Reference intervals for common coagulation tests of preterm infants (CME)

Christensen, Robert D.; Baer, Vickie L.; Lambert, D K; Henry, Erick; Ilstrup, Sarah J.; Bennett, Sterling T.

doi:10.1111/trf.12322

Cited by 82 publications

(77 citation statements)

References 25 publications

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“…Specifically, "sepsis" was coded with either a positive culture from a typically sterile body fluid plus intravenous antibiotic treatment for a minimum of 5 consecutive days, or a diagnosis of clinical sepsis with intravenous antibiotic treatment for a minimum of 5 consecutive days. "DIC" was coded when there was abnormal clinical bleeding, oozing, or bruising, along with a fibrinogen level below the 5th percentile lower reference interval for age, and a PT, aPTT, and D-dimers all > 95th percentile upper reference interval for age [11]. Biochemical "iron deficiency" was defined by only one parameter, which was one or more reticulocyte hemoglobin content values < 25 pg [12,13].…”

Section: Methodsmentioning

confidence: 99%

Automated Quantification of Fragmented Red Blood Cells: Neonatal Reference Intervals and Clinical Disorders of Neonatal Intensive Care Unit Patients with High Values

et al. 2018

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Background: Schistocytes are circulating erythrocyte fragments. They can be identified microscopically from a blood smear; but automated systems evaluate more cells and avoid inconsistencies in microscopy. Studies using adult subjects indicate that automated quantification of schistocytes can be clinically useful. However, reference intervals for automated schistocyte counts of neonates have not been published, and the relevance of a high automated schistocyte count from neonates has not been reported. Objectives: Using retrospective automated neonatal complete blood count (CBC) data, we created reference intervals for fragmented red cells (FRCs) and sought to discover the clinical conditions of neonates with high FRCs (above the upper reference interval). Results: We created reference intervals based on 39,949 CBCs from 15,655 neonates 0–90 days old. The lower reference interval was 0 FRC/µL and the upper interval was 100,000/µL. The highest FRCs (96 CBCs from 44 neonates) were > 250,000/µL. These neonates clustered into the following groups: 37% had sepsis, 29% had disseminated intravascular coagulation (DIC), 17% had a genetic syndrome, 14% necrotizing enterocolitis (NEC), and 7% had iron deficiency (some had more than one diagnosis). Based on the reference intervals, we divided the 39,949 FRC values into 3 groups: (1) < 100,000/µL (“normal”), (2) 100,000–200,000/µL (“moderately elevated”), and (3) > 200,000/µL (“extremely elevated”). The odds that a microangiopathic condition (DIC, sepsis, NEC) or a microcytic disorder (iron deficiency) were present were significantly higher in the moderately elevated, and more so in the extremely elevated group. Conclusions: Our study suggests that a high FRC could prompt investigation into, or inform follow-up of, a neonatal microangiopathic or extremely microcytic disorder.

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Section: Methodsmentioning

confidence: 99%

Automated Quantification of Fragmented Red Blood Cells: Neonatal Reference Intervals and Clinical Disorders of Neonatal Intensive Care Unit Patients with High Values

et al. 2018

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“…First, normal reference intervals for these coagulation tests have been lacking for the smallest and most immature neonates [63,64,65], thus it has been unclear when a value is truly abnormal. Second, it is not clear under which specific conditions administering fresh-frozen plasma will reduce the risk of a serious hemorrhage [66,67]. Third, the total costs and risks of this approach require better definition in order to balance these against any proven benefits [67].…”

Section: Fresh-frozen Plasma Transfusionmentioning

confidence: 99%

“…Second, it is not clear under which specific conditions administering fresh-frozen plasma will reduce the risk of a serious hemorrhage [66,67]. Third, the total costs and risks of this approach require better definition in order to balance these against any proven benefits [67]. We judge that the evidence favors not performing routine coagulation screening tests of VLBW neonates [68,69,70,71,72], and that the recommendation is derived from category 2B evidence and the strength of this recommendation is graded C, because of the lack of sufficient studies.…”

Section: Fresh-frozen Plasma Transfusionmentioning

confidence: 99%

Evidence-Based Advances in Transfusion Practice in Neonatal Intensive Care Units

2014

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Background: Transfusions to neonates convey both benefits and risks, and evidence is needed to guide wise use. Such evidence is accumulating, but more information is needed to generate sound evidence-based practices. Objective: We sought to analyze published information on nine aspects of transfusion practice in neonatal intensive care units. Methods: We assigned ‘categories of evidence' and ‘recommendations' using the format of the United States Preventive Services Task Force of the Agency for Healthcare Research and Quality. Results: The nine practices studied were: (1) delayed clamping or milking of the umbilical cord at preterm delivery - recommended, high/substantial A; (2) drawing the initial blood tests from cord/placental blood from very low birth weight (VLBW, <1,500 g) infants at delivery - recommended, moderate/moderate B; (3) limiting phlebotomy losses of VLBW infants - recommended, moderate/substantial B; (4) selected use of erythropoiesis-stimulating agents to prevent transfusions - recommended, moderate/moderate-moderate/small B, C; (5) using platelet mass, rather than platelet count, in platelet transfusion decisions - recommended, moderate/small C; (6) permitting the platelet count to fall to <20,000/µl in ‘stable' neonates before transfusing platelets - recommended, low/small I; (8) permitting the platelet count to fall to <50,000/µl in ‘unstable' neonates before transfusing platelets - recommended, moderate/small C, and (9) not performing routine coagulation test screening on every VLBW infant - recommended, moderate/small C. Conclusions: We view these recommendations as dynamic, to be revised as additional evidence becomes available. We predict this list will expand as new studies provide more information to guide best transfusion practices.

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“…Subsequent studies by Christensen et al published in 20144 sought to determine the reference ranges for infants below 34 weeks’ gestation and those of extreme prematurity (table 1). This was a prospective study using cord blood samples (N=175).…”

Section: What Are the Reference Ranges In Neonates?mentioning

confidence: 99%

“…There is currently a lack of evidence surrounding the assessment of coagulation abnormalities within neonates, with recent studies4 demonstrating different ‘normal’ ranges for coagulation tests depending on gestational and postnatal age. There is also evidence that ‘abnormal’ coagulation tests are not associated with increased risk of bleeding, and there has been a move to reset the bar for transfusion in order to minimise risk of blood product administration.…”

Section: Introductionmentioning

confidence: 99%

Interpretation of clotting tests in the neonate: Table 1

Pal

Curley

Stanworth

2014

Arch Dis Child Fetal Neonatal Ed

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There are significant differences between the coagulation system in neonates compared with children and adults. Abnormalities of standard coagulation tests are common within the neonatal population. The laboratory tests of activated partial thromboplastin time (aPTT) and prothrombin time (PT) were developed to investigate coagulation factor deficiencies in patients with a known bleeding history, and their significance and applied clinical value in predicting bleeding (or thrombotic) risk in critically ill patients is weak. Routine screening of coagulation on admission to the neonatal intensive care unit leads to increased use of plasma for transfusion. Fresh frozen plasma (FFP) is a human donor plasma frozen within a short specified time period after collection (often 8 h) and then stored at -30°C. FFP has little effect on correcting abnormal coagulation tests when mild and moderate abnormalities of PT are documented in neonates. There is little evidence of effectiveness of FFP in neonates. A large trial by the Northern Neonatal Nursing Initiative assessed the use of prophylactic FFP in preterm infants and reported no improvement in clinical outcomes in terms of mortality or severe disability. An appropriate FFP transfusion strategy in neonates should be one that emphasises the therapeutic use in the face of bleeding rather than prophylactic use in association with abnormalities of standard coagulation tests that have very limited predictive value for bleeding.

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Reference intervals for common coagulation tests of preterm infants (CME)

Cited by 82 publications

References 25 publications

Automated Quantification of Fragmented Red Blood Cells: Neonatal Reference Intervals and Clinical Disorders of Neonatal Intensive Care Unit Patients with High Values

Automated Quantification of Fragmented Red Blood Cells: Neonatal Reference Intervals and Clinical Disorders of Neonatal Intensive Care Unit Patients with High Values

Evidence-Based Advances in Transfusion Practice in Neonatal Intensive Care Units

Interpretation of clotting tests in the neonate: Table 1

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