CPS Position Statement
Minimizing blood loss and the need for transfusions in very premature infants Brigitte Lemyre, Megan Sample, Thierry Lacaze-Masmonteil; Canadian Paediatric Society, Fetus and Newborn Committee
B Lemyre, M Sample, T Lacaze-Masmonteil; Canadian Paediatric Society, Fetus and Newborn Committee. Minimizing blood loss and the need for transfusions in very premature infants. Paediatr Child Health 2015;20(8):451-462. Reducing blood loss and the need for blood transfusions in extremely preterm infants is part of effective care. Delayed cord clamping is well supported by the evidence and is recommended for infants who do not immediately require resuscitation. Cord milking may be an alternative to delayed cord clamping; however, more research is needed to support its use. In view of concerns regarding the increased risk for cognitive delay, clinicians should avoid using hemoglobin transfusion thresholds lower than those tested in clinical trials. Higher transfusion volumes (15 mL/kg to 20 mL/kg) may decrease exposure to multiple donors. Erythropoietin is not recommended for routine use due to concerns about retinopathy of prematurity. Elemental iron supplementation (2 mg/kg/day to 3 mg/kg/day once full oral feeds are achieved) is recommended to prevent later iron deficiency anemia. Noninvasive monitoring (eg, for carbon dioxide, bilirubin) and point-of-care testing reduce the need for blood sampling. Clinicians should strive to order the minimal amount of blood sampling required for safe patient care, and cluster samplings to avoid unnecessary skin breaks. Key Words: Anemia; Bilirubin; Blood CO2; Cord clamping; Cord milking;
Français en page 457
Limiter les pertes de sang et le recours aux transfusions chez les grands prématurés Dans le cadre des soins efficaces aux très grands prématurés, il est important de limiter les pertes de sang et les transfusions. Le report du clampage du cordon, bien soutenu par les données probantes, est recommandé pour les nouveau-nés qui n’ont pas besoin d’une réanimation immédiate. La traite du cordon peut le remplacer, mais plus de recherches s’imposent pour en confirmer l’intérêt. Lorsqu’ils transfusent, les cliniciens doivent éviter de recourir à des seuils d’hémoglobine inférieurs à ceux qui sont utilisés lors des essais cliniques, en raison des craintes quant à l’augmentation du risque de retard cognitif. De plus gros volumes de transfusion (15 mL/kg à 20 mL/kg) peuvent réduire l’exposition à de multiples donneurs. L’utilisation systématique d’érythropoïétine n’est pas recommandée à cause du risque connexe de rétinopathie des prématurés. Les suppléments de fer élémentaire (de 2 mg/kg/jour à 3 mg/kg/jour une fois l’alimentation orale établie) sont recommandés pour prévenir une anémie ferriprive plus tard. Le monitorage non invasif (p. ex., dioxyde de carbone, bilirubine) et les tests au point de service réduisent les prélèvements de sang. Les cliniciens devraient demander le moins de prélèvements nécessaires pour prodiguer des soins sécuritaires aux patients et les regrouper pour éviter de transpercer la peau inutilement.
Erythropoietin; RoP; Supplementary iron
I
atrogenic anemia, secondary to blood draws, increases the need for transfusions in preterm infants.(1) There are risks associated with drawing blood, such as pain and its related complications, and sepsis from repeated breakage of the skin. Packed red blood cell (PRBC) transfusions may lead to acute lung injury, graft-versus-host disease,(2) and to increased in-hospital mortality of very low birth weight (VLBW) infants.(3) The association between PRBC transfusions and necrotizing enterocolitis remains controversial.(4-6) Variations exist among transfusion practices in neonatal intensive care units (NICUs), suggesting that blood sampling methods, the frequency of routine testing, the noninvasive monitoring of infants and indications or thresholds for transfusions may differ. (7-9) Reports of reduced transfusion rates and amounts, following implementation of quality improvement initiatives, further suggest that strategies to minimize blood loss and reduce transfusions can be effective.(10,11) The purpose of the present statement is to summarize evidence-based strategies to reduce blood sampling and blood transfusions in very preterm infants.
Methods A comprehensive search of the literature was performed by an expert librarian using MEDLINE, including in process and other nonindexed citations (1946 to August 31, 2014), Embase (1947 to August 31, 2014) and the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2, June 2014). The population of interest included VLBW infants (
Minimizing blood loss and the need for transfusions in very premature infants Brigitte Lemyre, Megan Sample, Thierry Lacaze-Masmonteil; Canadian Paediatric Society, Fetus and Newborn Committee
B Lemyre, M Sample, T Lacaze-Masmonteil; Canadian Paediatric Society, Fetus and Newborn Committee. Minimizing blood loss and the need for transfusions in very premature infants. Paediatr Child Health 2015;20(8):451-462. Reducing blood loss and the need for blood transfusions in extremely preterm infants is part of effective care. Delayed cord clamping is well supported by the evidence and is recommended for infants who do not immediately require resuscitation. Cord milking may be an alternative to delayed cord clamping; however, more research is needed to support its use. In view of concerns regarding the increased risk for cognitive delay, clinicians should avoid using hemoglobin transfusion thresholds lower than those tested in clinical trials. Higher transfusion volumes (15 mL/kg to 20 mL/kg) may decrease exposure to multiple donors. Erythropoietin is not recommended for routine use due to concerns about retinopathy of prematurity. Elemental iron supplementation (2 mg/kg/day to 3 mg/kg/day once full oral feeds are achieved) is recommended to prevent later iron deficiency anemia. Noninvasive monitoring (eg, for carbon dioxide, bilirubin) and point-of-care testing reduce the need for blood sampling. Clinicians should strive to order the minimal amount of blood sampling required for safe patient care, and cluster samplings to avoid unnecessary skin breaks. Key Words: Anemia; Bilirubin; Blood CO2; Cord clamping; Cord milking;
Français en page 457
Limiter les pertes de sang et le recours aux transfusions chez les grands prématurés Dans le cadre des soins efficaces aux très grands prématurés, il est important de limiter les pertes de sang et les transfusions. Le report du clampage du cordon, bien soutenu par les données probantes, est recommandé pour les nouveau-nés qui n’ont pas besoin d’une réanimation immédiate. La traite du cordon peut le remplacer, mais plus de recherches s’imposent pour en confirmer l’intérêt. Lorsqu’ils transfusent, les cliniciens doivent éviter de recourir à des seuils d’hémoglobine inférieurs à ceux qui sont utilisés lors des essais cliniques, en raison des craintes quant à l’augmentation du risque de retard cognitif. De plus gros volumes de transfusion (15 mL/kg à 20 mL/kg) peuvent réduire l’exposition à de multiples donneurs. L’utilisation systématique d’érythropoïétine n’est pas recommandée à cause du risque connexe de rétinopathie des prématurés. Les suppléments de fer élémentaire (de 2 mg/kg/jour à 3 mg/kg/jour une fois l’alimentation orale établie) sont recommandés pour prévenir une anémie ferriprive plus tard. Le monitorage non invasif (p. ex., dioxyde de carbone, bilirubine) et les tests au point de service réduisent les prélèvements de sang. Les cliniciens devraient demander le moins de prélèvements nécessaires pour prodiguer des soins sécuritaires aux patients et les regrouper pour éviter de transpercer la peau inutilement.
Erythropoietin; RoP; Supplementary iron
I
atrogenic anemia, secondary to blood draws, increases the need for transfusions in preterm infants.(1) There are risks associated with drawing blood, such as pain and its related complications, and sepsis from repeated breakage of the skin. Packed red blood cell (PRBC) transfusions may lead to acute lung injury, graft-versus-host disease,(2) and to increased in-hospital mortality of very low birth weight (VLBW) infants.(3) The association between PRBC transfusions and necrotizing enterocolitis remains controversial.(4-6) Variations exist among transfusion practices in neonatal intensive care units (NICUs), suggesting that blood sampling methods, the frequency of routine testing, the noninvasive monitoring of infants and indications or thresholds for transfusions may differ. (7-9) Reports of reduced transfusion rates and amounts, following implementation of quality improvement initiatives, further suggest that strategies to minimize blood loss and reduce transfusions can be effective.(10,11) The purpose of the present statement is to summarize evidence-based strategies to reduce blood sampling and blood transfusions in very preterm infants.
Methods A comprehensive search of the literature was performed by an expert librarian using MEDLINE, including in process and other nonindexed citations (1946 to August 31, 2014), Embase (1947 to August 31, 2014) and the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2, June 2014). The population of interest included VLBW infants (
