Received Exchange Transfusion Research Articles

Effect of HHFNC therapy on organ oxygenation and brain metabolism in neonates receiving exchange transfusion.

Exchange transfusion therapy is a complex and invasive procedure with a high risk coefficient. This method involves replacing the entire blood of a child with fresh blood with double circulating blood volume in a short period, typically in 1-2 h. This procedure can cause the body's internal environment to be unstable, which can put newborns under a lot of stress. This stress can lead to many, including abnormal laboratory biochemical examination, low or high blood pressure, and apnea. There is also the possibility of secondary infection and, in severe cases, cardiac arrest. This study investigated the effects of Humidified high-flow nasal cannula (HHFNC) ventilation on hemodynamic stability and oxygenation during exchange transfusion in neonates. Furthermore, the effects on brain metabolism and salivary cortisol during exchange transfusion were also analyzed. In this study, the control group consisted of 45 cases of children who underwent simple blood exchange between 1 May 2017, and 31 December 2019 control group. The observation group consisted of 33 cases of children who underwent blood exchange under HHFNC support between 1 January 2020, and 30 April 2022. The study compared various physiological parameters between the control and the observation group. These included blood gas analysis, pulmonary artery pressure, ejection fraction, invasive mean arterial pressure, heart rate, cerebral oxygenation, intestinal oxygenation, renal oxygenation, and duration of blood exchange. Furthermore, the study also compared the changes in brain metabolic and salivary cortisol indicators between the two groups of children. The results did not reveal any significant difference in PH, PaO2, and duration of blood exchange between the control and the observation group. However, the observation group's invasive mean arterial pressure, ejection fraction, cerebral oxygenation, intestinal oxygenation, and renal oxygenation were higher than those of the control group. Furthermore, compared with the control group, the pulmonary artery pressure, heart rate, and PaCO2 were lower in the observation group. There was a statistically significant difference between the two groups of children in the relevant clinical indicators (total bilirubin, hemoglobin, SPO2, etc.) after exchange transfusion. After 1 h of blood exchange and after blood exchange, the salivary cortisol levels of the observation group were lower than the control group. The difference was statistically significant. The NAA/Cho and Cho/Cr values of the two groups of children were also significantly different. During blood exchange, unstable hemodynamics substantially impact organ oxygenation. The results of this study suggest that HHFNC and specific ventilation pressure support can improve the respiratory rate and help maintain blood flow stability and organ oxygenation. This technique can also reduce adverse reactions caused by blood exchange, minimizing patient stress and reducing the impact on brain metabolism.

Risk Factors for Postnatal Complications in People with Sickle Cell Disease: A Preliminary Analysis

Introduction: Sickle cell disease (SCD) is the most common hemoglobin variant worldwide, and its systemic influence, driven by acute on chronic ischemia-reperfusion injury and hemolysis-induced vasculopathy, results in diffuse end-organ damage capable of inducing significant pain and disability (Malowany et al, 2012). In studies to date, the rate of postnatal complications has been variably defined and has been shown to range between 13-25% (Camous et al, 2008; Silva et al, 2018; Oteng-Nim et al, 2015; Koshy et al, 1995). While some studies assessed the influence of type of anesthesia (neuraxial vs. general) on postnatal sickling episodes, (Bakri et al, 2015; Camous et al, 2008; Koshy et al, 1995) only one small study of 55 pregnant people assessed potential risk factors for postnatal maternal complications (Della-Moretta et al, 2021). Aim: To characterize the frequency of postpartum complications in people with SCD and to determine potential risk factors for their occurrence. Methods: A retrospective cohort study of pregnant people with SCD who delivered at Mount Sinai Hospital between 2000 and 2018 was performed. The primary outcome of an adverse maternal postnatal outcome was a composite end-point of vaso-occlusive pain, acute chest syndrome, infection (blood, urine, lungs), ICU admission, and new onset hypoxia that occurred after delivery. Patient characteristics and maternal and fetal outcomes were collected on the basis of clinical and biological plausibility. For multi-fetal pregnancies, data from a randomly chosen single infant was included in the analysis. Variables with more than 10% of data missing were excluded from this study. A ‘complicated’ vaso-occlusive event (VOE) is defined as a VOE requiring admission plus another concurrent SCD-related complication. Results: A total of 201 pregnancies from 145 pregnant people are included in this analysis. Seventy-four (36%) of these pregnancies had a postpartum complication that met the criteria for the primary outcome (see Table 1). Of these, 35% were VOEs and 4% acute chest syndrome. When comparing the differences between those who experienced a SCD-related postnatal complication as defined above, compared to those who did not, there was a significant difference in the following: HbSS genotype (75% vs 39%, p<0.001), pulmonary complications prior to pregnancy (42% vs 28%, p=0.037) as well as during pregnancy (15% vs 3.9%, p=0.006), history of simple transfusions pre-dating pregnancy (78% vs 57%, p=0.003), hemoglobin levels at different time points throughout the pregnancy and delivery (see table 4), suspected chorioamnionitis (14% vs 5.9%, p=0.05), infection present 30 days before delivery (15% vs 5.5%, p=0.03), vaso-occlusive event in the third trimester (46% vs 31%, p=0.03). Also, for a postnatal morbidity event, there was no difference in the proportion who received exchange transfusions prior to pregnancy (15% vs 11%, p=0.4), nor in those who received prophylactic exchange transfusions during the pregnancy (8.1% vs 4.7%, p=0.4). Fetal outcomes and post-partum interventions are also described in table 2. Conclusion: This study is the largest cohort of sickle cell disease patients to date, in which risk factors and postnatal outcomes are described. We have identified several risk factors that may contribute to the likelihood of experiencing an SCD-related postnatal complication. A regression analysis will be performed to establish the individual contribution of these risk factors to the primary outcome.

FREQUENCY OF COMMON CAUSES OF SEVERE HYPERBILIRUBINEMIA IN NEONATES LEADING TO EXCHANGE TRANSFUSION

Neonatal often have hyperbilirubinemia, which may become severe if left untreated. Severe hyperbilirubinemia in neonates that necessitates exchange transfusions may lead to "kernicterus," which has a high risk of morbidity. This descriptive cross-sectional research examined the medical records of sixty newborns who had exchange transfusions at HMC Peshawar between March 2021 and March 2022 and weighed more than two kilos. There were 22 (36%) females and 38 (64%) males in the group. With 37.2% of cases, ABO incompatibility was the most common reason for exchange transfusions. Other causes, such as cephalohematoma and Crigler-Najjar syndrome, were followed by unidentified causes (26.5%), Rh incompatibility without immune hydrops (15.2%), sepsis (08.3%), and urinary tract infections (05.2%). Exclusive breastfeeding and vaginal deliveries were associated variables. It was discovered that the average serum bilirubin level was 28.5 mg/dl (SD = 09.02). The objective of our study was to identify and quantify the most frequent reasons babies needing exchange transfusions have severe hyperbilirubinemia. This study was conducted in the Department of Peaderitcs HMC Peshawar between March 2021 and March 2022. The causes of severe hyperbilirubinemia in neonates needing an exchange transfusion were investigated in this research using a descriptive cross-sectional methodology. Medical records from HMC Peshawar served as the primary source of information. In all, 60 infants weighing over two kilograms received exchange transfusions within the allotted period. The primary emphasis of the data extraction method was on variables such as serum bilirubin levels, linked diseases, gender, and the cause of hyperbilirubinemia. The causes included ABO incompatibility, Rh incompatibility without immune hydrops, sepsis, urinary tract infection, and cephalohematoma. Further information was also gathered on the kind of feeding and the mode of delivery. Frequencies, percentages, averages, and standard deviations were computed using statistical techniques, mostly descriptive statistics. The results were then examined about the study's objectives. Twenty-two (36%) and 38 (64%) of the sixty neonates studied for this research were female. ABO incompatibility was shown to be the most common cause of severe hyperbilirubinemia necessitating exchange transfusion, explaining 22 (37.2%) instances. In decreasing order of frequency, the other reasons were: sepsis, 5 (8.3%); urinary tract infection, 3 (5.2%); unidentified causes, 16 (26.5%); Rh incompatibility without immune hydrops, 9 (15.2%); and other causes such as cephalohematoma and Crigler-Najjar syndrome, 2 (3.3%). One interesting finding was that newborns born vaginally and those nursed exclusively were more likely to need an exchange transfusion. The average blood bilirubin level throughout the group was 28.5 mg/dl, with a standard deviation 9.02. This research emphasizes the need to watch for ABO incompatibility in neonates, particularly those delivered vaginally, as it is significantly linked to the requirement for exchange transfusions. The most common reason for exchange transfusions for hyperbilirubinemia was found to be ABO incompatibility. Adolescents who were nursed exclusively, male, and born vaginally were more likely to need an exchange transfusion. Neonatal with ABO incompatibility would need close observation after discharge, particularly if they were vaginally born.

Intravenous immunoglobulin G therapy for neonatal hyperbilirubinemia

BackgroundNeonatal hyperbilirubinemia (NHb) results from increased total serum bilirubin and is a common reason for admission and readmission amongst newborn infants born in North America. The use of intravenous immunoglobulin (IVIG) therapy for treating NHb has been widely debated, and the current incidence of NHb and its therapies remain unknown.MethodsUsing national and provincial databases, a population-based retrospective cohort study of infants born in Ontario from April 2014 to March 2018 was conducted.ResultsOf the 533,084 infants born in Ontario at ≥35 weeks gestation, 29,756 (5.6%) presented with NHb. Among these infants, 80.1–88.2% received phototherapy, 1.1–2.0% received IVIG therapy and 0.1–0.2% received exchange transfusion (ET) over the study period. Although phototherapy was administered (83.0%) for NHb, its use decreased from 2014 to 2018 (88.2–80.1%) (P < 0.01). Similarly, the incidence of IVIG therapy increased from 71 to 156 infants (1.1–2.0%) (P < 0.01) and a small change in the incidence of ET (0.2–0.1%) was noted.ConclusionIVIG therapy is increasingly being used in Ontario despite limited studies evaluating its use. The results of this study could inform treatment and management protocols for NHb.ImpactsClinically significant neonatal hyperbilirubinemia still occurs in Ontario, with an increasing number of infants receiving Intravenous Immunoglobulin G (IVIG) therapy.IVIG continues to be used at increasing rates despite inconclusive evidence to recommend its use.This study highlights the necessity of a future prospective study to better determine the effectiveness of IVIG use in treating neonatal hyperbilirubinemia, especially given the recent shortage in IVIG supply in Ontario.The results of this study could inform treatment and management protocols for neonatal hyperbilirubinemia.

Does strengths of a positive direct antiglobulin test predicts the need for phototherapy and duration of phototherapy? – a single center, retrospective study

Background Use of Direct Antiglobulin test (DAT) in management of neonatal hyperbilirubinemia is conflicting. Objective whether strength of positive DAT predicts the need for phototherapy, duration of phototherapy and need for major interventions. Methods We retrospectively collected data on all DAT positive neonates with birth gestational age ≥32 weeks over six years (2014–2019). Data regarding blood group, DAT and clinical details were obtained from a hospital database. We also collected data on serial hemoglobin and other relevant laboratory parameters. We also collected data on infants receiving major interventions such as exchange transfusion, in-utero transfusion, immunoglobulins, and postnatal transfusion for the duration of the study period. All of these infants were electronically followed up for a period of 6 weeks. This study was approved by institutional audit authority. All the statistics were performed using SPSS software. Results Out of 1285 DAT tests performed, only 91 infants were positive (7%), and 78 DAT positive infants were available for analysis. There were 54 infants with DAT (1+), 15 infants with DAT (2+), 7 infants with DAT (3+) and 2 infants with DAT (4+). There was no significant statistical difference in terms of need for phototherapy, duration of phototherapy, need for major interventions and hemoglobin levels at different time points between the groups (DAT 1+ Vs DAT ≥2+; DAT ≤2+ Vs DAT >2). A Total of 10 infants received major intervention, with one infant receiving all three interventions (DAT 3+ with significant maternal antibodies), 2 additional infants (both DAT1+) received exchange transfusion, 6 additional infants received immunoglobulin (2 infants: DAT 2+; 4 infants: DAT 1+) and one additional infant (DAT 1+) with significant maternal antibodies received a postnatal transfusion. Conclusion Strength of a DAT did not predict the need for phototherapy, duration of phototherapy, and the need for major hemolysis related intervention in the first 6 weeks of life.

Live birth prevalence of hemolytic disease of the fetus and newborn in the United States from 1996 to 2010

Hemolytic disease of the fetus and newborn (HDFN) is mediated by maternal alloantibodies, a consequence of immune sensitization during pregnancy with maternal-fetal incompatibility with ABO, Rhesus factor (Rh), and/or other red blood cell antigens. RhD, Kell, and other non-ABO alloantibodies are the primary cause of moderate to severe HDFN, whereas ABO HDFN is typically mild. HDFN live birth prevalence owing to Rh alloimmunization among newborns in the United States was last estimated to be 106 per 100,000 births in 1986. HDFN live birth prevalence owing to all alloantibodies was estimated to be 817 to 840 per 100,000 in Europe. There is a need for updated prevalence estimates in the United States and a better understanding of disease demographics, severity, and treatments. This study aimed to estimate the live birth prevalence of HDFN and the proportion of severe cases of HDFN in the United States, to describe the associated risk factors, and to compare the clinical outcomes and treatments among healthy newborns, newborns with HDFN, and newborns who are sick without HDFN using a nationally representative hospital discharge database. In this retrospective, observational cohort study, we used data from the 1996 to 2010 National Hospital Discharge Survey to identify live births, defined by inpatient visits with the newborn flag, with and without a diagnosis of HDFN across 200 to 500 sampled hospitals (≥6 beds) per year. Patient and hospital characteristics, alloimmunization status, disease severity, treatment, and clinical outcomes were evaluated. Frequencies and weighted percentages were calculated for all variables. Logistic regression was used to compare the characteristics between newborns with HDFN and other newborns using odds ratios. Of 480,245 live births identified, 9810 HDFN cases were recorded. When weighted to the United States population, this corresponded to a live birth prevalence of 1695 per 100,000 live births. Compared with other newborns, newborns with HDFN were more likely to be female, Black, living in the South (vs the Midwest or West), and treated at larger (>100 beds) and government-owned hospitals. ABO and Rh alloimmunization accounted for 78.1% and 4.3% of newborns with HDFN, respectively, whereas HDFN caused by other antigens, such as Kell and Duffy, accounted for 17.6% of the cases. Among newborns with HDFN, 22% received phototherapy, 1% received simple transfusions, and 0.5% received exchange transfusions or intravenous immunoglobulin. Newborns affected by HDFN caused by Rh alloimmunization were more likely to require medical interventions, including simple or exchange transfusions, and more likely to be delivered by cesarean delivery. Overall, HDFN was associated with a longer hospital length of stay in the neonatal intensive care unit when compared with healthy and other sick newborns, a higher rate of cesarean delivery, and a higher rate of nonroutine discharge than healthy newborns. Overall, the live birth prevalence of HDFN was higher than those previously reported, whereas Rh-induced HDFN live birth prevalence was similar to those previously reported. HDFN live birth prevalence owing to Rh alloimmunization decreased over time, likely because of continued Rh immune globulin prophylaxis. Treatment patterns for newborns with HDFN and the comparative clinical outcomes when compared with healthy newborns confirm the continued clinical needs of this population.

İndirekt Hiperbilirubinemide Exchange Transfüzyon Uygulanması: Tek Merkez Deneyimi

Objective: Hyperbilirubinemia is a common clinical condition in newborn infants, and bilirubin encephalopathy remains an important health problem today. Decreased bilirubin anxiety and inadequate etiological evaluations lead to serious problems such as kernicterus. In this study, the development of bilirubin encephalopathy and its etiological causes were evaluated in patients who received exchange transfusion due to indirect hyperbilirubinemia for a period of one year. Methods: Newborns admitted to the Neonatology clinic between September 2020 and August 2021 due to indirect hyperbilirubinemia and undergoing exchange transfusion were analyzed retrospectively. Demographic data, laboratory parameters, and incidence of complications related to exchange transfusion were investigated. Results: A total of 62 infants, 61.3%(38) boys and 38.7%(24) girls, were included in the study. 53.2%(33) of the patients were delivered by cesarean section. Mean gestational age was 38(36-41) weeks and mean birth weight was 3063±478 grams. The median age at presentation was found to be 5 (1-22) days. In the etiological evaluation of the cases, 27.4%(44) Rh incompatibility, 50%(31) ABO incompatibility, 46.8%(29) Subgroup incompatibility were observed. More than one discrepancy was detected in 33.8%(21) of the patients. Glucose 6 phosphate dehydrogenase enzyme deficiency was detected in 21% (13) of the cases. No etiological cause was found in 4.8%(3) of the patients. Conclusion: Indirect hyperbilirubinemia and related bilirubin encephalopathy still remain a serious problem and therefore exchange transfusion may be required. In order to reduce serious morbidity and even mortality due to indirect hyperbilirubinemia, bilirubin monitoring should be done closely and risky babies should be determined in advance with etiological evaluations.

Patterns and Determinants of Blood and Blood Products Transfusion in Neonate: An Experience of Single Institute

BACKGROUND: Neonates requiring intensive care are among the most frequently transfused group of patients. Indications for blood transfusion in neonates could be physiological or pathological. However, despite frequent blood transfusions in neonates in Iraq, there is a paucity of studies on its indications and patterns among neonates in our setting. AIM: The aim of the study is to shed light on the details of giving blood and blood products in the unit of neonate in Children Welfare Teaching hospital, Baghdad and the justifications for giving and its complication. PATIENTS AND METHODS: A descriptive study (cross-section study) includes all neonates admitted to neonatal care unit in Children Welfare Teaching Hospital. The study includes a group of newborns who were blood transfused during their admission to hospital, over a period of 6 months from October 1, 2019 to March 30, 2020. All data were collected from each patient and recorded in predesigned forma, these data include patient’s clinical data and analyzed using descriptive statistics. RESULTS: A total number of cases admitted over a period of 6 months were 862. One hundred and forty neonates received blood and its products transfusion, (61.4%) were male and (38.6%) were female, (62.9%) received packed red blood cells (PRBCs) followed by (18.6%) received exchange transfusion, (11.4%) received Fresh frozen plasma and (7.1%) received platelets. Most neonates received blood products transfused at (3–4) weeks. Post-natal age and were term babies (37–41) weeks. Gestational age mostly received PRBCs. CONCLUSIONS: Most neonates with a high rate of blood and blood product transfusion were males, term, need assistant ventilation, and transfused at 3–4 weeks postnatal age.

Retrospective analysis of direct antiglobulin test positivity at tertiary academic hospital over 10 years

BackgroundHemolytic disease of the fetus and newborn (HDFN) is a clinically significant problem that may potentially affect any pregnancy. Direct antiglobulin test (DAT) is considered to be an important test in identifying newborns who are suspected to have HDN. This study aims in reviewing data regarding a positive DAT result concerning etiology and the development of HDN over a period of 10 years. Study design and methodsA retrospective study of all neonates with a positive DAT result between January 2011 and December 2020 was performed. Data were obtained from patients' electronic hospital files, transfusion medicine databases, and medical birth records. Laboratory parameters along with clinical interventions in neonates with a DAT-positive result and a comparison group of DAT-negative neonates were performed. Results36,000 deliveries were registered in this period. 176 (2.65 %) neonates had a positive DAT result. ABO-incompatibility was the most common cause with 59.1 %; Rh incompatibility 13.8 %, minor blood group incompatibility, and other RBC-related antibodies 10.1 %, and unspecified etiology in 17 % of cases. Among DAT-positive cases, 32.7 % of neonates were diagnosed with HDN. ABO-incompatibility was the major reason as well. Initial mean total bilirubin levels were higher in the DAT-positive group than the control group (p < 0.001), and these neonates also had a lower initial hemoglobin level (p < 0.001). The need for therapeutic interventions was significantly higher in DAT-positive neonates (p < 0.001) as 86.8 % underwent phototherapy, with 32.7 %, and 17.6 % receiving exchange transfusion (ET) and intravenous immunoglobulin (IVIG), respectively. ConclusionIn conclusion, ABO incompatibility was the most common cause for neonatal DAT positivity. Besides the common causes of DAT positivity, there would be rare but important conditions that may lead to a positive result, such as antibodies passively acquired from mothers in the context of alloimmunizations or using drugs. In addition, as a high rate of therapeutic intervention was identified among neonates with a DAT-positive result, there is a crucial need for increasing awareness regarding early diagnosis of the condition, careful monitoring, and the employment of prenatal alloimmunization screening tests.

Causes of Neonatal Jaundice Requiring Exchange Transfusion

Background: Neonatal jaundice is highly prevalent in Asia and has serious complications, such as kernicterus. Therefore, it is very important to identify the risk factors of jaundice requiring exchange transfusion since it can be helpful in the prevention of the disease and early diagnosis of its complications. Objectives: The present study aimed to identify the causes of neonatal jaundice requiring blood exchange. Methods: The present cross-sectional study was performed on 251 term and preterm neonates. The studied newborns were 2-14 days old (born at ≥ 35 weeks of gestation) with jaundice and bilirubin of more than 17 mg/dL and received exchange transfusion during 2011 - 2020 in Ghaem teaching hospital, Mashhad, Iran. The required data of the study variables, such as hyperbilirubinemia risk factors, laboratory tests, the documented history of the mothers and neonates, and physical examination results, were collected through a questionnaire and the medical records of the patients. Finally, the collected data were analyzed in SPSS software (version 20). Results: Based on the results, the mean value of the total serum bilirubin level in neonates who received exchange transfusion was 27.53 ± 10.05 mg/dL. The blood types of about 40% of mothers and their neonates were O and A/B, respectively. Moreover, 11.4% of mothers were Rh-negative; however, their neonates were Rh-positive. The results also revealed that the causes of exchange transfusion were unknown, ABO incompatibility, Rh incompatibility, glucose-6-phosphate dehydrogenase deficiency (G6PDD), and sepsis in 52.7 %, 24%, 7.1%, 5.3%, and 5.3% of the neonates, respectively. Conclusions: The findings of this study suggest that after unknown causes, the most common causes of exchange transfusion were ABO incompatibility, Rh incompatibility, G6PDD, and sepsis. Therefore, since most of these causes can be recognized, it is recommended to perform related tests and take related measures in the Midwifery Department of the hospital to prevent the occurrence and exacerbation of jaundice. Moreover, it is recommended to perform an early follow-up after the discharge.

Therapeutic approach to pediatric patients with acute chest syndrome: national multicenter survey of non invasive ventilation (NIV) and transfusion

BackgroundIntensive care units (ICUs) have seen a spike in the use of noninvasive ventilation (NIV) for many medical conditions. We sought to investigate the attitudes and clinical practice regarding the management of acute chest syndrome (ACS) with a focus on NIV in pediatric ICUs. MethodMembers of the French Group for Pediatric Intensive Care Emergencies (GFRUP) were asked to complete an online survey on physicians’ attitudes toward children with ACS admitted to the PICU during 2015. ResultsThe survey was answered by teams from 17 PICUs (240 beds). In total, 15 centers (88%) had a local transfusion unit and 14 (82%) worked in connection with a sickle cell disease (SCD) reference center.During 2015, 360 patients with SCD were managed (median: 7 per center; 21) of whom 137 (38%) for an ACS (median: 4 ACS per center; 8). The median length of PICU stay for ACS was 5 days (3.1).Among the 137 patients who presented with ACS, 73 (53%) received simple blood transfusion and 16 (12%) received exchange transfusion. For patients who required noninvasive ventilatory support, NIV with bilevel pressure (BiPAP) was the most frequent method (n = 68, 50%), followed by continuous positive airway pressure (CPAP) (n = 23, 17%) and high-flow oxygen (n = 21, 15%). The proportion of patients on BiPAP was up to 71% in the centers most frequently managing ACS patients. ConclusionBiPAP is commonly used in PICUs for SCD patients with ACS, especially in trained centers. Future physiological studies and randomized controlled trials might help to choose the best ventilatory support for ACS.

Hemoglobin Target and Transfusion Modality for Adult Patients With Sickle Cell Disease Acute Chest Syndrome.

Despite the importance of transfusion in treating sickle cell disease acute chest syndrome, the target hemoglobin and optimal modality for transfusion remain unknown. To compare hospital length of stay (LOS) in intensive care unit (ICU) patients with acute chest syndrome transfused to hemoglobin ≥ 8 g/dL versus patients transfused to hemoglobin < 8 g/dL; and to compare hospital LOS in acute chest syndrome patients treated with and without exchange transfusion. We performed a retrospective cohort study of all acute chest syndrome patients treated in the medical ICU at 2 tertiary care hospitals between January 2011 and August 2016 (n = 82). We compared median hospital LOS in patients transfused to hemoglobin ≥ 8 g/dL by the time of ICU transfer to the medical floor versus patients transfused to hemoglobin < 8 g/dL as well as patients who received exchange transfusion versus no exchange transfusion using Wilcoxon rank-sum tests. We modeled the association between hospital LOS and hemoglobin at ICU transfer to the medical floor using multivariable log-linear regression. Median hospital LOS was about half as long for patients transfused to hemoglobin ≥ 8 g/dL versus hemoglobin < 8 g/dL (8.0 versus 16.5 days, P = 0.008). There was no difference in LOS for patients treated with and without exchange transfusion. On average, a 1 g/dL increase in hemoglobin was associated with a 19.5% decrease (95% CI 10.8-28.2%) in LOS, controlling for possible confounding factors. Transfusion to a hemoglobin target ≥ 8 g/dL is associated with decreased hospital LOS in patients with acute chest syndrome. There was no difference in LOS between patients who received exchange transfusion and those who did not.

Comparison of Efficacy of Prophylactic versus Therapeutic Phototherapy in Preterm Neonates

Background: Jaundice neonatorum may predisposes preterm to develop bilirubin induced neurologic dysfunction even at lower total serum bilirubin level than term infant. Prophylactic phototherapy helps to maintain a lower serum bilirubin level may reduce the need for exchange transfusion in order to prevent kernicterus. Objective: To compare the efficacy of prophylactic versus therapeutic phototherapy among preterm neonates in reducing the frequency of exchange transfusion. Study Design: Randomized Controlled Trial. Settings: Neonatal Unit of Pediatrics department, Sir Ganga Ram Hospital Lahore-Pakistan. Duration: September 2018 to June 2019. Methodology: Two hundred preterm admitted in neonatal unit were enrolled and divided into 2 groups (A and B) using random numbers. Prophylactic phototherapy was initiated in Group A neonates within first 6 hours of life while it was applied when the serum bilirubin has reached to a pre-specified level in Group B. Daily total serum bilirubin level (also direct and indirect) was measured. Efficacy was measured in terms of preventing exchange transfusion. Data was entered and analyzed with SPSS version 21. Chi square was applied to compare efficacy between two groups with p ˂ 0.05 as significant. Results: Mean gestational age was 35.4 0.9 weeks in group A and 35.6 0.7 weeks in group B. There were 54% males and 46% females in group A while 51% males and 49% females in group B. The peak mean serum bilirubin level was observed on 3rd and 4th days in groups A and B respectively. Jaundiced neonates who received exchange transfusion in group A and B were 3% and 8% respectively (p=0.1209). Prophylactic phototherapy found efficacious in 97% preterm although, they received it for longer duration (147 34.25 vs 98 27.10 hours) (p 0.00001). Conclusion: Neonates received prophylactic phototherapy required less exchange transfusions compared to therapeutic group.

19 Treatment of Neonatal Hyperbilirubinemia – Ontario Cohort 2014-2018

Abstract Background Serious complications that could result from severe neonatal hyperbilirubinemia include acute and chronic bilirubin encephalopathy. In Ontario, the incidence of severe neonatal hyperbilirubinemia and its associated treatments in term and near-term infants is currently unknown. Although IVIG therapy has been increasingly discussed in the literature, a recent Cochrane review (2018) indicated that there was a lack of evidence for recommending IVIG therapy for routine use. Objectives The purpose of this study was to determine the current incidence of severe neonatal hyperbilirubinemia and its treatments (Intravenous Immunoglobulin (IVIG) therapy, exchange transfusion and phototherapy) most often used in Ontario. Design/Methods A population-based retrospective cohort study of all term and near-term infants (≥ 35 weeks’ gestation) born in Ontario from April 2014 to March 2018 was conducted. National and provincial databases including Better Outcomes Registry Network Ontario (BORN) and Canadian Neonatal Network (CNN) were utilized. Results Data was collected from 533,084 infants born in Ontario over the 4 years. Of the total infants screened, 29,756 (6%) infants were diagnosed with neonatal hyperbilirubinemia. In terms of treatments, 24,646 (83%) infants received phototherapy, 54 (0.18%) infants received an exchange transfusion and 458 (1.5%) infants received IVIG therapy. In Ontario, neonatal hyperbilirubinemia had a statistically significant increase from 2014 to 2018 (P&amp;lt;0.0001). Although phototherapy was used on almost all neonates with hyperbilirubinemia (83%) there was a significant decrease from 2014 to 2018 (from 88% to 80%) (P&amp;lt;0.0001). Of the babies with hyperbilirubinemia in 2014, 71 (1.06%) infants received IVIG therapy and 15 (0.22%) infants received exchange transfusion. Within 4 years, IVIG therapy incidence had a significant increase from 71 (1.06%) infants to 156 (2.04%) infants (P&amp;lt;0.0001), while exchange transfusion remained relatively constant (P=.315). Exchange transfusion rates allows for the prediction that the rate of severe neonatal hyperbilirubinemia is stable in Ontario. Conclusion In conclusion, (severe) hyperbilirubinemia still exists amongst neonates in Ontario, despite the advancements in managing hyperbilirubinemia, indicating the need for better treatments and/or monitoring. There was also a significant rise in the use of IVIG despite the continued debate about its utility. Further research should be conducted nationally to determine the incidence of severe neonatal hyperbilirubinemia and to indicate the usage of IVIG therapy.

Neurodevelopmental outcome at 6 months of age in full-term healthy newborns with neonatal hyperbilirubinemia

Background: Neonatal hyperbilirubinemia (NNH) is an important cause of preventable brain damage among infants. Neurodevelopmental assessment and Brainstem-Evoked Response Audiometry (BERA) may help in the early identification and management of neurodevelopmental sequelae. Objectives: The objectives of this study were to find the association between neonatal peak serum bilirubin levels and the neurodevelopmental outcomes at 6 months in term infants with NNH and to assess the changes in BERA of these neonates. Methodology: A prospective cohort study was conducted in the Department of Pediatrics, Gandhi Medical College, Bhopal. All healthy, full-term, appropriate-for-date neonates, admitted from December 2014 to June 2015 with hyperbilirubinemia and serum bilirubin >12 mg/dL, were included in the study and were followed up till 6 months of age. The neurodevelopmental assessment was done using the Denver Developmental Screening Test II and BERA was done at an average age of 69 ± 6 days. Results: A total of 77 newborns were enrolled, and 73 completed the study. Of these 77 neonates, 40 (51.65%) had abnormal BERA results, whereas 3 (3.9%) had neurodevelopmental abnormalities. BERA and neurodevelopmental abnormalities were associated with a mean serum bilirubin of 22.58 mg/dL and 31.33 mg/dL, respectively. The cutoff value of serum bilirubin was 16.3 mg/dL and 23.8 mg/dL, respectively, to detect BERA and neurodevelopmental abnormalities, respectively. All patients (11) who received exchange transfusion had BERA abnormalities, and 3/11 (27.3%) had neurodevelopmental abnormalities. The association of ABO incompatibility was significant (P

Sickle cell disease related cerebral fat embolism: Characterizing the clinical syndrome

To characterize the clinical syndrome of sickle cell disease (SCD) related cerebral fat embolism syndrome (CFES) SCD-related CFES results from bonemarrow embolism in the absence of trauma and except for a few single case reports, its clinico-imaging spectrum has not been fully characterized. Twelve SCD patients (6 women and 6 men, aged 28.4±9.9 years), were evaluated for neurological complications such as altered sensorium (n=12) and seizures (n=2) in the setting of acute chest syndrome, fever and no preceding trauma (n=12). Laboratory findings included high CRP (11 out of 11 tested) and thrombocytopenia (n=12), normal CSF findings (n=2 out of 2 tested). EEG showed non-specific diffuse slowing in 9 out of 10 cases and occasional left temporal spike discharges (n=1). Cerebral PET scan obtained in a single case showed globally reduced glucose uptake. Lipid laden macrophages were demonstrated in the broncho-alveolar lavage in two cases. CFES was diagnosed based on the characteristic finding of multiple cerebral microbleeds in the splenium and subcortical location on susceptibility weighted imaging (SWI). Our patients received exchange transfusion, antibiotics, ventilatory assistance (n=12) and anticonvulsant (n=2). One patient died, while the others survived with variable functional disability. In SCD patients presenting with acute chest syndrome, altered mental status and fever, the presence of thrombocytopenia and high CRP provides important clue to the possibility of CFES. The diagnosis is confirmed with SWI MRI that usually demonstrates multiple microbleeds in the splenium and subcortical areas. SCD-related CFES carries considerable short-term morbidity and occasional mortality.

Severe neonatal hyperbilirubinemia in the southeast region of Turkey

Severe neonatal hyperbilirubinemia is an important cause of morbidity and mortality in developing countries. The aim was to assess etiologic reasons for development of severe hyperbilirubinemia and define risk factors for exchange transfusion and acute bilirubin encephalopathy (ABE) in Şanlıurfa located in the southeast region of Turkey. An observational cohort study included 115 infants with ≥35 weeks of gestation admitted with diagnosis of severe hyperbilirubinemia in a period of 18 months. Potential risk factors associated with exchange transfusion and development of ABE were analyzed. Among 115 infants, 67 (58.3%) received exchange transfusion and 45 (39.1%) developed ABE. Rh isoimmunization (OR: 24.6, 95% CI = 2.2–271, P = 0.009), glucose-6-phosphate dehydrogenase deficiency (G6PD) (OR: 21.1, 95% CI = 1.8–238.4, P = 0.01), early discharge (OR: 14.4, 95% CI = 4.2–48.9, P ≤ 0.001), and male sex (OR: 4.3, 95% CI = 1.3–14.1, P = 0.02) were independently associated with an increased risk for exchange transfusion. Being a refugee (OR: 6.8, 95% CI = 1.8–25.8, P = 0.005) and G6PD deficiency (OR: 9.9, 95% CI = 1.3–71.9, P = 0.02) were associated with development of ABE. Early discharge, Rh isoimmunization, and G6PD deficiency are significant risk factors for severe hyperbilirubinemia and exchange transfusion. Prevention of early hospital discharges, family education to increase awareness for hazardous effects of hyperbilirubinemia, and early follow-up visits after discharge would reduce the disease burden.

Predictors of Adverse Outcome in Sickle Cell Disease Patients from Oman

Introduction: Sickle cell disease (SCD) is a major public health problem in Oman with high morbidity and mortality. The ability to identify the risk factors that are associated with mortality among SCD patients would permit accurate prognostication and provide an opportunity to use effective prophylactic management.Objective: The study aimed at identifying the risk factors associated with mortality in SCD patients by studying the clinical course of 86 patients who died at two tertiary care hospitals in Oman.Methods: We analyzed the electronic records of 86 SCD patients who died between 2006 to 2016. These data included cardiac parameters, SCD manifestations like frequency of painful crisis, acute chest syndrome, splenic and hepatic sequestration, dactylitis, and stroke. Furthermore, we also analyzed the haematological, biochemical and radiological parameters as well as use of antibiotics and exchange blood transfusion. Data were transcribed to Excel and later analyzed by IBM SPSS Ver23.Results±13.7. Previous complications prior to death included acute chest syndrome in 66.3% cases, followed by stroke in 20.9%, hepatic sequestration in 6.9%, splenic sequestration in 3.5% and dactylitis in 2.3% cases. At the terminal event, patients presented with fever, cough and crepitation in 47%, 29% and 36% respectively, while abnormal pulse, blood pressure, respiratory rate and O2 saturation were seen in 55%, 64%, 46% and 55% respectively. Further abnormal chest x-ray, CT scan and abdominal ultrasound were seen in 57.5%, 88.5% and 50% respectively. Amongst the haematology parameters, there was a significant drop in the mean hemoglobin and platelet counts from baseline, whereas there was a significant rise in the WBC counts (p<0.05, student's t test). The biochemical parameters showed a significant rise in the LDH and CRP levels (p<0.05). All patients received antibiotics, 88% received blood transfusions, 35.7% received exchange transfusions, whereas 87.5% required NIV/ventilation. Finally, all patients presented with multi-organ terminal events that varied in the severity, but sepsis showed the commonest cause of death (54.3%).Conclusion: Multi-organ failure was mostly associated with the terminal events relating to mortality. Although sepsis played a major role as a cause of death in association with multiorgan failure, low hemoglobin, and low platelet counts with increased WBC counts along with elevated LDH and CRP played a significant role in the terminal event in this cohort of SCD patients. DisclosuresNo relevant conflicts of interest to declare.

Impact of Red Blood Cell Transfusions on Height and Growth of Adolescents with Sickle Cell Disease & Short Stature

BACKGROUND:Children with sickle cell disease (SCD) commonly have delayed or impaired growth. There are no clear guidelines as how to manage these patients. Current evidence suggests that children who are treated long term with red blood cell (RBC) transfusions (simple red cell or exchange transfusions) for different SCD related complications, achieve better height and growth, although, it is not clear when to start such treatment for the maximum benefit. Timing of such treatment(s) may be critical as to achieve optimum height and growth. Children with SCD who are started transfusion therapy before the age of 14 years, may achieve better height velocity. However, some children may present late during adolescence and whether to adopt measures like regular blood transfusions to improve their growth, remains challenging. We treated adolescents with SCD and delayed growth with regular RBC transfusions and observed the effect on their growth. The major concern of the parents was short stature, and our aim was achievement of better height.Methods:Adolescent patients with SCD being followed at our department, who were observed to have short stature or were referred to us for this problem and received RBC transfusion therapy to improve their growth, were included in this study. They were started on regular RBC transfusions after thorough counseling (parents and patients). They were informed of the likely benefits and possible side effects including usual transfusion related adverse events and particularly the likelihood of iron overload and possible need for iron chelation therapy in future.A chart review was performed recording weight, height, and body mass index (BMI) measurements, timing and length of transfusion therapy along with laboratory parameters. When iron overload (defined as a serum ferritin ≥ 1000 µgm/l) developed, it was treated with deferasirox at an average dose of 20-30mg/kg body weight. RBC transfusions were continued for 3-6 months after achieving the maximum height (plateau phase).Patients were either already receiving hydroxyurea (HU) or were started at the beginning of transfusion therapy. The average dose of HU was 500 mg daily (20mg/kg body weight) at the start of transfusion therapy in all patients and was increased according to the weight gain. Two patients also received growth hormone for a short period.RESULTS:Six patients received RBC transfusion therapy for short stature (5 males). Median age at start of therapy was 15.5 years (range 13.9 -17.4). Patients were treated for a median duration of 32 months (range 23-53). One (female) patient continues to have ongoing transfusions as she has not achieved the maximum height. Median height at start of therapy was 137.25 cm and 152.25 cm at the end of therapy. Pre-therapy median weight was 28 kg and post therapy 38.2 kg. Median increase in height was 16.25 cm (p < 0.025) and median increase in weight 10.15 kg (p=0.007). BMI measurements showed improvement in 5 patients but the increase was modest, likely due to better height gain as compared to weight gain.Five patients received regular RBC transfusions while one patient received exchange transfusions after one year of simple transfusions because of high base line Hb. Four patients were already receiving HU for one year or more, while 2 patients started HU shortly after commencing transfusion therapy.There were no significant SCD related or transfusion related complications during transfusion therapy but all patients developed iron overload and received chelation therapy. However, 3 patients had s/ferritin around or above 1000 µgm/l at the base line. Mean pre-transfusion s/ferritin was 901 µgm/l and 2304 µgm/l at the end of transfusion therapy.CONCLUSIONS:RBC transfusion therapy improved height of all patients with SCD & short stature, even if started during late adolescence. However, the improvement was variable. There were no significant adverse events except iron overload, which developed in all patients and required chelation therapy. RBC Transfusion therapy should be considered in adolescent children with SCD and short stature, even if they present during late adolescence. RBC exchange therapy may be an alternative option to reduce the complication of iron overload and should be explored in further studies. DisclosuresNo relevant conflicts of interest to declare.

Birthplace is a risk factor for exchange transfusion in outborn infants admitted for jaundice in Myanmar: a case-control study

Aim: To evaluate the role of pathway to admission for jaundice among the risk factors for exchange transfusion in outborn infants in a low resource setting.Methods: This retrospective case-control study (1:1 ratio) was carried out at the Yankin Children’s Hospital in Yangon (Myanmar). All cases were neonates admitted for treatment of jaundice between March 2013 and February 2014 and who required an exchange transfusion. Each control was the next noncase neonate admitted for treatment of jaundice and treated with phototherapy. Infant characteristics, pathways of admission and clinically relevant factors for exchange transfusion were collected.Results: One hundred thirty-four cases and 134 controls were included in the study. Among cases, home was the most common place of birth while public hospital was the most frequent source of referral. Among controls, private/public hospitals were the commonest places of birth and referral. At multivariable analysis, homebirth was associated with increased likelihood of receiving exchange transfusion at admission (OR 3.30, 95% C.I. 1.31–8.56).Conclusion: Homebirth was an independent risk factor for exchange transfusion at admission for jaundice in a low-resource setting. Appropriate health education of pregnant women and traditional/home birth attendants may contribute to reduce the need for exchange transfusion in low-resource settings.