Red blood cell transfusion–related necrotizing enterocolitis in very‐low‐birthweight infants: a near‐infrared spectroscopy investigation

Abstract

Background Recent evidence suggests that antecedent packed red blood cell (PRBC) transfusions increase the risk for necrotizing enterocolitis (NEC), the most common gastrointestinal emergency encountered by very low birth weight (VLBW) infants. The underlying mechanism for this association is unknown. Altered oxygenation of the mesenteric vasculature during PRBC transfusion has been hypothesized to contribute to NEC development and was investigated in this study. Study design and methods Oxygenation patterns among four VLBW infants who developed transfusion-related NEC (TR-NEC) were compared to four VLBW infants with similar gestational age who were transfused but did not develop NEC (non-NEC). Cerebral and mesenteric patterns were recorded before, during and 48 hours subsequent to PRBC transfusion using near-infrared spectroscopy technology (NIRS). Percentage change from mean baseline regional saturation (rSO2) values and cerebro- splanchnic oxygenation ratio (CSOR) were analyzed. Results All TR-NEC infants (24–29 weeks gestation; 705–1080 grams) demonstrated greater variation in mesenteric oxygenation patterns surrounding transfusions than non-NEC infants (27.6–30 weeks gestation; 980–1210 grams). TR-NEC infants received larger mean volumes of total blood (27.75 ml/kg ± 8.77) than non-NEC infants (15.25ml/kg ± 0.5). Conclusion Wide fluctuation and decreases in mesenteric oxygenation patterns are more pronounced in TR-NEC infants, especially prior to TR-NEC onset, as compared to non-NEC infants. Greater total volume of infused blood was associated with TR-NEC in preterm infants. Using NIRS, larger prospective studies are needed to further evaluate potential risk factors for NEC in this high risk population.

Deformability of transfused red blood cells is a potent determinant of transfusion‐induced change in recipient's blood flow

“…As discussed in the Introduction section, there is a growing body of evidence for the deleterious effects of PRBC transfusion, such as increased hospitalization and mortality, renal failure, sepsis, and more . This study provides direct evidence, for the first time in humans, that the deformability of transfused PRBC is a potent effector of transfusion outcome.…”

“…As discussed in the Introduction section, there is a growing body of evidence for the deleterious effects of PRBC transfusion, such as increased hospitalization and mortality, renal failure, sepsis, and more. 4,6,[50][51][52] This study provides direct evidence, for the first time in humans, that the deformability of transfused PRBC is a potent effector of transfusion outcome. As noted above, the current blood banking routine is confined to testing the immune compatibility between transfused PRBC units and the recipients, and of infectious agents, while the functionality of the transfused RBC is ignored.…”

“…A growing number of studies have shown that the transfusion of PRBC may cause damage rather than benefit to recipients, including prolonged mechanical ventilation, renal failure, sepsis, increased hospitalization, and hospital mortality . In particular, studies with trauma, sepsis, medical‐surgical intensive care, or thalassemia patients have reported that PRBC transfusion reduced blood perfusion and oxygen saturation in the recipients.…”

Research Opportunities to Improve Neonatal Red Blood Cell Transfusion

“…These studies have largely relied on hemoglobin thresholds, along with respiratory support and postnatal age, as determinants of RBC transfusion without incorporating measures of oxygen delivery. Mesenteric NIRS, a tool to measure regional oxygen saturation of the gut, offers the ability to assess oxygen delivery in real-time and follow trends that may provide insight into both the need for RBC transfusion and an individual’s risk for developing NEC [32]. …”

Quality Improvement Initiative to Reduce the Necrotizing Enterocolitis Rate in Premature Infants

“…[27][28][29] To this end, the conservative feeding transfusion policy of holding feeds and/or not changing volume or fortification on the same day as a transfusion was felt to be of low risk and potentially high benefit to the reduction of the incidence of NEC. Despite the overall decrease use of indomethacin therapy for hemodynamically significant patent ductus arteriosus, we instituted a conservative feeding guideline to ensure use of a standardized feeding regimen in our neonatal network.…”