Red blood cell transfusion in newborn infants

Red blood cell transfusion is an important and frequent component of neonatal intensive care. The present position statement addresses the methods and indications for red blood cell transfusion of the newborn, based on a review of the current literature. The most frequent indications for blood transfusion in the newborn are the acute treatment of perinatal hemorrhagic shock and the recurrent correction of anemia of prematurity. Perinatal hemorrhagic shock requires immediate treatment with large quantities of red blood cells; the effects of massive transfusion on other blood components must be considered. Some guidelines are now available from clinical trials investigating transfusion in anemia of prematurity; however, considerable uncertainty remains. There is weak evidence that cognitive impairment may be more severe at follow-up in extremely low birth weight infants transfused at lower hemoglobin thresholds; therefore, these thresholds should be maintained by transfusion therapy. Although the risks of transfusion have declined considerably in recent years, they can be minimized further by carefully restricting neonatal blood sampling.     

Red blood cell transfusions in newborn infants: Revised guidelines

In general, health care professionals taking care of high risk infants in neonatal intensive care units have become more restrictive in their use of red blood cell transfusion over the past 10 years. The present statement is intended for those caring for high risk newborn infants (preterm to one month of age). The objectives of this statement are to provide guidelines to reduce the incidence of anemia in preterm and term infants, to identify strategies to decrease the need for red blood cell transfusions and to limit donor exposure in this population. Recommendations for red blood cell transfusions are included.     

Mesenteric blood flow velocities in the newborn with single-ventricle physiology: modified Blalock-Taussig shunt versus right ventricle-pulmonary artery conduit.

BACKGROUND: Neonates with ductal-dependent single-ventricle congenital heart disease palliated with a modified Blalock-Taussig shunt (mBTS) commonly have retrograde diastolic flow in the aorta, which may place them at increased risk of mesenteric ischemia. Recently, palliation with a right ventricle-to-pulmonary artery conduit, known as the Sano procedure, has been shown to eliminate retrograde diastolic flow, theoretically leading to better systemic perfusion. OBJECTIVE: To compare the changes in superior mesenteric artery (SMA) and celiac artery velocities and flow after a bolus enteral feed in patients with single-ventricle congenital heart disease palliated with an mBTS vs. those palliated with the right ventricle-to-pulmonary artery conduit. DESIGN: Prospective clinical study. SETTING: Cardiothoracic intensive care unit and pediatric ward of a tertiary care children's hospital. PATIENTS: A total of 27 patients with single-ventricle congenital heart disease (15 with mBTS, 12 with Sano) after stage-1 palliation. INTERVENTION: Doppler ultrasound of the SMA and celiac artery was performed 30 mins before and after a bolus enteral feed. MEASUREMENTS AND MAIN RESULTS: SMA and celiac artery peak systolic flow velocity, mean flow velocity, and time-velocity integral were measured. After a bolus enteral feed, 8 of 15 infants palliated with an mBTS had retrograde diastolic flow through the SMA yet demonstrated significant increases in all variables of both the SMA and celiac artery flow velocities (SMA peak systolic flow velocity: 0.96 +/- 0.33 vs. 1.2 +/- 0.4 m/sec, p = .01). Those palliated with the Sano procedure did not demonstrate SMA retrograde diastolic flow but also did not have any significant changes in their mesenteric flow variables (SMA peak systolic flow velocity: 0.79 +/- 0.16 vs. 0.89 +/- 0.26 m/sec, p = .2). CONCLUSION: Postprandial retrograde diastolic flow was observed in the majority of patients palliated with an mBTS vs. none of the patients in the Sano group. However, contrary to expectations, postprandial mesenteric blood flow velocities in those palliated with an mBTS are significantly higher than in Sano patients, although the increase is not as high as that historically seen in normal neonates. This may place this population at risk for mesenteric ischemia and feeding intolerance in the postoperative period, and the risk may be even greater for those neonates palliated with a right ventricle-to-pulmonary artery conduit.     

Thrombopoiesis in newborn infants after exchange blood transfusion

In this study, thrombopoiesis was traced after exchange transfusions in 24 newborn babies with hyperbilirubinemia. This was done with the help of platelet spreading preparation slides. The examinations took place before, at the end and at various intervals after the transfusion. One thousand thrombocytes were counted from each slide and were divided into giant, large, small and non-extended forms.The number of giant, large and small spreading forms (young platelets) increased until day 10. The increase in large forms was statistically significant. This and other aspects showed that these forms were suited to the calculation of the degree of thrombopoiesis.The thrombocyte turnover was also traced in this study; to this purpose, the number of large and small spreading forms and that of the non-extended forms (old platelets) were taken and used in the calculation of this thrombopoiesis balance by means of a coefficient. Thus, it was possible to determine the proportion of the younger and hemostatically most effective platelets in the thrombocyte population of the specimen cases as against that of normal adults.The results showed that the thrombopoiesis balance in the specimen cases (TB=0.64) before the exchange transfusion was lower than that of normal adults (TB=1.0); at the end of the transfusion there were distinctly low values (TB=0.39); on days 6–9 a peak was reached (TB=1.29); and on days 10–14 after the transfusion the thrombopoiesis balance equalled that at the outset (TB=0.68).

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Zusammenfassung In vorliegender Studie wurde mit Hilfe von Plättchen-ausbreitungspräparaten die Thrombopoese nach Austauschtransfusionen bei 24 Neugeborenen mit Hyperbilirubinämie verfolgt. Die Untersuchungen erfolgten vor, am Ende und in verschiedenen Zeitabständen nach Austausch. Von jedem Präparat wurden je 1000 Thrombocyten ausgezählt und in Riesen-, große, kleine und nicht ausgebreitete Formen unterschieden.Die Riesen-, großen und kleinen ausgebreiteten Formen (junge Thrombocyten) nahmen bis zum 10. Tag zu. Diese Zunahme war für die großen formen statistisch signifikant. Diese Formen zeigten sich auch unter anderen Gesichtspunkten zur Berechnung des Thrombopoese-Grades geeignet.In dieser Studie wurde auch der Thrombocytenumsatz verfolgt; zu diesem Zweck wurde die Anzahl der großen und kleinen Ausbreitungsformen sowie die der nicht ausgebreiteten Formen (alte Plättchen) zur Berechnung dieser Thrombopoese-Bilanz genommen, mittles eines Koeffizienten. So konnte der Anteil der jüngeren und hämostatisch effektivsten Plättchen der Probanden im Vergleich zu dem erwachsener Normalpersonen in derzeitiger Thrombocytenpopulation bestimmt werden. Dabei ergab sich, daß die Thrombopoese-Bilanz der Probanden (TB=0,64) vor Austausch gegenüber der erwachsener Normalpersonen (TB=1,0) schon erniedrigt war, am Ende des Austausches deutlich niedrige Werte lieferte (TB=0,39), am 6.–9. Tag einen Gipfel erreichte (TB=1,29) und am 10.–14. Tag nach Austausch fast dem Ausgangswert entsprach (TB=0,68).

     

Lead exposure from blood transfusion to premature infants

OBJECTIVE: The objective of this study was to determine the exposure of premature infants to lead from blood transfusions. STUDY DESIGN: Blood lead concentrations were determined for 19 very premature infants at the time of admission, at 4 weeks of life, and before and after transfusions and in the donor packed red blood cells of 79 transfusions. RESULTS: The number of transfusions per patient was 4. 2 +/- 2.8 (mean +/- SD) with 15.7 +/- 1.9 mL/kg packed red blood cells for a lead dose of 1.56 +/- 1.77 microg/dL. The total dose of lead from these transfusions over the 4-week period was 4.0 +/- 2.8 microg/kg (range, 0.9-10.6 microg/kg). Increases in post-transfusion blood lead concentration were linear with doses higher than 1.5 microg/dL. Packed red blood cells with a blood lead concentration of > or = 5 microg/dL resulted in an elevated post-transfusion blood lead concentration in some infants. CONCLUSIONS: The lead exposure to these infants through blood transfusion exceeds the acceptable daily intake values for lead and may result in unacceptably high post-transfusion blood lead concentrations. Use of packed red blood cells with lead concentrations <3.3 microg/dL is one cost-effective means to reduce exposure.     

Necrotizing enterocolitis after red blood cell transfusion in preterm infants with patent ductus arteriosus: a case series

Aim: Both patent ductus arteriosus (PDA) and packed red blood cell (PRBC) transfusion are risk factors for necrotizing enterocolitis (NEC). The combination of PDA and PRBC transfusion may have a synergistic effect on the intestinal circulation. Methods: We present four cases of NEC in very low birth weight (VLBW) infants within 14 h after PRBC transfusion. Results: All infants were growing on full enteral feeding, and they all had a PDA. Conclusion: We are concerned that the simultaneous presence of a PDA and PRBC transfusion in VLBW infants may place the infant at even greater risk of NEC than each of these factors alone.     

Empiric red cell transfusion in asymptomatic preterm infants

In a prospective randomized trial, asymptomatic very low-birth-weight infants in a neonatal intensive care unit were either electively transfused with red cells to maintain capillary haematocrit greater than 0.35 l/l (group 1; n = 9), or were not transfused (group 2; n= 10). Individuals from both groups were excluded if they subsequently received non-elective transfusions, necessitated by their clinical condition. Electively transfused infants gained weight more rapidly than their non-transfused counterparts, but the duration of hospitalization was not shortened. Criteria of morbidity, such as patent ductus murmurs, apnoea and failure to thrive, were similar in both groups. We conclude that in the absence of clinical indications, transfusion to achieve a haematocrit greater than 0.35 l/l as an empiric procedure, improves weight gain but the risks of transfusion are likely to outweigh the benefits.     

Effect of blood transfusion in low birthweight infants.

143 fresh blood transfusions were given to 32 low birthweight babies, 28 of whom had hyaline membrane disease. The arterial or central venous pressure was raised by a blood transfusion if before transfusion the mean arterial pressure was less than 35 mmHg or if the diastolic central venous pressure was less than -- 0-5 mmHg. There was no effect of blood transfusion on pH. It therefore appears either that metabolic acidosis in hyaline membrane disease is not caused by poor peripheral perfusion or that blood transfusion does not increase peripheral blood flow in this condition. The safety of the procedure is assessed.