Satellite Packs Research Articles

Late erythropoiesis-stimulating agents to prevent red blood cell transfusion in preterm or low birth weight infants.

Preterm infants have low plasma levels of erythropoietin (EPO), providing a rationale for the use of erythropoiesis-stimulating agents (ESAs) to prevent or treat anaemia. Darbepoetin (Darbe) and EPO are currently available ESAs. To assess the effectiveness and safety of late initiation of ESAs, between eight and 28 days after birth, in reducing the use of red blood cell (RBC) transfusions in preterm or low birth weight infants. We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 5 June 2018), Embase (1980 to 5 June 2018), and CINAHL (1982 to 5 June 2018). We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. Randomised or quasi-randomised controlled trials of late initiation of EPO treatment (started at ≥ eight days of age) versus placebo or no intervention in preterm (< 37 weeks) or low birth weight (< 2500 grams) neonates. We performed data collection and analyses in accordance with the methods of the Cochrane Neonatal Review Group. We used the GRADE approach to assess the quality of the evidence. We include 31 studies (32 comparisons) randomising 1651 preterm infants. Literature searches in 2018 identified one new study for inclusion. No new on-going trials were identified and no studies used darbepoetin. Most included trials were of small sample size. The meta-analysis showed a significant effect on the use of one or more RBC transfusions (21 studies (n = 1202); typical risk ratio (RR) 0.72, 95% confidence interval (CI) 0.65 to 0.79; typical risk difference (RD) -0.17, 95% CI -0.22 to -0.12; typical number needed to treat for an additional beneficial outcome (NNTB) 6, 95% CI 5 to 8). There was moderate heterogeneity for this outcome (RR I² = 66%; RD I² = 58%). The quality of the evidence was very low. We obtained similar results in secondary analyses based on different combinations of high/low doses of EPO and iron supplementation. There was no significant reduction in the total volume (mL/kg) of blood transfused per infant (typical mean difference (MD) -1.6 mL/kg, 95% CI -5.8 to 2.6); 5 studies, 197 infants). There was high heterogeneity for this outcome (I² = 92%). There was a significant reduction in the number of transfusions per infant (11 studies enrolling 817 infants; typical MD -0.22, 95% CI -0.38 to -0.06). There was high heterogeneity for this outcome (I² = 94%). Three studies including 404 infants reported on retinopathy of prematurity (ROP) (all stages or stage not reported), with a typical RR 1.27 (95% CI 0.99 to 1.64) and a typical RD of 0.09 (95% CI -0.00 to 0.18). There was high heterogeneity for this outcome for both RR (I² = 83%) and RD (I² = 82%). The quality of the evidence was very low.Three trials enrolling 442 infants reported on ROP (stage ≥ 3). The typical RR was 1.73 (95% CI 0.92 to 3.24) and the typical RD was 0.05 (95% CI -0.01 to 0.10). There was no heterogeneity for this outcome for RR (I² = 18%) but high heterogeneity for RD (I² = 79%). The quality of the evidence was very low.There were no significant differences in other clinical outcomes including mortality and necrotising enterocolitis. For the outcomes of mortality and necrotising enterocolitis, the quality of the evidence was moderate. Long-term neurodevelopmental outcomes were not reported. Late administration of EPO reduces the use of one or more RBC transfusions, the number of RBC transfusions per infant (< 1 transfusion per infant) but not the total volume (mL/kg) of RBCs transfused per infant. Any donor exposure is likely not avoided as most studies included infants who had received RBC transfusions prior to trial entry. Late EPO does not significantly reduce or increase any clinically important adverse outcomes except for a trend in increased risk for ROP. Further research of the use of late EPO treatment, to prevent donor exposure, is not indicated. Research efforts should focus on limiting donor exposure during the first few days of life in sick neonates, when RBC requirements are most likely to be required and cannot be prevented by late EPO treatment. The use of satellite packs (dividing one unit of donor blood into many smaller aliquots) may reduce donor exposure.

Late erythropoiesis-stimulating agents to prevent red blood cell transfusion in preterm or low birth weight infants.

Preterm infants have low plasma levels of erythropoietin (EPO), providing a rationale for the use of erythropoiesis-stimulating agents (ESAs) to prevent or treat anaemia. Darbepoetin (Darbe) and EPO are currently available ESAs. To assess the effectiveness and safety of late initiation of ESAs, between eight and 28 days after birth, in reducing the use of red blood cell (RBC) transfusions in preterm or low birth weight infants. We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 5 June 2018), Embase (1980 to 5 June 2018), and CINAHL (1982 to 5 June 2018). We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. Randomised or quasi-randomised controlled trials of late initiation of EPO treatment (started at ≥ eight days of age) versus placebo or no intervention in preterm (< 37 weeks) or low birth weight (< 2500 grams) neonates. We performed data collection and analyses in accordance with the methods of the Cochrane Neonatal Review Group. We used the GRADE approach to assess the quality of the evidence. We include 31 studies (32 comparisons) randomising 1651 preterm infants. Literature searches in 2018 identified one new study for inclusion. No new on-going trials were identified and no studies used darbepoetin.Most included trials were of small sample size. The meta-analysis showed a significant effect on the use of one or more RBC transfusions (21 studies (n = 1202); typical risk ratio (RR) 0.72, 95% confidence interval (CI) 0.65 to 0.79; typical risk difference (RD) -0.17, 95% CI -0.22 to -0.12; typical number needed to treat for an additional beneficial outcome (NNTB) 6, 95% CI 5 to 8). There was moderate heterogeneity for this outcome (RR I² = 66%; RD I² = 58%). The quality of the evidence was very low. We obtained similar results in secondary analyses based on different combinations of high/low doses of EPO and iron supplementation. There was no significant reduction in the total volume (mL/kg) of blood transfused per infant (typical mean difference (MD) -1.6 mL/kg, 95% CI -5.8 to 2.6); 5 studies, 197 infants). There was high heterogeneity for this outcome (I² = 92%). There was a significant reduction in the number of transfusions per infant (11 studies enrolling 817 infants; typical MD -0.22, 95% CI -0.38 to -0.06). There was high heterogeneity for this outcome (I² = 94%).Three studies including 404 infants reported on retinopathy of prematurity (ROP) (all stages or stage not reported), with a typical RR 1.27 (95% CI 0.99 to 1.64) and a typical RD of 0.09 (95% CI -0.00 to 0.18). There was high heterogeneity for this outcome for both RR (I² = 83%) and RD (I² = 82%). The quality of the evidence was very low.Three trials enrolling 442 infants reported on ROP (stage ≥ 3). The typical RR was 1.73 (95% CI 0.92 to 3.24) and the typical RD was 0.05 (95% CI -0.01 to 0.10). There was no heterogeneity for this outcome for RR (I² = 18%) but high heterogeneity for RD (I² = 79%). The quality of the evidence was very low.There were no significant differences in other clinical outcomes including mortality and necrotising enterocolitis. For the outcomes of mortality and necrotising enterocolitis, the quality of the evidence was moderate. Long-term neurodevelopmental outcomes were not reported. Late administration of EPO reduces the use of one or more RBC transfusions, the number of RBC transfusions per infant (< 1 transfusion per infant) but not the total volume (mL/kg) of RBCs transfused per infant. Any donor exposure is likely not avoided as most studies included infants who had received RBC transfusions prior to trial entry. Late EPO does not significantly reduce or increase any clinically important adverse outcomes except for a trend in increased risk for ROP. Further research of the use of late EPO treatment, to prevent donor exposure, is not indicated. Research efforts should focus on limiting donor exposure during the first few days of life in sick neonates, when RBC requirements are most likely to be required and cannot be prevented by late EPO treatment. The use of satellite packs (dividing one unit of donor blood into many smaller aliquots) may reduce donor exposure.

Use of potassium adsorption filter for the removal of ammonia and potassium from red blood cell solution for neonates.

Ammonia in the plasma usually does not pass through the blood-brain barrier (BBB). However, it can affect the brain as a neurotoxin in neonates with anemia of prematurity. Excess intake of ammonia should therefore be restricted in conditions involving BBB breakdown, such as in premature neonates. A potassium adsorption filter (PAF) can remove not only potassium, but also ammonia from red blood cell (RBC) solution. PAF for neonates (PAF-n) has been recently introduced using small satellite packs. We evaluated the effects of PAF-n on the removal of ammonia and potassium from RBC solution in small satellite packs. RBC solutions were obtained from the Japanese Red Cross Society. Two units of RBC solution (280 mL) were divided into four satellite packs (70 mL/pack). The RBC solution was passed through PAF-n (Kawasumi Laboratories Inc.) that was primed with saline (100 mL) before use. The concentrations of ammonia and potassium were measured in the solution before and after filtration (four samples of 10 mL each of filtered RBC solution) by Biomedical Laboratories. Approximately 47 to 82 and 84% to 93% of ammonia and potassium were removed from the RBC solution, respectively, without dilution with saline. PAF-n can remove ammonia and potassium from RBC solution in small satellite packs. PAF-n could therefore improve the clinical prognosis of neonates with poorly developed BBB by limiting the delivery of excess ammonia found in the RBC solution.

G214(P) Reducing transfusion donor exposure in preterm babies: good communication is vital

BackgroundPreterm infants frequently require multiple blood transfusions. Splitting adult units into 6–8 satellite packs has been universally adopted by neonatal units to reduce donor exposure. Our NICU guideline is to...

G227(P) Reducing donor exposure from blood transfusions in preterm babies: improving the use of satellite pack

AimsPremature infants frequently require multiple red blood cell (RBC) transfusions. The practice of splitting a single adult unit into satellite packs has been widely adopted to reduce the risks of...

Reduction of exposure to blood donors in preterm infants submitted to red blood cell transfusions using pediatric satellite packs

OBJECTIVE: In preterm newborn infants transfused with erythrocytes stored up to 28 days, to compare the reduction of blood donor exposure in two groups of infants classified according to birth weight. METHODS: A prospective study was conducted with preterm infants with birth weight <1000g (Group 1) and 1000-1499g (Group 2), born between April, 2008 and December, 2009. Neonates submitted to exchange transfusions, emergency erythrocyte transfusion, or those who died in the first 24 hours of life were excluded. Transfusions were indicated according to the local guideline using pediatric transfusion satellite bags. Demographic and clinical data, besides number of transfusions and donors were assessed. . Logistic regression analysis was performed to determine factors associated with multiple transfusions. RESULTS: 30 and 48 neonates were included in Groups 1 and 2, respectively. The percentage of newborns with more than one erythrocyte transfusion (90 versus 11%), the median number of transfusions (3 versus 1) and the median of blood donors (2 versus 1) were higher in Group 1 (p<0.001), compared to Group 2. Among those with multiple transfusions, 14 (82%) and one (50%) presented 50% reduction in the number of blood donors, respectively in Groups 1 and 2. Factors associated with multiple transfusions were: birth weight <1000g (OR 11.91; 95%CI 2.14-66.27) and presence of arterial umbilical catheter (OR 8.59; 95%CI 1.94-38.13), adjusted for confounders. CONCLUSIONS: The efficacy of pediatrics satellites bags on blood donor reduction was higher in preterm infants with birth weight <1000g.

Donor exposure in neonatal blood transfusion - time to change strategy?

<h3>Background</h3> Previous studies have recommended reserving 8 satellite packs (SP) for extremely low birth weight (ELBW) babies to reduce donor exposure (DE) from blood transfusions.1 However, concentration of transfusions at the beginning and end of neonatal care coupled with short shelf-life of blood result in wastage of SPs and unavoidable DE. Neonatal transfusion practice may have changed due to restrictive transfusion guidelines, micro-sampling methods and practice of delayed cord clamping. We currently reserve only 4 SPs for ELBW babies and strictly follow British Committee for Standards in Haematology 2004 guidelines for blood transfusion². <h3>Aims</h3> To ascertain the root cause of excess DE and SP wastage in multi-transfused ELBW babies and suggest an optimum contemporary strategy that would balance DE with SP wastage. <h3>Methods</h3> Transfusion data was collected for all inborn ELBW babies and those transferred-in within 96 hours of birth in 2010. Rates and determinants of DE were analysed. Projected SP wastage and DE rates were calculated for different SP strategies. <h3>Results</h3> Thirty-eight ELBW babies with a mean gestation of 25.5 weeks and birth weight of 712 grams were included. Eight babies were not transfused while 7 received only one transfusion. Therefore, 23 babies were included for DE and 30 for SP wastage analysis. The mean SP usage was 3.97/baby. The mean DE was 2.47 and mean SP wastage 4.7/baby. The mean age of the donor unit at allocation was 20.2 days (95% CI 18.4, 22). The mean interval between the first and last transfusion was 35 days. Reducing donor unit age to 14 days at allocation would have reduced one donor exposure in 11/23 babies (47.8%). Table 1 shows the effect of different projected SP strategies on DE and SP wastage. <h3>Conclusions</h3> Younger age of blood unit at allocation is the key to reduce DE. A 4-SP strategy appears appropriate for current transfusion practice for ELBW babies.

317 The Effect of Human Red Cells Storage Time on the Microcirculation of Preterm Infants

Background: Red blood cell (RBC) transfusion practices for neonates are controversial, variable, and based on limited scientific information. To decrease donor exposure satellite packs are used leading to the transfusion of older RBCs. Transfusion of stored RBCs in a hemodiluted animal resulted in significant malperfused and underoxygenated microvasculature that was not detected at the systemic level. Objective: Does the age of transfused erythrocytes influence functional vessel density (FVD) in the skin in premature infants?. Design Methods: 17 preterm infants with birth weight < 1500g received RBC transfusion, 11 infants repeatedly from the same donor. The age of RBCs at repeated transfusions was significant higher than at the first transfusion. Using Sidestream Dark Field Imaging all preterm infants were examined before and 2, 24 and 48 hours after transfusion. Images were blinded and analyzed with Microvision Analysis Software. Results: FVD before first and repeated transfusion did not differ. In the 2nd, 24th and 48th hour after the treatment the Functional Vessel Density (FVD) was significantly lower after the repeated transfusion with longer storage time (2nd: 250 vs. 238 cm/cm2, p=0.045; 24th: 259 vs. 231 cm/cm2, p=0.001; 48th: 234 vs. 220 cm/cm2, p=0.035). The proportion of vessels with altered sluggish blood flow was also significantly higher when older RBCs were transfused (24h: 0.3% vs 2.5%, p=0.017; 48h: 1% vs. 3.3%, p=0.013). Conclusions: Similar to the animal model longer storage of the red blood cells reduces functional vessel density in the skin of premature infants and more vessels display sluggish blood flow.

Cochrane review: Late erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants

Cochrane review: Late erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants

Neonatal RBC Transfusions – Comparison of Two Patterns

Background: Red blood cell (RBC) transfusions performedover 5 years in a neonatal ward were retrospectivelyanalyzed. Despite the fact that ‘fresh’ RBC smallvolumetransfusions given to preterm infants are called‘traditional’ or even ‘historic’, this method of treatment isstill used in all neonatal wards in Poland. Patients andMethods: A total of 846 RBC units were transfused to216 patients, including 26 term and 190 pretermneonates. The transfusion rate and donor exposure ratewere calculated. The same parameters were calculatedfor hypothetical use of blood satellite packs for transfusionsin the analyzed patients and compared with theoriginal data. Results: Application of a limited donor programcould diminish the donor exposure rate more thantwofold, from 3.5 to 1.63, in the very-low-birth-weight infantsgroup and reduce the maximum number of donorsfrom 11 to 3, at the same transfusion rate of 5.35. Conclusion:Introduction of strict RBC transfusion guidelinesand a limited-donor blood program would improvetransfusion therapy.

Cost effective use of satellite packs in neonates: importance of birth weight

<b>Background:</b> Blood banks split an adult packed red cell bag (usually 250 ml) into 30 ml bags, making a total of eight neonatal “satellite” packs per donor. These packs are then “allocated”/“committed” to be used to serially transfuse a newborn. <b>Aim:</b> To study transfusion requirements of premature infants in relation to their birth weight and thereby attempt to rationalise the method of dispensing satellite blood packs. <b>Method:</b> Data on the distribution of neonatal transfusions with respect to weight were obtained retrospectively from unit A (51 infants, 168 transfusions) and unit B (46 infants, 151 transfusions). These data were used to model the effect of different policies on donor exposure and number of unused packs. <b>Results:</b> Infants weighing less than 1000 g at birth have significantly higher transfusion requirements than those weighing1000 g or more (p = 0.001 (unit A), p = 0.004 (unit B)). Our model predicted a significant reduction in donor exposure if eight packs/infant were allocated to those weighing &lt; 1000 g, and a significant cut in the number of unused packs if four satellite packs/infant were allocated to those weighing ⩾ 1000 g. <b>Conclusions:</b> It would be safer and cost effective to allocate eight packs/infant to those with birth weights &lt; 1000 g and four packs/infant to those with birth weights ⩾ 1000 g.

Low degree of regionalization and high transfusion rates in very low birthweight infants: a survey in Germany.

Although anemia is common in very low birthweight (VLBW) infants, widely accepted guidelines for red blood cell transfusions are lacking. Questionnaires regarding transfusion policy in VLBW infants in 1994 were sent to 391 German pediatric departments. 208 questionnaires were returned. 51 departments reported not to admit VLBW infants. Thus, results are based on 157 completed questionnaires. 54% of the respondents admitted less than 30 VLBW infants per year and 52% of the VLBW infants were admitted to departments with less than 50 VLBW infants per year. Overall transfusion rate ranged from 0 to 100% (median 65%). This range narrowed with the departments' size indicating stricter guidelines with less variation. Indication for transfusion varied considerably depending on the infants' postnatal age and need for ventilatory support. 34% of the respondents applied directed transfusions, most frequently from the infant's father. 70% used satellite packs. 51% stored the packs up to 7 days, 10% longer than 14 days. Red cells were irradiated in 35%, and washed in 23% of the departments. Median single transfusion volume was 12 ml/kg. We conclude that regionalization of VLBW infants in Germany is far from completeness and that hospital policies for transfusion show large variety especially in small departments.

Reducing donor exposure in preterm infants requiring multiple blood transfusions.

Preterm infants frequently require multiple blood transfusions. Traditionally, 'fresh' (less than seven days old) blood has been used but this often results in transfusions from multiple donors. To reduce donor exposure the policy for top-up transfusions was changed. A unit of blood under five days old with additional satellite packs was ordered for each infant and used up to its expiry date, allowing up to eight transfusions from a single donation to be given. The mean (SD) number of transfusions per infant in 43 infants transfused according to previous policy and in 29 transfused according to the new policy was similar at 5.6 (4.0) and 5.3 (3.1), respectively. However, donor exposure fell following the change in policy from 4.9 (3.5) to only 2.0 (0.9). Only one infant was exposed to more than three donors compared with 24 infants in the control group. Plasma potassium concentrations were not significantly different following transfusion of blood stored for up to 33 days. This simple change in policy has reduced donor exposure in infants requiring multiple top-up transfusions.