Rate Of Exchange Transfusion Research Articles

Prophylactic phototherapy for preventing jaundice in preterm or low birth weight infants

Low birth weight and premature infants are at major risk for exaggerated hyperbilirubinaemia and jaundice that can lead to bilirubin encephalopathy. Phototherapy is the most common treatment for neonatal hyperbilirubinaemia and could be most effective in preventing the sequelae of hyperbilirubinaemia if initiated prophylactically. To evaluate the efficacy and safety of prophylactic phototherapy for preterm (< 37 weeks gestational age) or low birth weight infants (birth weight < 2500 g). We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3) on 31 March 2011,MEDLINE (1950 to 31 March 2011), EMBASE (1980 to 31 March 2011) and CINAHL (1982 to 31 March 2011). Randomised controlled trials or quasi-randomised controlled studiesevaluating the effects of prophylactic phototherapy for preterm or low birth weight infants. Two authors independently obtained data from published articles. We performed fixed-effect meta-analysis for the outcomes: rate of exchange transfusion, cerebral palsy or other neurodevelopmental impairment, peak serum bilirubin level and all-cause mortality. Nine studies of 3449 participants were included. The rate of exchange transfusion was reduced in one study with liberal transfusion criteria (risk ratio (RR) 0.20; 95% confidence interval (CI) 0.13 to 0.31) but not in the other two more recent studies with stringent criteria (typical RR 0.66; 95% CI 0.19 to 2.28). There was no statistically significant difference in the rate of cerebral palsy (typical RR 0.96; 95% CI 0.50 to 1.85; two studies, 756 participants). However, one large study that reported on neurodevelopmental impairment (a composite outcome including cerebral palsy) found a slightly lower rate of neurodevelopmental impairment with prophylactic phototherapy (RR 0.85; 95% CI 0.74 to 0.99; 1804 participants). The prophylactic phototherapy group had lower peak bilirubin levels (mean difference (MD) -2.73; 95% CI -2.89 to -2.57; six studies, 2319 participants) and had fewer neonates with peak unconjugated serum bilirubin levels > 10 mg/dl (typical RR 0.27; 95% CI 0.22 to 0.33; three studies, 1090 participants) or peak unconjugated serum bilirubin levels > 15 mg/dl (typical RR 0.13; 95% CI 0.07 to 0.23; four studies, 1116 participants). There was no statistically significant difference in the rate of all-cause mortality between the two groups (typical RR 1.08; 95% CI 0.93 to 1.26; four studies, 3044 participants). Prophylactic phototherapy helps to maintain a lower serum bilirubin concentration and may have an effect on the rate of exchange transfusion and the risk of neurodevelopmental impairment. However, further well-designed studies are needed to determine the efficacy and safety of prophylactic phototherapy on long-term outcomes including neurodevelopmental outcomes.

The side effects of phototherapy for neonatal jaundice: what do we know? What should we do?

Neonatal phototherapy (NNPT), a noninvasive, easily available therapy, has been widely used for the treatment of neonatal jaundice for more than half a century. Its efficiency in decreasing plasma bilirubin concentration is well documented, and NNPT leads to greatly reduced exchange transfusion rates for neonates with hyperbilirubinemia. It is generally accepted that the side effects of NNPT are not serious and seem to be well controlled. This review will focus on these possible side effects as well as the approaches to minimize them.

Top-up transfusions in neonates with Rh hemolytic disease in relation to exchange transfusions

To study the effect of a restrictive guideline for exchange transfusion (ET) on the number of top-up transfusions in neonates with Rh hemolytic disease. Retrospective study of all (near)-term neonates with Rh hemolytic disease admitted to our center between 2000 and 2008. In December 2005, policy changed from using liberal ET criteria to more restrictive ET criteria. We recorded the number of ETs and the number of top-up transfusions in the group of neonates before (group I, n = 156) and after (group II, n = 27) the guideline change. The percentage of neonates requiring an ET decreased from 66% (103/156) in group I to 26% (7/27) in group II (P < 0.01). The percentage of neonates receiving a top-up transfusion increased from 68% (105/154) in group I to 81% (22/27) in group II (P = 0.25). The median number of top-up transfusions increased from 1 (interquartile range 0-2) in group I to 2 (interquartile range 1-3) in group II (P = 0.01). In this study, restrictive ET criteria in neonates with Rh hemolytic disease lead to a reduction of the rate of ET but an increase in the number of top-up transfusions for neonatal anemia.

Does Ibuprofen Increase Neonatal Hyperbilirubinemia?

The aim of this study was to investigate whether ibuprofen exposure was associated with increased hyperbilirubinemia in preterm infants. Since 2000, ibuprofen has been administered to all infants at <30 weeks of gestation who are admitted to our unit, to prevent patent ductus arteriosus. We retrospectively compared data for 418 infants subjected to ibuprofen prophylaxis (2000-2007) and 288 infants not exposed to ibuprofen (1993-1999). The ibuprofen group had a significantly higher peak total serum bilirubin level (9.0 +/- 2.5 mg/dL vs 7.3 +/- 3.3 mg/dL), more need for phototherapy (398 infants [95%] vs 254 infants [87.6%]), and a longer phototherapy duration (94.3 +/- 43.6 hours vs 87.2 +/- 38.6 hours). Groups did not differ with respect to gestational age, birth weight, gender ratio, glucose-6-phosphate dehydrogenase deficiency incidence, or hypoalbuminemia (<2.5 g/dL) incidence. Hemolytic isoimmunization was diagnosed with similar incidences (no-ibuprofen group: 7 of 288 infants; ibuprofen group: 8 of 418 infants). The rates of exchange-transfusion also were similar between the groups (no-ibuprofen group: 14 infants [4.8%]; ibuprofen group: 19 infants [4.5%]). Ibuprofen administration was associated with higher peak total serum bilirubin levels, and the more-pronounced hyperbilirubinemia led to longer phototherapy. The potential role of competition between ibuprofen and bilirubin in the hepatic glucuronidation pathway is discussed.

Effect of clofibrate in non-hemolytic indirect hyperbilirubinemia in full term neonates

Jaundice is a common clinical problem in neonatal period which may result in brain damage even in healthy full term newborns, when it is severe. The aim of this study was to characterize the therapeutic effect of clofibrate in full term neonates who present with nonhemolytic jaundice. A clinical controlled study was performed on 60 full term neonates who presented with non- hemolytic jaundice. 30 neonates were treated with a single oral dose of clofibrate (100 mg/Kg) plus phototherapy (case group), while 30 neonates received only phototherapy (control group). Both groups were compared in regard to post therapeutic mean total and indirect plasma bilirubin levels, admission duration and the rate of exchange transfusion. The reduction rate of total and indirect plasma bilirubin levels were significantly higher in the clofibrate- treated group as compared with the control group (P< 0.05). The mean duration of admission was found to be reduced from 2.9 +/- 0.9 days in the control groupl to 2.2 +/- 0.6 days in clofibrate- treated group (P=0.002). The mean plasma total bilirubin level was lower in the clofibrate- treated group. No cases required phototherapy after 48 hour in clofibrate- treated group, while 9 neonates (30%) and 2 neonates (6.7%) required phototherapy after 72 hour and 96 hour respectively in the control group. There was no difference between both the groups for sex, the time of developing jaundice and the rate of exchange transfusion. A single dose of clofibrate (100 mg/Kg) along with phototherapy is more effective than phototherapy alone in treating non-hemolytic hyperbilirubinemia in term healthy newborn infants.

Neurodevelopmental Outcome of Severe Neonatal Hemolytic Hyperbilirubinemia

We recruited 128 neonates with hyperbilirubinemia over a 5-year period (1995-2000) to study the short- and long-term effects of hemolytic hyperbilirubinemia on the auditory brainstem pathway and neurodevelopmental status. These children were divided into two groups: (1) a hemolytic group (n = 29; ABO incompatibility [n = 19], Rh incompatibility [n = 1], glucose-6-phosphate dehydrogenase deficiency [n = 8] and both ABO incompatibility and glucose-6-phosphate dehydrogenase deficiency [n = 1]) and (2) a nonhemolytic group (n = 99). All received phototherapy. Exchange transfusions were performed for four (13.8%) in the hemolytic group and three (3%) in the nonhemolytic group. The brainstem auditory evoked potential was recorded at a mean age of 3.2 months in the hemolytic group and 3.1 months in the nonhemolytic group. Serial brainstem auditory evoked potential assessments were performed until 2 years of age (3 in the hemolytic group and 18 in the nonhemolytic group). All had regular physical, neurologic, visual, and auditory evaluation until 3 years of age. The rate of exchange transfusion was significantly higher in the hemolytic group than in the nonhemolytic group (P < .05). Brainstem auditory evoked potential abnormalities at the initial assessment occurred in three (10.4%) in the hemolytic group (all related to ABO incompatibility) and nine (9.1%) in the nonhemolytic group. At 2 years, the brainstem auditory evoked potential returned to normal except in three cases with a slightly increased hearing threshold (one [3.5%] in the hemolytic group at 60 dB nHL and two [2%] in the nonhemolytic group at 50 dB nHL]). There were no significant differences in the rate of brainstem auditory evoked potential abnormalities at the initial or subsequent assessments between both groups. All except five cases had a normal neurodevelopmental outcome at 3 years (three [two with ABO incompatibility and one with glucose-6-phosphate dehydrogenase deficiency] in the hemolytic group [10.4%] and two [2%] in the nonhemolytic group). All had mild motor delay and hypotonia, which returned to normal at 3 years. The rate of abnormal neurodevelopmental outcome was higher in the hemolytic group than in the nonhemolytic group, although with no significant difference between both groups (P = .08). All five cases in both groups with abnormal neurodevelopment had a normal brainstem auditory evoked potential at the initial assessment. There was no relationship between the abnormal initial brainstem auditory evoked potential and the final neurodevelopmental outcome. The toxic effect of hyperbilirubinemia on the auditory brainstem pathway and neurodevelopmental status in our cohort was transient. The prognosis of neonatal hemolytic hyperbilirubinemia in our Chinese cohort is excellent, possibly owing to an aggressive early-intervention approach.

A Randomized Controlled Trial of Fluid Supplementation in Term Neonates With Severe Hyperbilirubinemia

To evaluate the effectiveness of fluid supplementation in decreasing the rate of exchange transfusion and the duration of phototherapy in term neonates with severe nonhemolytic hyperbilirubinemia. This was a randomized controlled trial conducted in a tertiary care referral unit in northern India. Seventy-four term neonates with severe nonhemolytic hyperbilirubinemia (total serum bilirubin > 18 mg/dL [308 micromol/L] to < 25 mg/dL [427 micromol/L]). The subjects were randomized to an "extra fluids" group (intravenous fluid supplementation for 8 hours and oral supplementation for the duration of phototherapy; n = 37) or a control group (n = 37). At inclusion, 54 infants (73%) had high serum osmolality, including 28 (75%) in the extra fluids group and 26 (70%) in the control group. The proportion of infants who underwent exchange transfusion was lower in the extra fluids group than in the control group: 6 (16%) versus 20 (54%)(P = .001; relative risk = 0.30; 95% confidence interval = 0.14 to 0.66). The duration of phototherapy was also shorter in the extra fluids group: 52 +/- 18 hours versus 73 +/- 31 hours (P = .004). Fluid supplementation in term neonates presenting with severe hyperbilirubinemia decreased the rate of exchange transfusion and duration of phototherapy.

A Randomized, Triple-Blind, Placebo-Controlled Trial of Prophylactic Oral Phenobarbital to Reduce the Need for Phototherapy in G6PD-Deficient Neonates

Decreased conjugation is probably more important than hemolysis for causing jaundice in G6PD-deficient neonates. The role of enzyme inducers, like phenobarbital, in G6PD deficiency is unclear. This randomized controlled trial was performed to evaluate Phenobarbital's role in reducing the need for phototherapy among G6PD-deficient neonates. This stratified, randomized, triple-blinded, placebo-controlled trial was conducted in a level III NICU. Consecutive babies with gestation >/=34 weeks and birth weight >/=1800 g were screened from cord blood. G6PD-deficient neonates, who were otherwise healthy, were enrolled. Rh isoimmunization, maternal Phenobarbital use and lack of parental consent were exclusion criteria. Subjects were randomly allocated to receive 5 mg/kg day of oral phenobarbital/ placebo for first 3 days. They were monitored daily for total serum bilirubin (TSB) until declining TSB was documented twice. The primary outcome was requirement for phototherapy and secondary outcomes were duration of phototherapy, need for exchange transfusion, peak TSB and adverse effects. Sample size of 56 could detect a decline in phototherapy requirement from 40 to 5% with 80% power and 5% error. Of 2370 babies screened, 63 were G6PD-deficient. Of them, 56 eligible babies were allocated to phenobarbital (n=27) or placebo (n=29). The mean age of administration of the first dose was 18.55+/-7.3 h. In total, 44% in phenobarbital group and 41% in placebo group required phototherapy (p=1.0). There was no significant difference in exchange transfusion rates (18.5 vs 10%, p=0.46). No baby had adverse reactions. Prophylactic oral phenobarbital does not decrease the need for phototherapy or exchange transfusions in G6PD-deficient neonates.

The impact of phototherapy in the management of neonatal hyperbilirubinemia: comparison of historical cohorts

To quantitatively assess the impact of phototherapy (PT) in the prevention of kernicterus we calculated the rate of exchange transfusion (ET) in two large historical cohorts of Greek neonates (birthweight > or = 2.5 kg), one before (period I: 1957-61) and one after (period II: 1980-92) the introduction of PT. Overall, the introduction of PT was associated with a reduction of the rate of ET from 0.43% in period I to 0.05% in period II. The reduction was observed in all etiological categories but was more marked in the ABO-incompatible group. With an estimated rate of kernicterus without treatment of 0.085% (excluding rhesus hemolytic disease of the newborn and prematurity) we estimated that 4.2 and 0.36 infants were treated by ET for each spared kernicterus in periods I and II, respectively. Finally, in period II 185 infants were treated with PT or PT and ET for each spared kernicterus.

Phototherapy for Hyperbilirubinemia of Hemolytic Disease of the Newborn

Although phototherapy has proven effective in lowering the serum bilirubin concentration of fullterm and premature infants with physiologic or idiopathic hyperbilirubinemia, its effect on serum bilirubin concentration in hemolytic disease due to ABO blood group incompatibility remains uncertain. Sisson and associates91 have reported a marked effect of phototherapy on serum bilirubin levels and exchange transfusion rates in premature and full-term infants with ABO incompatibility. Others have reported similar findings, but studies were retrospective49 or uncontrolled.80 On the other hand, Patel and associates79 found no significant clinical response to phototherapy in five infants (four with birth weight &amp;gt;2,500 g) with ABO and one infant (birth weight 2,660 g) with Rh incompatibility. A total of 1,339 infants were randomly selected for study between May 1974 and June 1976. Of the 1,339 infants, 79.4% weighed less than 2,500 g and 276 (20.6%) were 2,500 g or more at birth. Of the 1,063 infants who weighed less than 2,500 g, 17 had positive findings on Coombs tests, 14 due to ABO incompatibility and three due to Rh incompatibility. As phototherapy was administered early and prophylactically in infants weighing less than 2,000 g and late and therapeutically in infants weighing between 2,000 and 2,499 g, a combined analysis of the infants weighing less than 2,500 g and who had positive results on Coombs test was not possible. Of the 276 infants whose birth weight was 2,500 g or more, 64 (23.1%) had positive findings on Coombs tests, 58 due to ABO incompatibility and six to Rh incompatibility.

Phenobarbitone in neonatal jaundice.

Eighty-three jaundiced newborn infants were studied, 41 received phenobarbitone, and 42 served as controls. 48 hours after starting treatment the mean serum bilirubin level of the group of <i>normal</i> birthweight infants was significantly lower than that of controls. Exchange transfusions were required in 6 of the 32 control cases and in none of the 28 treated cases. There were no significant differences in the mean serum bilirubin levels or in the exchange transfusion rates between treated and control <i>low</i> birthweight infants.

MORTALITY OF EXCHANGE TRANSFUSION

We have presented the experience of an exchange transfusion service in performing 1,139 procedures over a 7-year period. The design and practices of this service have been described in order to provide the background necessary for a critical analysis of our results. Since no definition exists for "Mortality of Exchange Transfusion," we have suggested one. The outstanding features of this experience were: 1. The umbilical vein approach proved to be an extremely easy technique by which to initiate an exchange transfusion. 2. The great majority of the procedures were completed as planned. 3. In all but a very few exchange transfusions, a volume of donor blood at least 1.5 times the infant's blood volume was infused. We could show no correlations between the volume of donor blood employed in an initial procedure and the need for a repeat exchange. 4. Most of our exchange transfusions were completed in less than 1 hour; many in less than 30 minutes. We were unable to demonstrate a higher morbidity or mortality in infants being subjected to a faster as opposed to a slower procedure. 5. The best definition of the mortality rate of exchange transfusion appears to be the number of infants dying during or within 6 hours of a procedure expressed as a percentage of the number of infants transfused and again as a percentage of the number of exchange transfusions performed. 6. The incidence of death during or within 6 hours of an exchange transfusion appeared to be more closely related to an infant's clinical status at the beginning of a procedure then to the procedure itself. Most of the deaths occurred among critically ill infants with Rh-hemolytic disease. Vigorous infants, full-term or premature, regardless of diagnosis, tolerated exchange transfusions well. Our mortality rate in vigorous infants was very low.