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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 236-239

Oxygen content and prediction of packed red blood cell transfusion in mechanically ventilated neonate


Department of Neonatology, Bangabandhu Sheikh Mujib Medical University, BSMMU, Dhaka, Bangladesh

Date of Web Publication17-Oct-2017

Correspondence Address:
Mohammad Kamrul Hassan Shabuj
Department of Neonatology, Bangabandhu Sheikh Mujib Medical University, Shahbag-1000, Dhaka
Bangladesh
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_52_17

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  Abstract 

Background: Packed blood cell transfusion in mechanically ventilated neonate is a prime necessity to maintain adequate tissue oxygen supply. Hemoglobin (Hb) is the gold standard for making decision of blood transfusion. Hb estimation is time-consuming in relation to arterial blood gas analysis, total oxygen content (CaO2) is one of the components of the blood gas. In this study, we wanted to predict CaO2as a predictor for blood transfusion in mechanically ventilated baby. Materials and Methods: This is a cross-sectional study conducted to assess the performance of CaO2to detect the indication of packed red blood cell transfusion in mechanically ventilated neonates. CaO2and corresponding venous hemoglobin were measured in normally perfused baby. Test performance of CaO2with different cut-off value was validated by receiver operating curve, sensitivity, specificity and positive predictive value (PPV), and negative predictive value (NPV). Results: Prevalence rate of packed red blood transfusion in mechanically ventilated neonate was 53%. With setting a cut-off value for Hb of 13 g/dl for blood transfusion, the best cut-off value of CaO2for blood transfusion is 18.5 ml/dl and area under curve 0.802, sensitivity is 80% and specificity is 78%, PPV 76%, and NPV 82% and cut value of CaO2off ≤20 ml/dl area under curve 0.97 (95% confidence interval 0.95–1) and specificity 93% and PPV 96% and NPV 95%. Conclusion: Our study concluded that CaO2is an excellent predictor of blood transfusion in a positive-pressure ventilated baby, but actual decision should be taken according to clinical condition of the patient.

Keywords: Arterial blood gas, blood transfusion, hemoglobin, total oxygen content


How to cite this article:
Hassan Shabuj MK, Moni SC, Jahan I, Dey SK, Mannan MA, Shahidullah M. Oxygen content and prediction of packed red blood cell transfusion in mechanically ventilated neonate. J Clin Neonatol 2017;6:236-9

How to cite this URL:
Hassan Shabuj MK, Moni SC, Jahan I, Dey SK, Mannan MA, Shahidullah M. Oxygen content and prediction of packed red blood cell transfusion in mechanically ventilated neonate. J Clin Neonatol [serial online] 2017 [cited 2017 Nov 24];6:236-9. Available from: http://www.jcnonweb.com/text.asp?2017/6/4/236/216909




  Introduction Top


Packed red blood cell (PRBC) transfusion is one of the most widely utilized medical interventions practiced by clinicians. The criteria for PRBC transfusion in neonates are based on expert opinion and recent evidence-based medicine.[1] Oxygen delivery is dependent on cardiac output (CO) and oxygen content (CaO2).[2],[3],[4] and CaO2= (Hbo2) + (dissolve o2), where Hbo2 is oxygen bound to hemoglobin (Hb). PRBC transfusion in mechanically ventilated neonate is indicated when hematocrit (Hct) >35%–40%[5] or Hb 13 g/dl. We want to measure whether CaO2 rather than Hb concentration can predict the indication for PRBC transfusion in ventilated neonate.


  Materials and Methods Top


This was a cross-sectional study conducted in the Department of Neonatal Intensive Care Unit at Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh; in the period of January 2016 to December2016. We included a total of 148 neonates with positive-pressure ventilation either intermittent mandatory ventilation (IMV) or continuous positive airway pressure (CPAP), 0–28 days with any gestational age. We excluded those patients who required blood transfusion due to blood loss, any major congenital anomalies, and hematological disorder. Patients with different ventilation mode and CPAP support with normal capillary refill time (CRT) (<3 s) were included in this study. Blood gas as done as a routine schedule of unit protocol and simultaneous venous Hb or Hb measured within 48 h was taken as Hb value. Blood gas sample was obtained from radial or ulnar arteries, Allen test was done before blood drawing. Artery was located by palpation and the skin was prepared with povidone-iodine then chlorhexidine, a 25-G butterfly needle was inserted in the bevel up position at 45° angle through the skin against the direction of the arterial flow. Blood was allowed to come spontaneously in heparinized syringe, and blood gas analysis was done within 5 min by RAPID Point ® 500 Blood Gas Systems (by Siemens USA). One ml venous blood was collected in a test tube containing ethylenediaminetetraacetic acid, for Hb measurement by hematology analyzers by hemiglobincyanide method, by Beckman Coulter system. Informed written consent was taken from the parent or legal guardian, and study protocol was approved by Departmental Review Committee. Statistical analysis was done with Statistical Package for Social Science (SPSS software) with version 20 (SPSS inc, II, USA). Data were checked for normal distribution by Gaussian distribution curve. Demographic data were presented by proportion and by mean value with standard deviation. For test performance of CaO2 was validated by receiver operating characteristic (ROC) curve, sensitivity, specificity, and by positive predictive value (PPV) and negative predictive value (NPV).


  Results Top


During this 1 year study period, a total of 148 neonates got positive-pressure respiratory support. The mean gestational age of the included neonates was 33.27 ± 2.74 weeks, and mean weight was 1842.97 ± 556 g [Table 1]. Out of them, 78 patients got PRBC transfusion as per protocol of neonatal care unit and prevalence rate of blood transfusion were 53%. Of the patients, 41% were in synchronized IMV and 27% were in continuous mandatory ventilation, and CPAP were given in 16% of the patients, and remaining patients were in combination mode [Figure 1]. Unit protocol for PRBC transfusion in a mechanically Ventilated baby was when Hb value 13gm/dl or PCV 40% and we used it as gold standard for blood transfusion in positive-pressure ventilated baby. We considered CaO2 as a screening test. With this standard value of Hb for blood transfusion, the best cut-off value of blood transfusion for CaO2(the screening test) was 18.5 ml/dl [Table 2] and area under ROC 0.807 (95% confidence interval [CI] 0.73–0.89) and sensitivity is 80% with specificity 77% [Figure 2], PPV 76%, and NPV 82% [Table 3]. When we selected cut-off point of CaO2≤20 ml/dl then area under ROC is 0.978 (95% CI 0.95–1) [Figure 3], and sensitivity was 97% and specificity was 93% and PPV and NPV were 96% and 95%, respectively, which is an excellent predictor of blood transfusion in mechanically ventilated baby [Table 3].
Figure 1: Mode of Positive Pressure Ventilation

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Figure 2: ROC curve of with cut off Value 18.5ml/dl

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Figure 3: Area under the Curve with cut of value of Cao2 ≤ 20 ml/dl

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Table 1: Baseline characteristics

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Table 2: Cut off value of CaO2 and area under curve

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Table 3: Different cut off value with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV)

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  Discussion Top


Hb is the gold standard for blood transfusion; no other alternative has been studied. With this purpose, we considered CaO2 as an alternative predictor for blood transfusion. There are several studies related to Hb and blood gas, but there is no specific study was found to see the relation CaO2 with blood transfusion in mechanically ventilated baby.

In our study, the prevalence rate of packed red blood transfusion in mechanically ventilated neonate was high (53%). A study of Nayeri et al.[6] showed that in neonatal age group during the period of 2005–2006, blood transfusion rate in Iran was 34.5%. In our study, we set a cut-off value for Hb of 13 g/dl for blood transfusion in neonate with positive-pressure ventilation. The study by Whyte and Jefferies [7] showed that in the 1st week of life neonate with respiratory support threshold level of packed cell transfusion is 11.5 g/dl, and 10.0 g/dl and 8.5 g/dl in the 2nd and 3rd week, respectively. However, no study was found to show the cut-off value of CaO2 for packed cell transfusion in neonate with positive-pressure ventilation, but our study showed that the best cut-off value of CaO2 for blood transfusion is 18.5 ml/dl and area under curve 0.802, sensitivity is 80% and specificity is 78%, PPV 76%, and NPV 82% and cut-off value of CaO2 of ≤20 ml/dl area under curve 0.97 (95% CI 0.95–1) and specificity 93% and PPV 96% and NPV 95%. Some studies showed that Hb or Hct is the only predictor to make the decision to transfuse PRBC, but they did not consider CaO2 in their study. These studies showed that oxygen availability [8] depends on the functional measure of Hb, fractional oxygen extraction,[9] and RBC transport.[10] However, in our study, we found that CaO2 is good predictor to determine indication for PRBC transfusion in neonate with respiratory support. Several studies concluded that neonatal well-being depends on physiological compensations in regional blood flow or oxygen transport or changes in CO,[11],[12] but these predictors have not been adequately evaluated. One study showed that apnea of prematurity events has been reduced immediately by transfusion,[13] but what about volume expansion [8] was not observed in that study. In this study, we included all the neonates who have CRT ≤3 s. One study showed that in anemic infants, transfusion causes minor reductions in the heart and respiratory rates.[14] This benefits of transfusion may be justified on an individual basis. Our study population were already in respiratory support, so we are considering an alternative way within the shortest time to detect the indication of PRBC transfusion for better tissue oxygenation. We have several limitations such as small sample size, single centered study, and high prevalence of blood transfusion which may not represent other Neonatal Intensive Care Unit.


  Conclusion Top


Our study finding concluded that CaO2 is a good predictor for PRBC transfusion in neonate with positive-pressure ventilation. However, decision of PRBC transfusion should consider on clinical condition and substantial evidence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kasat K, Hendricks-Muñoz KD, Mally PV. Neonatal red blood cell transfusions: Searching for better guidelines. Blood Transfus 2011;9:86-94.  Back to cited text no. 1
    
2.
Ganong WF, editor. Review of Medical Physiology. 21st ed. USA: McGraw-Hill; 2003. p. 669-72.  Back to cited text no. 2
    
3.
Goldsmith JP, Karotkin EH, editors. Assisted Ventilation in Neonate. 4th ed. Philadelphia: Elsevier; 2009. p. 286-7.  Back to cited text no. 3
    
4.
Collins JA, Rudenski A, Gibson J, Howard L, O'Driscoll R. Relating oxygen partial pressure, saturation and content: The haemoglobin-oxygen dissociation curve. Breathe (Sheff) 2015;11:194-201.  Back to cited text no. 4
    
5.
Gomella TL, editor. Management, Procedure, On-call Problems, Diseases, and Drugs. 7th ed. New York: McGraw-Hill; 2015. p. 191.  Back to cited text no. 5
    
6.
Nayeri F, Nili F, Ebrahim B, Olomie Yazdi Z, Maliki Z. Evaluation of a new restricted transfusion protocol in neonates admitted to the NICU. Med J Islam Repub Iran 2014;28:119.  Back to cited text no. 6
    
7.
Whyte RK, Jefferies AL; Canadian Paediatric Society, Fetus and Newborn Committee. Red blood cell transfusion in newborn infants. Paediatr Child Health 2014;19:213-22.  Back to cited text no. 7
    
8.
Mohamed A, Shah PS. Transfusion associated necrotizing enterocolitis: A meta-analysis of observational data. Pediatrics 2012;129:529-40.  Back to cited text no. 8
    
9.
Bifano EM, Smith F, Borer J. Relationship between determinants of oxygen delivery and respiratory abnormalities in preterm infants with anemia. J Pediatr 1992;120(2 Pt 1):292-6.  Back to cited text no. 9
    
10.
Nelle M, Höcker C, Zilow EP, Linderkamp O. Effects of red cell transfusion on cardiac output and blood flow velocities in cerebral and gastrointestinal arteries in premature infants. Arch Dis Child Fetal Neonatal Ed 1994;71:F45-8.  Back to cited text no. 10
    
11.
Yu CW, Sung RY, Fok TF, Wong EM. Effects of blood transfusion on left ventricular output in premature babies. J Paediatr Child Health 1998;34:444-6.  Back to cited text no. 11
    
12.
Zagol K, Lake DE, Vergales B, Moorman ME, Paget-Brown A, Lee H, et al. Anemia, apnea of prematurity, and blood transfusions. J Pediatr 2012;161:417-21.e1.  Back to cited text no. 12
    
13.
Poets CF, Pauls U, Bohnhorst B. Effect of blood transfusion on apnoea, bradycardia and hypoxaemia in preterm infants. Eur J Pediatr 1997;156:311-6.  Back to cited text no. 13
    
14.
Chen HL, Tseng HI, Lu CC, Yang SN, Fan HC, Yang RC. Effect of blood transfusions on the outcome of very low body weight preterm infants under two different transfusion criteria. Pediatr Neonatol 2009;50:110-6.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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