Banked term umbilical cord blood to meet the packed red blood cell transfusion needs of extremely-low-gestational-age neonates: a feasibility analysis.

OBJECTIVES: To assess the feasibility of drawing, processing, safety-testing, and banking term umbilical cord blood to meet the packed red blood cell transfusion (RBC Tx) needs of extremely-low-gestational-age neonates (ELGANs). DESIGN: (1) Retrospectively analyze all ELGANs RBC Tx over the past three years, (2) Estimate local cord blood availability, (3) Assess interest in this project, and implementation barriers, through stakeholder surveys. RESULTS: In three years we cared for 266 ELGANs; 165 (62%) received ≥1 RBC Tx. Annual RBC Tx averaged 197 (95% CI, 152-243). If 10% of our 10,353 annual term births had cord blood drawn and processed, and half of those tested were acceptable for Tx, collections would exceed the 95th % upper estimate for need by >four-fold. Interest exceeded 97%. Identified barriers included FDA approval, training to collect cord blood, and cost. CONCLUSION: RBC Tx needs of ELGANS could be met by local cord blood collection.

Reference intervals for end-tidal carbon monoxide of preterm neonates.

OBJECTIVES: We constructed reference intervals for end-tidal carbon monoxide (ETCOc) levels of neonates 28 0/7 to 34 6/7 weeks gestation in order to assess hemolytic rate. STUDY DESIGN: This is a prospective four-NICU study in Bangkok, Thailand, and Utah, USA. RESULTS: Of 226 attempted measurements, 92% were successful. Values from day 1 through 28 were charted and upper (>95th percentile) reference interval limits calculated. During the entire 28 days, the ETCOc upper reference intervals from babies in Bangkok were higher than those in Utah (p < 0.01). No differences were found due to sex, or earliest vs. latest gestation at birth (both p > 0.1). Similar to term neonates, preterm neonates in Bangkok and Utah had higher ETCOc values during the first 48 h after birth than thereafter (p < 0.01). CONCLUSIONS: Using this methodology, and the reference interval chart, the hemolytic rate of preterm infants ≥28 weeks can be assessed.

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.

Effect of therapeutic hypothermia in neonates with hypoxic-ischemic encephalopathy on platelet function.

OBJECTIVE: Platelet dysfunction has been described in adults during hypothermia. We sought to determine whether it also occurs in neonates. METHODS: We measured bleeding times and PFA-100 (platelet function analyzer) times in 10 neonates with hypoxic-ischemic encephalopathy during and after head cooling. RESULTS: The 10 neonates were born at 38.2 ± 1.6 weeks' gestation (mean ± SD), with birth weights of 3,222 ± 746 g, pH 6.79 ± 0.17, base excess -25 ± 8, and 10-min Apgar 4 ± 2. Cooling was instituted 111 min (range: 66-180) after birth and continued 72 h. Bleeding times before cooling averaged 170 s (95% CI: 100-240). These lengthened during hypothermia, averaging 410 s (p = 0.000) and shortened after rewarming (p = 0.000). PFA-100 times were similar: prolongation during cooling and normalization after rewarming. Six neonates had clinical bleeding problems in the first 24 h of cooling, but were managed successfully, and no intracranial hemorrhages were identified. CONCLUSION: Defective platelet plug formation occurs during therapeutic hypothermia of neonates in a manner similar to that described in adults. Platelet impairment can be severe, but rapidly improves after rewarming.

Neonatal nitric oxide use: predictors of response and financial implications.

OBJECTIVE: To determine predictors of sustained response to inhaled nitric oxide (INO) and the financial impact of INO commercialization. DESIGN/METHODS: We evaluated the records of extra-corporeal membrane oxygenation (ECMO)-eligible infants consecutively treated with INO. We calculated the charges for INO therapy and for ECMO for each patient so treated. PUBLISHED BY ELSEVIER SCIENCE LTD. RESULTS: In total, 52 (59%) of 88 infants avoided ECMO; all received INO for >48 hours; all survived. A total of 36 infants received ECMO; 21 infants after <24 hours of INO; seven infants after 24 to 48 hours; and eight infants >48 hours of INO; one infant died. In total, 51 infants had sustained responses to INO; 19 infants were nonresponders and 18 were transient responders. Infants with PPHN and those older than 24 hours were more likely to respond to INO. Total INO charges for all 88 infants were $1,048,000. Total ECMO charges for the 36 infants so treated were $1,710,000. CONCLUSIONS: INO has added a charge-saving therapy to selective infants who can avoid ECMO.