Cord blood sampling for neonatal admission laboratory testing-An evidence-based blood conservation strategy.

Historically, blood for admission laboratory studies in neonates was obtained through direct neonatal phlebotomy. Over the past decade there has been an increase in studies evaluating the validity and clinical impact of using a cord blood sample for many admission laboratory studies. This article reviews various studies that together have shown that using cord blood samples for admission testing in neonates is both acceptable and beneficial.

Cord Blood Sampling - A Review of Umbilical Cord Blood Use for Admission Laboratory Tests in the Immediate Newborn Period.

Historically blood for admission laboratory studies in neonates was obtained through direct neonatal phlebotomy. Over the past decade, there has been a significant increase in studies evaluating the validity and clinical impact of using a cord blood sample for many admission laboratory studies. This article reviews various studies that together suggest that using cord blood samples for admission testing in neonates is both acceptable and beneficial.

Neonatal Umbilical Arterial Catheter Removal Is Accompanied by a Marked Decline in Phlebotomy Blood Loss.

BACKGROUND: Umbilical arterial catheters (UACs) are frequently used in critically ill neonates. UAC are convenient, reliable, and allow for caregiver convenience in performing painless arterial blood sampling. We hypothesized that UAC removal in extremely low birth weight (ELBW) neonates will result in significantly less phlebotomy blood loss (PBL) after correcting for severity of illness. STUDY DESIGN AND METHODS: PBL was measured at a single center in 99 ELBW infants who survived to day 28. Individual infant's paired daily PBL for the two 24-h periods before and after UAC removal were compared using the paired t test. Daily PBL up to 7 days before and 7 days after UAC removal were compared using a logistic regression with mixed model analysis for repeated measures. Cumulative 28-day phlebotomy loss was evaluated by multiple linear regression analysis. RESULTS: PBL 24 h before and after UAC removal were 1.7 mL (95% CI 1.5-1.9) and 0.9 mL (95% CI 0.8-1.0; p < 0.0001), respectively. Cumulative 28-day PBL increased by 2.2 mL (±0.7) per day that a UAC was present with or without correction for severity of illness (p < 0.001). CONCLUSION: UAC removal is independently associated with a marked decline in PBL. We speculate the ease and convenience of UAC blood sampling lead to more frequent blood testing and greater PBL.

Evaluating Otherwise-Discarded Umbilical Cord Blood as a Source for a Neonate's Complete Blood Cell Count at Various Time Points.

BACKGROUND: Previous studies have reported the use of cord blood for admission laboratory complete blood counts (CBCs). However, no studies have investigated its stability for the first 30 min after delivery. OBJECTIVES: We quantified blood cells drawn from the umbilical vein to determine the effect of (1) the time after placental delivery, and (2) the site of blood sampling (umbilical vein on an isolated cord segment vs. umbilical vein on the placental surface). METHODS: Timed phlebotomies were drawn at 2, 10, and 30 min from (1) the umbilical vein on an isolated, double-clamped cord segment, and (2) the umbilical vein near or on the placental surface. Leukocyte count, hemoglobin, platelet count, and fibrinogen were measured on each phlebotomy sample. RESULTS: Blood drawn from the isolated umbilical cord segments had leukocyte count, hemoglobin, platelet count, and fibrinogen that remained unchanged between the phlebotomies at 2, 10, and 30 min after delivery. However, blood drawn from the umbilical vein on the placental surface had, at 30 min, a leukocyte count (p = 0.002), hemoglobin (p = 0.01), and platelet count (p = 0.001) that were statistically different from the values at 2 and 10 min after delivery. There was no difference in fibrinogen at 2, 10, or 30 min. CONCLUSIONS: If cord blood is used for a neonate's initial CBC, the blood should be drawn within 10 min of the placental delivery when it is taken from the umbilical vein on or near the placenta. If an umbilical cord segment is obtained, the phlebotomy can be delayed for up to 30 min.

Bilirubin levels and phototherapy use before and after neonatal red blood cell transfusions.

BACKGROUND: Our previous retrospective study suggested that red blood cell (RBC) transfusion of preterm neonates can be associated with an increase in bilirubin, but this has not been tested prospectively. STUDY DESIGN AND METHODS: We studied neonates before and after RBC transfusions, recording serial bilirubin levels and whether they qualified for phototherapy. Because lysed RBCs release plasma-free hemoglobin (Hb), a precursor to bilirubin, we also measured plasma free Hb and bilirubin from the donor blood. RESULTS: We studied 50 transfusions given to 39 neonates. Gestation ages of transfused neonates, at birth, were 26 (24-29) weeks (median [interquartile range]); birthweights were 750 (620-1070) g. The study transfusion was given on Day of Life 9.9 (3.4-19.2). In 20% (10/50) phototherapy was being administered at the beginning of and during the transfusion. In these patients neither the 4- to 6- nor the 24- to 36-hour-posttransfusion bilirubin levels were significantly higher than before transfusion. However, in 30% of the others (12/40) phototherapy was started (or restarted) after the transfusion and 15% had a posttransfusion bilirubin increase of at least 2.5 mg/dL. These neonates received donor blood with a higher plasma-free Hb (p < 0.05). CONCLUSIONS: Neonates commonly qualify for phototherapy after transfusion. A minority (15% in this series) have a posttransfusion bilirubin increase of at least 2.5 mg/dL. We speculate that neonates qualifying for a RBC transfusion, who are judged to be at high risk for bilirubin-induced neurotoxicity, might benefit from checking their serum bilirubin level after the transfusion and providing donor blood with low plasma-free Hb levels.

Umbilical Cord Blood-An Untapped Resource: Strategies to Decrease Early Red Blood Cell Transfusions and Improve Neonatal Outcomes.

Umbilical cord blood is a resource that is available to all neonates. Immediately after delivery of the fetus, cord blood can be used for the direct benefit of the premature infant. Delayed cord clamping and milking of the umbilical cord are 2 methods of transfusing additional fetal blood into the neonate after vaginal or cesarean delivery. Additionally, umbilical cord blood can be utilized for neonatal admission laboratory testing rather than direct neonatal phlebotomy. Together these strategies both increase initial neonatal total blood volume and limit immediate loss through phlebotomy.

New and underutilized uses of umbilical cord blood in neonatal care.

BACKGROUND: In an era increasingly focused on quality improvement and cost containment, more emphasis is being placed on wiser utilization of medical care resources. One underutilized resource in early neonatal care is umbilical cord blood. FINDINGS: Umbilical cord blood can be utilized for admission laboratory studies in neonates thereby avoiding a significant phlebotomy event in the first minutes to hours of life. Additionally, umbilical cord blood can also be safely "transfused" into the neonate via delayed cord clamping or milking of the umbilical cord. This has been demonstrated to be particularly beneficial in premature infants by decreasing the rate of intraventricular hemorrhage. Delayed cord clamping has been formally endorsed by a number of medical societies, however it has not yet been universally adopted by obstetricians and neonatologists. CONCLUSIONS: Both uses of umbilical cord blood for neonatal admission laboratory testing and delayed cord clamping/milking of the umbilical cord have resulted in decreased transfusion rates as well as other outcomes reviewed herein.

Evidence-based advances in transfusion practice in neonatal intensive care units.

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.

Nonpharmacological, blood conservation techniques for preventing neonatal anemia--effective and promising strategies for reducing transfusion.

The development of anemia after birth in very premature, critically ill newborn infants is a universal well-described phenomenon. Although preventing anemia in this population, along with efforts to establish optimal red blood cell (RBC) transfusion and pharmacologic therapy continue to be actively investigated, the present review focuses exclusively on nonpharmacological approaches to the prevention and treatment of neonatal anemia. We begin with an overview of topics relevant to nonpharmacological techniques. These topics include neonatal and fetoplacental hemoglobin levels and blood volumes, clinical and laboratory practices applied in critically ill neonates, and current RBC transfusion practice guidelines. This is followed by a discussion of the most effective and promising nonpharmacological blood conservation strategies and techniques. Fortunately, many of these techniques are feasible in most neonatal intensive care units. When applied together, these techniques are more effective than existing pharmacotherapies in significantly decreasing neonatal RBC transfusions. They include increasing hemoglobin endowment and circulating blood volume at birth; removing less blood for laboratory testing; and optimizing nutrition.

Ultrasound prediction of growth abnormalities in fetuses with gastroschisis.

OBJECTIVE: We seek to determine whether (1) mean abdominal circumference (AC) of fetuses with gastroschisis is smaller than published normative values, (2) diagnosis of AC ≤ 2.5th percentile is supported by postnatal diagnosis of small-for-gestational age (SGA) and (3) adverse neonatal outcomes are more common in fetuses affected by gastroschisis with a sonographically measured small AC. METHODS: Retrospective review of pregnancies complicated with gastroschisis between 2000 and 2008. Patient demographics, method of closure, length of stay, use of ventilator support and gastrointestinal complications were compared. RESULTS: Seventy-four fetuses were identified with 368 ultrasound observations. Mean AC of fetuses with gastroschisis fell between the 2.5th and 50th percentile for gestational age. Thirty patients had AC measurements ≤ 2.5th of which 50% were SGA at delivery. Eleven of the 74 fetuses were diagnosed with intrauterine growth restriction (IUGR) and all were SGA. Birth weight was lower in those with a small AC (2104 g vs. 2665 g, p<0.001). There were no other differences in outcomes. CONCLUSION: AC values fell within the normal range of normative curves. Fifty percent of fetuses with small AC were SGA at birth. Neonatal outcomes in patients with small AC are similar to those with a normal AC.

Use of polyethylene bags in extremely low birth weight infant resuscitation for the prevention of hypothermia.

OBJECTIVE: To compare the clinical responses of extremely low birth weight (ELBW) infants resuscitated in polyethylene bags with ELBW infants who were resuscitated using traditional temperature control measures. STUDY DESIGN: Retrospective cohort investigation of 70 ELBW infants who were resuscitated using polyethylene bags (study) and 70 ELBW infants (control) resuscitated without polyethylene bags matched by birth weight, gestational age and gender. RESULTS: Infants in the study and control groups were comparable demographically and in obstetric risk factors. Study and control infants were similar in birth weight, gestational age and low 5-minute Apgar score. Axillary temperature on admission to the neonatal intensive care unit (NICU) and at 1 hour was greater in the study group as compared with controls. The incidence of grade III-IV intraventricular hemorrhage and periventricular leukomalacia (PVL) combined was decreased in the study group as compared with controls. Other neonatal comorbidities were not different. CONCLUSION: Resuscitation of ELBW infants in polyethylene bags led to higher skin temperature on admission to the NICU and at 1 hour of life. These infants were less likely to develop grade 3-4 PVL than infants resuscitated using traditional temperature control measures. No deleterious clinical effects were observed in infants resuscitated using polyethylene bags.