Can Red Blood Cell and Platelet Transfusions Have a Pathogenic Role in Bronchopulmonary Dysplasia?

OBJECTIVE: To evaluate whether transfusions in infants born preterm contribute to the pathogenesis of bronchopulmonary dysplasia (BPD). STUDY DESIGN: We conducted a multihospital, retrospective study seeking associations between red blood cell or platelet transfusions and BPD. We tabulated all transfusions administered from January 2018 through December 2022 to infants born ≤29 weeks or <1000 g until 36 weeks postmenstrual age and compared those with BPD grade. We performed a sensitivity analysis to assess the possibility of a causal relationship. We then determined whether each transfusion was compliant with restrictive guidelines, and we estimated effects fewer transfusions might have on future BPD incidence. RESULTS: Eighty-four infants did not develop BPD and 595 did; 352 developed grade 1 (mild), 193 grade 2 (moderate), and 50 grade 3 (severe). Transfusions were given at <36 weeks to 7% of those who did not develop BPD, 46% who did, and 98% who developed severe BPD. For every transfusion the odds of developing BPD increased by a factor of 2.27 (95% CI, 1.59-3.68; P < .001). Sensitivity analyses suggested that transfusions might contribute to BPD. Fifty-seven percent of red blood cell transfusions and 68% of platelet transfusions were noncompliant with new restrictive guidelines. Modeling predicted that complying with restrictive guidelines could reduce the transfusion rate by 20%-30% and the moderate to severe BPD rate by ∼4%-6%. CONCLUSIONS: Transfusions were associated with BPD incidence and severity. Lowering transfusion rates to comply with current restrictive guidelines might result in a small but meaningful reduction in BPD rates.

Iron Supplements for Infants at Risk for Iron Deficiency.

Professional societies have published recommendations for iron dosing of preterm neonates, but differences exist between guidelines. To help develop standardized guidelines, we performed a 10-year analysis of iron dosing in groups at risk for iron deficiency: IDM (infants of diabetic mothers), SGA (small for gestational age), and VLBW premature neonates (very low birth weight, <1500 g). We analyzed iron dosing after red cell transfusions and erythropoiesis-stimulating agents (ESA). Of IDM, 11.8% received iron in the hospital; 9.8% of SGA and 27.1% of VLBW neonates received iron. Twenty percent of those who received iron had it started by day 14; 63% by 1 month. Supplemental iron was stopped after red cell transfusions in 73% of neonates receiving iron. An ESA was administered to 1677, of which 33% received iron within 3 days. This marked variation indicates that a consistent approach is needed, and using this report and a literature review, we standardized our iron-dosing guidelines.

Instituting a program to reduce the erythrocyte transfusion rate was accompanied by reductions in the incidence of bronchopulmonary dysplasia, retinopathy of prematurity and necrotizing enterocolitis.

Bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), and necrotizing enterocolitis (NEC) all likely involve oxidative damage to immature tissues. It has been postulated that transfusions of adult erythrocytes contribute to the risk of developing these morbidities, as a consequence of adult hemoglobin releasing non-physiological quantities of O2 to developing tissues. In 2009, we instituted a concerted effort to diminish erythrocyte transfusions in our NICU, and in 2013 we performed a before vs. after practice change analysis of the incidence of BPD, ROP and NEC during the 8-year period spanning this change. The transfusion rate fell from a high of 14.8% of admissions in 2007 to a low of 6.3% in 2011 (p < 0.001). Concordant with this reduction patients had a lower incidence of; BPD (from 3.2% to 0.9%; OR, 3.722; CI 1.897-7.302), ROP (from 4.6% to 2.4%; OR 1.958, CI 1.247-3.073), and a trend toward less NEC (from 0.7% to 0.2%; OR 3.090, CI 0.835-11.443).

The effect of preoperative checklists on final histology and rates of hysterectomy for benign conditions.

OBJECTIVES: Our null hypothesis was that the introduction of preoperative hysterectomy checklists for fibroids, dysfunctional uterine bleeding (DUB), and chronic pelvic pain (CPP) would not affect the rate of hysterectomy or the proportion of cases with nonconfirmable final pathology. STUDY DESIGN: Using a prospective 6-month cohort, we compared the rate of hysterectomy (using ambulatory current procedural terminology codes for all eligible patients) and the preoperative diagnoses to final histologic diagnoses, to a baseline 6-month retrospective cohort. We also sought to determine the proportion of completed preoperative checklists among eligible cases. RESULTS: Checklist implementation was associated with a significant decrease in the hysterectomy rate for DUB: 25 (15.2%) of 165 fell to 12 (6.5%) of 185 (P = 0.014): for CPP: 11 (10.9%) of 101 to 3 (2.9%) of 105 (P = 0.044), as well as for the combined total rate: 86 (25.2%) of 341 to 52 (15.2%) of 342 (P = 0.002). There was a 50% decrease in nonconfirmable pathology for all cases: 21 of 86 at baseline compared to 6 of 52 after intervention (P = 0.049). CONCLUSION: In this 6-month pilot analysis, the use of preoperative hysterectomy checklists for 3 common nonmalignant conditions (fibroids, DUB, and CPP) was associated with a statistically significant decrease in hysterectomy rates and overall nonconfirmable pathology.

Reference ranges for lymphocyte counts of neonates: associations between abnormal counts and outcomes.

BACKGROUND AND OBJECTIVE: Both high and low lymphocyte counts at birth have been associated with adverse outcomes. However, the validity of defining a lymphocyte count as "abnormal" depends on having an accurate reference range. We established a reference range for neonatal lymphocyte counts by using multihospital data and used this to assess previously reported relationships between abnormal counts and early onset sepsis (EOS), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP), periventricular leukomalacia, and birth asphyxia. METHODS: We first created a data set that excluded counts from neonates with diagnoses previously associated with abnormal lymphocyte counts. Then the complete data (counts excluded plus included in the reference range) were used to test associations between abnormal counts and EOS, IVH, ROP, periventricular leukomalacia, and outcomes after birth asphyxia. RESULTS: Lymphocyte counts were retrieved from 40 487 neonates, 10 860 of which were excluded from the reference range. A count >95th percentile was associated with EOS (2.07; 95% confidence interval [CI]: 1.80-2.38) and IVH ≥grade 3 (2.93; 95% CI: 1.83-4.71). A count <5th percentile was associated with EOS (odds ratio:1.24; 95% CI: 1.04-1.48), IVH ≥grade 3 (3.23; 95% CI: 1.95-5.36), and ROP ≥stage 3 (4.80: 95% CI: 2.38-9.66). Among 120 meeting criteria for birth asphyxia, those with a low count and a high nucleated red cell count had higher mortality (37% vs 11%, P = .001), more transfusions (P = .000), and more neurology referrals (P < .01). CONCLUSIONS: A reference range for lymphocytes can identify neonates with abnormal counts, which can be useful because these neonates are at higher risk for certain adverse outcomes.

Implementing a program to improve compliance with neonatal intensive care unit transfusion guidelines was accompanied by a reduction in transfusion rate: a pre-post analysis within a multihospital health care system.

BACKGROUND: We previously reported that in the year 2006, approximately 35% of the transfusions administered in the Intermountain Healthcare neonatal intensive care units (NICU) were noncompliant with our transfusion guidelines. In January 2009 we instituted an electronic NICU transfusion ordering and monitoring system as part of a new program to improve compliance with transfusion guidelines. STUDY DESIGN AND METHODS: In the four largest NICUs of Intermountain Healthcare, we performed a pre-post analysis of compliance with transfusion guidelines and transfusion usage. RESULTS: After beginning the new transfusion compliance program all four NICUs had an increase in compliance from 65% to 90%. Accompanying the improved compliance, all four NICUs had a reduction in transfusions administered. Specifically, compared with 2007 and 2008, there were 984 fewer NICU transfusions given in 2009. This included 554 fewer red blood cell (RBC) transfusions, 174 fewer platelet transfusions, and 256 fewer frozen plasma infusions. We calculate that in 2009, a total of 200 NICU patients who in previous years would have received one or more transfusions instead received none. Applying specific Intermountain Healthcare billing data to the observed transfusion reductions, this new program resulted in an annual decrease of $780,074 in blood bank charges (blood administration charges were not included). During the 3-year period, January 2007 through December 2009, we detected no change in NICU demographics, major morbidities, length of hospital stay, or mortality rate. CONCLUSION: Implementing a systemwide NICU program to improve compliance with already-established transfusion guidelines increased compliance from 65% to 90%. Improved compliance with transfusion guidelines was accompanied by a significant reduction in transfusions given, with no increase in NICU length of stay or mortality rate.