Medical Center, Haikou, 570000 Hainan Province China
| | - Qian Zhang
- Department of Blood Transfusion, Hainan Women and Children’s Medical Center, Haikou, 570000 Hainan Province China
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13
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Eisler L, Jackson WM, Sun LS, Sands SA. Impact of Anesthetic Exposures on the Neurocognitive Profiles of Pediatric Brain Tumor Survivors: A New Direction for Research and Multidisciplinary Collaboration. J Neurosurg Anesthesiol 2023; 35:133-135. [PMID: 36745177 PMCID: PMC9902741 DOI: 10.1097/ana.0000000000000882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Primary brain tumors are the most commonly diagnosed solid tumors in children, and pediatric brain tumor survivors experience lasting, pervasive deficits of neurocognitive functioning. Repeated exposure to anesthetic drugs is a necessary component not only of surgical resection but also of multimodal cancer care for the youngest patients with brain tumors. The potential for anesthetic neurotoxicity to worsen neurocognitive outcomes in this vulnerable group, therefore, warrants our attention and further study through multi-disciplinary collaboration. This review discusses neurocognitive functioning in pediatric brain tumor survivors, highlighting the findings of a recent study of children with tumors of the posterior fossa which identified treatment-related risk factors for neurocognitive difficulties, with those undergoing multimodal therapies (eg, chemotherapy and irradiation) experiencing the greatest deficits compared with healthy controls. The role of anesthetic neurotoxicity in long-term outcomes among pediatric brain tumor survivors is also reviewed.
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Affiliation(s)
- Lisa Eisler
- Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY
| | - William M. Jackson
- Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Lena S. Sun
- Anesthesiology and Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY
| | - Stephen A. Sands
- Psychology, Memorial Sloan Kettering Cancer Center, New York, NY
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14
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Variane GFT, Pietrobom RFR, Noh CY, Van Meurs KP, Chock VY. Newer indications for neuromonitoring in critically ill neonates. Front Pediatr 2023; 11:1111347. [PMID: 37187586 PMCID: PMC10175818 DOI: 10.3389/fped.2023.1111347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/07/2023] [Indexed: 05/17/2023] Open
Abstract
Continuous neuromonitoring in the neonatal intensive care unit allows for bedside assessment of brain oxygenation and perfusion as well as cerebral function and seizure identification. Near-infrared spectroscopy (NIRS) reflects the balance between oxygen delivery and consumption, and use of multisite monitoring of regional oxygenation provides organ-specific assessment of perfusion. With understanding of the underlying principles of NIRS as well as the physiologic factors which impact oxygenation and perfusion of the brain, kidneys and bowel, changes in neonatal physiology can be more easily recognized by bedside providers, allowing for appropriate, targeted interventions. Amplitude-integrated electroencephalography (aEEG) allows continuous bedside evaluation of cerebral background activity patterns indicative of the level of cerebral function as well as identification of seizure activity. Normal background patterns are reassuring while abnormal background patterns indicate abnormal brain function. Combining brain monitoring information together with continuous vital sign monitoring (blood pressure, pulse oximetry, heart rate and temperature) at the bedside may be described as multi-modality monitoring and facilitates understanding of physiology. We describe 10 cases in critically ill neonates that demonstrate how comprehensive multimodal monitoring provided greater recognition of the hemodynamic status and its impact on cerebral oxygenation and cerebral function thereby informing treatment decisions. We anticipate that there are numerous other uses of NIRS as well as NIRS in conjunction with aEEG which are yet to be reported.
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Affiliation(s)
- Gabriel F. T. Variane
- Division of Neonatology, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Correspondence: Gabriel Variane
| | - Rafaela F. R. Pietrobom
- Division of Neonatology, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
| | - Caroline Y. Noh
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Packard Children's Hospital Stanford, Palo Alto, CA, United States
| | - Krisa P. Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Packard Children's Hospital Stanford, Palo Alto, CA, United States
| | - Valerie Y. Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Packard Children's Hospital Stanford, Palo Alto, CA, United States
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15
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Joshi R, Myers E, Kokhanov A. Congenital Disorders of Red Blood Cells. Neoreviews 2022; 23:e813-e828. [PMID: 36450647 DOI: 10.1542/neo.23-12-e813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
See Bonus NeoBriefs videos and downloadable teaching slides Understanding the physiologic process of red blood cell development in utero and subsequent erythropoiesis in the neonate is crucial as this determines red blood cell structure and therefore function, which is vital to neonatal health. Infants frequently experience anemia, and special consideration must be given to the evaluation of these infants to determine the correct etiology. Traditionally, anemia is conceptualized in terms of inadequate red blood cell production, increased red blood cell destruction, or whole blood loss. This framework translates well to inherited red blood cell defects, which include genetic abnormalities in bone marrow productivity or structure of the red blood cell membrane, enzymes, or hemoglobin. This article highlights fetal and neonatal erythropoiesis and the underlying etiologies of the inherited red blood cell disorders, as well as reviews the appropriate diagnostic evaluation and next steps in management. It is imperative that neonatal clinicians remain informed about these disorders to enable early recognition and treatment, and ultimately to improve outcomes in affected infants.
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Affiliation(s)
- Rhucha Joshi
- Division of Neonatal Medicine, Department of Pediatrics, University of California Irvine, Irvine, CA
| | - Erin Myers
- Department of Pediatrics, University of California Irvine, Irvine, CA
| | - Artemiy Kokhanov
- Department of Neonatology, MemorialCare Miller Children's and Women's Hospital Long Beach, Long Beach, CA
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16
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Boix H, Sánchez-Redondo MD, Cernada M, Espinosa Fernández MG, González-Pacheco N, Martín A, Pérez-Muñuzuri A, Couce ML. Recomendaciones para la transfusión de hemoderivados en neonatología. An Pediatr (Barc) 2022. [DOI: 10.1016/j.anpedi.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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17
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Recommendations for transfusion of blood products in neonatology. An Pediatr (Barc) 2022; 97:60.e1-60.e8. [PMID: 35725819 DOI: 10.1016/j.anpede.2022.05.003] [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: 02/10/2022] [Accepted: 05/02/2022] [Indexed: 11/23/2022] Open
Abstract
The scant evidence on the use of transfusions in neonatal care explains the limitations of current clinical guidelines. Despite this, in this document we explore the most recent evidence to make recommendations for the clinical practice. The prevention of anaemia of prematurity, the use of protocols and restrictive transfusion strategies constitute the best approach for clinicians in this field. In the case of platelet transfusions, the risk of bleeding must be assessed, combining clinical and laboratory features. Lastly, fresh frozen plasma is recommended in neonates with coagulopathy and active bleeding, with congenital factor deficiencies for which there is no specific treatment or with disseminated intravascular coagulation. All blood products have adverse effects that warrant a personalised and thorough assessment of the need for transfusion.
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18
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Franco-Fuenmayor ME, Jain SK. Is a higher hemoglobin transfusion threshold better for extremely low birthweight infants? J Perinatol 2022; 42:839-841. [PMID: 35249101 DOI: 10.1038/s41372-022-01358-w] [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: 01/31/2022] [Revised: 02/04/2022] [Accepted: 02/15/2022] [Indexed: 11/09/2022]
Affiliation(s)
- María E Franco-Fuenmayor
- Department of Pediatrics, Division of Neonatology, University of Texas Medical Branch, Galveston, TX, USA.
| | - Sunil K Jain
- Department of Pediatrics, Division of Neonatology, University of Texas Medical Branch, Galveston, TX, USA
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19
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Silvera F, Gagliardi T, Vollono P, Fernández C, García-Bayce A, Berardi A, Badía M, Beltrán B, Cabral T, Abella P, Farías L, Vaamonde L, Martell M, Blasina F. Study of the relationship between regional cerebral saturation and pCO2 changes during mechanical ventilation to evaluate modifications in cerebral perfusion in a newborn piglet model. Braz J Med Biol Res 2022; 55:e11543. [PMID: 35239775 PMCID: PMC8905677 DOI: 10.1590/1414-431x2022e11543] [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] [Received: 07/03/2021] [Accepted: 01/04/2022] [Indexed: 11/22/2022] Open
Abstract
Near-infrared spectroscopy (NIRS) could be a useful continuous, non-invasive technique for monitoring the effect of partial pressure of carbon dioxide (PaCO2) fluctuations in the cerebral circulation during ventilation. The aim of this study was to examine the efficacy of NIRS to detect acute changes in cerebral blood flow following PaCO2 fluctuations after confirming the autoregulation physiology in piglets. Fourteen piglets (<72 h of life) were studied. Mean arterial blood pressure, oxygen saturation, pH, glycemia, hemoglobin, electrolytes, and temperature were monitored. Eight animals were used to evaluate brain autoregulation, assessing superior cava vein Doppler as a proxy of cerebral blood flow changing mean arterial blood pressure. Another 6 animals were used to assess hypercapnia generated by decreasing ventilatory settings and complementary CO2 through the ventilator circuit and hypocapnia due to increasing ventilatory settings. Cerebral blood flow was determined by jugular vein blood flow by Doppler and continuously monitored with NIRS. A decrease in PaCO2 was observed after hyperventilation (47.6±2.4 to 29.0±4.9 mmHg). An increase in PaCO2 was observed after hypoventilation (48.5±5.5 to 90.4±25.1 mmHg). A decrease in cerebral blood flow after hyperventilation (21.8±10.4 to 15.1±11.0 mL/min) and an increase after hypoventilation (23.4±8.4 to 38.3±10.5 mL/min) were detected by Doppler ultrasound. A significant correlation was found between cerebral oxygenation and Doppler-derived parameters of blood flow and PaCO2. Although cerebral NIRS monitoring is mainly used to detect changes in regional brain oxygenation, modifications in cerebral blood flow following experimental PaCO2 changes were detected in newborn piglets when no other important variables were modified.
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Affiliation(s)
- F Silvera
- Department of Neonatology, Centro Hospitalario Pereira Rossell, Administración de los Servicios de Salud del Estado, and Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - T Gagliardi
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - P Vollono
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - C Fernández
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - A García-Bayce
- Division of Pediatric Imagenology, Centro Hospitalario Pereira Rossell, Administración de los Servicios de Salud del Estado, and Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - A Berardi
- Department of Neonatology, Centro Hospitalario Pereira Rossell, Administración de los Servicios de Salud del Estado, and Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - M Badía
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - B Beltrán
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - T Cabral
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - P Abella
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - L Farías
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - L Vaamonde
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - M Martell
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
| | - F Blasina
- Department of Neonatology, Hospital de Clínicas Dr. Manuel Quintela, Faculty of Medicine, Republic University, Montevideo, Uruguay
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20
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Meyer MP, O'Connor KL, Meyer JH. Thresholds for blood transfusion in extremely preterm infants: A review of the latest evidence from two large clinical trials. Front Pediatr 2022; 10:957585. [PMID: 36204671 PMCID: PMC9530179 DOI: 10.3389/fped.2022.957585] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
There are two recently completed large randomized clinical trials of blood transfusions in the preterm infants most at risk of requiring them. Liberal and restrictive strategies were compared with composite primary outcome measures of death and neurodevelopmental impairment. Infants managed under restrictive guidelines fared no worse in regard to mortality and neurodevelopment in early life. The studies had remarkably similar demographics and used similar transfusion guidelines. In both, there were fewer transfusions in the restrictive arm. Nevertheless, there were large differences between the studies in regard to transfusion exposure with almost 3 times the number of transfusions per participant in the transfusion of prematures (TOP) study. Associated with this, there were differences between the studies in various outcomes. For example, the combined primary outcome of death or neurodevelopmental impairment was more likely to occur in the TOP study and the mortality rate itself was considerably higher. Whilst the reasons for these differences are likely multifactorial, it does raise the question as to whether they could be related to the transfusions themselves? Clearly, every effort should be made to reduce exposure to transfusions and this was more successful in the Effects of Transfusion Thresholds on Neurocognitive Outcomes (ETTNO) study. In this review, we look at factors which may explain these transfusion differences and the differences in outcomes, in particular neurodevelopment at age 2 years. In choosing which guidelines to follow, centers using liberal guidelines should be encouraged to adopt more restrictive ones. However, should centers with more restrictive guidelines change to ones similar to those in the studies? The evidence for this is less compelling, particularly given the wide range of transfusion exposure between studies. Individual centers already using restrictive guidelines should assess the validity of the findings in light of their own transfusion experience. In addition, it should be remembered that the study guidelines were pragmatic and acceptable to a large number of centers. The major focus in these guidelines was on hemoglobin levels which do not necessarily reflect tissue oxygenation. Other factors such as the level of erythropoiesis should also be taken into account before deciding whether to transfuse.
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Affiliation(s)
- Michael P Meyer
- Neonatal Unit, KidzFirst, Middlemore Hospital, Auckland, New Zealand.,Department of Paediatrics Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Kristin L O'Connor
- Neonatal Unit, KidzFirst, Middlemore Hospital, Auckland, New Zealand.,Department of Paediatrics Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Jill H Meyer
- Department of Biomedicine and Medical Diagnostics, Auckland University of Technology, Auckland, New Zealand
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21
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Cardiorespiratory monitoring of red blood cell transfusions in preterm infants. Eur J Pediatr 2022; 181:489-500. [PMID: 34370081 PMCID: PMC8821053 DOI: 10.1007/s00431-021-04218-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 11/21/2022]
Abstract
Clinical improvement after red blood cell (RBC) transfusions in preterm infants remains debated. This study aims to investigate the effect of RBC transfusion on the occurrence of desaturations and hypoxia, and other cardiorespiratory outcomes in preterm infants. In this longitudinal observational study, prospectively stored cardiorespiratory parameters of preterm infants who received at least one RBC transfusion between July 2016 and June 2017 were retrospectively analyzed. Sixty infants with 112 RBC transfusions, median GA of 26.7 weeks, were included. The number of desaturations and area < 80% SpO2 limit, as a measure of the hypoxic burden, were calculated in 24 h before and after RBC transfusion. A mixed effects model was used to account for repeated measurements. Overall, the mean (SE) number of desaturations per hour decreased from 3.28 (0.55) to 2.25 (0.38; p < 0.001), and area < 80% SpO2 limit decreased from 0.14 (0.04) to 0.08 (0.02) %/s (p = 0.02). These outcomes were stratified for the number of desaturations in 24 h prior to RBC transfusion. The largest effect was observed in the group with the highest mean number of desaturations (≥ 6) prior to RBC transfusion, with a decrease from 7.50 (0.66) to 4.26 (0.38) (p < 0.001) in the number of desaturations and 0.46 (0.13) to 0.20 (0.06) in the area < 80% SpO2. Perfusion index increased significantly after RBC transfusion (p < 0.001). No other significant effects of RBC transfusion on cardiorespiratory data were observed.Conclusions: RBC transfusions in preterm newborns could help decrease the incidence of desaturations and the area < 80% SpO2 as a measure of the hypoxic burden. The higher the number of desaturations prior to the RBC transfusion, the larger the effect observed. What is Known: •Red blood cell transfusions potentially prevent hypoxia in anemic preterm infants by increasing the circulatory hemoglobin concentration and improving tissue oxygenation. •There is not a predefined hemoglobin concentration cut-off for the occurrence of symptomatic anemia in preterm infants. What is New: •Oxygen desaturations and hypoxia in anemic preterm infants can be improved by RBC transfusions, especially if more desaturations have occurred before transfusion. •Cardiorespiratory monitor data may help identify infants who will benefit most from red blood cell transfusions.
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22
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Leon RL, Ortigoza EB, Ali N, Angelis D, Wolovits JS, Chalak LF. Cerebral Blood Flow Monitoring in High-Risk Fetal and Neonatal Populations. Front Pediatr 2021; 9:748345. [PMID: 35087771 PMCID: PMC8787287 DOI: 10.3389/fped.2021.748345] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/15/2021] [Indexed: 12/18/2022] Open
Abstract
Cerebrovascular pressure autoregulation promotes stable cerebral blood flow (CBF) across a range of arterial blood pressures. Cerebral autoregulation (CA) is a developmental process that reaches maturity around term gestation and can be monitored prenatally with both Doppler ultrasound and magnetic resonance imaging (MRI) techniques. Postnatally, there are key advantages and limitations to assessing CA with Doppler ultrasound, MRI, and near-infrared spectroscopy. Here we review these CBF monitoring techniques as well as their application to both fetal and neonatal populations at risk of perturbations in CBF. Specifically, we discuss CBF monitoring in fetuses with intrauterine growth restriction, anemia, congenital heart disease, neonates born preterm and those with hypoxic-ischemic encephalopathy. We conclude the review with insights into the future directions in this field with an emphasis on collaborative science and precision medicine approaches.
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Affiliation(s)
- Rachel L Leon
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Eric B Ortigoza
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Noorjahan Ali
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Dimitrios Angelis
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Joshua S Wolovits
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Lina F Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States.,Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, United States
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