Reduction in Red Blood Cell Transfusions Among Preterm Infants: Results of a Randomized Trial With an In-Line Blood Gas and Chemistry Monitor

Widness, John A.; Madan, Ashima; Grindeanu, Ligia A.; Zimmerman, M. Bridget; Wong, David; Stevenson, David K.

doi:10.1542/peds.2004-1680

Cited by 141 publications

(147 citation statements)

References 20 publications

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“…A retrospective review following the introduction of bedside point-of-care testing decreased transfusions by 43% without a change in the number of tests done [34]. A randomized controlled trial which decreased phlebotomy losses by 25% in the 1st week of life through the use of in-line blood gas and chemistry monitoring led to a 33% decrease in RBC transfusions [35]. …”

Section: Rbc Transfusionmentioning

confidence: 99%

Evidence-Based Advances in Transfusion Practice in Neonatal Intensive Care Units

2014

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Background: Transfusions to neonates convey both benefits and risks, and evidence is needed to guide wise use. Such evidence is accumulating, but more information is needed to generate sound evidence-based practices. Objective: We sought to analyze published information on nine aspects of transfusion practice in neonatal intensive care units. Methods: We assigned ‘categories of evidence' and ‘recommendations' using the format of the United States Preventive Services Task Force of the Agency for Healthcare Research and Quality. Results: The nine practices studied were: (1) delayed clamping or milking of the umbilical cord at preterm delivery - recommended, high/substantial A; (2) drawing the initial blood tests from cord/placental blood from very low birth weight (VLBW, <1,500 g) infants at delivery - recommended, moderate/moderate B; (3) limiting phlebotomy losses of VLBW infants - recommended, moderate/substantial B; (4) selected use of erythropoiesis-stimulating agents to prevent transfusions - recommended, moderate/moderate-moderate/small B, C; (5) using platelet mass, rather than platelet count, in platelet transfusion decisions - recommended, moderate/small C; (6) permitting the platelet count to fall to <20,000/µl in ‘stable' neonates before transfusing platelets - recommended, low/small I; (8) permitting the platelet count to fall to <50,000/µl in ‘unstable' neonates before transfusing platelets - recommended, moderate/small C, and (9) not performing routine coagulation test screening on every VLBW infant - recommended, moderate/small C. Conclusions: We view these recommendations as dynamic, to be revised as additional evidence becomes available. We predict this list will expand as new studies provide more information to guide best transfusion practices.

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Section: Rbc Transfusionmentioning

confidence: 99%

Evidence-Based Advances in Transfusion Practice in Neonatal Intensive Care Units

2014

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“…The anemia of prematurity occurs in all very low birth weight (VLBW) premature infants (birth weight Ͻ1500 g) and is exacerbated by iatrogenic blood loss resulting from frequent laboratory blood sampling for managing clinical illness (Strauss, 1995;Lin et al, 2000;Madan et al, 2005;Widness et al, 2005). The resulting development of clinically significant anemia is managed by the administration of red blood cell (RBC) transfusions, creating dynamic changes in the Hb mass in these infants due to both the physical removal and administration of erythrocytes.…”

mentioning

confidence: 99%

“…This is largely due to the complications in determining the erythropoiesis rate caused by frequent phlebotomies and RBC transfusions altering the RBC/Hb mass, and the effect of each phlebotomy on the RBC/Hb removal rate due to the life span-based disposition of RBCs (Landaw, 1988;Freise et al, 2007Freise et al, , 2008. Previous studies have demonstrated that on average 33.8 ml/kg blood is removed and 27.0 ml/kg blood is transfused during the first 4 weeks of life in infants born at a gestational age of less than 28 weeks (Madsen et al, 2000), and other studies have reported even higher phlebotomy blood loss volumes in the first 2 weeks of life alone (Lin et al, 2000;Widness et al, 2005). Thus, the effects of the physical removal and administration of RBCs are substantial and cannot be ignored.…”

mentioning

confidence: 99%

Erythropoietic Response to Endogenous Erythropoietin in Premature Very Low Birth Weight Infants

Freise

Widness²,

Veng‐Pedersen³

2009

J Pharmacol Exp Ther

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Despite the common occurrence of anemia in very low birth weight (VLBW) infants, the erythropoiesis and Hb production rates and their relationship to plasma erythropoietin (EPO) concentrations remain unknown in these subjects. To determine these quantities, all blood removed by phlebotomy and administered by red blood cell (RBC) transfusion over the first 30 days of life was recorded in 14 ventilated VLBW infants born at 24 to 28 weeks of gestation. Discarded blood from frequent clinically ordered laboratory blood samples was used to construct plasma EPO, Hb, and RBC concentration-time profiles for each infant. A pharmacodynamic Hb mass balance model that accounted for the dynamic hematological conditions experienced by these infants was simultaneously fitted to the plasma EPO, Hb, and RBC concentrations from each individual subject, while accounting for subject growth. Based on the model estimates, an average of 4.69 g of Hb was produced over the first 30 days of life, compared with 5.97 g removed by phlebotomies and 12.3 g administered by transfusions. These high transfusion amounts were consistent with a relatively short RBC life span and rapidly expanding blood volume with infant growth. The estimated mean body weight-scaled Hb production rate dropped nearly 3-fold after birth to 0.144 g/day⅐(kg) 3/4 . Although only estimated in a subset of the subjects, the mean plasma EPO EC 50 of 28.5 mU/ml and maximal Hb production rate (E max ) indicated that a severalfold increase in Hb production rate could be achieved with only a modest increase in plasma EPO concentrations.

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“…Moreover, although the number of transfusions has decreased over the past 20 years, extremely low birth weight (ELBW) infants are still receiving 3 to 5 PRBC transfusions per hospitalization, and are being exposed to 2 to 3 donors. 24,25 The success of this study compared with previous studies may be in part because of differences in study design. We compared early Darbe administration and the usual erythropoietic dose of Epo with placebo to determine if ESAs could decrease or prevent transfusions.…”

Section: Figurementioning

confidence: 94%

A Randomized, Masked, Placebo-Controlled Study of Darbepoetin Alfa in Preterm Infants

Ohls¹,

Christensen

Kamath‐Rayne

et al. 2013

Pediatrics

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BACKGROUND: A novel erythropoiesis stimulating agent (ESA), darbepoetin alfa (Darbe), increases hematocrit in anemic adults when administered every 1 to 3 weeks. Weekly Darbe dosing has not been evaluated in preterm infants. We hypothesized that infants would respond to Darbe by decreasing transfusion needs compared with placebo, with less-frequent dosing than erythropoietin (Epo). METHODS: Preterm infants 500 to 1250 g birth weight and ≤48 hours of age were randomized to Darbe (10 μg/kg, 1 time per week subcutaneously), Epo (400 U/kg, 3 times per week subcutaneously) or placebo (sham dosing) through 35 weeks’ gestation. All received supplemental iron, folate, and vitamin E, and were transfused according to protocol. Transfusions (primary outcome), complete blood counts, absolute reticulocyte counts (ARCs), phlebotomy losses, and adverse events were recorded. RESULTS: A total of 102 infants (946 ± 196 g, 27.7 ± 1.8 weeks’ gestation, 51 ± 25 hours of age at first dose) were enrolled. Infants in the Darbe and Epo groups received significantly fewer transfusions (P = .015) and were exposed to fewer donors (P = .044) than the placebo group (Darbe: 1.2 ± 2.4 transfusions and 0.7 ± 1.2 donors per infant; Epo: 1.2 ± 1.6 transfusions and 0.8 ± 1.0 donors per infant; placebo: 2.4 ± 2.9 transfusions and 1.2 ± 1.3 donors per infant). Hematocrit and ARC were higher in the Darbe and Epo groups compared with placebo (P = .001, Darbe and Epo versus placebo for both hematocrit and ARCs). Morbidities were similar among groups, including the incidence of retinopathy of prematurity. CONCLUSIONS: Infants receiving Darbe or Epo received fewer transfusions and fewer donor exposures, and fewer injections were given to Darbe recipients. Darbepoetin and Epo successfully serve as adjuncts to transfusions in maintaining red cell mass in preterm infants.

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Reduction in Red Blood Cell Transfusions Among Preterm Infants: Results of a Randomized Trial With an In-Line Blood Gas and Chemistry Monitor

Abstract: As long as an umbilical artery catheter is available for blood sampling with an in-line blood gas and chemistry monitor, significant reductions in neonatal RBC transfusions can be achieved. The patients most likely to benefit from monitor use are the smallest, most critically ill newborns.

Cited by 141 publications

References 20 publications

Evidence-Based Advances in Transfusion Practice in Neonatal Intensive Care Units

Evidence-Based Advances in Transfusion Practice in Neonatal Intensive Care Units

Erythropoietic Response to Endogenous Erythropoietin in Premature Very Low Birth Weight Infants

A Randomized, Masked, Placebo-Controlled Study of Darbepoetin Alfa in Preterm Infants

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