Minimising blood loss and the need for transfusion in very premature infants

Question 1

What are the risks of drawing blood?

3

Answer 1

Pain
Infection - from skin breakdown
Anemia

Question 2

What are the risks of PRBC transfusions?

5

Answer 2

acute lung injury
graft-versus-host disease
increased hospital mortality of VLBW
infection
transfusion reaction

Question 3

How can we minimise transfusions for preterm infants?

3

Answer 3

fewer blood sampling
delayed cord clamping - evidence based association with fewer need for transfusions
cord milking - but not enough evidence so it cannot be routine practice. it is faster than delayed cord clamping

Question 4

Who should get delayed cord clamping?

Answer 4

Everyone

Question 5

Is there any harm to cord milking stable kids?

Answer 5

No

No higher rates of IVH

Question 6

Does a lower Hb threshold for transfusion reduce the need for transfusion?

Answer 6

Yes.

Lower reduction in the need for one or more transfusions as well as in donor exposure

Question 7

Were there any adverse effects of having a lower transfusion threshold?

Answer 7

There was no increased risk of death or serious morbidity at discharge.

There is no clear impact on neurodevelopment outcome. There may be an impact on mild neurocognitive outcomes, but unclear at present.

Question 8

Should we treat with EPO?

Answer 8

No.

It does decrease the need for transfusion BUT the number of donors may not be reduced and early use of EPO does increase the presence of severe ROP (Number needed to harm 33). Administrating EPO later may lessen the risk of severe ROP

Question 9

Are there any groups of people in which you would strongly encourage EPO?

Answer 9

Only in those who refuse transfusions

Question 10

Does early iron supplementation reduce the need for transfusion?

Answer 10

No. Iron within the first 8.5 weeks makes no difference.

Question 11

Why do we use iron?

Answer 11

We use it because it has been demonstrated to improve haemoglobin and ferritin levels after two months of treatment and reduce the risk of iron deficiency anaemia

Question 12

Why do we want to prevent iron deficiency anemia

Answer 12

it has been associated with poor cognitive outcomes

Question 13

When do we start iron?

Answer 13

Once at full feeds

Question 14

Does ETCO2 correlate well? Are there any populations you would not use it in?

Answer 14

yes

Yes, kids with bad lung disease – there is too much dead space

Question 15

Does transcutaneous bilirubin monitor correlate with the serum?

Answer 15

Yes

Question 16

Does non-invasive monitoring reduce the need for transfusion?

Answer 16

Nope. No evidence to support this. We like the thought of it though.

Question 17

Does point of care testing reduce the need for transfusion?

Answer 17

Yes

Question 18

Can we use SC continuous glucose monitoring?

Answer 18

It does reduce the need for transfusion, but i s not accurate enough with >10% variability.
Dialysis microcatheters seem to have some promise

Question 19

Is one type of blood sampling better than another?

Answer 19

Nope. (Art, venous, cap all the same)

Question 20

How long can you delay cord clamping for?

Answer 20

180s

Question 21

What are the thresholds for transfusion

Answer 21

Week 1 100
Week 2 85
higher if respiratory support

Question 22

What volume of blood should you transfuse?

Answer 22

20ml/kg if the respiratory status will permit