Larry D. Eggert

Implementing a program to improve compliance with neonatal intensive care unit transfusion guidelines was accompanied by a reduction in transfusion rate: a pre-post analysis within a multihospital health care system.

BACKGROUND: We previously reported that in the year 2006, approximately 35% of the transfusions administered in the Intermountain Healthcare neonatal intensive care units (NICU) were noncompliant with our transfusion guidelines. In January 2009 we instituted an electronic NICU transfusion ordering and monitoring system as part of a new program to improve compliance with transfusion guidelines.

Association, among very‐low‐birthweight neonates, between red blood cell transfusions in the week after birth and severe intraventricular hemorrhage

Previous reports describe a statistical association, among very‐low‐birthweight (VLBW, <1500 g) neonates, between red blood cell (RBC) transfusion in the first days after birth and development of severe intraventricular (brain) hemorrhage (IVH).

Practice-based validation of calcium and phosphorus solubility limits for pediatric parenteral nutrition solutions.

In an effort to maximize the precipitation-free delivery of calcium and phosphorus to neonates, Fitzgerald and MacKay published in 1986 the results of empirical determination of calcium-phosphate saturation curves for a number of parenteral nutrition (PN) solutions. The saturation curves generated from these investigations have been used to formulate thousands of PN solutions. The curves were developed testing only calcium and phosphate without other components added to PN solutions. The authors reviewed 38,019 PN orders from 2007-2010 and plotted the calcium and phosphate concentrations for each solution in relation to the published curves to assess the practical validity of the curves. The solutions reviewed were compounded using standard weight ranges for electrolytes, trace minerals, and vitamins. The solutions were evaluated for precipitation using standards for visual compatibility against a black and white background. There were no visual precipitates found in the 38,019 PN solutions. All calcium and phosphorus concentrations plotted below the precipitation limits predicted by the published curves despite a large range of concentrations of electrolytes and minerals. There has always been concern about extrapolating data from solubility curves that were developed empirically from a limited number of test solutions based on the few variables of calcium, phosphorus, amino acid concentration, and presence of cysteine HCl and/or fat emulsion. This experience validates the calcium and phosphorus solubility limits represented by published curves. Moreover, the findings support the concept that principal variables governing calcium and phosphorus precipitation in PN solutions are calcium, phosphorus, amino acid concentrations, temperature, and pH.

Acute Kernicterus in a Neonate With O/B Blood Group Incompatibility and a Mutation in SLC4A1

We cared for a term female newborn, who at 108 hours of age, with a total serum bilirubin of 15.4 mg/dL, was discharged from the hospital on home phototherapy. At a return appointment 44 hours later, her total serum bilirubin was 41.7 mg/dL and signs of acute kernicterus were present. Maternal/fetal blood group O/B incompatibility was identified, with a negative direct antiglobulin test, which was positive on retesting. She had abundant spherocytes on blood smear, and these persisted at follow-up, but neither parent had spherocytes identified. A heterozygous SLC4A1E508K mutation (gene encoding erythrocyte membrane protein band 3) was found, and in silico predicted to result in damaged erythrocyte cytoskeletal protein function. No mutations were identified in other red cell cytoskeleton genes (ANK1, SPTA1, SPTB, EPB41, EPB42) and the UGT1A1 promoter region was normal. Neurologic follow-up at 2 and 4 months showed developmental delays consistent with mild kernicterus.

Techniques and Procedures: Pediatric Parenteral Nutrition via Computerized Worksheet and Automated Compounding

Ordering parenteral nutrition (PN) that is nutritionally appropriate, pharmacy acceptable, and physically compatible can be complex and time consuming. The Nutrition Support Service at Primary Childrens Medical Center has developed a user-friendly, single-screen computer program for prescribing individualized PN orders for pediatric patients based on weight and nutrient requirements. Educational windows define dosage guidelines and unacceptable parameters. An internal surveillance process identifies incompatibilities resulting from calcium and phosphate concentrations, fluid restrictions, dosages, and cation and anion imbalances. An incompatible solution is prevented and corrected before it is compounded. The completed PN order generates a medical order, pharmacy order documentation sheet, compounding document, and label. The stored PN order interfaces directly with an automated system for compounding without physical manipulation. The computerized worksheet enhances efficient ordering of individualized ...