Marian M. Adams

Reduction in Red Blood Cell Transfusions Using a Bedside Analyzer in Extremely Low Birth Weight Infants

BACKGROUND:Preterm infants typically experience heavy phlebotomy losses from frequent laboratory testing in the first few weeks of life. This results in anemia, requiring red blood cell (RBC) transfusions. We recently introduced a bedside point-of-care (POC) blood gas analyzer (iSTAT, Princeton, NJ) that requires a smaller volume of blood to replace conventional Radiometer blood gas and electrolyte analysis used by our neonatal intensive care unit (NICU). The smaller volume of blood required for sampling (100 vs 300–500 μl), provided an opportunity to assess if a decrease in phlebotomy loss occurred and, if so, to determine if this resulted in decreased transfusions administered to extremely low birth weight (ELBW) infants.OBJECTIVE:We hypothesized that the use of the POC iSTAT analyzer that measures pH, PCO2, PO2, hemoglobin, hematocrit, serum sodium, serum potassium and ionized calcium would result in a significant decrease in the number and volume of RBC transfusions in the first 2 weeks of life.DESIGN/METHODS:A retrospective chart review was conducted of all inborn premature infants with birth weights less than 1000 g admitted to the NICU that survived for 2 weeks of age during two separate 1-year periods. Blood gas analysis was performed by conventional laboratory methods during the first period (designated Pre-POC testing) and by the iSTAT POC device during the second period (designated post-POC testing). Data collected for individual infants included the number of RBC transfusions, volume of RBCs transfused, and the number and kind of blood testing done. There was no effort to change either the RBC transfusion criteria applied or blood testing practices.RESULTS:The mean (±SD) number of RBC transfusions administered in the first 2 weeks after birth was 5.7±3.74 (n=46) in the pre-POC testing period to 3.1±2.07 (n=34) in the post-POC testing period (p<0.001), a 46% reduction. The mean volume of RBC transfusions decreased by 43% with use of the POC analyzer, that is, from 78.4±51.6 ml/kg in the pre-POC testing group to 44.4±32.9 ml/kg in the Post-POC testing group (p<0.002). There was no difference between the two periods in the total number of laboratory blood tests done.CONCLUSIONS:Use of a bedside blood gas analyzer is associated with clinically important reductions in RBC transfusions in the ELBW infant during the first two weeks of life.

Screening for Symptoms of Postpartum Traumatic Stress in a Sample of Mothers with Preterm Infants

There are no established screening criteria to help identify mothers of premature infants who are at risk for symptoms of emotional distress. The current study, using data obtained from recruitment and screening in preparation for a randomized controlled trial, aimed to identify potential risk factors associated with symptoms of depression, anxiety and posttraumatic stress in a sample of mothers with premature infants hospitalized in a neonatal intensive care unit. One hundred, thirty-five mothers of preterm infants born at 26–34 weeks of gestation completed three self-report measures: the Stanford Acute Stress Reaction Questionnaire, the Beck Depression Inventory (2nd ed.), and the Beck Anxiety Inventory to determine their eligibility for inclusion in a treatment intervention study based on clinical cut-off scores for each measure. Maternal sociodemographic measures, including race, ethnicity, age, maternal pregnancy history, and measures of infant medical severity were not helpful in differentiating mothers who screened positive on one or more of the measures from those who screened negative. Programs to screen parents of premature infants for the presence of symptoms of posttraumatic stress, anxiety, and depression will need to adopt universal screening rather than profiling of potential high risk parents based on their sociodemographic characteristics or measures of their infants medical severity.

Frequency and Timing of Symptoms in Infants Screened for Sepsis: Effectiveness of a Sepsis-Screening Pathway

To determine the frequency and timing of symptoms and to evaluate the effectiveness of a sepsis-screening pathway in term and near-term infants, data were collected prospectively for a period of 1 year from December 1, 2000, to November 30, 2001. Results confirmed that a sepsis-screening pathway using a combination of at least 2 serial complete blood cell count and C-reactive protein measurements in both symptomatic and asymptomatic infants is a safe, simple strategy that prevents unnecessary treatment of infants with risk factors with antibiotics. However, most infants with presumed or suspected early-onset sepsis are symptomatic. Routine treatment of asymptomatic infants with risk factors or prior treatment with intrapartum antibiotics is unnecessary. A combined approach of screening in the presence of risk factors and /or symptoms of sepsis and adequate follow-up for infants discharged at less than 72 hours of age may help reduce unnecessary treatment of infants with antibiotics.

Effects of Prone and Supine Position on Sleep in Preterm Infants at One Month Corrected Age

Effects of Prone and Supine Position on Sleep in Preterm Infants at One Month Corrected Age

Sleeping Position in Preterm Infants Does Not Affect Sleep Organization|[dagger]| 940

The American Academy of Pediatrics recommended in 1992 that term infants and also in 1996 that asymptomatic preterm infants sleep nonprone to reduce risk for sudden infant death syndrome (SIDS). While healthy preterm infants at term age have better ventilation responses to CO2 in prone position(Martin et al. 1997), the advantage of reduced SIDS risk was felt to be greater than a short-term clinical benefit. Three month old term infants have more total sleep time (TST), more quiet sleep (QS), and fewer arousals during prone compared to supine sleeping (Kahn et al. 1993). The increase in QS and decrease in arousals seen with prone sleeping may explain why there is an increased vulnerability for SIDS in the first 4 months of life. Last year we reported our results on 6 preterm infants who showed no effect of body position on sleep. We have expanded our study to 16 infants, studied at a PCA of 36.5±0.6 weeks. The infants (mean gestational age of 32.2±3 weeks; mean birth weight of 1733±135 g) were all recorded with videopolysomnography (VPSG) for two consecutive daytime nap periods (6 hours). VPSG was scored for TST, QS, Active Sleep (AS), and Indeterminate Sleep (IS). Arousal was defined as body movement, cry, or eye opening lasting 10-60 seconds. An arousal > 60 seconds was scored as an awakening. Indices were calculated as number of arousals or awakenings per 100 minutes. Our results(see table) showed no significant differences in sleep organization based on body position. TST and percentage of QS were similar for prone and supine. The awakening index was significantly greater for supine, supporting that supine sleeping was more interrupted and less efficient. We speculate that the increase in QS and decrease in arousals which has been reported for prone sleeping in older term infants may not appear until 1-3 months corrected age, a time when the risk for SIDS is also higher for preterm infants. If the effect of body position on sleep was the mechanism for decreased SIDS risk, nonprone sleep position before and at term conceptional age may not have the same benefit in the preterm infant and there may be some physiologic disadvantages, e.g., decreased ventilatory response to CO2.

Prone Preterm Infants Have More Quiet Sleep, Fewer Awakenings, and Less Heart Rate Variability After Feeding • 1014

Prone Preterm Infants Have More Quiet Sleep, Fewer Awakenings, and Less Heart Rate Variability After Feeding • 1014

A SERIES OF NEONATAL PATIENTS WITH PARADOXICAL SEIZURE-LIKE REACTIONS TO BOLUS INTRAVENOUS INJECTIONS OF MIDAZOLAM † 790

A SERIES OF NEONATAL PATIENTS WITH PARADOXICAL SEIZURE-LIKE REACTIONS TO BOLUS INTRAVENOUS INJECTIONS OF MIDAZOLAM † 790

EFFECTS OF SLEEPING POSITION ON CLINICAL VARIABLES IN HEALTHY PRETERM INFANTS. |[dagger]| 1124

To evaluate effects of prone (P) versus supine (S) sleeping position in healthy preterm infants, 20 infants [mean birth weight 1661 ± 435g and mean gestational age 31 ± 2 wks] in the Intermediate Care Nursery at Packard Childrens Hospital at Stanford between August 1994 and July 1995 were randomized at 33 weeks post-conceptional age (PCA) to either P (n=13) or S(n=7) sleeping position until discharge. Clinical data regarding weight, apnea, bradycardia [heart rate (HR) < 100], desaturations (oxygen saturation < 95%), and feeding were collected from the nursing records.